Every finding on record at Hope Springs Care Center

Based on observation, record review and interviews, the facility failed to ensure two (#31 and #50) of four residents reviewed for nutrition out of 28 sample residents received the care and services necessary to meet their nutritional needs and maintain their highest level practicable physical well-being. Resident #31 was admitted to the facility for long-term care on 8/12/24 with diagnoses of hypertension (high blood pressure), depression and atrial fibrillation. Upon admission on 8/12/24, the resident weighed 120.8 lbs. On 10/17/24, Resident #31 weighed 94 pounds. Resident #31 lost 26.8 lbs (22.1%) in less than three months, which was considered severe. The facility implemented several nutritional interventions on 10/17/24 which included encouraging her family to bring in her favorite food items, that Resident #31 preferred sweet foods, and to provide assistance and cueing as needed, which did not assist Resident #31 to increase her weight. The facility implemented nutritional supplements on 11/1/24 which were occasionally accepted by Resident #31 and also did not increase Resident #31's weight. On 11/20/24, the resident weighed 82.8 pounds. Resident #31 lost 11.2 lbs (11.9%) in less than three months which was considered severe. Due to the facility's failure to effectively implement nutrition interventions timely, Resident #31's weight continued to decline. Additionally, Resident #50 was admitted to the facility on [DATE] with diagnoses of dementia and adult failure to thrive. Upon admission, the resident weighed 119.1 pounds (lbs). Resident #50 sustained 23.1 lbs (19.4%) weight change from 8/16/24 to 11/20/24, in three months, which was considered severe weight loss. On 8/29/24 Resident #50 had an order for a high calorie nutritional supplement (Mighty Shake). Progress notes and the medication administration record (MAR) identified the resident did not receive the nutritional supplement on two occasions because the supplement was not available. Resident #50 lost 7.4 lbs between 9/3/24 and 9/19/24, indicating a 6.18% weight change in two weeks. The new intervention to combat the weight loss was to offer her snacks between meals. The record review identified Resident #50 did not have a nutrition care plan until 10/24/24 and not until after the resident had lost 17.7 lbs with a 14.86% weight change. The review of Resident #50's weights identified potential weight inaccuracies related to large weight gains and a lack of timely and consistent reweighs after the resident had significant weight changes. Findings include: I. Facility policy and procedure The Weight Management policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 12/10/24 at 5:52 p.m. It documented in pertinent part, Residents are monitored for weight change on a regular basis. Results are reviewed and analyzed by the facility for interventions as appropriate. Residents identified with weight change will be assessed by the interdisciplinary (IDT) team, and further interventions will be implemented to minimize the risk for further weight change where possible and to promote weight stability. Weigh all residents upon admission, then weekly or as indicated by physician orders. Document the results in the medical record. Residents with weight variance (loss or gain) are reweighed. Significant and severe weight variance is defined as 5% change in one month, 7.5% change in three months, or 10% change in six months. The IDT meets weekly to review residents with identified weight change, develops a plan, implements, evaluates, and re-evaluates interventions to minimize the risk for weight change. Nursing staff is to notify food and nutrition services and the registered dietician (RD) of a resident's weight change. The RD further assesses the resident to determine root cause of weight change and makes recommendations to reduce or stabilize the weight change. II. Resident #31 A. Resident status Resident #31, age greater than 65, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included hypertension, depression and atrial fibrillation. The 11/12/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of five out of 15. The resident required substantial or maximum assistance with bathing, toileting hygiene, lower body dressing, and footwear. The resident required supervision with personal hygiene. The resident required set-up or clean-up assistance with oral hygiene. The assessment documented Resident #31 was able to eat independently with no assistance. -However, the facility documented that the resident required assistance or cueing on the nutritional plan of care. The assessment documented the resident was 60 inches (5 foot) tall. The assessment documented the resident weighed 88 lbs. The assessment documented the resident had experienced 10% or more weight loss in the last six months and was on a physician-prescribed weight loss regimen. B. Observations During a continuous observation in the main dining hall on 12/4/24, beginning at 11:47 a.m. and ending at 12:11 p.m. the following was observed: At 11:56 a.m. Resident #31 received her plate of food which included meatloaf, a dinner roll and a cookie. At 11:58 a.m. Resident #31 was eating a cookie with both hands. An unidentified staff member encouraged her to eat several food options on her plate, which she refused. At 12:06 p.m., Resident #31 had eaten the entire cookie. The unidentified staff member offered an alternative meal option to Resident #31, which she refused. During a continuous observation on 12/9/24, beginning at 5:38 p.m. and ending at 6:43 p.m. the following was observed: At 6:09 p.m. Resident #31 was assisted to the dining room in her wheelchair by an unidentified staff member. At 6:21 p.m. Resident #31 received her plate of food which included shrimp alfredo, toast, peas, and a cookie. Resident #31 immediately picked up the cookie and began eating it. At 6:22 p.m. CNA #1 offered Resident #31 assistance with her meal. CNA #1 was observed to encourage the resident towards the other items on her plate, which Resident #31 refused. At 6:27 p.m., CNA #1 was observed to encourage Resident #31 to eat the other food items on her plate, which she refused. Resident #31 continued to eat the cookie which she held with both hands. At 6:31 p.m., Resident #31 finished eating the entire cookie. Resident #31 then laid her head back in her wheelchair and closed her eyes for several minutes. At 6:40 p.m., Resident #31 picked up her fork, moved the shrimp alfredo on her plate around with the fork, and then she set the fork back down on the table and closed her eyes. At 6:43, CNA #1 asked Resident #31 if she was done eating, which she affirmed. CNA #1 offered Resident #31 an alternative food option, which she refused. C. Record review The nutrition care plan, initiated on 8/12/24 and revised on 10/17/24, revealed a goal of maintaining Resident #31's weight through the review period. Interventions added on 10/17/24 included notifying the nursing staff that Resident #31 had always been a picky eater, Resident #31 preferred sweet foods, encouraging Resident #31's family to bring her favorite foods and providing Resident #31 with assistance and cueing as needed during meals. -A review of the comprehensive care plan revealed there were no new or revised interventions implemented after the resident sustained severe weight loss on 11/20/24. Resident #31's weights were documented in the electronic medical record (EMR) as follows: -On 8/15/24, the resident weighed 120.8 lbs; -On 8/20/24, the resident weighed 122.4 lbs; -On 9/3/24, the resident weighed 120.8 lbs; -On 9/16/24, the resident weighed 119.7 lbs; -On 9/23/24, the resident weighed 119.2 lbs; -On 10/8/24, the resident weighed 94.6 lbs; -On 10/17/24, the resident weighed 94 lbs; -On 10/23/24, the resident weighed 94 lbs; -On 10/29/24, the resident weighed 92.6 lbs; -On 11/6/24, the resident weighed 87.8 lbs; -On 11/13/24, the resident weighed 84 lbs; and, -On 11/20/24, the resident weighed 82.8 lbs. -The resident lost 26.2 lbs (21.7%), from 9/3/24 to 10/18/24, in one month, which was considered severe. -The resident lost 11.2 lbs (11.9%) from 10/17/24 to 11/20/24, in one month, which was considered severe. -The resident lost 38 lbs (31.5%) from 8/15/24 to 11/20/24, in three months, which was considered severe. The food preferences documentation, dated 10/2/24, revealed Resident #31's favorite foods were sweets. The food and nutritional admission assessment, dated 8/22/24, documented Resident #31's admission body weight was 120.8 lbs. The assessment documented Resident #31's weight in the hospital before admission to the facility was 121 lbs. The assessment documented Resident #31 was not at risk for an altered nutrition or hydration status. The assessment documented it was okay to offer the resident smaller portions of food as regular portions may be overwhelming. It also documented the regular portions were providing more than her estimated needs. The quarterly nutritional assessment, dated 11/12/24, documented Resident #31's usual body weight was 112 lbs. The assessment documented Resident #31 had experienced significant weight loss since her admission to the facility. The assessment documented Resident #31 had a poor appetite. -However, the facility failed to implement a person-centered nutrition intervention after Resident #31 was identified to have significant weight loss. The multidisciplinary care conference documentation, dated 11/19/24, revealed a care conference was held on 11/19/24 with the nurse, dietary staff, the MDS nurse, the social worker, a certified nurse aide (CNA), the activities department, the therapy department, medical records, the director of nursing (DON), the provider, the NHA, the resident and the resident's representative. The care conference documented the resident weighed 88 lbs and had lost five pounds in the last week. The care conference documented Resident #31 required cueing, encouragement and occasional assistance with dining. The care conference documented Resident #31's favorite foods were fresh fruit and ice cream. A review of the December 2024 CPO revealed the following physician's orders related to nutrition: Regular diet, regular texture, with regular or thin consistency, ordered on 8/12/24. Mighty shakes (frozen nutritional supplement) three times per day for weight maintenance, record percentage consumed, ordered on 11/1/24. Unavoidable weight loss due to chronic pain and age related adult failure to thrive. Please continue to encourage supplement and food intake and manage pain with medications and non-medication methods, ordered on 12/10/24 at 3:42 p.m (during the survey) by medical doctor (MD) #2. Nutritional supplement intake documentation was reviewed between 11/1/24 and 11/30/24. Out of 90 nutrition supplement intake opportunities, Resident #31 refused to consume the supplement on 15 occasions. The intake documentation revealed 28 occasions where Resident #31 consumed fifty percent or less of the nutritional supplement. The intake documentation included 45 occasions where Resident #31 consumed the entire nutritional supplement offered. Nutritional meal intake documentation was reviewed between 11/6/24 and 12/4/24. Of 85 meal opportunities in the review period, Resident #31 was documented to have refused four meals. The facility documented Resident #31 ate less than fifty percent of her meal on 52 occasions. The facility documented Resident #31 ate 75 to 100 percent of her meal on 12 occasions. CNA task response documentation of the assistance Resident #31 required to eat her meal was reviewed between 11/6/24 and 12/4/24. Of 85 meal opportunities in the review period, the facility documented Resident #31 ate 16 meals independently, five meals with set-up or clean-up assistance, 12 meals with supervision or touching assistance, three meals with moderate assistance, and Resident #31 was dependent on nursing staff to eat 26 meals. The facility documented 23 meals were not applicable. -However, the facility documented the resident was independent with eating on the MDS assessment (see above). D. Staff interviews CNA #1 was interviewed on 12/9/24 at 5:48 p.m. CNA #1 said Resident #31 often refused her meals. CNA #1 said Resident #31 usually ate a cookie or sweet dessert if that was offered to her, but getting her to eat more nutritious food had been difficult. CNA #1 said he felt Resident #31 mostly ate sweets and ignored other foods. Licensed practical nurse (LPN) #3 was interviewed on 12/9/24 at 4:24 p.m. LPN #3 said Resident #31 mostly refused to eat her meals, or would only choose to eat the dessert item. LPN #3 said Resident #31 loved to eat cookies. LPN #3 said the nursing staff tried to get Resident #31 to eat more nutritious foods but it had been difficult to convince her to eat more than dessert. The registered dietitian (RD) was interviewed on 12/10/24 at 12:01 p.m. The RD said she had been working in the facility for approximately 18 months. The RD said when a resident experienced weight loss, she would try to individualize the diet of the resident and utilize a food first approach which included giving the resident their favorite foods using sweet foods, salty foods and ethnic foods as examples. The RD said when a resident lost weight it could be difficult to determine the cause. She said she would review the resident's food preferences to see if the resident was refusing certain kinds of foods often. The RD said that the interdisciplinary (IDT) team reviewed residents experiencing weight loss weekly. The RD said residents who experienced weight loss should have their nutrition plans of care reviewed and updated. The RD said she thought Resident #31 was losing weight because she did not have a desire to eat. The RD said that one time Resident #31's family brought in her favorite chili recipe which the resident refused. The RD said she did not know if Resident #31's weight loss was unavoidable. -However, Resident #31 was observed to eat 100% of the offered dessert on 12/4/24 and 12/9/24. The DON was interviewed on 12/10/24 at 2:49 p.m. The DON said residents who experienced weight loss were reviewed weekly and nutritional interventions were implemented by the RD. The DON said if all possible interventions were in place, then the facility would reach out to the physician or the family to ask for more help. The DON said if a resident was only eating sweet foods but was experiencing weight loss, then the facility should offer the resident additional sweets to give them enough calories to eat. The DON said a review from the physician could also be helpful in determining root causes for the weight loss. The DON said she did not believe a physician review had occurred for Resident #31's weight loss. The DON said the facility could have done more to slow the progression of Resident #31's weight loss. 40467 III. Resident #50 A. Resident status Resident #50, age greater than 65, was admitted to the facility on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included unspecified dementia severe without behavioral disturbance, cognitive communication deficit, adult failure to thrive, pressure induced tissue damage to the left heel, muscle weakness and a need for assistance with personal care. The 10/10/24 minimum data set (MDS) assessment documented Resident #50 had moderate cognitive impairments with a BIMS score of nine out of 15. The MDS assessment did not identify the resident had a rejection of care behaviors. The MDS assessment did not indicate Resident #50 had weight loss prior to her admission to the facility. B. Observations During a continuous observation on 12/9/24, between 6:08 p.m. and 6:36 p.m. in the dining room. The following was observed: At 6:08 p.m. Resident #50 was assisted to the dining room for dinner. The resident was placed at the dining table with other residents who required assistance with eating. At 6:19 p.m. Resident #50 continued to wait for her meal to be served. Her tablemates had already been served and were eating their meals. Resident #50 proceeded to push herself away from the dining table in her wheelchair. An unidentified CNA encouraged her to return to the dining table. At 6:29 p.m. Resident #50 was served a pork chop cut in bite sized pieces, peas and garlic bread. The resident was not served pudding or ice cream as identified on her meal ticket and as a nutritional intervention (see interview below). -Resident #50 was the last to be served at her table and waited over 20 minutes before she was served. At 6:36 p.m. Resident #50 attempted to stand up from her wheelchair. The resident was assisted out of the dining room. The resident ate less than 25% of her meal. C. Record review The nutrition care plan, dated 10/24/24, documented Resident #50 had a nutritional problem or a potential for a nutritional problem related to leaving greater than 25% of meals uneaten, unintended weight loss, a body mass index (BMI) of 18% and an increased nutrient need to support wound healing. Interventions, initiated 10/24/24, directed the staff to encourage the resident to dine at the assistance/cue table; offer the resident gentle redirection to table with cues to eat and drink; monitor weights as ordered; provide and serve the resident her supplements as ordered to include Mighty Shake (frozen nutritional supplement) between meals, offer snacks between meals, and Juven twice a day (wound support supplement); provide and serve her diet as ordered; monitor intake and record every meal; and the registered dietitian (RD) to evaluate the resident and make diet change recommendations PRN (as needed). The nutrition care plan intervention, dated 11/7/24, indicated Resident #50 would consume food and fluids at desired pace and amount to her level of comfort. -The review of the nutritional care plan revealed the care plan was not created until 10/24/24, over a month since the resident was admitted to the facility and after the resident sustained a weight loss of 17.7 lbs (and a 14.86%) in just over two months. Resident #50's weights were documented in the resident's EMR as follows: -On 8/16/24, the resident weighed 119.1 lbs, obtained with a chair scale; -On 9/3/24, the resident weighed 119.8 lbs, obtained with a chair scale; -On 9/19/24, the resident weighed 112.4 lbs, obtained with a wheelchair scale; -On 9/24/24, the resident weighed 104.4 lbs, this weight was struck out and indicated a reweigh was completed on 10/8/24; -On 10/2/24, the resident weighed 117.8 lbs, obtained with a standing scale; -On 10/8/24, the resident weighed 105.4 lbs, obtained with a wheelchair scale; -On 10/9/24, the resident weighed 103.6 lbs, obtained with a wheelchair scale; -On 10/23/24, the resident weighed 101.4 lbs, obtained with a wheelchair scale; -On 10/29/24, the resident weighed 102.4 lbs, obtained with a wheelchair scale; -On 11/6/24, the resident weighed 98 lbs, obtained with a wheelchair scale; -On 11/20/24, the resident weighed 96 lbs, obtained with a wheelchair scale; -On 11/27/24, the resident weighed 98 lbs, obtained with a wheelchair scale; and, -On 12/5/24, the resident weighed 99.8 lbs., obtained with a wheelchair scale. -The resident lost 14.7 lbs (12.3%) from 8/16/24 to 9/24/24, in one month, which was considered severe. -The resident lost 23.1 lbs (19.4%) from 8/16/24 to 11/20/24, in three months, which was considered severe. -The facility failed to reweigh the resident after a significant weight loss. The physician order, dated 8/16/24. identified Resident #50 had a regular texture diet. The food and nutrition assessment, dated 8/29/24, identified the RD met and observed Resident #50 eating breakfast in her room. The resident told the RD she had a good appetite, no mouth pain and no swallowing difficulties. According to the assessment, the RD discussed the role of good nutrition and wound healing with the resident. The assessment documented the resident ate on average 26% to 50% of her breakfast, 26% to 50% of her lunch and 50% to 75% of her dinner. The assessment documented the resident was at a healthy weight. The food and nutrition note, dated 9/19/24, documented Resident #50 triggered for significant weight loss in a month. The resident chose to eat in her room for most meals and ate greater than 50% of meals with some meals over 75% intake. According to the note, the resident was offered and consumed 75% of her Mighty Shake (frozen nutritional supplement) and received Juven (oral protein supplement) for wound healing. The note indicated snacks would be offered between meals at the new intervention and continue to monitor intakes and weight. The interdisciplinary team (IDT) note, dated 9/26/24, identified the resident lost 16 lbs in 30 days. According to the note, the supplemental shakes were increased from one to two times a day and staff would offer snacks such as ice cream. The note indicated the resident's weight may fluctuate due to disease process. The food and nutrition note, dated 9/27/24, documented staff would continue to update and adjust the nutritional care plan as needed. -However, the resident did not have a nutritional care plan until 10/24/24. The 10/1/24 administration note read the Mighty Shakes were not available in the kitchen. -The Mighty Shake nutrition supplement was not available to the resident as ordered. The food and nutrition note, dated 10/10/24, documented the resident loss at 8 lbs with a 7% weight change in 30 days. According to the note, the resident had poor appetite over the past few days. The note identified the resident needed redirection to the dining room. -Despite the facility noting the weight loss the facility failed to implement a new person centered intervention to address the resident's eight pound weight loss in 30 days. The administration note, dated 10/15/24 documented the Mighty Shake was not in stock. -The Mighty Shake nutrition supplement was not available to the resident as ordered. The 11/19/24 quarterly food review assessment documented Resident #50 had a weight loss trend/significant weight loss greater than 5% over the last 30 days. According to the food review, the resident's meal intakes varied with an average intake of 25-50%. The review indicated the resident declined her house supplement most of the time and the resident declined speaking to the RD regarding her food preferences. The review identified the resident did not have swallowing or chewing difficulties and the IDT reviewed the resident weekly related to her wounds and weight loss. The 11/19/24 progress note documented RD has attempted to update food preferences however the resident did not want to talk to RD. The note indicated the resident was offered Mighty Shakes, assisted dining, nutrition supplements and an adjustment of timing to attempt to increase acceptance, updated food preferences when the resident allowed, Juven twice a day to support wound healing and an ongoing review with IDT. According to the note, staff were to update the nutrition plan of care as needed and whole milk with meals and ice cream was added to the resident's meal ticket. The 11/22/24 mini nutrition assessment, dated 11/22/24, documented the resident was at risk for malnourishment. According to the assessment, the resident had no weight loss in the last three months and ate about 75% of her meals. -However, a review of the resident's electronic medical record (EMR) identified the resident had lost weight in the past three months and ate less than 75% of her meals. The physician's order for mighty shakes, dated 10/31/24, identified the resident had an order for Mighty Shakes three times a day for weight maintenance, an increase from twice a day that was ordered on 8/29/24. The November 2024 and December 2024 (11/10/24 to 12/10/24) intake record for the amount of food the Resident #50 ate indicated she ate 13 meals at 75% to 100%; 46 meals at 51% to 75%; 22 meals at 26% to 50% and she ate 4 meals at 0% to 25%. According to the record, the resident ate 51% to 75% of her 12/9/24 dinner meal. -However, the resident was observed to have eaten less than 25% of her meal (see observation above). The food and nutrition progress note, dated 12/5/24, indicated the resident's weight was overall stable for the past 30 days. The note identified the resident refused two meals in a seven day look back, refused her house supplement twice since 12/1/24 and had an average meal intake of 50%. According to the note, the IDT would continue the current interventions, routinely monitor the resident's weight and meal and supplement intake and acceptance. An unavoidable weight loss order, dated 12/10/24 (during the survey period), was provided by corporate consultant (CC) #3 on 12/10/24 at 4:25 p.m. The order indicated Resident #50 had unavoidable weight loss due to her adult failure to thrive. The order directed the staff to encourage supplements and food intake using foods the resident preferred. -However, according to the physician orders and the review of the resident's EMR, the resident did not have unavoidable weight loss until 12/10/24, during the survey period, and after the registered dietitian identified Resident #50's weight was stable. The review of the EMR, observations and interviews identified opportunities that would have potentially prevented weight loss. A facility action plan for weight loss, dated 11/27/24, was provided by the nutritional CC #3. The action plan documented the facility had concerns with residents losing weight. The action plan identified new interventions to address the facility weight loss concern, According to the action plan, staff were to weigh the residents on Monday and Tuesday instead of any day of the week, supplemental shakes would be administered by the nurse on the floor, names of residents with weight loss were to be posted at the nurses station, a list of residents with supplement shakes were to be in the nurses book on the cart for easy access and the residents would be encouraged to eat meals in the dining room. D. Staff interviews CC #3 was interviewed on 12/10/24 at 2:46 p.m. CC #3 said she was a nutrition resource to the facility when needed. She said the facility asked her in November 2024 to look at all the residents' nutritional needs. She said she reviewed the residents' nutritional needs and management and reported back to the facility who they should be focusing on. CC #3 said she identified Resident #50 had a calorie deficit and recommended the physician to identify if the resident had possible unavoidable weight loss due to her weight loss versus intake. The RD and CC #3 were interviewed on 12/10/24 at 2:54 p.m. The RD said she had been following Resident #50 weekly related to her weight loss and pressure injury. She said the staff had been trying to encourage the resident to eat in the dining room. The RD said the resident's meal intake varied whether she ate in the dining or in her room. She said the resident was placed at the meal assistance table in the dining room for meal intake encouragement, however if the staff cued the resident she could become frustrated which would be counter productive. The RD said she had had a difficult time obtaining the resident's food preferences. She said the resident was offered high calorie supplements but the resident's consumption of the supplements had been hit or miss. She said the resident received fortified food which could be butter or heavy cream. CC #3 said ice cream or pudding was added to the resident's meal ticket. The RD said she reviewed the resident's weights. She said she believed the wrong weight was stuck out in error. She said the 117.8 lb weight was probably not an accurate weight and the 104.4 lb weight should have been identified as the correct weight because the resident was not eating well. The RD said the facility needed to have the same staff weigh the resident using the same scale at the same time of day to determine an accurate weight. The RD said the resident had severe weight loss since her 8/16/24 admission but the facility was able to slow down the weight loss and put interventions in place. She confirmed the resident did not have a nutritional care plan until 10/24/24. She said the staff could review the physician orders to identify the interventions instead of a care plan. CC #3 said the interventions should have been on the care plan. CC #3 said the care plan needed to be improved. The RD said she had not identified the weight loss was unavoidable and did not believe the resident's physician identified the resident's weight to be unavoidable. She said the resident did not have orders for an unavoidable weight loss. She said the resident was currently maintaining her weight. The RD said she had identified some inaccuracy with the resident's weight record. She said the facility's assistant director of nursing (ADON) used to oversee the residents' weights and management but since she had the facility, the documentation had been inconsistent. She said weight management consistency could help accuracy of the nutrition program. CC #3 said Resident #50 had past trauma in her life and the facility needed to look at if the trauma could contribute to her weight loss. The CC said depression could contribute to the resident's weight loss. CC #3 was interviewed again on 12/10/24 at 3:42 p.m. CC #3 said Resident #50 should have been offered ice cream or pudding on 12/9/24 during the dinner meal. The DON was interviewed on 12/10/24 at 3:48 p.m. The DON said she was aware of the resident's weight loss. She said she accepted the supplement shakes but did not eat a lot. The DON said the mini nutritional assessment, dated 11/22/24 was inaccurate. She said the resident often ate less than 75% and had significant weight loss. She said the point of an accurate assessment was to capture weight loss. She said the staff had not had a recent education on how to identify meal percentages. She said the last time it was reviewed was during the July 2024 skills fair. The DON said the facility needed to have the same staff weigh the residents using the same scale each time to help with accuracy of weights. She said the facility started the process a couple a weeks ago (refer to the above 11/27/24 action plan). The DON said she was not sure why Resident #50 did not have a nutritional care plan until 10/24/24. The DON said the RD was responsible for creating the nutrition care plans but the facility should have identified the need for the care plan prior to 10/24/24 and after the resident's initial weight loss. The DON said adequate nutrition was important for a resident's overall health. The DON said a care plan was a care directive so staff knew to provide the recommended interventions. The DON said it was possible Resident #50's weight loss was not unavoidable. CC #3 was interviewed again on 12/10/24 at 4:24 p.m. CC #3 said the resident had an adult failure to thrive diagnosis that may have contributed to her weight loss but the facility had work to do related to weight management.

Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to treat and prevent pressure injuries for two (#46 and #50) of six residents reviewed for pressure ulcers out of 28 sample residents. Resident #46, who was known to be at risk for pressure injuries, was admitted on [DATE]. The resident had diagnoses of dementia, cognitive communication deficit, chronic pain, and generalized muscle weakness. On 11/11/24, Resident #46 developed a facility-acquired stage 2 pressure injury to her sacrum, however, the facility did not initiate further pressure ulcer interventions on the resident's pressure ulcer prevention care plan once the stage 2 pressure injury was identified and did not update the care plan to include the new pressure injury. On 11/19/24, physician documentation indicated Resident #46's pressure wound had worsened to an unstageable pressure injury. Despite the worsening of the pressure injury, the facility failed to implement a low air loss pressure relieving mattress until 11/26/24, 15 days after the initial pressure ulcer was identified. Despite the worsening of the resident's pressure injury, the facility did not initiate Resident #46's pressure injury care plan, which identified the resident had an actual pressure injury, until 12/4/24, two weeks later. Furthermore, observations during the survey revealed the facility failed to ensure Resident #46's low air loss mattress was appropriately set to the correct firmness level, per the physician's orders. Due to the facility's failure to implement timely interventions to prevent the development of pressure injuries and the facility's failure to implement additional interventions following pressure injury development, Resident #46 developed a facility-acquired stage 2 pressure injury, which worsened to an unstageable pressure injury. Additionally, Resident #50, who was at risk for developing pressure injuries, was admitted on [DATE]. On 9/2/24, facility documentation indicated Resident #50 had a new pressure injury located on her left heel. On 9/3/24, the wound note identified the left heel wound as an unstageable pressure injury and further identified pressure relieving heel protector boots were to be worn by the resident. According to the resident's skin integrity care plan, pressure injury prevention interventions were not initiated until 9/2/24, after the resident's left heel wound was identified. Wound care documentation for September 2024, October 2024 and November 2024 revealed wound care treatments and wound care interventions were not documented as occurring on several occasions. Observations during the survey revealed several occasions where Resident #50 was not wearing her pressure relieving heel protector boots. Due to the facility's failure to implement timely interventions to prevent the development of pressure injuries, Resident #50 developed a facility-acquired unstageable pressure injury to her left heel. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA (2019), retrieved on 12/16/24 from https://www.internationalguideline.com/guideline, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as' the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedure The Pressure Ulcer policy and procedure, dated 2/29/24, was provided by the nursing home administrator (NHA) on 12/10/24 at 5:52 p.m. It documented in pertinent part, Protecting against the effects of pressure, friction, and shear: reduce pressure over bony prominences by offloading and positioning, develop turning and repositioning plans for residents in bed or the chair, and evaluate the need for a pressure-reducing mattress or overlay - check for bottoming out to ensure appropriateness of mattress choice. Develop a plan of care in conjunction with the multidisciplinary team based on the individual's goals. Evaluate the plan of care and provide revisions and updates as needed. Any changes in pressure injury condition should be reported to the physician. III. Resident #46 A. Resident status Resident #46, age greater than 65, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included dementia, cognitive communication deficit, chronic pain, and generalized muscle weakness. The 9/3/24 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The assessment documented the resident was independent with eating, required set-up or clean-up assistance with oral hygiene, and required partial or moderate assistance with all other activities of daily living. The assessment documented the resident was independent when rolling left to right in bed and required moderate assistance when changing positions in bed. The assessment indicated the resident was at risk for pressure ulcers and did not have any skin conditions at the time of the assessment. The assessment indicated the resident did not have rejections of care. B. Resident observations On 12/9/24 at 10:03 a.m. Resident #46's wound care was observed with the director of nursing (DON) and licensed practical nurse (LPN) #4. The resident's sacrum had a large crater-like wound with a black scab at the medial base (towards the middle or center) of the wound. The skin around the wound was red and purple in color and extended approximately two centimeters (cm) around the outside of the open wound. The wound measured 6.0 cm long by 3.0 cm wide and 2.0 cm deep, per the DON's measurement. Additionally, the DON measured that the wound had 2.0 cm of tunneling (a channel or tunnel that extends into deeper tissue under the surface of the wound) at the 1:00 and 9:00 position within the wound. The DON cleansed the wound with wound cleanser, applied collagenase to the wound bed and then applied a foam dressing to cover the wound. During a continuous observation on 12/9/24, beginning at 2:24 p.m. and ending at 5:02 p.m., the following was observed: At 3:03 p.m. an unidentified male staff member entered Resident #46's room to assist the resident. At 3:06 p.m. LPN #2 entered and exited Resident #46's room. At 3:06 p.m. Resident #46's low air loss mattress was observed to be firm and taut. The mattress setting level was observed to be set at 400 firmness. -The facility failed to set Resident #46's mattress firmness level in accordance with physician's orders (see physician's order below). At 4:20 p.m. LPN #2 entered and exited Resident #46's room. At 5:02 p.m. LPN #2 again entered and exited Resident #46's room. At 5:02 p.m. Resident #46's mattress was observed to be firm and taut. The mattress setting level was observed to be set at 400 firmness. -The facility failed to set Resident #46's mattress firmness in accordance with physician's orders. On 12/10/24 at 10:22 a.m. Resident #46's mattress was observed to be softer than observations on 12/9/24. The mattress setting level was observed to be set at 125 firmness. A piece of tape with a drawn arrow was on the mattress firmness setting dial to indicate the correct firmness level the mattress should be set at. C. Record review The pressure ulcer prevention plan of care, initiated 6/5/24 and revised 11/26/24, documented that Resident #46 had potential for pressure ulcer development because of her impaired mobility, incontinence and dementia. The care plan goal was to minimize Resident #46's risk of skin breakdown, redness or the development of blisters or discoloration. Interventions included encouraging Resident #46 to reposition herself in bed and to assist the resident when needed, utilizing a low air loss mattress on the resident's bed (initiated 11/26/24), a pressure reducing wheelchair cushion and conducting a weekly skin check by the nurse. -The facility failed to initiate the intervention of a low air loss mattress on the resident's bed until 11/26/24, 15 days after resident #46 was identified as having a stage 2 pressure ulcer and seven days after the initial pressure ulcer had worsened to an unstageable pressure ulcer The pressure ulcer plan of care, initiated 12/4/24 and revised 12/4/24, documented the resident had an unstageable pressure ulcer. Interventions included identifying possible causative factors and resolving them when possible, monitoring and documenting the pressure ulcer, encouraging good nutrition and hydration and following facility protocols for treatment. -The facility failed to initiate a pressure ulcer plan of care for the actual pressure ulcer until three weeks after Resident #46 was identified as having a facility-acquired stage 2 pressure ulcer and two weeks after the initial pressure ulcer worsened to an unstageable pressure ulcer. An encounter note, written by nurse practitioner (NP) #1 and dated 11/11/24, documented that Resident #46 had functional quadriplegia. The encounter note documented Resident #46 had a new pressure wound to the sacral region that was a stage 2 pressure wound. The note documented the resident's sacral region had been moist due to incontinence and resident immobility. The note documented the facility initiated a turning schedule and wound nurse rounding for the resident. A wound assessment report, written by medical doctor (MD) #1 and dated 11/19/24, documented that Resident #46 had an unstageable pressure ulcer on her sacrum measuring 2.5 cm) wide by 2 cm long and 0.6 cm deep. MD #1 documented the periwound (the skin surrounding the wound) was fragile. -The facility failed to implement timely interventions to prevent Resident #46's facility acquired stage two pressure ulcer from progressing to an unstageable pressure ulcer. An encounter note, written by NP #1 and dated 11/22/24, documented that Resident #46 did not want to seek western medicine and wished to pursue a comfort-focused care approach. NP #1 documented that Resident #46 likely experienced several neurological events recently which had contributed to her decline. The note documented that Resident #46's decline was precipitous and unavoidable. A wound assessment report, written by MD #1 and dated 11/25/24, documented that Resident #46 had an unstageable pressure ulcer on her sacrum measuring 2.5 cm wide, 1.5 cm. long and 0.6 cm deep. A Braden Scale assessment (tool used for predicting pressure ulcer risk), dated 11/30/24, documented Resident #46 was at a moderate risk for developing a pressure injury.The assessment documented Resident #46 could make occasional slight changes in body or extremity position but was unable to make frequent changes independently. -However, the 9/3/24 MDS assessment documented that the resident required moderate assistance when changing positions in bed (see resident status above). A wound assessment report, documented by MD #1 and dated 12/3/24, documented that Resident #46 had an unstageable pressure ulcer on her sacrum measuring 4.8 cm wide, 1.5 cm. long and 0.6 cm deep. -The measurements of the wound indicated the wound had worsened. An encounter note, written by NP #1 and dated 12/5/24, documented that Resident #46 had a stage three pressure injury on her sacrum. -However, MD #1's 12/3/24 wound assessment note documented the resident's wound was an unstageable pressure ulcer. NP #1's 12/5/24 encounter note further documented that Resident #46's sacral wound had progressed. The note documented the wound was now reddened and full thickness with some eschar at the base. The note documented the area had been moist due to incontinence and immobility of the resident. The note documented the wound now required a wet-to-dry packing daily for the next seven days. The note documented NP #1 spoke with Resident #46's representative to clarify Resident #46's goals of care. The note documented the plan of care was to continue assisting Resident #46 with ADLs and to continue offering treatments to Resident #46. A review of Resident #46's December 2024 CPO revealed the following physician's orders for wound care: To pressure area on sacrum, cleanse area with wound cleanser, apply [collagenase] to wound bed, cover with dry dressing, change daily and as needed. Observe for abnormalities in wound bed, surrounding skin, or pain associated with wound. Must notify provider of abnormalities and document under progress notes, ordered 12/9/24. Low air mattress to bed. Set at 125 firmness. Check the mattress every shift for proper setting and function, ordered 11/25/24. E. Staff interviews The DON was interviewed on 12/9/24 at 10:08 a.m. The DON said she performed wound care as the wound care nurse for the facility. The DON said she worked with MD #1, who was the wound care physician for the facility. The DON said Resident #46's pressure injury was facility-acquired after Resident #46 experienced a previous change in condition which made her more immobile in bed. The DON said Resident #46's pressure injury looked much worse today (12/9/24) than it did the previous week. The DON said she could not see bone in the wound bed, but there was eschar present in the base of the wound bed. The DON said even though Resident #46's wound was an unstageable pressure ulcer and she did not see bone, the wound appeared to be a stage four pressure wound to her. The DON said the wound physician would classify the wound as an unstageable pressure ulcer that was facility-acquired. The DON said that Resident #46's wound had last been evaluated by MD #1 on 12/3/24 and she would communicate with MD #1 regarding Resident #46's worsening pressure injury on 12/10/24 when he assessed the wound again via telehealth (video monitoring). The DON said the facility had been having difficulty getting a wound doctor to be present in the facility and the facility exclusively used telehealth services for wound care physician services. LPN #4 was interviewed on 12/9/24 at 12:21 p.m. LPN #4 said she had only visualized Resident #46's wound a few times. LPN #4 said Resident #46's wound on her sacrum looked much worse than previously. LPN #4 said she did not know what size the wound was, but she said she knew it was bigger than it had been the previous week. LPN #4 said Resident #46 was being turned every two hours with wedge pillows and had a low air loss mattress to prevent the worsening of the pressure ulcer. -However, the low air loss mattress was not set to the correct firmness level according to physician's orders (see observations above and interview below) MD #1 was interviewed on 12/9/24 at 12:59 p.m. MD #1 said Resident #46 was experiencing an expected decline. MD #1 said Resident #46 had a physician's order that she was experiencing unavoidable weight loss and this was contributing to the development of her pressure ulcer. MD #1 said Resident #46's pressure ulcer on her sacrum was facility-acquired. MD #1 said she did not know the facility had not initiated a plan of care for Resident #46's facility-acquired pressure ulcer until the pressure ulcer had progressed to an unstageable pressure ulcer. MD #1 said that the resident's pressure ulcer was unavoidable. -However, there was no documentation in Resident #46's electronic medical record (EMR) which indicated the pressure ulcer was unavoidable. Certified nursing aide (CNA) #4 was interviewed on 12/9/24 at 6:42 p.m. CNA #4 said she was comforting Resident #46 because it hurt her to sit up in bed to eat. CNA #4 said Resident #46 had to be sat up in bed so she would not choke when she ate, but she said the resident was hurting because of her pressure ulcer. The DON was interviewed again on 12/10/24 at 2:49 p.m. The DON said when a resident developed a pressure ulcer, the facility would complete a documented change of condition, notify the resident's representative and notify her. The DON said physician's orders should always be followed. The DON said Resident #46's bed firmness level had not been set correctly and she did not know how long the resident's bed firmness level was not set correctly. The DON said she noticed the bed appeared to be way too firm this morning (12/10/24), and she observed the firmness level setting to be at 400. The DON said she lowered Resident #46's low air mattress firmness level and added a marker to indicate where the mattress's firmness dial should be set for Resident #46. The DON said it was not acceptable for Resident #46's mattress level firmness to be set at 400 when it should have been set at 125. The DON said she did not know if the mattress's firmness could have contributed to the worsening of Resident #46's pressure ulcer. 40467 IV. Resident #50 A. Resident status Resident #50, age greater than 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included unspecified dementia, severe without behavioral disturbance, cognitive communication deficit, repeated falls, unsteadiness on feet, muscle weakness, lack in coordination, need for assistance with personal care and age-related osteoporosis without current pathological fracture. The 8/20/24 MDS assessment documented Resident #50 had moderate cognitive impairment with a BIMS score of nine out of 15. The resident used a walker and A wheelchair. The MDS assessment did not identify the resident had a rejection of care behaviors. The MDS assessment indicated Resident #50 was at risk for pressure ulcer development and had an unhealed pressure ulcer. B. Wound care observations and DON interview Resident #50's wound care was observed on 12/9/24 at 9:48 a.m. with the DON. Resident #50 was in bed. She was not wearing pressure relieving boots to protect her heels prior to the wound care. Resident #50 had a black scab covering her entire left heel. The wound measured 2.3 cm by 2.7 cm. The DON said the wound was getting better and smaller. The DON applied wound cleanser and betadyne to the wound and then left the wound open to air (OTA). After completing the wound care, the DON retrieved the resident's pressure relieving boots from her closet and offered them to the resident. Resident #50 allowed the DON to put the pressure relieving boots on her feet without resistance or need for encouragement. During a continuous observation on 12/9/24, beginning at 2:31 p.m. and ending at 4:19 p.m., the following was observed: At 2:31 p.m. Resident #50 was lying in bed on her left side. Resident #50's pressure relieving boots were on the resident's wheelchair instead of on the resident's feet. The resident's heels were not offloaded as she laid on her left side. At 2:58 p.m. the resident remained in the same position and her pressure relieving boots remained on her wheelchair. At 3:03 p.m. LPN #2 entered and exited Resident #50's room. The resident remained on her side without her heels offloaded and without her pressure relieving boots on. At 4:19 p.m. LPN #2 and certified nurse aide (CNA) #1 entered and exited the resident's room. Resident #50 remained on her side without her heels offloaded and her pressure relieving boots remained on her wheelchair. On 12/10/24 at 9:44 a.m. Resident #50 was in bed laying on her left side. Her pressure relieving boots were on her lounge chair next to her bed. The resident's heels were not offloaded. At 9:51 a.m. LPN #2 identified the pillow between the knees of Resident #50 was not floating her heels. LPN #2 pulled the pillow down and placed it under the resident's left foot. He did not offer to put the resident's pressure relieving boots on her feet. C. Record review The skin integrity care plan, revised 12/2/24, identified Resident #50 had a deep tissue injury to her heel related to immobility. Pertinent interventions, initiated 9/2/24, included encouraging the resident to reposition herself throughout the shift and assisting her as needed, utilizing pressure relieving devices/adaptive equipment/soft booties when appropriate to potential pressure areas, floating the resident's heels with pressure relieving heel protectors or pillows at all times and, if the resident refused, conferring with the resident, the interdisciplinary team (IDT) and family to determine the reason for the refusal, trying alternative methods to gain compliance and documenting the alternative methods. -The skin integrity care plan did not identify that Resident #50 refused the pressure relieving boots. The 9/2/24 nursing progress note documented Resident #50 had a new pressure injury to her left heel with new physician orders for betadine and pressure relieving boots when in bed. According to the note, the staff implemented pressure relieving measures and offloading as tolerated. The 9/3/24 weekly wound round note identified Resident #50's left heel pressure injury as unstageable, dark purple in color and fluid-filled. The unstageable pressure ulcer measured 3.5 cm by 4 cm. According to the note, the interventions were to reposition the resident every two hours, float her heels and apply pressure relieving boots. The note documented staff should reapply the pressure relieving boots after wound care treatment. The 9/18/24 wound physician note identified Resident #50's wound as a pressure-induced deep tissue damage of the left heel measuring 3 cm by 4 cm with a 100% eschar. The wound physician recommended the use of heel protectors. The 9/22/24 weekly wound note identified the resident's left heel wound as unstageable and documented it measured 2.5 cm by 3 cm. The 10/23/24 wound physician note identified Resident #50's wound as a pressure-induced deep tissue damage of the left heel measuring 2.3 cm by 3 cm with a 100% eschar. The wound physician recommended the use of heel protectors. The 11/26/24 weekly wound note documented the resident's left heel pressure ulcer measured 2 cm by 2.5 cm. According to the note, the resident was to have her heel pressure offloaded when she was in bed. The 12/2/24 weekly wound note, documented the unstageable pressure wound to Resident #50's left heel measured 2.2 cm by 2.1 cm. The 12/3/24 wound physician note, documented the left heel pressure injury had100% eschar and measured 2.1 cm by 2.4 cm. The wound physician recommended the resident wear heel protectors. -Review of Resident #50's September 2024 treatment administration record (TAR) revealed the intervention to reposition the resident frequently for comfort was not documented as occurring on 9/12/24 and 9/28/24 during the 6:00 p.m. to 6:00 a.m. shift. -The September 2024 TAR did not identify the resident refused the intervention or why the intervention was not provided as ordered on 9/12/24 and 9/28/24. -Review of Resident #50's September 2024 TAR further revealed the intervention to float the resident's heels for pressure relief was additionally not documented as occurring on 9/12/24 and 9/28/24 during the 6:00 p.m. to 6:00 a.m. shift. -The September 2024 TAR did not identify the resident refused the intervention or why the intervention was not provided as ordered on 9/12/24 and 9/28/24. -Review of Resident #50's October 2024 TAR revealed the resident's daily wound care was not documented on 10/7/24, 10/20/24, 10/23/24 and 10/26/24. -The October 2024 TAR did not identify the resident refused the wound care treatment or why the wound care was not provided as ordered on 10/7/24, 10/20/24, 10/23/24 and 10/26/24. -Additional review of Resident #50's October 2024 TAR revealed the intervention to reposition the resident frequently for comfort was not documented as occurring on 10/20/24 during the 6:00 a.m. to 6:00 p.m. shift. -The October 2024 TAR did not identify the resident refused the intervention or why the intervention was not provided as ordered on 10/20/24. -Review of Resident #50's October 2024 TAR further revealed the intervention to float the resident's heels for pressure relief was additionally not documented as occurring on 10/20/24 during the 6:00 a.m. to 6:00 p.m. shift. -The October 2024 TAR did not identify the resident refused the intervention or why the intervention was not provided as ordered on 10/20/24. -Review of Resident #50's November 2024 TAR revealed the resident's daily wound care was not documented on 11/12/24 and 11/26/24. -The November 2024 TAR did not identify the resident refused the wound care treatment or why the wound care was not provided as ordered on 11/12/24 and 11/26/24. -Additional review of Resident #50's November 2024 TAR revealed the intervention to reposition the resident frequently for comfort was not documented as occurring on 11/12/24 and 11/26/24 during the 6:00 a.m. to 6:00 p.m. shift. -The November 2024 TAR did not identify the resident refused the intervention or why the intervention was not provided as ordered on 11/12/24 and 11/26/24. -Review of Resident #50's November 2024 TAR further revealed the intervention to float the resident's heels for pressure relief was additionally not documented as occurring on 11/12/24 and 11/26/24 during the 6:00 a.m. to 6:00 p.m. shift. -The November 2024 TAR did not identify the resident refused the intervention or why the intervention was not provided as ordered on 11/12/24 and 11/26/24. -Review of the CNA task sheet for floating the resident's heels, between 11/10/24 and 12/9/24, did not identify the resident refused to float her heels with either a pillow or pressure relieving boots. The CNA task sheet for floating the resident's heels identified the resident had her heels floated throughout the day on 12/9/24. -However observations did not identify the resident's heels were floated on the afternoon of 12/9/24 (see observations above). Review of Resident #50's progress notes between September 2024 and December 2024 did not identify the resident refused the pressure relieving boots. D. Staff interviews LPN #2 was interviewed on 12/10/24 at 9:45 a.m. LPN #2 said Resident #50 should have minimum pressure to her left heel. He said she spent most of her time in bed but would get up for dinner. He said she preferred to keep a pillow between her legs but she had pressure relieving boots she was supposed to wear to float her heels. He said staff attempted to reposition Resident #50 every two hours but she preferred to lay on her left side. He said she should probably have two pillows in bed with her, one to float her heels and one for her knees as was her preference. The DON was interviewed on 12/10/24 at 11:29 a.m. The DON said Resident #50 had a history of not wanting to reposition herself which resulted in multiple pressure ulcers. The DON said the resident's pressure ulcer was unstageable. She said the pressure injury to the resident's left heel started as a stage 2 pressure wound but became unstageable shortly after it developed. She said the pressure injury remained unstageable. She said the resident had pressure relieving boots available to her but the resident would refuse because the boots made her hot. -However, there was no documentation in the resident's electronic medical record (EMR) to indicate the resident refused to wear her pressure relieving boots (see record review above). The DON said Resident #50 preferred to use a pillow in between her knees. She said staff should still continue to offer the pressure relieving boots to the resident and if she refused, it should be documented. She said the boots would protect and relieve more pressure from the heel then a pillow and the boots would have been more likely to stay in place once they were put on. The DON said staff should not mark that pressure relieving devices were in place when the intervention was not done. The DON said staff should document wound treatments daily or identify why something was not charted on the TAR. She said the staff should document the care they were providing to the resident and not document when the resident had not received the treatment.

Based on record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to implement an effective water management plan. Findings include: I. Professional reference According to Center for Disease Control (CDC), Controlling Legionella in Potable Water Systems, last reviewed 3/15/24, was retrieved on 12/11/24 from https://www.cdc.gov/control-legionella/php/toolkit/potable-water-systems-module.html It read in pertinent part, Operation, maintenance, and control limits guidance: Monitor temperature, disinfectant residuals, and pH frequently based on Legionella performance indicators for control. Adjust measurement frequency according to the stability of performance indicator values. For example, increase the measurement frequency if there's a high degree of measurement variability. Hot water: Store hot water at temperatures above 140 F (degrees Fahrenheit) or 60 C (degrees Celsius). Ensure hot water in circulation does not fall below 120 F (49 C). Recirculate hot water continuously, if possible. Cold water: Store and circulate cold water at temperatures below the favorable range for Legionella (77-113 F, 25-45 C). Legionella may grow at temperatures as low as 68 F (20 C). Flushing: Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits. Ensure disinfectant residual is detectable throughout the potable water system. Clean and maintain water system components, such as thermostatic mixing valves, aerators, showerheads, hoses, filters, and storage tanks, regularly. Consider testing for Legionella in accordance with the routine testing module of this toolkit. B. Facility policy and procedure The Legionella Water Management Program policy, undated, was provided by the nursing home administrator (NHA) on 12/5/24 at 10:14 a.m. It documented in pertinent part, Health care facilities have been connected with the transmission of legionella to patients. Such cases frequently arise due to the presence of legionella bacteria in facility hot water distribution systems. A number of preventative measures are available including maintenance of appropriate facility hot water temperatures to limit the growth of legionella. Flush unoccupied areas (hot and cold) monthly. -However, the CDC recommended that all dead legs and low flow piping runs should be flushed at least weekly to prevent the growth and spread of legionella (see professional reference above). C. Record Review The water safety plan workbook, not dated, was provided by the NHA on 12/5/24 at 10:14 a.m. The plan documented the facility did not test for legionella bacteria but instead utilized visual inspection and hot water flushing to prevent the growth and spread of legionella. The water management plan documented the facility had a kitchen water system, a main hot water system, a swamp cooler system, and a laundry hot water system. -The water management plan failed to include a process flow diagram of water systems in the facility. On 12/5/24 at 3:05 p.m., the NHA documented that five resident rooms had been unoccupied for seven contiguous days or more in the last 60 days. -The water management plan failed to document when empty resident rooms had low flow piping runs and lead legs flushed. D. Staff interviews The maintenance director (MTD) was interviewed on 12/5/24 at 2:37 p.m. The MTD said he utilized a combination of visual inspection and water temperature testing to prevent the growth and spread of legionella in the facility. The MTD said there was no documentation of process flow diagrams within the facility water management plan. The MTD said he did not know what a process flow diagram was. The MTD said he had not received education on how to complete a process flow diagram of water systems within the water management plan. The MTD said he was not involved in making the current water management plan for the facility. The MTD said the current water management plan which was not dated was completed before he started working at the facility in April 2024. The MTD said that the resources section of the water management plan could be outdated since many of the CDC resources were dated between 2003-2013, which was old information. The MTD said all of the empty rooms in the facility had hot water run though all dead legs and low-flow piping runs of empty resident rooms in the facility every month. The MTD said that monthly flushing of resident rooms was sufficient to prevent the growth and spread of legionella. The MTD said the facility did not document when empty resident rooms were flushed with hot water to prevent the growth of legionella. The director of nursing (DON) was interviewed on 12/10/24 at 12:56 p.m. The DON said she also worked as the infection preventionist (IP) in the facility because the IP role was currently vacant. The DON said she was not directly involved in the water management plan because that was the responsibility of the maintenance department in the facility. The DON said she thought water had to be flushed daily to prevent the spread of waterborne pathogens such as legionella. The DON said she was not aware the facility practice was to flush water in empty resident rooms every month.

Based on observations, record review and interviews, the facility failed to provide adequate supervision during the use of assistive devices to keep residents free from safety hazards for five (#46, #28, #13, #32 and #50) of 12 residents out of 28 sample residents. Specifically, the facility failed to: -Consistently implement new and effective fall interventions in a timely manner for Resident #28, Resident #13, Resident #32 and Resident #50 after each fall; and, -Ensure Resident #46 had footrests on her wheelchair to prevent her foot from getting stuck while the staff pushed the wheelchair. Findings include: I. Fall failures for Resident #28, Resident #13, Resident #32 and Resident #50 A. Facility policy and procedure The Fall Management policy, revised 2/29/24, was provided by the nursing home administrator (NHA) on 12/10/24 at 1:30 p.m. It read in pertinent part, A fall risk evaluation will be completed within the first 24 hours following admission. Each resident will be reevaluated quarterly, annually and when a significant change occurs. Individualized care plan interventions will be implemented for those residents found to be at high risk for falls. Please note interventions are to be reevaluated when a resident falls for efficacy. Educate and communicate implemented interventions to direct care staff via verbal report. Document in the electronic health record the resident's response to interventions and revise interventions if they are not successful. If a resident experiences a fall with head injury, the fall is unwitnessed or a resident self-reports a fall, neurological checks will be initiated. The facility will review all falls daily (Monday through Friday) during the morning quality assurance and performance improvement (QAPI) meeting. Monthly, the QAPI committee will review residents with falls for updated interventions and/or recommendations. Fall review will include the following: -Review the risk management incident to ensure complete and appropriate parties have been notified regarding the incident; -Review the interdisciplinary team (IDT) risk management to ensure complete and appropriate interventions have been implemented; -Review that a care plan has been initiated; and, -Provide revisions to the plan of care as necessary after falls. B. Resident #28 1. Resident status Resident #28, age less than 65, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO) diagnoses included multiple sclerosis (autoimmune disease), a history of falling, dependence on a wheelchair and epilepsy. The 9/29/24 minimum data set (MDS) assessment revealed Resident #28 had a severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. The resident had no impairment in his lower extremities and used a wheelchair for mobility. The assessment indicated the resident had had two or more falls since his previous assessment. 2. Record review The fall care plan, initiated 10/25/19, revealed Resident #28 was a high fall risk due to exacerbation of multiple sclerosis. Resident #28 often crawled out of bed and chose to crawl in an attempt to meet his own needs instead of asking for help. The falls were identified as unavoidable due to the resident having poor cognition and poor impulse control despite multiple interventions in place. Interventions included encouraging the resident to go to the restroom before meals (initiated 5/6/24), anticipating the resident's needs and offering assistance to the bathroom (initiated 5/17/24, encouraging the resident to consume more fluids (initiated 6/7/24), adding anti-tipper devices to the resident's wheelchair (initiated 6/13/24, reviewing the resident's medications (initiated 7/29/24), strategically placing a soft touch call light in the resident's room (initiated 9/17/24) and activities staff to provide person-centered one-on-one activities for the resident (initiated 12/3/24). -The care plan documented the resident's falls were unavoidable due to the resident's poor cognition and poor impulse control, despite multiple interventions in place, however, Resident #28 had 18 falls from January 2024 to December 2024 and the facility failed to implement new fall interventions for 12 of those falls (see falls below). The 1/2/24 progress note revealed a certified nurse aide (CNA) notified the nurse that Resident #28 was found on the floor sitting cross-legged. The resident said he was looking for his remote control and sat down on the floor. The resident said he felt wobbly and he was unable to get back up. No injuries were noted. -The facility failed to implement a new fall intervention after the resident's fall. The 3/5/24 progress note revealed the nurse was notified Resident #28 was found on the floor on his buttocks with his legs out in front of him. The resident was found with no pants or shoes on, just socks. The resident said he was trying to go to the bathroom and he felt wobbly and fell on his knees then sat on his buttocks. No injuries were noted. -The facility failed to implement a new fall intervention after the resident's fall. The 3/20/24 progress note revealed the resident was found sitting cross-legged on the floor. The resident was unable to recall what happened. No injuries were noted. -The facility failed to implement a new fall intervention after the resident's fall. The 5/2/24 progress note revealed Resident #28 was found sitting on the floor under his sink. The resident said he slid down the wall because it was better than falling. No injuries were noted. On 5/6/24 Resident #28's fall care plan was updated with a new intervention for encouraging the resident to go to the restroom before meals. The 5/13/24 progress note revealed Resident #28 was found on the floor near his sink. He said he felt wobbly and hit his head on the grab bar near the sink. No injuries were noted. -The facility failed to implement a new fall intervention after the resident's fall. The 5/16/24 progress note revealed Resident #28 was found sitting on his floor cross-legged. The resident said he felt wobbly and slipped. No injuries were noted. On 5/17/24 Resident #28's fall care plan was updated with a new intervention for anticipating the resident's needs and offering assistance to the bathroom. The 6/6/24 progress note revealed Resident #28 was found sitting on the floor next to his bed. The resident was drowsy but was somewhat oriented. The resident said he passed out while he was self-transferring and woke up when his forehead hit the floor. The resident had an injury to the palm of his right hand. On 6/7/24 Resident #28's fall care plan was updated with a new intervention for encouraging the resident to consume more fluids. On 6/13/24 Resident #28's fall care plan was updated with a new intervention for anti-tippers to be added to his wheelchair. The 7/26/24 progress note revealed Resident #28 was found sitting on the floor cross-legged in the doorway to his bedroom. The resident said he sat down before he fell because he felt wobbly. No injuries were noted. On 7/29/24 Resident #28's fall care plan was updated with a new invention for reviewing the resident's medications. The 9/1/24 progress note revealed Resident #28 fell in the bathroom while he was self-transferring. The resident was noted to be barefoot and was not using an ambulatory device. The resident said he fell on his bottom in the bathroom and crawled to the side of his bed. No injuries were noted. -The facility failed to implement a new fall intervention after the resident's fall. The 9/16/24 progress note revealed Resident #28 self-reported a fall and was found sitting on his bed. The resident said he fell between his wheelchair and refrigerator and was able to pull himself back up. No injuries were noted. On 9/17/24 Resident #28's fall care plan was updated with a new intervention for strategically placing a soft touch call light in his room. The 10/14/24 progress note revealed Resident #28 was found on the floor between his nightstand and bed with his head resting on the heater vent. The resident said he rolled off his bed. No injuries were noted. -The facility failed to implement a new fall intervention after the resident's fall. The 11/18/24 progress note revealed Resident #28 was found on the floor between his bed and wheelchair. The resident said he was trying to get into his wheelchair. He had a 3 centimeter (cm) by 3 cm skin abrasion (scrape) on his upper left back. -The facility failed to implement a new fall intervention after the resident's fall. The 11/19/24 progress note revealed Resident #28 was assessed for a fall and no injuries were noted. -The facility failed to document the details of the fall or implement a new fall intervention after the resident's fall. The 11/20/24 progress note revealed Resident #28 was found sitting on the floor with his legs crossed. No injuries were noted. -The facility failed to implement a new fall intervention after the resident's fall. A second 11/20/24 progress note revealed Resident #28 was found on the floor right outside his room. The resident said he thought he hit his head. No injuries were noted. -The facility failed to implement a new fall intervention after the resident's fall. The 11/30/24 progress note revealed Resident #28 was found on the floor sitting on his buttocks on the fall mat with his back against the bed. The resident said he hit his forehead. No injuries were noted. -The facility failed to implement a new fall intervention after the resident's fall. The 12/2/24 progress note revealed Resident #28 was found cross-legged on the floor in between his bed and wheelchair on his buttocks. The resident said he was trying to get into bed and hit his head on the mattress. No injuries were noted. -The facility failed to implement a new fall intervention after the resident's fall. The 12/3/24 progress note revealed Resident #28 was found cross-legged on the floor in between his bed and wheelchair on his buttocks. The resident's wheelchair's brakes were engaged and the wheelchair was flipped on its side. The resident said he was trying to get into his wheelchair and he hit his left shoulder on the mattress. On 12/3/24 Resident #28's fall care plan was updated with a new intervention for activities to provide person-centered one-on-one activities for the resident. 3. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 12/10/24 at 12:05 p.m. LPN #1 said Resident #28 lacked decision-making capacity unless it was simple choice questions. She said the resident often self-transferred and fell a lot. LPN #1 said the resident's fall interventions were to have a floor mat placed by the bed, call light placed in his hand when he was in his room, educating the resident to call for assistance and trying to get the resident in his wheelchair before he sat up in bed. LPN #1 said when a resident fell the registered nurse (RN) had to assess the resident before he was moved and that LPNs did not update care plans after a fall. The director of nursing (DON) was interviewed on 12/10/24 at 4:11 p.m. The DON said Resident #28 fell a lot and the facility worked with the nurse practitioner (NP) to get laboratory (lab) work ordered. The neurologist said the resident was falling a lot because of his multiple sclerosis progressing. She said when a resident fell , the nurses entered a generalized intervention into the resident's care plan, then the IDT met and entered a more individualized intervention into the care plan. She said the interventions implemented depended on what the IDT felt would be effective in preventing falls. The DON said after falls, old interventions needed to be reviewed because if the intervention did not work, a new effective intervention was needed. She said Resident #28's current fall interventions were encouraging the resident to use the call light, anticipating his needs, encouraging the resident to wear non-skid socks and using grab bars. The DON said she was unaware Resident #28's care plan was not revised with new interventions after each fall. She said the resident's care plan should have been updated with new interventions instead of revising old interventions that were not effective. 50314 C. Resident #13 1. Resident Status Resident #13, age greater than 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included end stage renal disease, bipolar disorder and anemia. The 10/18/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required supervision or touching assistance when bathing, set-up or clean-up assistance with personal hygiene, and was independent with all other activities of daily living (ADL). 2. Record review The fall risk care plan, initiated 4/23/24 and revised 6/21/24, documented that Resident #13 was at risk for falling because of problems with her balance. Interventions included ensuring the resident's call light was within reach, anticipating the resident's needs and that the resident should use a shower bench when in the shower. A nursing progress note, dated 5/10/24, documented that Resident #13 experienced an unwitnessed fall. The progress note documented nursing staff found the resident at 7:05 p.m. sitting on the floor of the bathroom. A fall record documentation form, dated 5/10/24, documented that Resident #13 received neurological assessments beginning at 7:05 p.m. The fall record documented that Resident #13 did not receive a neurological assessment at 8:20 p.m. on 5/10/24 because the resident was smoking. The fall record documented that Resident #13 did not receive neurological assessments at 9:20 p.m., 9:50 p.m., 10:50 p.m., or 11:50 p.m. on 5/10/24 because the resident was sleeping. -The facility failed to perform neurological assessments consistently for Resident #13. -The facility failed to implement a new fall intervention on Resident #13's care plan after the 5/10/24 fall. A change of condition progress note, dated 5/20/24, documented that Resident #13 had an unwitnessed fall. The progress note documented the DON and a CNA found Resident #13 on the floor of her bedroom. The progress note documented Resident #13 was not able to follow commands and was experiencing confusion. The progress note documented the DON told the nurse to call for an ambulance. The note documented Resident #13 was transported to the hospital by emergency medical services (EMS). -The facility failed to provide and document a neurological assessment after the resident fell and before EMS arrived at the facility (see interview below). -The facility failed to implement a new fall intervention on Resident #13's care plan after the 5/20/24 fall. D. Resident #32 1. Resident status Resident #32, age greater than 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), incomplete paraplegia and paranoid schizophrenia. The 8/27/24 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS score of nine out of 15. He required moderate assistance with lower body dressing and footwear, required supervision or touching assistance with personal hygiene and showering, required set-up or clean-up assistance with upper body dressing and toileting hygiene and was independent with eating and oral hygiene. 2. Record Review The fall risk care plan, initiated 8/31/22 and revised 11/14/24, documented that Resident #32 was a fall risk because of his impaired mobility, poor safety awareness and medication use. Interventions included physical therapy evaluation for strengthening and transfer training, anticipating Resident #32's needs, ensuring the resident's call light was within reach and ensuring the resident was wearing appropriate footwear. The Morse Fall Risk Scale assessment, dated 5/13/23, documented Resident #32 was a high risk for falling with a score of 75. The fall risk assessment documented a score of 45 or above indicated a resident was a high risk for falling. The assessment documented Resident #32 had a history of falling previously and had an impaired gait. The assessment documented that Resident #32 overestimated or forgot his limits. A fall record documentation form, dated 11/14/24, documented that Resident #32 experienced an unwitnessed fall at 6:15 a.m. The form documented Resident #32 should receive a neurological assessment at 5:10 p.m, however, there was no documentation for the neurological assessment on the form. The form further documented Resident #32 did not receive a neurological assessment at 5:10 a.m. on 11/15/24 because the resident was sleeping. -The facility failed to perform neurological assessments consistently for Resident #32. E. Staff interviews RN #1 was interviewed on 12/9/24 at 3:45 p.m. RN #1 said if a resident experienced an unwitnessed fall, the resident must be assessed immediately by a nurse and neurological assessments should be performed per the neurological assessment form. RN #1 said the facility protocol for neurological assessments was printed on the paper where neurological assessments were documented. RN #1 said that it was never acceptable to skip a resident's neurological assessments. LPN #3 was interviewed on 12/9/24 at 4:24 p.m. LPN #3 said if a resident experienced an unwitnessed fall, the RN would assess the resident right away while the LPN or a CNA obtained vital signs for the resident. LPN #3 said the neurological assessments started immediately after a fall and were conducted according to the protocol on the neurological assessment form. LPN #3 said RNs must perform assessments in the facility. LPN #3 said residents who fell should have their care plans looked at to see if there was anything else that could be done to prevent a resident from falling again. The DON was interviewed on 12/10/24 at 2:49 p.m. The DON said she defined a fall as any unplanned descent to the floor. The DON said neurological assessments were performed immediately and according to the protocol on the neurological assessment documentation form. The DON said it was important to perform the neurological assessments per the protocol to ensure that residents did not have a delayed head injury or suffered trauma. The DON said it was not acceptable for bedside nursing staff to skip or miss a neurological assessment unless the resident refused the assessment. The DON reviewed neurological assessment documentation for Resident #13 and Resident #32. The DON said Resident #13 experienced an unwitnessed fall on 5/10/24 and neurological assessments were not completed appropriately. The DON said on 5/20/24 Resident #13 was sent to the hospital after an unwitnessed fall and she was present. The DON said she performed the neurological assessment before EMS arrived 10 minutes later, but she did not document that neurological assessment. The DON said she should have documented the neurological assessment she obtained because she was the RN working at the time and present in the resident's room. The DON said Resident #32's neurological checks were not appropriately completed after his unwitnessed fall on 11/14/24. The DON said if a resident experienced a fall, the resident's plan of care should be updated with new fall interventions. The DON said she preferred to implement an intervention immediately, if possible. She said the IDT would then review the fall and determine the root cause for the fall. The DON said the fall interventions implemented in the plan of care should closely match the reason for the fall. The DON reviewed Resident #13's plan of care. The DON said Resident #13's fall plan of care was not updated after she fell on [DATE] and 5/20/24. 40467 F. Resident #50 1. Resident status Resident #50, age greater than 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included unspecified dementia, severe without behavioral disturbance, cognitive communication deficit, repeated falls, unsteadiness on feet, muscle weakness, lack in coordination, need for assistance with personal care and age-related osteoporosis without current pathological fracture. The 8/20/24 MDS assessment documented Resident #50 had moderate cognitive impairment with a BIMS score of nine out of 15. She did not have inattention, disorganized thinking or rejection of care behaviors. The resident required assistance with ADLs and used both a walker and a wheelchair for mobility According to the MDS assessment, Resident #50 had a history of falls in the past six months. 2. Resident observation During a continuous observation on 12/9/24, beginning at 2:33 p.m. and ending at 4:19 p.m., the following was observed: At 2:33 p.m. Resident #50 was asleep in bed and her call light cord was draped over her head board and the call light was lying on the floor on the back side of the head board. Resident #50's call light button was not within reach of the resident. At 3:03 p.m. licensed practical nurse (LPN) #2 and a CNA #1 entered the resident's room and assisted Resident #50's roommate before exiting the room. Resident #50's call light remained draped over the head board of the resident's bed and remained out of reach after LPN #2 and CNA #1 exited the resident's room. At 3:50 p.m. an unidentified housekeeper exited Resident #50's room. The resident's call light cord was on the fall mat and not attached to the wall. The call light was not within reach of the resident and the call light was not operational. At 4:07 p.m. Resident #50's call light remained on the resident's fall mat with the cord pulled out of the wall. At 4:18 p.m. LPN #2 entered and exited the resident's room. The resident's call light remained on the floor after LPN #2 exited the room. At 4:19 PM LPN #2 and CNA #1 entered the resident's room and identified that the call light was not activated when the cord was pulled from the wall. LPN #2 and CNA #1 reattached the resident's call light to the wall prior to exiting the resident's room. On 12/10/24 at 9:53 a.m. the maintenance of director (MTD) was in Resident #50's room repairing the call light wall attachment from the day prior (see interview below). During a continuous observation on 12/10/24, beginning at 1:40 p.m. and ending at 2:31 p.m., the following was observed: At 1:40 p.m. Resident #50 was in bed. The call light was between the wall and the back side of the resident's bed. The call light was not within reach of the resident. At 1:42 p.m. LPN #2 retrieved the call light from the back side of the bed and placed it on the resident's bed within her reach. At 2:31 p.m. the call light was on the floor on the fall mat. The cord remained attached to the wall. 3. Record review The 8/16/24 nursing fall risk assessment identified Resident #50 was at high risk for falls. Resident #50's fall care plan, initiated 8/16/24 and revised 10/24/24, directed staff to ensure Resident #50's call light was within reach and encouraged the resident to use it for assistance as needed. According to the fall care plan, the resident needed prompt response to all requests for assistance. a. Fall with injury on 9/11/24 The 9/11/24 unwitnessed fall incident report documented Resident #50 had an unwitnessed fall on 9/11/24 at 6:05 a.m. The report identified a CNA informed the nurse during the nurse to nurse report that Resident #50 was found on the floor. The LPN and a RN entered the resident's room and observed the resident sitting on the floor with a pillow behind her back against the bed frame. According to the note, the resident could not say what happened other than to tell the staff to get her off the floor. The resident was assessed and did not have an injury as a result of the 9/11/24 fall. -The incident report did not identify if the resident's call light was turned on prior to the fall or if the resident's call light was within reach at the time of the fall. The 9/11/24 skilled nursing progress note indicated education was provided regarding the resident's call light usage. The resident did not have complaints of pain or discomfort noted after the fall. According to the note, the resident was awake in bed with her call light and fluids within reach. The note documented the resident called excessively once she was in bed. The 9/16/24 IDT risk management review note documented the resident had an unwitnessed fall on 9/11/24 at 6:05 p.m. The resident was found sitting on the floor sitting next to her bed with a pillow between herself and the bed. According to the note, the resident was currently working with therapy. The IDT note identified intentional rounding was put in place as an intervention after the resident fell . -The IDT risk management review note did not identify Resident #50 had a second fall on 9/13/24 (see below). b. Fall on 9/13/24 The 9/13/24 nursing progress note documented a CNA informed the nurse during the nurse to nurse report that Resident #50 was found on the floor at 3:46 a.m. The note identified the LPN and the RN entered the room and observed the resident sitting on the floor with a pillow behind her back against the bed frame. According to the note, the resident could not say what happened other than to tell the staff to get her off the floor. The note identified the resident was not injured as a result from the 9/13/24 fall. -The 9/13/24 nursing progress note identified Resident #50 fell in the exact same manner as the fall on 9/11/24. -The 9/13/24 progress note did not identify if the resident's call light was turned on prior to the fall or if the resident's call light was within reach at the time of the fall. The 9/14/24 at 5:03 a.m. nursing progress note documented Resident #50 did not complain of pain or discomfort and she was able to get herself out of bed. According to the note, Resident #50 used her call light frequently on night shift. c. Fall on 9/17/24 The 9/17/24 nursing progress note documented Resident #50 was observed sitting on the floor next to her bed when the nurse was making the rounds. The note identified the resident's call light was in reach at the time of the fall and there were no injuries. -The progress note did not identify if the resident's call light was on at the time of the fall. The 9/17/24 unwitnessed fall incident report documented the fall occurred at 10:40 p.m. and the resident was not able to describe what happened. The 9/19/24 IDT note documented the IDT reviewed Resident #50's fall on 9/17/24. The note identified the resident was self transferring at the time of the fall. The note documented a perimeter defining mattress was placed on the resident's bed to help assist the resident identify the bed's perimeters. According to the note, staff would continue to provide the resident's fall interventions, including the use of a low bed and a fall mat on the floor and the continuation of therapy services. -The IDT note did not indicate the resident fell again the following day, on 9/18/24. d. Fall on 9/18/24 The 9/18/24 nursing progress note identified Resident #50 fell on [DATE] without injury. The note documented the resident wore non-skid socks and her walker was close to her at the time of the fall. According to the note, the resident said she was trying to get up. The resident was educated on the spot to call for assistance. -The progress note did not identify if the resident's call light was within her reach at the time of the resident's fall and did not identify if the call light was on at time of the fall. The 9/18/24 IDT risk management review note identified Resident #50 had a fall on 9/18/24 at 10:40 p.m. She had weakness and confusion and was found on the floor next to her bed -The note did not identify additional fall interventions put into place after the 9/18/24 fall. e. Fall on 9/24/24 The 9/24/24 nursing progress note indicated Resident #50 had another unwitnessed fall. The note identified a CNA found Resident #50 on the floor of her room. The note documented the nurse entered the room and saw the resident sitting on the floor with her head down next to the bed. The RN assessed the resident after the unwitnessed fall. According to the note, the resident's call light was within reach at the time of the fall and she was educated on the importance of using a call light to call for assistance when wanting to get up. The resident would be monitored for 72 hours after the 9/24/24 fall. The 9/25/24 IDT risk management review note identified Resident #50 was confused and attempted to self transfer from bed without calling for help on 9/24/24. The note directed staff to encourage the resident to spend time out of bed and engage in activities of choice. The resident continued with physical therapy for strengthening. The IDT note, dated 9/26/24, documented the fall on 9/24/24 was without injury and was caused by the resident's poor safety awareness. f. Fall on 9/27/24 The 9/27/24 nursing progress note , indicated Resident #50 had another unwitnessed fall. The note identified Resident #50 was found lying on the floor in her room by the DON on 9/27/24 at approximately 11:05 a.m. The resident did not have injuries as a result of the fall. According to the note, the resident did not remember what happened to cause the fall. The note documented the call light was within reach and the resident was encouraged to use the call light when she needed assistance. The note indicated the resident verbalized understanding. The 9/30/24 IDT risk management review note documented that staff placed signs in the resident's room that read call don't fall. g. Fall on 10/22/24 The 10/22/24 nursing progress note indicated Resident #50 had another unwitnessed fall. The note identified the resident was found on the floor in her room. The resident's call light was not on. According to the note, the resident was last seen propelling herself in her wheelchair toward her room. The resident was not able to say what happened other than she wanted to go to bed. The 10/23/24 IDT risk management review note documented the resident had another unwitnessed fall. The resident was not injured. The note identified the 10/22/24 fall occurred at 6:45 p.m. while she tried to get into her bed. According to the note, the staff needed to offer the resident assistance to go to bed directly after meals as was her usual preference. h. Fall on 10/25/24 The 10/25/24 nursing progress note indicated Resident #50 had another unwitnessed fall. The note identified the resident fell on the floor next to bed on after attempting to go to the restroom without assistance. The note revealed the call light was not within reach of the resident at the time of the fall. The 10/25/24 f incident report identified Resident #50 was found on the floor without injury on 10/25/24 at 6:50 p.m. with her head near her bed and her feet directed towards her roommate's bed. According to the incident report, the resident did not know what happened. i. Fall on 11/9/24 The 11/9/24 nursing progress note indicated Resident #50 fell on [DATE]. The note identified the resident's nurse was notified by another resident that Resident #50 had fallen. The nurse and a CNA found the resident on the floor of her room with her head pointed towards the window and her feet pointed towards the bed. The resident was lying on her right side. The resident said she wanted to go back to bed. According to the note, the resident was in her recliner prior to the fall. The note revealed the resident's call light was not within reach of the resident. The resident said she wanted to go back to bed. The call light was placed within the r[TRUNCATED]

Based on record review and interviews, the facility failed to ensure each resident had the right to formulate an advanced directive for one (#8) of four residents out of 28 sample residents. Specifically, the facility failed to ensure Resident #8's proxy selected or refused life-saving treatments within the power of a proxy. Findings include: I. Medical Orders for Scope of Treatment (MOST) form The MOST form documented that a Proxy-by-Statute (decision maker selected through a proxy process) may not decline artificial nutrition or hydration for an incapacitated resident without an attending physician and a second physician trained in neurology who certified that artificial nutrition or hydration would merely prolong the act of dying and was unlikely to result in the restoration of the resident to independent neurological functioning. II. Resident status Resident #8, age greater than 65, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included stage 3 chronic kidney disease, hemiplegia affecting right dominant side (paralysis on one side of the body), expressive language disorder, aphasia (difficulty understanding and speaking) following a cerebral infarction (stroke) and schizotypal disorder (personality disorder). The [DATE] minimum data set (MDS) assessment revealed Resident #8 had a moderate cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. III. Record review A proxy selection document, completed on [DATE], revealed that Resident #8 lacked decision-making capacity and had a proxy appointed. Resident #8's MOST form, reviewed on [DATE], documented the resident was a do-not-resuscitate (DNR), indicating the resident did not want cardiopulmonary resuscitation (CPR). Resident #8's MOST form was completed by his proxy and the proxy declined artificial nutrition on [DATE]. -However, the facility failed to have a physician's note signed by the resident's physician and a neurologist declaring the artificial nutrition was only prolonging death, as was required and instructed on the MOST form (see above). A quarterly social services evaluation, completed on [DATE], documented Resident #8 had a code status of DNR. Resident #8 was documented as his own decision-maker and had a severe cognitive impairment. -However, according to the [DATE] proxy selection document, Resident #8 lacked decision-making capacity (see above). IV. Staff interviews The business office manager (BOM) and the nursing home administrator (NHA) were interviewed together on [DATE] at 10:00 a.m. The NHA said she was unaware of what a proxy could approve or deny on the MOST form. The BOM said she was unaware of what the difference between a proxy and a medical durable power of attorney (MDPOA) was. The social services director (SSD) was interviewed on [DATE] at 10:05 a.m. The SSD said she reviewed MOST forms and ensured the forms were signed by the physician. The SSD said she had not read the back of the MOST form and was unaware a proxy was unable to decline artificial nutrition on the MOST form. The NHA was interviewed again on [DATE] at 10:30 a.m. The NHA said she was provided information that a proxy was able to refuse artificial nutrition on the MOST form ahead of time as long as when the time came to needing artificial nutrition, the proxy reviewed it with the resident's physician. The NHA said if a resident went to the hospital, the hospital provided treatment based on the MOST form and she saw it was an issue where the hospital probably would not provide the resident with nutrition. The director of nursing (DON) was interviewed on [DATE] at 4:11 p.m. The DON said the SSD trained her on the MOST forms and the DON then trained the nurses. The DON said she had not read the back of the MOST form and was unaware a proxy had different decision-making capabilities than a medical durable power of attorney (MDPOA).

Based on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints for two (#18 and #39) of four residents out of 28 sample residents. Specifically, the facility failed to: -Identify the staff were using clothing to restrain Resident #18; and, -Ensure Resident #39 had a physician's order for a wander guard restraint. Findings include: I. Facility policy and procedure The Physical Restraint Management policy, revised 9/30/23, was provided by the nursing home administrator (NHA) on 12/10/24 at 1:30 p.m. It read in pertinent part, Physical restraints shall only be used for the safety and wellbeing of resident(s) and only after other alternatives have been tried unsuccessfully. Residents shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience, or for the prevention of falls. Any resident requiring a restraint will have a current physician order with the following components: the specific reason for the restraint (as it relates to the resident's medical symptoms device is to be used for), how and when the device is to be used to benefit the resident's medical symptoms and the type of restraint and period of time for the use of the restraint. The Resident Rights policy, revised February 2021, was provided by the NHA on 12/10/24 at 1:30 p.m. It read in pertinent part, Employees shall treat all residents with kindness, respect and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: -A dignified existence; -Be treated with respect, kindness and dignity; -Be free from corporal punishment or involuntary seclusion and physical or chemical restraints not required to treat the resident's symptoms; and, -Privacy and confidentiality. II. Resident #18 A. Resident status Resident #18, age greater than 65, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included dementia, Alzheimer's disease with late onset and need for assistance with personal care. The 11/14/24 minimum data set (MDS) assessment revealed Resident #18 had a severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. Resident #18 required substantial/maximal assistance with upper body dressing. Resident #18 had no behavioral symptoms and had a wandering device restriction documented. B. Observations At 1:28 p.m. an unidentified staff member walked through the common area and saw Resident #18 without his shirt on. The staff offered to assist the resident and she put his shirt back on. At 1:35 p.m. Resident #18 was observed in a clean shirt with a pair of overalls on. C. Record review Resident #18's care plan, revised on 11/14/24, revealed the resident often took his shirt off in common areas. The intervention was documented as assisting the resident with putting on a clean shirt if he removed his shirt. -Review of Resident #18's electronic medical record (EMR) revealed an assessment and consent for Resident #18's wander guard and not the use of overalls or two shirts to prevent the resident from taking off his clothes. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 12/10/24 at 12:05 p.m. LPN #1 said Resident #18 removed his shirt in the common areas numerous times every day. LPN #1 said she did not know why the resident removed his shirt. She said the staff tried to redirect the resident to put his shirt back on but he usually removed his shirt anyway. LPN #1 said when Resident #18 removed his shirt, the staff took him to his room and placed two shirts on him or a shirt and overalls to prevent him from taking off his shirt around other residents. LPN #1 said the overalls restricted the resident the best and he was unable to remove his shirt. Certified nurse aide (CNA) #1 was interviewed on 12/10/24 at 1:59 p.m. CNA #1 said Resident #18 always removed his shirt and the staff were unable to figure out why. CNA #1 said when he saw Resident #18 without his shirt on he assisted the resident with putting it back on. He said other staff placed the resident in two shirts or a shirt and overalls. CNA #1 said it was not necessarily to restrain the resident but the idea was to make it harder for the resident to remove his shirt. The director of nursing (DON) was interviewed on 12/10/24 at 4:11 p.m. The DON said Resident #18 constantly removed his shirt. She said she asked the resident if he was hot, cold, itchy or uncomfortable and the resident was unable to answer. She said the staff assisted the resident with putting his shirt back on or getting a clean shirt. She said the staff were not supposed to place him in two shirts or a shirt and overalls to restrict or restrain the resident from undressing. The DON said Resident #18 liked wearing overalls because he was a farmer when he worked but the staff were not to use the clothing as a restraint. III. Resident #39 A. Resident status Resident #39, age greater than 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included frontotemporal neurocognitive disorder (brain disorder), dementia, senile degeneration of brain (progressive neurological disorder) and anxiety. The 10/16/24 MDS assessment revealed Resident #39 had long and short-term memory problems and her daily decision-making skills were severely impaired per staff assessment. Resident #39 needed supervision or touching assistance with getting dressed, showering and putting on footwear. He required partial/moderate assistance with toileting. He required set up or clean up assistance with oral hygiene and was independent with eating. The assessment indicated Resident #39 used a wander or elopement alarm daily. B. Record review A review of the December 2024 CPO revealed the following physician's orders: Signaling device (wander guard) to be monitored according to the manufacturer's recommendations and as needed to ensure the device functioned properly and to notify the DON if Resident #39's wander guard malfunctioned, ordered on 10/3/24. Assess Resident #39's skin to the right wrist twice a day where the wander guard was placed and staff to notify the provider of any skin changes, ordered on 10/12/24. -The facility failed to have a physician's order for the wander guard device that included the specific reason for the restraint (as it related to the resident's medical symptoms the device was to be used for), how and when the device was to be used to benefit the resident's medical symptoms and the type of restraint and period of time for the use of the restraint. -A review of Resident #39's EMR did not reveal documentation that the facility attempted a less restrictive intervention than the wander guard. C. Staff interviews LPN #1 was interviewed on 12/10/24 at 12:05 p.m. LPN #1 said Resident #39 was not using a restraint. She said she was not aware the wander guard was a restraint. The DON was interviewed on 12/10/24 at 4:11 p.m. The DON said the physician's orders entered for Resident #39 on 10/3/24 and 10/14/24 were not the orders for the restraint itself but for maintenance of the restraint once it was in place. The DON said a physician's order was going to be obtained for the wander guard and documented in the resident's chart on 12/10/24.

Based on observation and interviews, the facility failed to ensure residents received professional standards of care for one (#48) resident reviewed for ileostomy care out of 28 sample residents. Specifically, the facility failed to: -Provide appropriate ileostomy care in a timely manner, which caused Resident #48 to develop dermatitis to the skin surrounding his ileostomy; and, -Failed to obtain physician's orders timely for Resident 48's ileostomy care. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., Fundamentals of Nursing, 10 ed. (2020), Elsevier, St. Louis Missouri, pp. 2554, retrieved on 12/14/24, Preserving peristomal (the skin around an ostomy) skin is critical because skin excoriation may cause an ineffective seal between the wafer and the skin and leakage of effluent. This in turn causes more skin and tissue damage. Leakage may indicate the need for a different type of pouch system or sealant. Pouches are usually changed every three to five days, preferable before leakage occurs. To decrease skin irritation, avoid changing the entire system. In a one or two piece pouching system, change the skin barrier only every three to seven days, never daily. II. Facility policy and procedure The Colostomy/Ileostomy care policy, revised October 2010, was provided by the nursing home administrator (NHA) on 12/10/24 at 5:52 p.m. It documented in pertinent part, The purpose of this procedure is the provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter. When evaluating the condition of the resident's skin, note the following: breaks in the skin, excoriation, and signs of infection. Notify the supervisor of any abnormal findings (i.e. breaks in skin, excoriation, signs of infection) III. Resident #48 A. Resident status Resident #48, over the age of 65, was admitted on [DATE] and discharged on [DATE]. According to the November 2024 computerized physician order (CPO), diagnoses included dehiscence of the gastrointestinal tract with surgical ileostomy placement, chronic obstructive pulmonary disease (COPD) and respiratory failure. According to the 10/29/24 minimum data set (MDS) assessment, Resident #48 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The assessment documented Resident #48 had no rejections of care. The assessment documented the resident had major surgery in the 100 days prior to admission to the facility. The assessment documented the resident's surgery required skilled nursing facility care. The assessment documented the resident had a surgical wound that required surgical wound care at the facility. B. Record review The hospital discharge instructions, dated 10/25/24, documented Resident #48 had an ileostomy placed during the hospital stay. The discharge instructions documented Resident #48 should go to the emergency room if his skin or site of infection was not getting better or looked different or worse, or if his wound is red, painful or smelled. Nursing progress note, dated 11/9/24, documented Resident #48's ileostomy bag was leaking again. The progress note documented Resident #48's peristomal skin was very red, sweating, and had dots of blood present after cleansing the skin. -The facility failed to prevent exposure of fecal matter to Resident #48's skin which caused Resident #48 to develop dermatitis of the skin. Skilled nursing progress note dated 11/9/24 at 5:08 a.m. documented that Resident #48's ileostomy bag was changed multiple times during the shift. The note documented Resident #48 felt upset that the ileostomy bag was not staying sealed. -However, ileostomy bags should never be changed more frequently than every three to five days. (see professional reference above) Mental health provider note, dated 11/9/24 at 11:19 a.m., documented Resident #48's family requested for Resident #48 to be sent to the hospital because his ileostomy bag was constantly leaking. The note documented Resident #48 and his family expressed concerns that Resident #48 was developing an infection transferring between the ileostomy bag and the abdominal dressing with the wound vac. The note documented the director of nursing (DON) was notified and Resident #48 consented to be transported to the hospital. Nursing progress note, dated 11/9/24 at 3:59 p.m., documented Resident #48 arrived back at the facility in good spirits with a new ileostomy bag. The note documented Resident #48 had been diagnosed by MD #4 to have dermatitis of the skin caused by a leaking ileostomy bag. -The facility failed to prevent exposure of fecal matter to Resident #48's skin which caused Resident #48 to develop dermatitis of the skin. Skilled nursing progress note, dated 11/10/24, documented Resident #48's wound dressing was changed multiple times. The progress note documented Resident #48's skin was red, sweating, and bled after being cleansed. -The facility failed to prevent liquid stool from causing dermatitis to the skin between the ileostomy and the midline abdominal wound. Alert progress note, dated 11/11/24, documented Resident #48 had dermatitis to his ostomy site which was currently being treated by being left open to air. The note documented the ostomy site was being cleansed with warm water and pat dry, placing a dry towel over the ostomy site to absorb any liquid stool. -The facility failed to assist Resident #48 to apply an ileostomy bag, which allowed liquid stool from the ileostomy to be uncontained. -The facility failed to obtain a physician's order to leave Resident #48's ileostomy open to air. Skilled nursing note, dated 11/11/24 at 11:04 p.m,. documented =Resident #48's ileostomy had dermatitis to the surrounding skin,and was being treated by cleaning with a warm washcloth and placing a dry washcloth over the ileostomy to absorb any liquid stool. The ostomy clinic initial evaluation, dated 11/13/24, documented Resident #48 was being evaluated in the clinic for ostomy appliance management. The documentation included Resident #48's statement that the facility had been caring for his ileostomy and they had been unable to get any appliance to adhere to his skin. Resident #48 said the facility had been leaving his ileostomy open to air without any appliance on it at all and had been applying Neosporin (antibiotic ointment) to his reddened skin around the ileostomy. Resident #48 said the facility had been cleansing his skin with warm water and towels every 15 minutes between 11/6/24 and 11/13/24. Resident #48 said he went to the emergency room over the weekend to have his ileostomy appliance evaluated as well. The ostomy clinic evaluation documented Resident #48 was alert and oriented to person, place, time, and situation. -A review of the November 2024 CPO did not reveal a physician's order for the nurses to apply Neosporin to the resident's skin around the ileostomy. The ostomy clinic physical exam documented Resident #48's peristomal (skin around the resident's ileostomy) skin condition had irritant contact dermatitis related to liquid stool. The physical exam documented Resident #48's skin was red, raw, open circumferentially around the stoma and had a widespread fungal rash. The ostomy clinic assessment documented Resident #48 arrived with no ostomy device in place. The clinic assessment documented facial tissues were stuck to the stoma and Resident #48 had stool leakage on his pants. The assessment documented the ostomy clinic gave Resident #48 new pants to wear home. The assessment documented Resident #48's wound vac device had failed because stool had gotten underneath the wound vac device. The assessment documented Resident #48's wound vac was also removed during the clinic evaluation and Resident #48's midline incision was soaked and treated before replacing the dressing. The ostomy clinic documented nystatin powder (used to treat fungal infections) was applied and rubbed into the peristomal skin which contained a fungal rash. The ostomy clinic documented pictures and serial numbers of all cremes and devices used to replace Resident #48's ileostomy device in the wound clinic evaluation and treatment. The documentation included pictured nursing instructions of how to clean and replace Resident #48's ileostomy device. The ostomy clinic documentation included that it discussed the case with the DON on 11/13/24. The ostomy clinic documented that they told the DON what devices to order, and that it would fax the facility its recommendations for care including step-by-step instructions. Skilled nursing note dated 11/13/24 at 11:01 p.m. documented that Resident #48's ileostomy bag had been changed earlier that day at his appointment. Nursing progress note, dated 11/22/24, documented Resident #48 had been discharged home with home health services. The note documented Resident #48 and his family had received colostomy care education. Review of the November 2024 CPO included the following orders: Ileostomy directions, please follow instructions on paper in the cart. This was ordered on 11/14/24 and was active until the resident was discharged on [DATE]. -The facility failed to prevent the progression of the midline abdominal wound which now required a wet to dry dressing and was caused by exposure to liquid stool from Resident #48's ileostomy. -The facility failed to obtain physician's orders for Resident #48's ileostomy care before 11/14/24. IV. Staff interviews Registered nurse (RN) #1 was interviewed on 12/9/24 at 3:45 p.m. RN #1 said she remembered Resident #48 when he was admitted to the facility. RN #1 said the facility had ileostomy supplies. RN #1 said Resident #48's ileostomy was often leaking. RN #1 said Resident #48's ileostomy was left open to air for about a day. RN #1 said Resident #48's ileostomy was a difficult case for the facility. RN #1 said Resident #48's wife and the wound clinic supplied Resident #48's ileostomy supplies after his wound clinic visit. RN #1 said when Resident #48 was discharged he was still using the supply of ileostomy supplies the wound clinic had provided him. RN #2 was interviewed on 12/9/24 at 4:59 p.m. RN #2 said she was the home health nurse that was supposed to admit Resident #48 to home health services on 11/22/24 after he discharged from the facility. RN #2 said when she arrived at the resident's home, Resident #48 only had one spare ileostomy wafer left from the supply provided by the wound clinic on 11/13/24. RN #2 said Resident #48's wife reported that Resident #48 had become increasingly short of breath and had passed out that day when going upstairs. RN #2 said when she first looked at Resident #48's ileostomy, the ileostomy pouch was actively leaking. RN #2 said she and Resident #48's wife attempted to replace the ileostomy pouch and wafer, but were both unsuccessful. RN #2 said she felt uncomfortable about how Resident #48 looked upon assessment that she did not admit him to home health services and recommended that Resident #48 go to the emergency room . RN #2 said Resident #48 and his wife decided to call an ambulance and go to the emergency room . The DON was interviewed on 12/10/24 at 2:49 p.m. The DON said when a resident was seen at the wound clinic and received new orders, those orders were entered into the CPO and central supply ordered the necessary supplies. The DON said if a resident received a physician's order for a specialty product by the wound clinic, then she would review her available vendors to see if she can order the recommended item or a reasonable substitute. The DON said a resident's ileostomy should never be left open to air and nursing staff cannot leave an ileostomy open to air without a physician's order. The DON said if an ileostomy was left open to air, then the skin around the ileostomy could become infected or develop dermatitis. The DON said that dermatitis of the skin was painful and uncomfortable. The DON said Resident #48's ileostomy was difficult for the nursing staff to fit an appliance. The DON said the facility had ordered ileostomy supplies after receiving recommendations from the wound clinic on 11/13/24, but the supplies had not arrived at the facility by the time the resident discharged on [DATE]. The DON said the specialty ileostomy supplies Resident #48 required took two to four weeks to arrive at the facility.

Based on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal and influenza vaccinations for one (#29) of five residents out of 28 sample residents. Specifically, the facility failed to offer the influenza and pneumococcal vaccinations to Resident #29. Findings include: I. Facility policy and procedure The Immunizations policy, dated 7/28/23, was provided by the social services director (SSD) on 12/4/24 at 11:44 a.m. It documented in pertinent part, Each resident will be offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period. The facility will determine whether or not a resident has received a pneumococcal immunization at the time of admission to the facility and again after age 65 if the resident ages in place to turn 65. Pneumococcal immunizations to be offered as indicated following CDC recommendations. II. Resident #29 A. Resident status Resident #29, over the age of 65, was admitted to the facility on [DATE] and readmitted [DATE]. According to the December 2024 CPO, diagnoses included dementia, diabetes mellitus, and depression. The 11/12/24 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of three out of 15. The assessment documented the resident had not received the influenza vaccine in the facility for this year's influenza season. The assessment documented the facility did not offer the influenza vaccine. The assessment documented that Resident #29's pneumococcal vaccination was not up to date, and the facility had not offered a pneumococcal vaccination to the resident. B. Record review The state immunization tracking documentation was provided by the director of nursing (DON) on 12/10/24 at 11:38 a.m. It documented that Resident #29 had not received a pneumococcal immunization previously and required a pneumococcal immunization. It documented that Resident #29 last received an influenza vaccination on 10/1/2020 and required an influenza vaccination. -The facility failed to offer Resident #29 a pneumococcal or influenza vaccination III. Staff interviews The DON was interviewed on 12/10/24 at 12:56 p.m. The DON said that her normal process was to begin offering the influenza and pneumococcal vaccinations annually beginning in October. The DON said that Resident #29 had not been offered influenza vaccination or pneumococcal vaccination before 12/10/24 (during the survey) since he was admitted to the facility. The DON said Resident #29 should have been offered influenza and pneumococcal vaccinations earlier. The DON said that the facility would offer influenza and pneumococcal vaccinations to Resident #29 on 12/10/24.

Based on observations, record review and interviews, the facility failed to ensure care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect, in full recognition of his or her individuality for two (#18 and #46) of 28 sample residents reviewed for respect and dignity. Specifically, the facility failed to: -Ensure Resident #18 did not remove his clothing in the common areas of the facility; -Identify communication techniques for Resident #46 to decrease the resident's frustration and allow her to effectively and consistently express her needs and wants; and, -Ensure the staff stopped and listened to Resident #46 when the resident yelled no, hurt and enough as she was pushed with her wheelchair and her foot was dragged under her wheelchair. Findings include: I. Facility policy and procedure The Dignity policy, revised February 2021, was provided by the nursing home administrator (NHA) on 12/10/24 at 1:30 p.m. It read in pertinent part, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. Individual needs and preferences of the resident are identified through the assessment process. Staff promote, maintain and protect resident privacy, including bodily privacy. The Resident Rights policy, revised February 2021, was provided by the NHA on 12/10/24 at 1:30 p.m. It read in pertinent part, Employees shall treat all residents with kindness, respect and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence, be treated with respect, kindness and dignity, communication with and access to people and services, both inside and outside the facility; and, privacy and confidentiality. II. Resident #18 A. Resident status Resident #18, age greater than 65, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO) diagnoses included dementia, Alzheimer's disease with late onset and need for assistance with personal care. The 11/14/24 minimum data set revealed Resident #18 had severe cognitive impairments with a brief interview for mental status (BIMS) score of zero out of 15. Resident #18 had no behavioral symptoms documented. B. Observations On 12/5/24 at 10:11 a.m. Resident #18 was in the common area without his shirt on and trying to reach out to another resident. During a continuous observations on 12/5/24, beginning at 1:19 p.m. and ending at 1:21 p.m. the following was observed: At 1:19 p.m. Resident #18 was in the common area near the nurse's station sitting in his wheelchair and positioned with his back to the nurse's station. Resident #18 had his right arm in the sleeve of his shirt but the rest of his shirt was off and laid in his lap. There were eight other residents in the common area. At 1:21 p.m. Resident #18 removed his shirt completely and continued reading a newspaper. Two staff members passed the resident in the common area and did not offer the resident assistance with putting on his shirt. At 1:23 p.m. Resident #18 attempted to put his right arm in his sleeve but could not pull the sleeve up past his elbow. One staff passed the resident in the common area and did not offer the resident assistance with putting on his shirt. At 1:24 p.m. Resident #18 again removed his shirt completely. Four staff members walked through the common area passing Resident #18 without his shirt on. At 1:25 p.m. Resident #18 again attempted to put his right arm in his sleeve and pulled his arm out. At 1:27 p.m. Resident #18 placed his right arm in the sleeve to his shirt but was unable to pull the sleeve up past his elbow. Resident #18 sighed loudly, took his arm out of the sleeve and placed his shirt in his lap and looked frustrated. At 1:28 p.m. an unidentified staff member walked through the common area and saw Resident #18 without his shirt on. The staff offered to assist the resident and she put his shirt back on. At 1:35 p.m. Resident #18 was observed in a clean shirt with a pair of overalls on. -Resident #18 was in the common area around other residents without a shirt for 11 minutes. During continuous observations on 12/10/24, beginning at 1:54 p.m. and ending at 1:57 p.m At 1:54 p.m. Resident #18 was in the hallway near the dining room and removed his shirt. 11 other residents were participating in an activity in the dining room. Resident #18 was yelling help over and over outside of the activity room. At 1:55 p.m. a staff walked past Resident #18 and said hi Resident #16 and continued walking past him and did not offer to help him put his shirt back on. At 1:56 p.m. Resident #18 self-propelled in his wheelchair closer to the dining room. The activity director counted how many residents were in the dining room and walked past Resident #18. At 1:57 p.m. certified nurse aide (CNA) #1 walked by the resident and noticed Resident #16 was not wearing his shirt. CNA #1 sat his lunch box and coat on the dining room table and assisted the resident with putting his shirt back on. -Resident #18 was in the common area around other residents without a shirt for three minutes. C. Record review Resident #18's care plan, revised 11/14/24, revealed the resident often took his shirt off in common areas. The intervention was documented as assisting the resident with putting on a clean shirt if he removed his shirt. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 12/10/24 at 12:05 p.m. LPN #1 said Resident #18 removed his shirt in the common areas numerous times every day. LPN #1 said she did not know why the resident removed his shirt. She said the staff tried to redirect the resident to put his shirt back on but he usually removed his shirt anyway. LPN #1 said the other residents laughed and called Resident #18 the facility's stripper. LPN #1 said when Resident #18 removed his shirt, the staff took him to his room and placed two shirts on him or a shirt and overalls to prevent him from taking off his shirt around other residents. LPN #1 said the overalls restricted the resident the best and he was unable to remove his shirt. (Cross-reference F604 failure to be free from restraints) CNA #1 was interviewed on 12/10/24 at 1:59 p.m. CNA #1 said Resident #18 always removed his shirt and the staff were unable to figure out why. CNA #1 said when he saw Resident #18 without his shirt on he assisted the resident with putting it back on. He said other staff placed the resident in two shirts or a shirt and overalls. CNA #1 said it was not necessarily to restrain the resident but the idea was to make it harder for the resident to remove his shirt. The director of nursing (DON) was interviewed on 12/10/24 at 4:11 p.m. The DON said Resident #18 constantly removed his shirt. She said she asked the resident if he was hot, cold, itchy or uncomfortable and the resident was unable to answer. She said staff assisted the resident with putting his shirt back on or getting a clean shirt. She said staff were not supposed to place him in two shirts or a shirt and overalls to restrict or restrain the resident from undressing. The DON said Resident #18 liked wearing overalls because he was a farmer when he worked but the staff were not to use the clothing like a restraint. 40467 III. Resident #46 A. Resident status Resident #46, age greater than 65, admitted to the facility on [DATE]. According to the November 2024 CPO, diagnoses included atrial fibrillation (irregular heartbeat), vascular dementia, cognitive communication deficit, chronic pain, unsteadiness on feet, muscle weakness, abnormalities of the gate and mobility and dependence on the wheelchair. The 9/3/24 MDS assessment documented Resident #46 was cognitively intact with a BIMS score of 14 out of 15. She did not have rejection of care behaviors. According the MDS assessment, Resident #46 used a wheelchair for mobility. B. Observations On 12/4/24 at 12:43 p.m. Resident #46 was yelling extremely loud. The resident had garbled speech and repeatedly said no as she was being assisted in her wheelchair to the dining room. Her right foot was dragging underneath her wheelchair for approximately 15 to 20 feet before certified nurse aide (CNA) #2 stopped and told the resident she needed to pick up her feet. CNA #2 attempted to move the resident's wheelchair forward again. Resident #46's feet were not on the foot rests that were attached to the wheelchair. She had her left foot firmly planted on the floor in front of her to prevent the wheelchair from moving forward. The resident's right foot was extended back and under her wheelchair. The resident had garbled speech repeatedly and said no, enough and hurt could be identified. CNA #2 identified the foot under the wheelchair and slightly pulled the wheelchair back. The resident was able to pull her foot forward and lift feet up. The resident was taken to a dining room table. At 12:57 p.m. Resident #46 remained visibly upset. The resident continued to say no repeatedly in a loud and tearful tone as a staff member sat next to her asked her to calm down and if she was hurting. The resident said no proceeded to tap her hand on the table. During a continuous observation on 12/4/24, beginning at 2:35 p.m. and ending at 2:43 p.m., the following was observed: At 2:35 p.m. Resident #46 was heard from the hallway in her room. The resident loudly and repeatedly said no. At 2:39 p.m. CNA #4 exited a resident's room next store to Resident #46 with a bag of soiled items. She placed the soiled items in a hall closet/utility room. At 2:41 p.m. CNA #4 exited the room, walked past Resident #46's room, and left the hall as Resident #46 continued to loudly say no. At 2:42 p.m. CNA #4 returned to the hall and re-entered the neighbor's room. At 2:43 p.m. Resident #46's roommate turned on the call light. CNA #4 entered Resident #46's room. On 12/10/24 at 10:24 a.m the speech therapist (ST) entered Resident 46's room. The ST attempted to find Resident #50's communication sheet in the resident's room. The ST was unable to find the communication sheet. At 12:35 p.m. Resident #46 was in the lobby repeatedly saying no, no, no. LPN #2 approached the resident and offered her water. The resident accepted the water and then repeated the words no. At 12:55 p.m. a staff member approached the resident and asked her what she needed. The resident continued to say no. The staff member left the resident. At 12:56 p.m. the nursing home administrator (NHA) approached the resident and asked her if she wanted to go back to her room and lay down. Resident #46 said yes. The NHA informed the resident that she could lay down and the staff was waiting on two CNA's to be available. C. Resident representative interview Resident #46's representative was interviewed on 12/9/24 at 3:20 p.m. He said Resident #46 would say no but she did not always mean no when she said it. He said the ST used a communication board with pictures and words on it to work with her. He said he had not seen the communication board for a while. D. Record review The cognition care plan, dated 6/4/24, identified the care plan had interventions to help her understand related to cognitive deficits but not how to help her with communicating her needs and wants to staff. The cognitive care plan for communication read in part, use the residents preferred name, reducing any distractions, turing off the television radio and closing the door The care plan documented the resident understood consistent, simple, directive sentences and for staff to provide the resident with necessary cues, stop and return if agitated. -The care plan did not direct staff to use a communication sheet. C. Staff interviews LPN #2 was interviewed on 12/9/24 at 4:26 p.m. LPN #2 said Resident #46 had repetitive verbalization which made communication difficult but she would nod yes and no to indicate what she wanted. CNA #4 was interviewed on 12/9/24 at 6:42 p.m. CNA #4 said Resident #46 would usually repeat the word no so she would try to anticipate the resident's needs. She said the resident would say other words other than no at times. CNA #5 was interviewed on 12/9/24 at 6:51 p.m. CNA #5 said the resident would often say no when she was asked a question. CNA #5 said she would start to walk away and the resident would loudly and urgently say no repeatedly which would let her know Resident #50 meant to say yes. The DON was interviewed on 12/9/24 at 5:19 p.m. The DON said Resident #46 hollered if she needed or wanted something. She said the resident tried to say what she wanted but had difficulty speaking. She said the staff had to guess what she wanted. The DON said if the staff guessed wrong and did not understand the resident, she would become frustrated and raise the tone in her voice. The ST was interviewed on 12/10/24 at 10:02 a.m. The ST said Resident #46 was on her case load from 5/29/24 to 7/10/24. The ST said when the resident was first admitted to the facility (5/29/24) the resident was able to communicate in full sentences. The ST said the resident was at her highest level of ability for speech so speech therapy was discontinued. The ST said Resident #46 was restarted on speech therapy services after the resident had a decline in communication and had signs of dysphagia (difficulty swallowing). The ST said the resident was able to use less words and had expressed more frustration with her communication. The ST said Resident #46 was added to her caseload on 8/16/24 through 9/13/24. The ST said the resident had a generic communication board she received from the hospital but the resident did not respond well to it. She said created a new communication sheet/board using familiar phases and words the resident would use. The ST said she responded well to the new communication board and saw an improvement in her communication. She said she had not seen the staff use the communication board but figured it was somewhere in her room. The ST said the resident was still able to communicate a little when she was not agitated. The ST said Resident #46 was going to be added to her caseload again but was told the resident was possibly going to go on hospice so providing additional speech therapy was halted. The ST said the resident did not go on hospice services so she would request the resident to have speech therapy orders again. The ST said the facility had a lot of staff turnover which could have effected consistent communication with Resident #46 and the use of the communication board. She said once the resident was back on her caseload she would work with the resident again using the communication board. The ST said she could show the staff how to help the resident find her words. She said the use of purposeful sounds could also be effective in her communication. She said she could also educate the staff to anticipate Resident #46's needs and asked basic questions when the resident was agitated. The ST said there was an opportunity to educate staff and improve the resident's communication. The director of rehabilitation (DOR) was interviewed on 12/10/24 at 1:02 p.m. The DOR said the resident required wheelchair assistance and did not self propel her own wheelchair. She said the staff should have listened to the resident as they transported the resident to the dining room on 12/4/24, when the resident expressed there was a problem. LPN #2 was interviewed again on 12/10/24 at 10:44 a.m. LPN #2 said he had been Resident #46's nurse for the past five weeks and was not aware of a communication sheet for her. The ST was interviewed again on 12/10/24 at 1:12 p.m. The ST said a communication sheet was laminated and added to the back of the resident's wheelchair on 12/10/24 (during the survey). She said she was going to do one to one education with the staff to show them how to use it. The ST said CNA #5 was aware of the communication board and knew where it was. She said CNA #5 found the board attached to a pink clip board and on her dresser covered with other items. The ST said some of the other staff may not have known where the board was and it was not readily in view. She said the staff should use the communication board/sheet when they tried to communicate with her. The ST said there had not been a consistent way to communicate with the nursing staff. She said sometimes she would speak directly to them or she would post a sign on the wall in a resident's room but the signage was not always welcomed. She said there had been a breakdown in communication with nursing staff and saw it as an area where improvements could be made. The ST said she would ask the NHA and the DON how they would like to implement the staff education related to communication with Resident #46. The ST said she was not familiar with the care plan process but the communication board/sheet should be added to make sure all staff were on the same page, improved communication for the resident and between the departments and decrease the resident's frustration when trying to communicate with staff. The ST said Resident #46 received new physicians orders for speech therapy as of 12/10/24 (during the survey). CNA #1 was interviewed on 12/10/24 at approximately 2:30 p.m. CNA #1 said Resident #46 had a communication sheet but she did not like it so staff stopped using it. The DON was interviewed again on 12/10/24 at 2:05 p.m. The DON said she was not informed that Resident #46 had a communication board. She said no one including the therapy department informed her of the communication board. She said when therapy had a new intervention, they would put in a request/verbal order and the DON would approve it. The DON said the therapy inventions could also be added to the care plan. She said when she was aware of the therapy intervention, the nursing staff could be educated on the intervention. The DON said there was a need to improve communication between therapists and the nursing department. She said the staff should come together and determine how to communicate with Resident #46, create a plan and add it to the care plan.

Based on observations, record review and interviews the facility failed to store, prepare, distribute and serve food in a sanitary manner. Specifically, the facility failed to ensure: -The dishwashing machine temperature and sanitizer levels were consistently addressed when not in range; and, -Resident water cups were consistently cleaned and sanitized. Findings include: I. Dishwasher temperatures and sanitation A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part, The temperature of the wash solution in spray-type warewashers that use chemicals to sanitize may not be less 120 F (Fahrenheit). A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times shall meet the criteria. A chlorine solution shall have a minimum temperature based on the concentration and PH of the solution. Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. B. Manufacturer's label The manufacturer's label on the dishwashing and sanitizing machine read: Water temperatures: Washing: 120 degrees Fahrenheit minimum, 140 degrees Fahrenheit recommended. Rinsing: 120 degrees Fahrenheit minimum, 140 degrees Fahrenheit recommended. C. Record review The dishwasher temperature record was provided by cook #1 on 11/29/23 at 3:30 p.m. and the incorrect temperature or sanitation levels were: 11/1/23: Breakfast: The water temperature was 120 degrees Fahrenheit and the sanitation level was 200. Lunch: The water temperature was 120 degrees Fahrenheit and the sanitation level was 200. 11/2/23: Lunch: The water temperature was 126 degrees Fahrenheit and the sanitation level was 200. 11/3/23: Lunch: The water temperature was 120 degrees Fahrenheit and the sanitation level was 200. Dinner: The water temperature was 100 degrees Fahrenheit and the sanitation level was 122. 11/5/23: Breakfast: The water temperature was 120 degrees Fahrenheit and the sanitation level was 200. Dinner: The water temperature was 100 degrees Fahrenheit and the sanitation level was 200. 11/6/23: Breakfast: The water temperature was 120 degrees Fahrenheit and the sanitation level was 200. Dinner: The water temperature was 100 degrees Fahrenheit and the sanitation level was 200. 11/7/23: Breakfast: The water temperature was 120 degrees Fahrenheit and the sanitation level was 200. 11/8/23: Lunch: The water temperature was 120 degrees Fahrenheit and the sanitation level was 200. 11/9/23: Breakfast: The water temperature was 120 degrees Fahrenheit and the sanitation level was 200. Lunch: The water temperature was 120 degrees Fahrenheit and the sanitation level was 200. 11/10/23: Breakfast: The water temperature was 120 degrees Fahrenheit and the sanitation level was 200. Lunch: The water temperature was 120 degrees Fahrenheit and the sanitation level was 100. Dinner: The water temperature was 100 degrees Fahrenheit and the sanitation level was 120. 11/11/23: Breakfast: The water temperature was 50 degrees Fahrenheit and the sanitation level was 120. Lunch: The water temperature was 120 degrees Fahrenheit and the sanitation level was 200. Dinner: The water temperature was 100 degrees Fahrenheit and the sanitation level was 120. 11/12/23: Lunch: The water temperature was 120 degrees Fahrenheit and the sanitation level was 200. Dinner: The water temperature was 117 degrees Fahrenheit and the sanitation level was 235. 11/13/23: Lunch: The water temperature was 120 degrees Fahrenheit and the sanitation level was 200. Dinner: The water temperature was 220 degrees Fahrenheit and the sanitation level was 104. 11/16/23: Lunch: The water temperature was 120 degrees Fahrenheit and the sanitation level was 200. Dinner: The water temperature was 118 degrees Fahrenheit and the sanitation level was 217. 11/17/23: Breakfast: The water temperature was 110 degrees Fahrenheit and the sanitation level was 210. Dinner: The water temperature was 119 degrees Fahrenheit and the sanitation level was 218. 11/18/23: Dinner: The water temperature was 123 degrees Fahrenheit and the sanitation level was 20. 11/19/23: Breakfast: The water temperature was 120 degrees Fahrenheit and the sanitation level was 200. Lunch: The water temperature was 100 degrees Fahrenheit and the sanitation level was 200. Dinner: The water temperature was 124 degrees Fahrenheit and the sanitation level was 2. 11/20/23: Breakfast: The water temperature was 120 degrees Fahrenheit and the sanitation level was 200. Lunch: The water temperature was 120 degrees Fahrenheit and the sanitation level was 200. Dinner: The water temperature was 99.9 degrees Fahrenheit and the sanitation level was 215. 11/21/23: Breakfast: The water temperature was 120 degrees Fahrenheit and the sanitation level was 200. Lunch: The water temperature was 120 degrees Fahrenheit and the sanitation level was 200. Dinner: The water temperature was 128 degrees Fahrenheit and the sanitation level was 227. 11/23/23: Dinner: The water temperature was 100 degrees Fahrenheit and the sanitation level was 120. 11/24/23: Dinner: The water temperature was 100 degrees Fahrenheit and the sanitation level was 122. 11/25/23: Dinner: The water temperature was 100 degrees Fahrenheit and the sanitation level was 120. 11/26/23: Dinner: The water temperature was 100 degrees Fahrenheit and the sanitation level was 120. 11/27/23: Breakfast: The water temperature was 100 degrees Fahrenheit and the sanitation level was 105. Lunch: The water temperature was 100 degrees Fahrenheit and the sanitation level was 110. 11/28/23: Breakfast: The water temperature was 100 degrees Fahrenheit and the sanitation level was 100. Lunch: The water temperature was 100 degrees Fahrenheit and the sanitation level was 110. Dinner: The water temperature and sanitation levels were not documented. -On numerous occasions, the staff documented the incorrect water temperature and chemical levels for the sanitizing dishwasher (based on cook #1's interview, see below) and there was no documentation of the machine being serviced except on 11/22/23 and 11/30/23 (see below). C. Staff interviews and observations Cook #1 was interviewed on 11/29/23 at 3:30 p.m. He said the dishwashing staff had left for the day and it was his weekend. He said the kitchen staff scrapped food off the residents' dishes, hand scrubbed the dishes and then ran them through the sanitizing dishwasher. He said he told the staff not to overload the machine so the machine worked properly. He said they ran each tray of dishes twice to ensure the dishes were thoroughly sanitized. He said the dishes air-dried and then were put away in their designated locations. Cook #1 said the machine's water temperatures and chemical levels were checked after each meal. He said the sanitizing dishwasher worked as it should last time he checked. Cook #1 ran the machine twice and the water temperature reached 110 degrees Fahrenheit and the chemical strip showed the chemical was at a 10. He said the sanitizing dishwasher should not reach a temperature over 120 degrees Fahrenheit and the chemicals should be between 50 and 100. He ran another cycle on the machine. The water temperature reached 120 degrees Fahrenheit and the chemical tested at 10 again. He ran the machine again and switched to another tube of chemical strips and the water temperature reached 132 degrees Fahrenheit and the chemical still tested at 10. He primed the machine's chemicals and ran it again. The water temperature reached 138 degrees Fahrenheit and the chemical levels were still at 10. Cook #1 said he reached out to the representative for the machine and someone was going to check the machine. He switched to disposable dishes and cutlery for the next meal and sanitize-ready spray chemicals for the meal trays until the machine was serviced. He said if the machine did not show the correct chemical level, the staff drained the water, primed the chemicals, ran the machine and tested it again. He said he had not seen mold on the residents' dishes. The dietary manager was not available during the survey for an interview. The director of nursing (DON) and regional operations manager (ROM) were interviewed on 11/30/23 at 4:19 p.m. The ROM said if the staff ran the dishwasher at the wrong temperature then they needed more education to correct the situation. She said the kitchen team was fairly new. She said the facility would provide education on the dishwasher and sanitization process. V. Facility follow-up The ROM provided service reports for the sanitizing dishwashing machine on 12/3/23 at 10:33 a.m. She provided the service report for 11/22/23 and 11/30/23. A. 11/22/23 service report The technician stopped in to make sure the dish machine was working properly and placed an order for the dish machine chemical. B. 11/30/23 service report The technician changed the squeeze tubes and lines. The machine worked well. II. Resident water cups A. Representative interview Resident #3's representative was interviewed on 11/29/23 at 1:54 p.m. He said he visited the resident every day and the resident never had water in his room. The representative said he was trained to rinse out the resident's water cup and fill it with fresh water. He said he had seen mold in the resident's water cup on two separate occasions. B. Staff interviews The assistant director of nursing (ADON) was interviewed on 11/30/23 at 12:05 p.m. She said she had seen mold in the residents' pink water cups on three separate occasions. She said it was something the facility was working on correcting. She said she had no idea where the mold came from but assumed the cups sat too long. She said the facility tried to keep the pink cups for iced water only but residents requested other liquids in the cups and then the liquids just sat in the cups. The ROM was interviewed on 11/30/23 at 2:12 p.m. She said she could not find an exact number but mold usually took 24 to 48 hours to grow because there were different types of mold. She said mold did not grow in a couple of hours. She said when staff passed ice, they gave the residents new water cups and took the old cups to the kitchen to be cleaned. She said cups should be swapped out each day by staff. The DON was interviewed on 11/30/23 at 3:10 p.m. She said residents' water cups were swapped out by staff every day. She said it was important for the cups to be swapped out and properly sanitized to prevent the residents from getting sick. She said she was not aware there had been mold seen in the residents' water cups.

Based on observations, record review and interviews, the facility failed to provide appropriate treatment and services to maintain or improve residents' ability to perform activities of daily living (ADLs) for three (#1, #2 and #3) of five residents reviewed for ADLs out of 11 sample residents. Specifically, the facility failed to ensure: -Resident #3's catheter bag was emptied regularly; -Resident #3 was provided incontinence care and repositioning consistently; -Resident #2 was offered and provided timely bathing and oral care; and, -Resident #1 was offered and provided bathing at least twice a week or as preferred. Findings include: I. Staff assistance with catheter care, repositioning and incontinence care A. Facility policy 1. The Emptying of a Urinary Collection Bag procedure, revised April 2022, was provided by the regional operations manager (ROM) on 11/30/23 at 4:00 p.m. and read in pertinent: The purposes of this procedure are to prevent the collection bag from becoming full and allowing urine to flow back into the bladder. Empty the urinary collection bag at least every eight hours or more often if needed to keep the bag from becoming full. Keep the collection bag below the level of the resident's bladder. Keep the collection bag and tubing off the floor at all times to prevent contamination and damage. Place the clean equipment on the bedside stand or overbed table. Arrange the supplies so they can easily be reached. Wash and dry your hands thoroughly. Put on disposable gloves. Place a paper towel on the floor beneath the drainage bag. Position the measuring container under the collection bag. Remove the drain tube from its holder. Unclamp the valve on the drain spout and let the urine flow into the measuring container. After the drainage bag has been emptied, clamp the valve. Wipe the drain with an alcohol sponge or swap. Discard the sponge or swap into the designate container. Replace the drain spout back into its holder. Pour urine down the commode. Flush the commode. Rinse the measuring container and return to its designated storage area. Discard all disposable items into designated containers. Remove gloves. Wash and dry your hands. Clean the bedside stand or overbed table. Return the overbed table to its proper position. Reposition the bed covers. Make the resident comfortable. Place the call light within easy reach of the resident. Wash and dry your hands. 2. The Pressure Injury policy, revised on 3/10/23, was provided by the ROM on 11/30/23 at 4:00 p.m. and read in pertinent: The purpose of the policy was to assess and implement interventions as appropriate to reduce the likelihood of development of pressure injuries and that a resident who has a pressure injury receives appropriate care and services to promote healing and to prevent additional pressure injuries. General skin care guidelines: Cleanse the skin with warm water and mild soap. Do not massage bony prominences vigorously. Apply cream or lotion to the skin as needed. Use appropriate techniques for repositioning the resident. Keep bed and linen clean, dry, and free of wrinkles or crumbs. Report any abnormal skin conditions to the supervisor. Check residents for incontinence per the plan of care. Cleanse the skin after each incontinent episode. Protecting against the effects of pressure, friction, and shear: Reduce pressure over bony prominences by offloading and positioning. Develop turning and repositioning plans for the resident in bed or chair. Position with the head of the bed no more than 30 degrees if applicable. Maintain good hydration. B. Resident #3's status Resident #3, age 65, was admitted to the facility on [DATE] and discharged on [DATE]. According to the November 2023 computerized physician orders (CPO) diagnoses included fracture of the right femur, hemiplegia (paralysis) and hemiparesis (muscle weakness) following unspecified cerebrovascular disease affecting the right (dominant) side, aphasia (loss of ability to understand or express speech caused by brain damage) following cerebral infarction (stroke), dementia, Parkinson's disease, and B-cell lymphoma (cancer) of the head, face, and neck. The 9/25/23 minimum data set (MDS) assessment showed a severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. Resident #3 required extensive assistance from two staff for bed mobility, transfers, toileting, showering, and dressing. He required extensive assistance from one staff for dressing and grooming. C. Representative interview Resident #3's representative was interviewed on 11/29/23 at 1:54 p.m. He said he visited Resident #3 every day at the facility and he never had water to drink in his room. He said he saw the resident's catheter bag full of urine and backed up into his bladder which caused a urinary tract infection (UTI). He said the staff did not position Resident #3 frequently and he ended up getting a stage 2 pressure ulcer on his buttocks and sores on his back. He said the resident's hospice nurse informed him of the pressure ulcer and that the resident was not being cleaned or repositioned enough. He said he visited one day and a certified nurse aide (CNA) emptied Resident #3's catheter bag without putting gloves on. The CNA emptied the catheter bag into the plastic receptacle over the resident's eating table and spilled urine on the floor. The CNA did not clean the urine he spilled and did not wash his hands when he left the room. He said he watched the CNA continue to pass fluids to other residents after he left Resident #3's room. He said he cleaned up the urine off the floor after the CNA left. D. Hospice nurse interview Resident #3's hospice registered nurse (RN) was interviewed on 11/30/23 at 10:45 a.m. She said on several occasions when she visited Resident #3 his catheter bag had not been emptied. She said she saw him between mid-morning and early afternoon and his urine was backed up. She said he was unshowered and wore dirty clothes. The hospice RN said the staff told her Resident #3 refused care. She said Resident #3 had expressive dysphagia which meant he had a hard time expressing what he needed or wanted. She said the staff never approached the resident after he refused care the first time. She said she checked his catheter the last few visits because he had issues with it. She noticed his brief was pulled up too tight into his groin. She said the actual stat lock was pulled up into his urethra, when she pulled it to clean it the whole catheter came out and Resident #3 felt immediate relief because it caused him a lot of pain being pulled up too high. The hospice RN said the CNA entered the room and provided a bed bath. She noticed shearing on the resident's buttocks while the CNA provided care. She said she told Resident #3's nurse for the day that he had shearing and asked for the resident to get repositioned every two hours and for the nurse to pass it on to the other nurses. She said she told the nurse the staff needed to reapproach if the resident refused care because it was not good for him to sit soiled. She said about two to three weeks later she ran into the assistant director of nursing (ADON) and asked how Resident #3's shearing was healing and the ADON told her she did not know anything about shearing for him. She said the nurse did not pass on the information and his skin was not being treated to prevent the shearing from worsening. She said Resident #3 was incontinent of his bowels and he did not realize he was incontinent. She said no staff checked on him in the mornings because she would come in and he was soiled with dried feces on him and his catheter bag full. She said one visit was really bad when his catheter back was completely full and backed up into the bladder and he had dried feces on his stomach, face and hands, and coming out of each hole of the brief with feces dried up along his back. She said she grabbed a CNA to help get the resident cleaned and it took them about 45 minutes to get him cleaned up. She said when the brief was removed from the resident the feces made the brief stick to his skin and when the brief was peeled off the shearing was a stage 2 pressure ulcer. The hospice RN said it looked like he had sat in the condition for a while and he was not checked on by the staff all morning. She said there was feces on his sheets and his hospital gown. She noticed a clean cloth pad had been placed on top of a dirty pad and there was feces on both cloth pads. She said at that point she asked for the nurse to come into the room. The ADON was covering the floor that day and the hospice nurse pointed out what was going on with Resident #3. She told the ADON the pressure ulcer was a skin shear a couple of weeks ago and no staff treated it. The ADON grabbed the director of nursing (DON) to inform her of the situation. The hospice RN said she wanted to inform the ADON and DON so they knew what was wrong and to ensure Resident #3 got treated for it. The hospice RN said she cleaned the pressure ulcer and applied a bandage. E. Record review A change of condition was completed for Resident #3 on 6/28/23. It documented the resident experienced 10 out of 10 abdominal pain and was sent to the emergency room to be treated. A nursing progress note was also documented on 6/28/23 at 9:01 a.m. It documented that at 7:50 a.m. the resident reported pain in his abdomen as a 7 out of 10. A bloated abdomen was noted. Simethicone 80mg (relieves pain from gas in the stomach and intestines) and Pantoprazole 40 mg (reduces acid in the stomach) was administered at 6:00 a.m. At 8:40 a.m. the resident still complained of pain but it was in the lower abdomen this time. Vitals were within normal limits. The resident reported his last bowel movement was the previous day on 6/27/23. The resident refused all of his morning medications due to being in pain. The nurse called the physician and spoke to his medical assistant who said the doctor needed to see the resident before any order could be written. In coordination with the DON, the resident was sent to the emergency room . A 6/30/23 progress note documented that when the family was visiting the resident they informed the nurse that the emergency room doctor said Resident #3 was diagnosed with a UTI when he was at the emergency room . The family picked up his Macrobid 100mg (antibiotic) and provided it to the facility. A 7/5/23 progress note documented Resident #3 was continent of bowel and had no skin issues. A 7/18/23 progress note documented Resident #3 was continent of bowel and had no skin issues. A 7/25/23 progress note documented Resident #3 was continent of bowel and had no skin issues. An 8/2/23 progress note documented Resident #3 was continent of bowel and had no skin issues. An 8/14/23 hospice progress note documented that Resident #3 had some discomfort with his catheter. The resident was lying on the tubing and the catheter itself was kinked. The stat lock was attached and was in the urethra. The hospice RN adjusted the catheter and the urine was draining better and Resident #3 felt relief. An 8/15/23 progress note documented Resident #3 was continent of bowel and had no skin issues. An 8/18/23 progress note documented the CNA and nurse went to the resident's room to assist him. It was really difficult to understand his needs due to his communication. He got frustrated with the staff and then said sorry. The resident acted like he wanted to get into his wheelchair and go to the restroom even though he had a catheter and wore a brief. The staff assisted the resident to the edge of the bed and he grabbed the wheelchair bar with his good arm and hand and tried to stand up. His foot slipped out from under him and he started going down to the floor on his bottom. The nurse helped assist him down to the ground in a sitting position. The CNA was sent to find help to get him up off the floor. The staff used a Hoyer (mechanical) lift and got the resident back into bed and the resident mentioned he was not in any pain. No bruises or scrapes were noticed. He did not sustain any injuries. His hospice nurse was notified. The resident was resting in bed and had his call light within reach. An 8/18/23 hospice progress note documented the resident attempted to stand with two staff members assisting him and he fell on his buttocks to the ground. No injuries were noted. An 8/21/23 hospice progress note documented Resident #3 complained about his catheter hurting him. The hospice RN took the catheter out of the stat lock and the discomfort resolved. The hospice RN told the facility nurse about the resident's discomfort. An 8/22/23 progress note documented Resident #3 was incontinent of his bowel and had no skin issues. A 9/19/23 hospice progress note documented Resident #3's catheter bag was emptied. 1300cc of urine was removed from the catheter bag and the urine was dark with sediment in it. A 9/21/23 hospice progress note documented the hospice social worker visited the resident and noticed a smell of infection and the resident appeared to need a shower. The hospice social worker documented she informed the facility staff. A 9/28/23 hospice progress note was documented that the resident's catheter bag was emptied. 650cc was removed from the catheter bag and the urine was dark in color. The hospice CNA documented she provided a bed bath and noticed a vertical red area that was splotchy on his right inner thigh where his brief sat on his leg. A 9/29/23 progress note documented Resident #3 was incontinent of his bowel and had no skin issues. A 10/9/23 hospice progress note documented the hospice RN emptied Resident #3's catheter bag. 675 cc of amber-colored urine with sediment was removed. A 10/10/23 progress note documented the resident's right buttock had a slight rash but was noted to be clearing with the use of protective skin cream. A 10/12/23 hospice progress note documented the hospice CNA emptied Resident #3's catheter bag. She removed 1400cc of dark and cloudy urine. A 10/16/23 hospice progress note documented that Resident #3 had some shearing to his right buttocks in two spots and Cavilon barrier cream was applied. Bruising was also noted on his right upper leg. A 10/18/23 progress note documented the resident had some excoriation to his buttock, heel protectors were placed, and the resident was resistant to position changes and preferred to lay on his back for comfort. Staff offloaded pressure when checking and changing the resident and barrier cream was in place for wound prevention. A 10/25/23 hospice progress note documented upon the hospice RN's arrival she discovered Resident #3 resting comfortably in bed but a foul odor was noticed in his room. The hospice RN checked Resident #3's catheter bag and noticed the resident's brief was full of stool and there was dried stool on his hospital gown and groin area. Resident #3's catheter bag was completely full and the hospice RN drained approximately 3000cc of urine from the bag. The hospice RN located a facility CNA to assist with getting the resident changed. The CNA was documented as very apologetic during the brief change. While the hospice RN cleaned Resident #3's buttocks she discovered a stage two pressure ulcer where skin shearing was discovered the week before. The hospice RN asked the CNA to get the ADON and DON to assess the wound. The wound measured 3.5cm x 2cm x 0.1 (width by length by depth). The hospice RN cleansed the wound thoroughly and applied a barrier film spray and a foam dressing provided by the facility. The hospice RN departed her visit with Resident #3 and attended the facility's interdisciplinary team (IDT) meeting for Resident #3. She expressed her frustration with the situation and reported that the quality of care was unacceptable during the IDT meeting. The facility's social worker, nursing home administrator (NHA) and DON were made aware of the situation during the meeting. A 10/26/23 hospice progress note documented Resident #3's representative requested to move the resident to another facility due to the lack of care he received. The hospice social worker spoke with Resident #3 who agreed he wanted to move to another facility. A 10/27/23 progress note documented Resident #3 had a bowel movement that morning. The CNA and nurse cleaned and changed the resident. The nurse changed the resident's dressing. Another 10/27/23 progress note documented the resident had a telehealth visit with his physician and an order was sent to monitor the resident's pressure wound and change the dressing as ordered. -However, the facility was inconsistent with documenting the weekly nursing notes and did not appropriately track the resident's pressure ulcer. F. Staff interviews A staff member who requested to remain anonymous was interviewed on 11/29/23. The staff member said the facility had a problem with providing good incontinence care. The staff member said residents were sometimes left in wet pants. The ADON was interviewed on 11/30/23 at 12:05 p.m. She said if a resident refused care she sent in another CNA or attempted to approach the resident in a different way. If the resident continued to refuse she documented the refusal and what approaches were tried. She said she had the following shift approach the resident as well. She said she experienced a lot of residents refusing care in the facility. She said the facility provided staff training and she believed the facility covered residents refusing care. The ADON said she remembered the hospice RN told her Resident #3 had not been changed and the hospice RN was upset about it. She said Resident #3 refused care if it was a female staff because he preferred male staff. She said she remembered the resident had a pressure injury on his buttocks before he left the facility but it was the first sore she recalled him having since he was admitted . She said he refused to reposition and preferred to lay flat on his back. She said the staff offered to position him on his side or to transfer him to a recliner and he refused. She said he was not able to verbalize very much but could say no or shake his hand if he did not want something. She said the resident was really stiff if they tried to move him and once he was repositioned he would roll onto his back. She said if the facility staff noticed a skin issue they would have completed a change of condition, started preventative measures and changed the resident more frequently. She said the nurses documented weekly nursing forms which included skin checks. The ADON said catheter bags needed to be emptied frequently and could be emptied by CNAs and RNs. She said the staff should not empty the urine over a table, catheter bags should be emptied over the floor in case the staff spilled the urine. If urine did spill the staff cleaned it up with sani-wipes. She said she had to direct staff to empty catheter bags more frequently because she noticed Resident #3's bag was full and it was important the urine did not back up into the bladder because it caused UTIs. She provided informal education to the staff about emptying catheter bags frequently and for catheter bags to be checked every time the staff entered the resident's room. She said the facility completed a lot of in-services and she felt the staff did not retain the information as well as they did when trained in the moment. She said she worked with the CNAs on bathing and hygiene provided to the residents. She wanted the residents to be cleaned up before they left their rooms. She said the CNAs got overwhelmed and rushed through bathing residents to get all of the baths or showers completed. She said she was actively working on it and bathing had slowly gotten better. Licensed practical nurse (LPN) #1 was interviewed on 11/30/23 at 1:20 p.m. She said she had to talk to the night shift staff that morning because a resident was left soiled when she completed her rounds. She said she had not experienced residents not being changed until 11/30/23 but was aware it happened. The DON was interviewed on 11/30/23 at 3:10 p.m. She said when a resident refused care the staff should document the refusals and approach the resident again. She said if residents refused care constantly the facility needed to do what they could to get the resident to accept the care but it was also their right to refuse. She said catheter bags needed to be emptied every shift but the facility did not document the output of urine. She said the facility and the hospice provider collaborated together for the resident and hospice nurses came out pretty regularly to oversee the resident's care and pain management while the hospice CNAs came out one to two times a week to bathe the residents. She said if the hospice RN discovered a wound they assessed and the facility nurse assessed to make sure they were in agreement with what was going on and how it needed to be treated. The facility nurse was responsible for completing a change of condition. She said Resident #3 was checked and changed every two hours and as needed per the facility's policy. The DON said there were multiple factors to a resident developing a pressure ulcer but the main cause was pressure. She said some residents were at a higher risk for pressure ulcers than others. If the skin was red and it did not dissipate then it was documented as a stage 1 pressure ulcer. She said skin shearing could be caused during the positioning of a resident and that skin shearing could lead to a pressure ulcer. She said she was not aware of how much stool was on Resident #3 when the hospice RN reported it to her. She was told the dried stool was just on his stomach and the cloth pad on his bed. She was unaware of how long the resident sat like that but if the stool was runny then it would not take long to dry. The DON said the staff offloaded the residents if they did not have good mobility to do it themselves. The staff repositioned the resident, even if it was a slight pressure change it helped. She said she saw nothing in Resident #3's medical record that indicated he had a pressure ulcer or what caused it but pressure ulcers could occur in a very short amount of time. She said when hospice provided their progress notes medical records uploaded them to the resident's chart. She was unsure if the facility read through hospice notes before uploading them. 40467 II. Personal hygiene A. Facility policy The Resident Shower policy, revised February 2021, was provided by the facility on 11/30/23. The policy read in part: It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. B. Resident #2 1. Resident status Resident #2, age under 65, was admitted on [DATE] and readmitted on [DATE]. According to the November 2023 computerized physician orders (CPO), diagnoses included cerebral infarction (stroke) due to thrombosis of the left anterior cerebral artery, aphasia (a language disorder after damage to the brain) following cerebral infarction, depression, chronic pain syndrome, other speech and language deficits following a cerebral infarction. According to the 11/7/23 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for a mental status (BIMS) score of 10 out of 15. The MDS assessment did not identify behavioral symptoms or rejections of care. The MDS assessment indicated the resident had occasional severe pain. The 11/7/23 MDS assessment did not include her current ADL status. The 1/12/2020 admission MDS assessment identified the resident needed assistance with self care. According to the MDS assessment, Resident #2 needed partial to moderate assistance with bathing. She needed supervision to include verbal cues or touching for oral hygiene. 2. Resident interview Resident #2 was interviewed on 11/29/23 at 3:59 p.m. She said she did not have enough showers/bathing offered to her. She said would like a shower at least two to three times a week. She said she received a shower once a week or less. The resident said she last received a shower on 11/27/23. Resident #2 said the staff did not brush her teeth daily. She said she would like to have her teeth brushed everyday in the morning and before she went to bed. Resident #2 said she needed help brushing her teeth and she did not refuse offers from staff to help her brush her teeth. The resident today (11/29/23) staff brushed her teeth well but staff did not often brush her teeth twice a day and sometimes staff did not brush her teeth at all in a day. She said she might have a cavity. 3. Frequent facility visitor interview A frequent facility visitor was interviewed on 11/30/23 at 9:19 a.m. The visitor said on 10/25/23 Resident #2's skin felt dirty on touch, her hair was disheveled and her teeth were not clean. The visitor said the resident did not know the last time she had a shower. 4. Record review The October 2023 and November 2023 progress notes for Resident #2 were reviewed. The notes identified the only documented day Resident #2 refused a shower on 11/22/23. According to the 11/22/23 note, staff would ask the nurse on the next shift (licensed practical nurse #1) to offer a shower to Resident #2 (see below.) The October 2023 bathing/shower record for Resident #2 was provided by the facility on 12/5/23 via fax. The October 2023 bathing/shower record for Resident #2 identified Resident #2 refused a shower on 10/2/23, 10/11/23 and 10/20/23. The bathing record identified the resident received a shower on 10/7/23 and on the evening of 10/25/23. -The resident received two showers out of an estimated eight opportunities for showers. The November 2023 bathing/shower record for Resident #2 was provided by the facility on 11/30/23. The bathing record identified she received a shower on 11/13/23 and 11/27/23. -The record did not identify the resident refused bathing opportunities in November 2023. The November 2023 shower/bathing sheets were reviewed for Resident #2. The bathing sheets identified Resident #2 had three showers in November 2023. According to the bathing sheet, Resident #2 received a shower on 11/13/23, 11/22/23 and 11/27/23. -The resident had only three showers out of an estimated eight opportunities to shower for November 2023. -The bathing sheets did not identify the resident refused other opportunities for bathing. The November 2023 oral hygiene record was provided by the facility on 11/30/23. The oral hygiene record did not identify Resident #2 had her teeth brushed on 11/2/23, 11/6/23, 11/7/23, 11/21/23, 11/22/23 and 11/24/23. The record was marked not applicable for 11/2/23, 11/6/23, 11/7/23, 11/21/23, 11/22/23 and 11/24/23. The oral hygiene record identified Resident #2 had her teeth brushed only once a day on 11/1/23, 11/1/23, 11/4/23, 11/5/23, 11/8/23, 11/9/23, 11/11/23, 11/12/23, 11/15/23, 11/15/23, 11/16/23, 11/17/23, 11/18/23, 11/19/23, 11/26/23, 11/27/23 and 11/28/23. The oral hygiene identified the resident refused on 11/3/23. -There was no other refusals for oral hygiene documented in November 2023 for Resident #2. The activities of daily living (ADL) care plan, initiated on 8/29/23, read Resident #2 had a ADL self-care performance deficit r/t hemiplegia, impaired balance, and limited mobility. The care plan identified the resident required extensive physical assistance from one staff member. The care plan directed staff to observe, document and report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, and declines in function. -The ADL care plan did not identify the resident refused showers. -The ADL care plan did not identify what staff should do if the resident refused showers. The oral health care plan, initiated on 1/24/2020, read Resident #2 had the potential for dental/oral health problems related to a change in the resident's ADL ability. -The care plan did not identify Resident #2 refused oral care. C. Resident #1 1. Resident status Resident #1, age under 65, was admitted on [DATE] and readmitted on [DATE]. According to the November 2023 CPO, diagnoses included chronic respiratory failure with hypoxia (low oxygen level), morbid (severe) obesity, major depressive disorder, bipolar disorder, anxiety and chronic fatigue. According to the 10/2/23 MDS assessment, the resident's cognition was intact with a BIMS score of 15 out of 15. The MDS assessment did not identify behavioral symptoms or rejections of care. The 10/2/23 MDS assessment did not include her current ADL status. The 7/2/23 MDS assessment identified the resident needed substantial to maximal assistance with bathing, transferring and bed mobility. 2. Resident interview Resident #1 was interviewed on 11/29/23 at 11:33 p.m. Resident #1 said she received bed baths and had not received them as she should. She said she should be offered bed baths at least twice a week. She said she did not receive a bed bath last Friday (11/24/23) or Sunday (11/26/23). She said she only received a partial or mini bed bath on Tuesday (11/28/23). Resident #1 said she had issues with her skin and was concerned that if she did not have routine bed baths, her skin would worsen. Resident #1 indicated she preferred bed baths instead of showers. 3. Record review The bathing care plan, initiated on 4/5/23, read Resident #1 was dependent on staff for bathing related to morbid obesity. The ADL care plan, initiated on 6/3/16, read Resident #1 had an ADL self-care performance deficit related variances in mobility between day and night time abilities and morbid obesity. The November 2023 shower/bathing sheets were reviewed for Resident #1. The bathing sheets identified Resident #1 had three bed baths in November 2023. According to the bathing sheet, Resident #1 received a bed bath on 11/3/23, 11/12/23 and 11/21/23. -The bathing sheets did not identify the resident refused a bed bath on 11/17/23. -The bed bath for 11/19/23 was left blank and did not identify if the resident received a bed bath or refused. The November 2023 bathing/shower record for Resident #1 was provided by the facility on 11/30/23. The bathing record identified she received a bed bath on 11/3/23, 11/12/23, 11/19/23 and 11/28/23. The record identified the resident refused a bed bath on 11/17/23. -The resident had four bed baths out of an estimated eight bathing opportunities for November 2023. The November 2023 progress notes for Resident #1 were reviewed. The progress notes did not identify the resident refused a bed bath. The ADL care plan for Resident #1 was initiated on 6/3/16.Resident #1 has an ADL self-care performance deficit related to variances in mobility between day and night time abilities and morbid obesity. D. Resident council minutes The November 2023 resident council minutes were provided by the ROM on 11/29/23 11:15 a.m. The minutes identified residents in the resident council requested bathing preferences to be updated. An action plan generated on 11/15/23 identified a staff member would be assigned to obtain residents' bathing preferences. E. Staff interviews A staff member who requested to remain anonymous was interviewed on 11/29/23. The staff member said staff did not regularly brush residents' teeth or hair and there was often dried food on the residents' clothing. The activity director (AD) and the ROM was interviewed on 11/29/23 at 11:04 p.m. The AD said residents in the resident council felt the facility needed to update residents' bathing preferences. The ROM said a staff member on light duty was going around to all the residents to a[TRUNCATED]

Based on observations, record review, and interviews the facility failed to effectively follow an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection for two out of six halls. Specifically, the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) when providing care to the residents in rooms #15, #16, #17 and #43 who were on isolation protocol. Findings include: I. Observations A. 11/29/23 At 9:00 a.m., room [ROOM NUMBER] was observed to not have PPE outside of the door but had a sign posted the resident was on contact precautions. The sign documented that anyone who entered the room needed to clean their hands before entering and when leaving the room and needed to wear a gown, gloves, N95 respirator and eye protection. At 9:00 a.m. room [ROOM NUMBER] was observed to have PPE hanging on the outside of the door which contained surgical masks, gloves, face shields and sugar bags (dissolvable bags to transport clothes to laundry). There was a sign posted that the resident was on contact precautions. The sign documented that anyone who entered the room needed to clean their hands before entering and when leaving the room and needed to wear a gown, gloves, N95 respirator and eye protection. There was a table and trash can located outside of room [ROOM NUMBER]. At 10:34 a.m., room [ROOM NUMBER] was observed to have PPE hanging on the outside of the door which included sugar bags, surgical masks, gloves and gowns. The table and trash can that were outside of room [ROOM NUMBER] were moved in between room [ROOM NUMBER] and room [ROOM NUMBER] with extra gowns and masks placed on it. The PPE was inconsistently stored with the resident rooms on isolation. At 10:37 a.m., the physical therapist (PT) entered room [ROOM NUMBER] wearing only an N95 mask and did not have all the appropriate PPE donned. At 10:46 a.m., room [ROOM NUMBER] was observed to have PPE hanging on the outside of the door. No trash can or gowns were visible for staff to put on before they entered the room. The door had a sign posted that the resident was on contact precautions. The sign documented that anyone who entered the room needed to clean their hands before entering and when leaving the room and needed to wear a gown, gloves, N95 respirator and eye protection. The PPE holder only contained three N95 masks, gloves and sugar bags. At 10:54 a.m., the table between room [ROOM NUMBER] and room [ROOM NUMBER] contained hand sanitizer, N95 masks, and face shields. At 10:58 a.m., the PT entered room [ROOM NUMBER], which was not on contact precautions. She performed hand hygiene before she entered the room however she had previously been in room [ROOM NUMBER] without wearing a gown and provided care to the resident in isolation and then provided care to a resident not in isolation. At 1:24 p.m., room [ROOM NUMBER] did not have gowns for the staff to wear before they entered to provide the resident with care. At 2:42 p.m., certified nurse aide (CNA) #2 was in room [ROOM NUMBER] with the door cracked. CNA #2 removed his gloves and an N95 mask before he left the room. He put on a new surgical mask but did not perform hand hygiene. He was not wearing a gown or goggles, just his normal glasses. At 4:19 p.m., the table with PPE and trash can between room [ROOM NUMBER] and room [ROOM NUMBER] were no longer in the hallway. room [ROOM NUMBER] was prepped for a new admission who would be on isolation protocol. The door to room [ROOM NUMBER] had a PPE holder that held gloves, gowns, N95 masks, hand sanitizer, hazardous material bags and one pair of unwrapped goggles. At 5:55 p.m., CNA #3 brought plastic silverware to room [ROOM NUMBER] for dinner. She put on a gown and added an N95 mask over her surgical mask, which did not allow the N95 to accurately seal to her face since the surgical mask prevented the N95 from touching her skin and put on a face shield and gloves. She entered room [ROOM NUMBER] and closed the door. She exited the room a few minutes later without any PPE on. At 6:14 p.m., the assistant director of nursing (ADON) was administering medications to room [ROOM NUMBER]. She put on a gown and gloves and was already wearing an N95 mask and goggles. When she left room [ROOM NUMBER], she removed all of her PPE except her N95 mask and goggles. At 6:28 p.m., the ADON prepared to enter room [ROOM NUMBER] to administer medications. She put on a new gown and gloves but continued wearing the same N95 mask and goggles. She administered room [ROOM NUMBER]'s medications and gave him his meal tray for dinner. She removed all of her PPE except for her N95 mask and goggles. At 6:32 p.m., CNA #2 was already wearing an N95 mask but put on a gown and goggles to serve room [ROOM NUMBER] his meal tray. CNA #2 did not wear goggles, only his normal glasses. He served room [ROOM NUMBER] the meal tray with the door left wide open. He removed his PPE except for his N95 mask and closed the door as he left the room. He did perform hand hygiene and put on a new gown and gloves while he grabbed room [ROOM NUMBER]'s meal tray. He was not wearing goggles, just his normal glasses as he entered room [ROOM NUMBER] and left the door wide open. He set up room [ROOM NUMBER]'s meal tray then removed his PPE, except for his N95 mask and closed the door when he left the room. CNA #2 then answered a call light in room [ROOM NUMBER], who was not in isolation, with the same N95 mask he wore in the isolation rooms and did not perform hand hygiene prior to entering room [ROOM NUMBER]. II. Staff interviews The ADON was interviewed on 11/29/23 at 1:41 p.m. She said the facility did not have a COVID-19 unit. She said room [ROOM NUMBER] and room [ROOM NUMBER] were admitted to the facility and were already positive for COVID-19. She said room [ROOM NUMBER] tested positive for COVID-19 on 11/29/23 at 6:00 a.m. The ADON said since room [ROOM NUMBER] only had one resident the facility did not move him to the hallway where the other residents with COVID-19 were placed. She said the gowns were worn to protect the staff and other residents so the staff did not carry COVID-19 throughout the building and expose other residents. She said the staff removed their PPE in the residents' room because that was where the trash can was placed and the staff wore an N95 mask in the isolation rooms but switched to a surgical mask when they left the rooms. She said the residents were not able to leave their rooms but staff and family went into the rooms as long as they wore the correct PPE and followed infection control protocols. The director of nursing (DON) and regional operations manager (ROM) were interviewed on 11/29/23 at 7:00 p.m. The DON said the staff needed to wear an N95 mask, eye protection, a gown and gloves before they entered the COVID-19 isolation rooms. The ROM said the staff needed to remove the N95 mask and put on a new mask each time they left an isolation room. She said eyeglasses did not count as eye protection unless the glasses had guards on them. She said if the N95 mask did not have a proper seal the droplets could get through the gap. The staff should only wear an N95 mask not both a surgical mask and an N95 mask. The ROM said she would put together an action plan and train the staff before she left for the night. She said the concern with proper PPE would be shared with the interdisciplinary team (IDT) so they could take over after she left. The DON said the COVID-19 outbreak was more of a trickle outbreak where only one person was positive and they would prepare to come off of COVID-19 outbreak precautions and someone else tested positive and they started over. The ROM said PPE training was provided during orientation for onboarding and reviewed annually and as needed if there was an issue. The ROM was interviewed on 11/30/23 at 11:35 a.m. She said she, the DON and the ADON provided training to the staff members for PPE requirements (see below). She said they completed it the night of 11/29/23 to ensure staff wore the PPE correctly in the isolation rooms. III. Facility follow-up A copy of the COVID-19 Education was provided by the ROM on 11/30/23 at 11:35 a.m. and read in pertinent: PPE required: N95 mask, eye protection (personal eyeglasses do not count must be goggles), gown, and gloves. Donning (putting on) and Doffing (removing): Appropriate masking surgical masks must be removed prior to placing an N95 mask. You will not get a seal if the surgical mask is under the N95 and you will not be protected. Facial hair must be removed so that the N95 mask can seal correctly. If facial hair is present the N95 will be ineffective. All required PPE must be put on before entering an isolation room. All PPE must be removed before exiting an isolation room at the door. This includes your N95 mask every time. Exit room, sanitize hands, and place a clean surgical mask on. Disinfect your face shield or eye protection then sanitize your hands. No PPE can be reused, it must all be discarded each time you leave an isolation room, except for eye protection or a face shield. Enhanced droplet precaution rooms: Doors must be kept closed at all times, when staff enter the room they must close the door behind them. Ensure that appropriate PPE is available on the outside of the isolation room.

Based on observations, record review and interviews, the facility failed to ensure one (#2) resident out of 11 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to: -Thoroughly assess Resident #2 after the resident reported a new or worsening condition; and, -Ensure the Resident #2 had a timely physician appointment scheduled as requested by the physician. Findings include: I. Facility policy The Changes in Resident Condition policy, dated 11/3/23, was provided by the facility on 11/30/23. The policy read in part: The resident, attending physician and legal representative or interested family member were notified when changes in conditions or certain events occur. Communication with the IDT (interdisciplinary) team and caregivers is also important to ensure that consistency and continuity are maintained for the resident's benefit. A facility must immediately inform the resident; consult the resident's physician; and if known notify the residents legal representative or an interest family member when there is: -An accident involving the resident which results in injury and potential for acquiring physical intervention; -A significant change in the resident's physical, mental, or psychosocial status; -A need to alter treatment significantly; -A decision to transfer or discharge the resident from the facility. The policy directed staff to document in the resident's medical record to include: -The date and time of the change of condition and who was notified regarding the change of condition. -What information was communicated. -The response from the communicated information and/or orders received. -Assessment of the resident's condition and ongoing monitoring of the resident's condition. -The care provided to the resident. II. Facility expectations The Change of Condition procedures, undated, was provided by the director of nursing (DON) on 11/30/23. The change of condition procedures identified what staff should do if a resident had a medical change of condition. According to the procedure the staff should: -Complete an eInteract form to include the physician and family notification. -Place an order for monitoring the change of condition as appropriate. -Complete a detailed nursing note under progress notes with a full assessment, orders received, interventions initiated, and outcome. III. Resident status Resident #2, age under 65, was admitted on [DATE] and readmitted on [DATE]. According to the November 2023 computerized physician orders (CPO), diagnoses included cerebral infarction (stroke) due to thrombosis of the left anterior cerebral artery, aphasia (a language disorder after damage to the brain) following cerebral infarction, depression, chronic pain syndrome, other speech and language deficits following a cerebral infarction. According to the 11/7/23 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for a mental status (BIMS) score of 10 out of 15. The MDS assessment did not identify behavioral symptoms or rejections of care. The MDS assessment indicated the resident had occasional severe pain. The MDS assessment did not identify the resident had signs of symptoms of a possible swallowing disorder. IV. Resident Interview Resident #2 was interviewed on 11/29/23 at 3:59 p.m. She said she did not go to the physician after she reported her severe sore throat to registered nurse (RN) #1 (on 10/25/23). The resident said she was not told why she was not seen by the physician after she had a severe sore throat. She said she went to the physician after she went to the hospital (11/10/23). The resident said sometimes her throat hurt when she swallowed but it was better than it was. V. Frequent facility visitor interview A frequent facility visitor was interviewed on 11/30/23 at 9:19 a.m. The frequent visitor said she was concerned Resident #2 was not assessed or seen by a physician after the resident complained of a severe throat and accompanying pain. The frequent visitor said on 10/25/23, she assisted Resident #2 to RN #1. The resident informed RN #1 of her severe throat pain. The RN said she was already aware of the resident's complaint of a sore throat. The frequent visitor asked the RN if the resident was assessed. According to the frequent visitor, RN #1 said she was not a doctor. VI. Record review A 10/17/23 physician progress note read the Resident #2 was seen by the physician on 10/17/23 for neck swelling, pain and mini seizures. During the appointment, the resident was assessed for a sore throat. The note read Resident #2 was seen on 10/17/23 after three days of a reported sore throat, nasal congestion and shortness of breath. The resident denied a cough, a fever or chills. The resident reported it was hard for her to swallow food because her throat hurt. The physician note identified labs (laboratory testing panel) were ordered for a COVID-19 test and a rapid strep test (a test to diagnose pharyngitis [inflammation of the pharynx] caused by a type of streptococci). The 10/17/23 physician progress note identified Resident #2 should return to the physician if symptoms worsened or there were no improvements in seven days. According to the note, there should be a one week follow up appointment if there was no improvement. The 10/25/23 nursing progress written by RN #1 read: (Resident #2) has aphasia which is a disorder that affects how you communicate. It can impact your speech, as well as the way you write and understand both spoken and written language. (Resident #2) was grabbing (her)throat and crying, no redness or changes assessed. (Resident #2) keeps grabbing at (her) throat. Notified provider. Provider wants her to come in to visit. -A review of the resident's vitals on 10/25/23 did not identify Resident #2's vitals were assessed after the resident reported severe sore throat pain and was crying and continued to grab at her throat. -A review of the resident's pain log and the treatment administration record (TAR) did not identify the resident had pain on 10/25/23 as identified in the 10/25/23 nursing note or the severity level of the pain. -A review of Resident #2's evaluations did not identify an eInteract change in condition evaluation was completed, identifying the results of a nursing assessment and the communication to the physician. A second 10/25/23 nursing progress written by RN #1 read the social service director (SSD) was made aware of the need for an appointment and would follow up with the appointment. The calendar for resident appointments was provided by the facility on 11/30/23. The calendar identified Resident #2 had an appointment scheduled on 11/14/23. -The appointment calendar did not identify the resident was scheduled for an appointment with her physician on or shortly after 10/25/23 as identified in the 10/25/23 nursing notes or before the resident was sent to the hospitalER on [DATE] (see below). -The review of progress notes did not identify why Resident #2 did not have an appointment with her physician on or shortly after 10/25/23 or before the resident was sent to the hospitalER on [DATE]. The 11/10/23 nursing progress note read Resident #2 returned from the emergency roiagnom on [DATE] with a diagnosis of probable acute pharyngitis (a rapid onset of a sore throat and pharyngeal inflammation, hypokalemia (a potassium deficiency) and dysphagia (a difficulty or discomfort when swallowing). A 11/14/23 physician note read Resident #2 saw the physician for her worsening aphasia exacerbated by a recent infection. The note identified a comprehensive metabolic panel (CMP) was ordered for low potassium; a swallow study was ordered for dysphagia and a request for a speech therapy evaluation was made. A 11/14/23 order form provided to the facility on [DATE] read a modified barium swallow test for oropharyngeal dysphagia was scheduled with radiology on 11/21/23. VII. Staff interview The SSD was interviewed on 11/29/23 at 1:55 p.m. The SSD said she told the facility van driver (FVD) #1 on 10/25/23 that Resident #2 needed a physician appointment. FVD #1 was interviewed on 11/29/23 at 1:59 p.m. FVD #1 said reviewed her scheduled appointments for Resident #2. She said the resident did not have an appointment with her physician on or shortly after 10/25/23 or was made aware Resident #1 needed an appointment. FVD #1 said the resident had only a hospital follow up appointment on 11/14/23. FVD #1 said she took the position as the facility transportation coordinator a couple of months ago. She said when she took the position, she identified the transportation department was left in a dysfunctional state and so much was left to be done. She said when she accepted the position she was a second van driver, FVD #2. She said maintaining the scheduled appointments, activity outings and booking new appointments was a two person job but the facility determined she was had to do it by herself without the assistance on FVD #2. The FDV said the facility took away the second van driver and she had to do booking of the appointments and drive. She said things such as new admission physician appointments started to fall through the cracks. FVD #1 said she was recently hurt and could not drive so FVD #2 was helping drive again, allowing her to get caught up on scheduling and organizing. FVD #2 entered the interview. FVD #1 and FVD #2 agreed there needed to be improved communication between the departments in relation to appointments that needed to be scheduled. FVD #1 said she often had late notice that a resident needed an appointment or was not notified a resident needed an appointment. FVD #1 said the nurses needed to consistently provide her with appointment requests forms. FVD #1 said the nurses sometimes would not provide the forms or the nurses would just tell her verbally of a needed appointment. The regional operations manager (ROM) was interviewed on 11/29/23 at 2:50 p.m. The ROM said FVD #1 was very new and working on a tracking system. The ROM said FVD #1 attended the morning meetings with the IDT. She said during the morning meetings the IDT reviewed all the upcoming appointments. Licensed practical nurse (LPN) #1 was interviewed on 11/30/23 at 10:43 a.m. She said when a resident had a sore throat, she would check to see if the throat was swollen and have vitals taken. She would review the resident's medical record and determine if the sore throat was a new onset or a worsening condition. LPN #1 said she would find out how soon an appointment could be scheduled and contact the physician. The LPN said she would complete an eInteract change of condition assessment. She said she would do a COVID-19 swab (test) as a precaution if the resident was presenting a sore throat. LPN #1 was interviewed again 11/30/23 at 11:23 a.m. She said the physicians could be contacted by calling their office or faxing them. The DON was interviewed on 11/30/23 at 11:53 a.m. The DON identified the process to access a resident. She said if the resident had something out of the usual and not the resident's baseline, the nurse would complete an eInteract change of condition evaluation. The DON said the eInteract form was an assessment and a communication form between the nurse and the physician. The physician would be notified by phone or by fax. If the resident was presenting potential signs and symptoms of COVID-19 such as a sore throat, the nurse should do a COVID-19 test. The DON said vital signs should be taken and a visual check of the resident's throat done. The DON reviewed the medical chart of Resident #2. She said on 10/25/23 the change of condition form was not completed and vital signs were not taken. The DON said the vital signs should have been taken. The DON said there was no evidence a COVID-19 test was completed. The DON said Resident #2 was negative for COVID-19 after a test on 10/18/23 but was positive on 10/30/23 after facility wide testing was done. The DON said she did not know if RN #1 knew how to properly assess the resident on 10/25/23. The DON said on 11/1/23 she put together an educational checklist folder/packet and presented the packets to the nurses. The DON said the packet was a help book clearing outlined procedures to be followed. She said the packet included assessment procedures when a resident had a change of condition to make sure all the nurses knew the proper steps to take (see above under Change of Condition procedures). FVD #2 was interviewed with DON on 11/30/23 at 1:20 p.m. FVD #2 said the van drivers were having difficulty scheduling appointments at the office/clinic where Resident #2 saw her physician because the available appointments were usually booked up. FVD #2 said he was teaching FVD #1 to document in progress notes any scheduling details or difficulties that may have occurred when attempting to book a physician appointment. The medical assistant (MA) for Resident #2's physician assistant (PA) was interviewed on 11/30/23 at 2:20 p.m. The MA said the physician's office tracked all contacts made from the facility to the physician's office. The MA reviewed all recent contacts between the facility and the physician's office regarding Resident #2. The MA said she did not see anything to show an appointment with the office on or shortly after 10/25/23 and before the resident went to the hospital on 11/10/23. The MA said an appointment was made with the physician as an ER follow up appointment.

Based on record review and interviews, the facility failed to ensure proper medication administration without significant medication errors for one (#1) resident of three residents reviewed for medications. Specifically, the facility failed to: -Properly transcribe hospital physician discharge orders for digoxin to ensure Resident #1 received his correct dosage as ordered; -Ensure Resident #1 was administered the correct dose of digoxin; and, -Ensure all nursing staff were thoroughly trained on the facility expectations of the 24-hour double-check process, triggered warnings in the electronic medication administration record (EMAR), and the apical pulse monitoring to prevent potential future medication errors. Findings include: I. Facility policy and procedure The Medication Administration policy, revised 11/1/22, was provided by the interim director of nursing (IDON) on 10/11/23. The policy read in pertinent part: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in the state, as ordered by The Physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Compare medication source with MAR (medication administration record) to verify resident name, Medication name, form, dose, route, and time. Refer to drug reference material if unfamiliar with this medication, including its mechanism of action or common side effects. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by the physician. Correct any discrepancies and report to the nurse manager. II. Resident #1 A. Resident status Resident #1, age 86, was admitted on [DATE]. He transferred to the hospital on 6/19/23 and did not return to the facility. According to the June 2023 computerized physician orders (CPO), diagnoses included chronic diastolic congestive heart failure (CHF), long standing persistent atrial fibrillation (A-Fib), chronic obstructive pulmonary disease with acute exacerbation (COPD) and acute and chronic respiratory failure. According to the 6/19/23 minimum data set (MDS) assessment, the staff assessment for mental status indicated Resident #1 had modified independence with a short and long term memory problem. He required physical assistance by one person for bed mobility, and dressing, toileting and personal hygiene. Resident #1 needed physical assistance by two staff for transferring. B. Record review 1. The hospital assessment and plan The 6/16/23 discharge hospital assessment and plan read Resident #1 needed a skilled nursing facility and physical and occupational therapy evaluations post post surgery. According to the assessment, a hospice consult had been placed due to his overall decline in the past year, worsening dementia and a current hip fracture. Hospice was declined by his family with hopes to complete therapy and enroll in palliative care. The resident was stable for discharge for long term care placement. 2. Hospital transfer orders The 6/17/23 hospital transfer orders were provided to the facility on [DATE]. The physician orders from the hospital for digoxin read in part: 125 Mcg (microgram) Tab (tablet), 0.125 MG (milligram) PO (by mouth) Q6PM (every 6:00 p.m.) for 30 days, #30 Tab (number of tablets per physician order). 3. Physician orders The 6/17/23 physician orders as transcribed by the facility for digoxin read Digoxin oral tablet 125 MCG by mouth every six hours for A-Fib. -The physician orders as transcribed in the facility orders, directed staff to administer digoxin every six hours instead of every 6:00 p.m. as prescribed by the hospital physician. 4. Medication administration record The June 2023 medication administration record (MAR) read Resident #1 received digoxin on 6/17/23 at 7:00 p.m. He received dioxin on 6/18/23 at 1:00 a.m. by the former DON, at 7:00 a.m. and 1:00 p.m. by registered nurse (RN) #2; and once again at 7:00 p.m. by RN #1. -The June 2023 MAR facility orders identified facility staff administered digoxin every six hours on 6/18/23 instead of once a day at 6:00 p.m. as prescribed by the hospital physician. 5. Progress notes An alert progress note was generated by the facility's electronic medical record after the physician orders were entered into the system. The alert for the 6/17/23 order note read: This order is outside of the recommended dose or frequency. Digoxin Oral Tablet 125 MCG Give 1 tablet by mouth every 6 hours for A-Fib. This dose fails a general dose range check based on drug inputs and/or the patient information provided. This drug's dose should be adjusted based on renal function. Manual screening is required. The 6/19/23 at 3:28 a.m. nursing progress note read: At approx 0010 (12:10 a.m.) while going through medication cards to look for what (was) needed to be ordered this evening. I found (the) resident's Digoxin card and noticed that it stated to be given once a day at 1800. The EMAR (electronic medication administration record) order showed that it was to be given Q6H. I raced down to resident's room and found him obtunded (slowed responses to stimulation) and aroused with sternal rub, without his O2 (oxygen) cannula on. Nasal cannula put back on. According to the 6/19/23 note, Resident #1's vitals were taken. The resident's blood pressure was 78/47, his heart rate was 104, his respirations were 24, and his oxygen levels were 74% on room air. (The vital signs were outside of the normal limits.) The physician, 911 and his medical power of attorney (MPOA) was contacted. 6. The 6/19/23 hospital records The 6/19/23 Progress and Procedures read in part: Course of Care: [AGE] year old male presents for evaluation after possible over medication of digoxin. He was just discharged from the hospital after an extended stay secondary to a hip fracture. Apparently, yesterday he was started on digoxin at the care facility and they had been accidentally giving him 125 mcg Every 6 hours instead of once a day. He has had a total of four doses in the last 24 hours, the last about 6:00 p.m. Here, he overall seems asymptomatic, his heart rate is okay. His EKG (electrocardiogram) does show some new ST (myocardial infarction/heart attack) changes which could be secondary to digoxin effect versus potentially some ischemia. The patient had no real complaints now, denies any chest pain though he has been weak and generally unwell. It is hard to say how different this is from when he was at the hospital, he has no focal neurological deficit. His vital signs are stable. His other lab work generally looks okay. Troponin (protein that is released into the bloodstream during a heart attack.) is indeterminate. He has not been complaining of chest pain. I discussed the case with poison control. They recommended a second dose of digoxin level at 12 hours from his last dose which would be at 6:00 a.m. I think I will recheck his troponin at this time as well. If either of these are up trending the patient may need more aggressive care. The patient's nieces are at bedside, they stated that if this does turn out to be a more significant cardiac event he does not want catheterization or more aggressive therapy at this time. Care at 6:00 a.m. (6/19/23): Patient was resting comfortably and his digoxin level has returned and is minimally increased to 1.5 troponin came back and has increased from .056-0 through to .154. (Above .4 ng/ml [nanograms per milliliter] indicates a probable heart attack) According to the note, the resident's family identified they wanted to transfer him to a different facility and they recognize that he may have had a heart attack but do not want any aggressive treatment. C. Facility investigation The 6/19/23 facility reported incident read Medication order was erroneously transcribed at time of admission, and the patient was given the wrong dose. Upon identification of error, the patient was sent to ER (emergency room ) for evaluation. A full house MAR to cart audit was conducted. Re-education to all nurses was provided related to medication transcription, 24 hr double check process and 5 Rights to medication administration. (Resident #1) was sent to the ER for further diagnostics. He is still in the hospital, but not related to medication error, it is due to preexisting comorbidities. (He is in) stable condition. Resident (#1) was given more than prescribed dose of medication, but upon admission to hospital, was within normal therapeutic range and was not at risk of overdose. No negative impacts occurred due to medication error. (The) employee who transcribed the order is now aware of the error and has been re-educated on 5 rights, transcription process and 24hr (hour) double check. Re-education provided to all nurses involved. Hospital is also re-educating their discharge physicians, as it was noted that the order was written in an abnormal fashion. According to the incident report, Resident #1 was given more than prescribed dose of medication, but upon admission to hospital, was within normal therapeutic range and was not at risk of overdose. No negative impacts occurred due to medication error. Resident #1's medication administration facility investigation regarding the 6/19/23 significant medication error was provided by the IDON on 10/10/23. The facility investigation included the following: Corrective action: It was identified that Resident #1 was admitted on [DATE]. He had an order that was written for Digoxin Q6PM (once a day at 6:00 p.m.) but was transcribed as Q6 hours (once every six hours). The consultant pharmacist reviewed the orders and noted no irregularities on 6/17/23. Digoxin was administered on 6/17/23 at 7:00 p.m., and on 6/18/23 at 1:00 a.m., 7:00 a.m., 1:00 p.m., and 7:00 p.m. At approximately 12:10 a.m. on 6/19/23, the nurse pulled the medication card while she worked on a medication refill order and noticed the medication card said to administer once a day at 6:00 p.m. and not to administer once every six hours. She immediately went to assess the patient. He was arousable with a sternal rub and was hypotensive and bradycardic. She called 911 and the patient was sent back to the hospital at approximately 12:40 a.m. Identification of others: all other residents have the potential to be affected. Systemic change: Nurse managers will conduct a full house medication administration record (MAR) to cart audit to ensure that there are no other transcription errors. The audit will be completed by 6/23/23. Nurses will be interviewed and re-educated on the 24-hour double-check process for all new admissions and new orders. This will also include input of Advanced directives and updating if there is a change to the MOST form. Ongoing monitoring: Nurse managers and the nursing home administrator (NHA) will conduct daily audits, five times a week, for accurate order entry and transcription of all new admissions and new orders for no less than 90 days unless substantial compliance is maintained in 30 days. The facility included the 6/17/23 pharmacist review of Resident #1's medications entered into his electronic medication administration record (EMAR) which said: New admit review- 1. Medication considerations -Medications have been reviewed for appropriateness of dose and indication for use -Please add apical pulse monitoring for digoxin -please add 'rinse mouth after use' to Breo Ellipta order to help prevent oral thrush infection. Thank you for taking the time to review the above. The former DON followed up with the hospital on 6/21/23 regarding Resident #1. She documented her phone call with Resident #1's care coordinator manager at the hospital as follows: Resident #1's Digoxin review with the hospital. This nurse contacted the hospital and was directed to speak with the care coordinator manager. She reports she knew the incident well and was available to review the system breakdown and health of the patient with me. She reports she was notified by the hospital staff of the off-wording of the Digoxin 1.25 micrograms (mcg) 'po Q6PM (by mouth once daily at 6:00 p.m.).' She reports that the standard for an order such as this should read 'Digoxin 1.25 mcg PO daily at 6:00 p.m.' She further reports that this instance resulted in an internal inquiry within the hospital to prevent such further orders which can easily be misinterpreted. She reviewed the lab work of Resident #1 upon entry to the emergency room (ER). He was noted to have a Digoxin level of 1.4 upon arrival to the ER after midnight on 6/19/23. Labs were completed again at 6:00 a.m. on 6/19/23 and his Digoxin level was 1.5. Both levels were within normal limits for Digoxin therapy. His heart rate remained stable while at the ER. The medical director chart review was sent to the facility on [DATE] at 5:21 p.m. According to the medical director's review, the resident had a very complicated cardiopulmonary history and was at extremely high risk. The medical director noted he had concerns. The report read: Although we do not frequently use digoxin, that would be a reason for a responsible nurse to look up if he/she had never seen it. For those that had used it before, it would be obvious that it is not a drug you use four times a day. Four different nurses administered it, so there is reasonable expectation that one of the four of them should have recognized that this way was very unusual. According to the medical director chart review, the facility's medical director wanted to see the digoxin levels and felt there are multiple other etiologies that could have explained his change of condition. The 6/19/23 facility's performance improvement note read transcription error of digoxin. Total of five doses. The note identified the transcription error was reviewed with the facility's interdisciplinary team (IDT). D. Training A Rapid Inservice was conducted by staff development coordinator on 6/19/23. The inservice read When a resident admits on a medication like digoxin, ensure how often a medication should be given. If you have questions, look up the medication, reach out to the on call physician (PCP) or pharmacy. If an alert pops up on PCC (electronic medical record) don't ignore it. Also ensure with medication monitoring of apical pulse or blood pressure depending on medication. Ensure you use five rights. Never hesitate to ask questions. Research alerts that pop up on PCC. The rapid inservice indicated education was provided to the former DON, RN #1, RN #2 and RN #3. Education was provided by the former director of nursing (DON) to the nurses involved in the medication error. - However, only the former DON's name was listed on the education as completed by, was undated, and did not include who attended the training. 1. Re-education on the 24-hour check process and order verification for new admissions. a. All orders entered for a new admission should be verified for accuracy by a second nurse prior to activating them b. All orders should be checked for accuracy every night shift by the nurse on duty. If there was a transcription error, that nurse would correct the order and enter a risk console to alert the nurse managers to the error for follow-up. All orders should be signed and dated with a notation that the 24-hour check was completed. 2. 5 rights of medication administration a. The right patient b. The right drug c. The right time d. The right dose e. The right route 3. Procedure for Apical pulse assessment with Digoxin administration: a. When entering the digoxin order, add the apical pulse to the supplementary documentation. This will flag it on the MAR with the administration time. b. Check the apical pulse (heartbeat) with a stethoscope for a full minute prior to medication administration. 4. Alerts with order entry a. If you received a system alert with an order you entered, it is your responsibility to follow up on the alert, not just sign the note. These are safeguards in the system to reduce the likelihood of a medication error or adverse reaction. 5. Advanced directive orders a. Enter the advanced directive order into PCC as written on the discharge/admit orders. This must be done at time of admission, even if a MOST form has not been completed. b. Once a MOST form is completed, verify the resident wishes match the order in (the electronic medical record system). If they do not match, update the order to reflect what the MOST form states. A copy of the completed MOST form with residents/family signature will go into the MOST form binder at the nurses' station and the original goes to Medical Records for MD signature. III. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 10/10/23 at 1:09 p.m. She was unaware of any residents taking Digoxin on her side of the facility. As LPN #2 checked the residents' orders the assistant director of nursing (ADON) said the facility does not have any residents on Digoxin. LPN #2 confirmed she could not find any orders for Digoxin. The ADON was interviewed on 10/10/23 at 3:45 p.m. She said when the electronic medication administration record (EMAR) triggered a warning for a medication below the daily recommended dose the facility did not expect any follow-up because it would be considered preventive. If the EMAR triggered a warning for a medication above the daily recommended dose then the nurse needed to reach out to a nurse manager or the pharmacy to confirm the order and a separate progress note would be entered into the EMAR. The interim director of nursing (IDON) was interviewed on 10/10/23 at 4:27 p.m. She said the nurses should reach out to the nurse manager, pharmacy or physician if the EMAR triggered for a medication above the daily recommended dose. She said it was more crucial for the follow-up to be provided if the trigger was for above the daily recommended dose because the charting system triggered a lot of warnings for medications below the daily recommended dose which the facility had no control over. The nurse needed to enter a progress note that documented the follow-up for the warning. LPN #1 was interviewed on 10/10/23 at 5:47 p.m. She said when a resident received a new order she entered them into the computer and double-checked everything. She said the DON or the ADON usually provided the double-check to make sure the orders were correct. She said the key components to the five rights of medications were right medication, right dose, right frequency, right patient, and right time. LPN #1 said if she did not know a medication the she looked it up and checked if it had any precautions like checking a pulse before the medication was administered. She said if a medication triggered in the EMAR she verified with the doctor and documented a progress note. She said Digoxin was a medication for the heart and caused nausea for some people. She said the nurses needed to check the resident's apical pulse (check the heartbeat with a stethoscope for 60 seconds) before the medication was administered. She said the medication could not be administered if the pulse was below 60 beats per minute. LPN #1 said she had not received any specific training about Digoxin, the 24-hour double-check process, triggered warnings in the EMAR, or the apical pulse since she started working for the facility. She said she just knew about everything based on her training as a LPN. Registered nurse (RN) #1 was interviewed on 10/10/23 at 6:03 p.m. RN #1 said she primarily worked the night shift and new orders were usually added during the day shift. She said if a new order packet was left on the desk for her, she would double check the packet orders with the current order in record. The RN said she would make sure to follow the five rights of medication administration. She said if she did not know a medication, she would look it up. RN #1 said medication alerts frequently pop up so she would read it. They were usually related to possible allergic reactions or the resident was not getting the standard dose. She said there were lots of reasons older adults, such as many of the facility residents, would not get a standard dose of a medication. She said she would not be too concerned unless the ordered amount was way more than the standard dose. RN #1 said digoxin was a drug that had a narrow therapeutic dose and vitals needed to be taken before it was given and his pulse monitored. Digoxin should not be given if under 50 beats per minute. She said there was a resident (Resident #1) that had too much of the digoxin medication. RN #1 said she gave the resident his scheduled dose at 7:00 p.m. and was preparing to give him his 1:00 a.m. dose. She said she had some spare time was going through Resident #1's medication packet. The RN said that was when she discovered the medication error in the order. She said the order was written funny and not in the standard format. The RN said he should have been receiving digoxin at 6:00 p.m. daily and not every six hours. She said she jumped up, took his blood pressure. She said she sent him to the ER for an evaluation, contacted the physician and the family. RN #1 said she thought she might have had additional education on transcribing orders the 24 hour double check process, and pulse monitoring. She said the facility usually trained staff by passing out a hand out. She said she did not recall anything specific on digoxin or related to the incident. She said the medication hand out could have been in June 2023. RN #1 said the facility did not offer a lot of training to staff. She said there were a lot of agency staff and the director of nursing turnover. The hospital case manager was interviewed on 10/11/23 at 9:04 a.m. She said Resident #1 was sent to the hospital on 6/19/23 after a medication error was identified. The order from the hospital was accurate but not in standard format and it was easy to misinterpret. She reviewed the incident with former DON. The order was missed by the pharmacy review and administered incorrectly by the facility. The hospital has now corrected its medical library to use only standard medication language. She said the resident went to a different facility and was doing alright. The IDON was interviewed on 10/11/23 at 10:20 a.m. She said the facility investigation identified a transfer order for digoxin was confusing and it was incorrectly transcribed. The IDON said multiple nurses did not identify digoxin q6hrs was not the correct medication orders and administered digoxin every 6 hours instead of once a day at 6:00 p.m. Resident #1 received 3 more doses on 6/18/23 then he should have received. She said with digoxin, there was an increased risk of toxicity and slowing of the heart rate. The medical director felt his lower heart rate on 6/19/23 was related to other comorbidities. The IDON said the nursing staff was educated after the incident. She said the facility investigation also identified the 24 hour check process was not completed. The IDON said nursing management should have been reviewing all new orders as extra set out eyes to reduce the risk. She said when the facility received new orders, the nurse should read the orders, reach out to the physician if he/she needed more clarification, and have a second nurse review the orders. The IDON said nurse management should complete a triple check review of the new orders. She said the nurses who administered the digoxin and the nurse who transcribed the digoxin order, received the rapid inservice on 6/19/23. She said all nursing staff received education through medication administration competency review after the incident. The IDON said if there were concerns with the competency, the nurse would have received additional training at that time. She said for new nursing staff, the five rights for medication administration was part of the on boarding process. The IDON said Resident #1 did not return to the facility. She said according to his family, he was discharged from the facility to a different facility. The IDON said the digoxin was within normal limits. The order was not standard and the facility worked with the hospital and the pharmacy to ensure orders sent to the facility were standardized. The IDON said the main focus of the plan of action after the 6/19/23 was auditing all of the residents medical administration records to make sure there were no additional medication order concerns and provide education to staff. The IDON said she was not the IDON at the time of the education but understood the education focused on how to read orders and reach out for assistance if anything triggers a concern. The IDON said the staff were educated on order alerts. She said the order system generates multiple alerts which could be overkill and when there was large number of alerts, the staff has a risk of ignoring them. She said staff should stop and see each alert by reading the order, make sure they understand the order, and notify the physician if there was a concern. She said the stop and see was part of the normal medication training and included in the five rights. The IDON said she was not directly involved in the education but believed staff took the education component seriously and the education was through with an understanding of expectations and process. LPN #3 was interviewed on 10/11/23 at 1:11 p.m. She said there was a bin at the nurses' station that had paper orders in it and the night nurses compared the paper orders to the orders transcribed in the EMAR. If the orders matched the nurse signed the paper order, if they did not match the nurse corrected the transcribed order so they matched. LPN #3 said the key components to the five rights of medication pass were right patient, right dose, right time, right route, and right medication (struggled with the right medication). She said if she had questions about a medication or did not know a medication she texted the on-call doctor to get clarification. She said she held the medication until she received clarification. LPN #3 said if an alert was triggered on the EMAR she double-checked the alert and the order then she reached out to the pharmacy. She said Digoxin was a cardiac (heart) medication and the heart rate should not be below 60 beats per minute prior to administration. She said if the heart rate was close to 60 beats per minute she asked another nurse or nurse manager to take the pulse again to be safe. She said apical pulse monitoring was listening to the heart rate with a stethoscope for 60 seconds. She said she had not received additional training about Digoxin, transcribing orders, the 24-hour double-check process, or pulse monitoring from the facility and just went based on her training as an LPN. LPN #3 said, I never received the facility's expectations or training, I just do what I do for other facilities. The IDON was interviewed on 6/11/23 at 1:25 p.m. She said Digoxin had a high toxicity rate with a very narrow therapeutic index which needed to be monitored with labs and kept a very close eye on. She said the pulse was required before Digoxin would be administered. She said the pulse check would be documented in the EMAR with the medication so the nurses would not be able to mark it as administered without entering the pulse. She said the pulse needed to be greater than 60 beats per minute. If it was lower than 60 beats per minute then the nurses held the medication. The IDON said everything should have been documented on the resident's EMAR and instead of marking administered the nurses marked not administered and explained why it was not given. The nurses were not expected to notify the physician unless the order specified to call every time the medication was held or it ended up as a consistent situation where the medication was held every day.

Based on observations, interviews and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen and in the activities room. Specifically, the facility failed to: -Ensure food was labeled and dated in the walk-in refrigerators, dry storage and reach-in refrigerator in the main kitchen and in the activities room refrigerator; -Ensure expired food was disposed of in a timely manner; -Ensure cooked food items were monitored and cooled properly; -Ensure artificial nails with policy were not worn by a food worker; -Ensure appropriate use of gloves when handling ready-to-eat foods; and, -Ensure food was stored off the floor in the main kitchen/walk-in freezer. Findings include: I. Ensure food was labeled and dated correctly A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It revealed in pertinent part, A date marking system that meets the criteria stated in (1) and (2) of this section may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (a) of this section; Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (b) of this section; or Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Department upon request. (Retrieved [DATE]). B. Facility policy and procedure The Labeling and Dating policy, dated 2017, was provided by the dining district manager (DDM) on [DATE] at 3:36 p.m. It revealed in pertinent part, Importance of labeling and dating: proper labeling and dating ensures that all foods are stored, rotated, and utilized in a First In First Out (FIFO) manner. This will minimize waste and also ensure that items that are passed their due date are discarded. Food labels must include: the food item name, the date of preparation/receipt/removal from freezer, the 'use by' date as outlined in the attached guidelines. Leftovers must be labeled and dated with the date they are prepared and the 'use by' date. C. Observations On [DATE] at 10:36 a.m. the initial kitchen you was conducted and the following was observed: -In the walk-in refrigerator, there were three burritos and a corn dog in a metal container labeled ,d+[DATE], a bag of chopped celery labeled ,d+[DATE], a bag of green chili not labeled, a container of alfredo sauce labeled ,d+[DATE], a container with cooked burgers labeled ,d+[DATE], a container of hot dogs labeled ,d+[DATE], a carton of liquid eggs opened with no open date, a piece of ham wrapped in plastic wrap labeled ,d+[DATE], half a watermelon wrapped in plastic wrap not labeled, a cut-up cantaloupe in a bag labeled ,d+[DATE], a piece of deli meat in a bag labeled [DATE], a chunk of raw beef labeled ,d+[DATE], an unknown piece of raw meat opened to air with no label or date and a raw pork loin wrapped in plastic wrap dated ,d+[DATE]. -In the dry storage there was a bag of powdered mashed potatoes opened and not labeled and a plastic container of oatmeal labeled ,d+[DATE]. On [DATE] at 11:19 a.m. at the lunch meal the following was observed: -In the walk-in refrigerator there was a container of cooked chicken labeled ,d+[DATE], two bags of green beans labeled ,d+[DATE], a bag of chopped celery labeled, a container of hot dogs labeled, a container of cooked hamburgers labeled ,d+[DATE], a piece of ham wrapped in plastic wrap where the date was not legible, a half of a watermelon wrapped in plastic wrap labeled ,d+[DATE], a chunk of beef labeled ,d+[DATE] and a cut-up cantaloupe labeled ,d+[DATE]. -In the reach-in refrigerator there was a container of chocolate pudding labeled ,d+[DATE], a container of grape jelly labeled ,d+[DATE], a container of ranch labeled ,d+[DATE], a container of onion that was not labeled or dated, a container of pickles that was not labeled or dated, a container of shredded cheese that was not labeled or dated and a container of Jell-O that was labeled ,d+[DATE]. -In the main kitchen there was a bag of corn starch with a manufacturer label of [DATE], a container of soy sauce that was opened on ,d+[DATE] that documented to refrigerate after opening and a container of teriyaki sauce that was opened on ,d+[DATE] that documented to refrigerate after opening. On [DATE] at 3:10 p.m. the following was observed in the activities room refrigerator: -An opened jar of cherries with no open date; -An opened jar of salsa with no open date; -An individual serving of pineapple tidbits that expired on [DATE]; -Another individual serving of pineapple tidbits with no expiration date; -Three individual servings of pear apple sauce that expired on [DATE]; -An opened bottle of lavender syrup with no open date; -A bottle of Snapple with no open date; -Two cups of cut-up lemons with no date; -An opened container of pre cut watermelon with no date; -A container of french onion dip with no open date; -A sandwich from an outside source with no date; and, -There was not a thermometer in the refrigerator. -In the freezer, there was a bag of frozen buns that expired on [DATE] and an opened bag of marshmallows with no date. D. Staff interviews The activities assistant (AA) was interviewed on [DATE] at 3:20 p.m. The AA said the food that was stored in the refrigerator in the activities room was used for activities for the residents. The AA said all staff were responsible for cleaning the refrigerator in the activities room. The AA said she had not been instructed to monitor the temperature of the refrigerator in the activities room. The activities director (AD) was interviewed on [DATE] at 9:53 a.m. She said she did not know how to label and date food properly. The AD said the kitchen staff were responsible for cleaning the refrigerator in the activities room. The AD said she would go through the refrigerator and dispose of any expired foods. The dietary manager (DM) and the district dietary manager (DDM) were interviewed on [DATE] at 10:02 a.m. The DM said all dining staff were responsible for labeling and dating food items in the kitchen. The DM said all foods though have a received date, a preparation or open date and a use-by date. The DM said she would correct the items in the kitchen that only had one date. The DDM said he was not aware there was a refrigerator in the activities room. He said he would order a thermometer and have the dining staff monitor the refrigerator. The DDM said he would educate all staff on proper labeling and dating of foods. II. Ensure expired food was disposed of in a timely manner A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. The day or date marked by the food establishment may not exceed a manufacturer's use-by-date if the manufacturer determined the use-by date based on food safety. (Retrieved [DATE]). B. Facility policy and procedure The Labeling and Dating policy, dated 2017, was provided by the DDM on [DATE] at 3:36 p.m. It revealed in pertinent part, The manufacturer's expiration date, when available, is the 'use by' for unopened items. The manufacturer's instructions for the discarding of opened items supersedes the general guide below. C. Observations On [DATE] at 10:36 a.m. the initial kitchen you was conducted and the following was observed: -In the walk-in refrigerator, there were three gallons of chocolate milk that expired on [DATE]. -In the reach-in refrigerator there were two gallons of chocolate milk that expired on [DATE]. On [DATE] at 11:19 a.m. at the lunch meal the following was observed: -In the walk-in refrigerator, there was a gallon of chocolate milk that expired on [DATE]. -Dietary aide (DA) #2 created a serving station for drinks and placed a gallon of chocolate milk in the bucket of ice that expired on [DATE]. Three cups of chocolate milk were served to residents. -At 11:55 a.m. the DM was notified of the expired chocolate milk. The DM removed all expired chocolate milks. -However, without prompting the expired chocolate milk would have continued to be served to the residents. D. Staff interviews The DM and the DDM were interviewed on [DATE] at 10:02 a.m. The DM said she removed the expired chocolate milk out of service immediately after she was notified the milk was expired. The DM said expired foods should not be utilized in the kitchen and should be disposed of when they expire. The infection preventionist (IP) was interviewed on [DATE] at approximately 12:50 p.m. The IP said she was not aware expired chocolate milk was served to the residents. The IP said all foods needed to be labeled with an open date and discarded timely. The nursing home administrator (NHA) and corporate regional director of operations (CRDO) were interviewed on [DATE] at 1:25 p.m. The NHA said she was not aware expired chocolate milk was served to the residents. The NHA said foods should be disposed of timely. III. Ensure cooked food items were monitored and cooled properly A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It revealed in pertinent part, Maintain the records required to confirm that cooling and cold holding refrigeration time/temperature parameters are required as part of the HACCP (hazard analysis critical control point) plan. (Retrieved [DATE]). B. Facility policy and procedure The Cooling Log policy, undated, was provided by the DDM on [DATE] at 3:36 p.m. It revealed in pertinent part, All cooked foods not prepared for immediate service must be cooled from 135 F (degree fahrenheit) to 70 F within two hours of preparation and from 70 F to 41 F or colder within an additional four-our period. If an item does not reach the target temps in the allotted windows, it may be reheated one time to 165 F and the cooling process can begin a second time. If temps are not reached after a second attempt the item must be discarded. C. Observations On [DATE] at 10:36 a.m. the initial kitchen you was conducted and the following was observed: -In the walk-in refrigerator there was a container of cooked hamburgers labeled ,d+[DATE] and cooked alfredo sauce labeled ,d+[DATE]. On [DATE] at 11:19 a.m. at the lunch meal the following was observed: -In the walk-in refrigerator there was a container of cooked chicken labeled ,d+[DATE], a container of cooked hamburgers labeled ,d+[DATE]. D. Record review A request was made for the documented cooling monitor system on [DATE]. -The DDM said the facility did not have a documented cooling monitor log in place (see interview below). E. Staff interviews The DM and the DDM were interviewed on [DATE] at 10:02 a.m. The DM said they utilized a cooling log to monitor the cooling of leftover foods. The DM said it was important to ensure food was cooled properly to prevent bacteria growth. The DDM was interviewed again on [DATE] at 2:44 p.m. He said the facility did not have a current documented cooling log in place. He said he would educate all dining staff on proper cooling procedures and implement the use of a cooling log. IV. Ensure artificial nails were not worn by a food service worker A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part, Unless wearing intact gloves in good repair,a food employee may not wear fingernail polish or artificial fingernails when working with exposed food. (Retrieved [DATE]). B. Observations On [DATE] at 11:19 a.m. at the lunch meal the following was observed: -The DM was assisting in serving plates on the line with no gloves on. The DM had artificial painted nails. -At 3:06 p.m. the DM was preparing a cake with no gloves on and she had artificial painted nails. C. Staff interviews The DM and the DDM were interviewed on [DATE] at 10:02 a.m. The DM said she had removed her artificial nails. The DM said artificial nails or painted nail polish should not be worn in the kitchen as it could be a physical contaminate. V. Ensure appropriate use of gloves when handling ready-to-eat foods A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. -Ready-to-eat is considered a food without further washing, cooking, or additional preparation and that is reasonably expected to be consumed in that form. -Single-use gloves shall be used for only one task, such as working with ready-to-eat food, or with raw animal food. Single-use gloves shall be used for no other purpose, and discarded when damaged, when interruptions occur in the operation, or when the task is completed. (Retrieved [DATE]). B. Observations During a continuous observation on [DATE] beginning at 11:38 a.m. and ended at 12:46 p.m. the following was observed: -At 12:24 p.m. certified nurse aide (CNA) #13 began assisting a resident with eating. She picked up half of a sandwich with her bare hands and handed it to the resident. On [DATE] at 11:19 a.m. at the lunch meal the following was observed: -DA #2 was filling pitchers of water and ice to put on the tables in the dining room. She used her bare hand to guide the ice into the pitchers. DA #2 was touching the ice with her bare hands that would be put into the resident's drinking water. C. Staff interviews The NHA and the CRDO were interviewed on [DATE] at 1:25 p.m. The NHA said ready-to-eat foods should not be handled with bare hands. The DDM was interviewed on [DATE] at 3:36 p.m. He said ready-to-eat foods such as ice and sandwiches should not be handled with bare hands. The DDM said he would conduct and in-service with all staff regarding proper handling of ready-to-eat foods. VI. Ensure food was stored off the floor A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. Food shall be protected from contamination by storing the food, in a clean dry location, where it is not exposed to splash, dust or other contamination and at least 15 centimeters (6 inches) above the floor. (Retrieved [DATE]). B. Facility policy and procedure The Food Storage: Cold Foods policy, reviewed [DATE], was provided by the DDM on [DATE] at 3:36 p.m. It revealed in pertinent part, All food items will be stored 6 inches above the floor and 18 inches below the sprinkler unit. The Food Storage: Dry Good policy, reviewed [DATE], was provided by the DDM on [DATE] at 3:36 p.m. It revealed in pertinent part, All items will be stored on shelves at least 6 inches above the floor. C. Observations On [DATE] at 10:36 a.m. the initial kitchen was conducted and the following was observed: -In the walk-in freezer there were two boxes of nutritional supplements and a box of cauliflower stored directly on the ground. On [DATE] at 11:19 a.m. at the lunch meal the following was observed: -In the walk-in freezer, there was a box of spinach, a box of asparagus and a box of green beans directly on the ground. -In the main kitchen, there was a bag of opened corn starch, a crate of mayo, jelly, spices and vinegar and a box of vanilla wafers were directly on the ground. -In the parking lot outside of the main kitchen, the weekly food had been delivered. There were five boxes of food that were stored directly on the ground. D. Staff interviews The DM and the DDM were interviewed on [DATE] at 10:02 a.m. The DM said all foods should be stored at least six inches off the ground. The DM said the food delivery person put the food directly on the parking lot ground. The DM acknowledged food was stored on the kitchen floor. The DDM said he would conduct training with all staff regarding the storage of foods.

Based on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive. Specifically, the facility failed to ensure resident food was palatable in taste, texture and appearance. Findings include: I. Facility policy and procedure The Food: Quality and Palatability policy, dated September 2017, was provided by the dining district manager (DDM) on 5/25/23 at 3:36 p.m. It revealed in pertinent part, Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. Food attractiveness refers to the appearance of the food when served to the residents. Food palatability refers to the taste and/or flavor of the food. The Cook(s) prepare food in accordance with the recipes, and season for region and/or ethnic preferences, as appropriate. Cook(s) use proper cooking techniques to ensure color and flavor retention. II. Resident group interview A group interview was conducted on 5/24/23 at 9:30 a.m. with ten alert and oriented residents (#35, #32, #20, #4, #11, #8, #37, #39, #21 and #42) per the facility and assessment. All the residents in the group interview said the food was not palatable. Some of the comments were as follows: -The food was often too salty; -They did not take food orders, they just serve whatever they want; -The kitchen frequently ran out of food on the alternative menu; -The meat was so tough it could not cut it; -The food was often dry, tasteless and hard; -The vegetables were hard, plain and tasteless; and, -They were afraid the pork and chicken were not cooked properly at times. III. Resident interviews All residents were identified by facility and assessment as interviewable. Resident #20 was interviewed on 5/22/23 at 2:09 p.m. Resident #20 said the food did not look good or taste good. Resident #20 said he was often hungry after meals because he was not served enough food or the food he was served was not good. Resident #20 said there was an alternative menu, but when he tried to order off the alternative menu the kitchen staff would tell him they were out of those items until later in the week. Resident #20 said the food quality was extremely poor. He said it was frustrating to him to see the facility order in food from an outside restaurant for the staff only and the residents were served a poorly made turkey and cheese sandwich with no condiments. Resident #20 said the residents had brought up food complaints in the resident council and food committee, but as the resident council president he did not feel the resident's concerns were being addressed. Resident #35 was interviewed on 5/22/23 at 4:04 p.m. He said the food was often terrible. He said the quality of the meat was not good and it often caused him not to eat it. Resident #5 was interviewed on 5/22/23 at 4:32 p.m. He said he had lived at the facility for several years. He said the food quality in the last few months had decreased tremendously. Resident #5 said he was served pork a couple days ago that was so hard it bent his fork when he tried to pick it up. Resident #5 said the meat was often so tough that he was unable to eat it. Resident #5 said there was an always available menu, but when he tried to order off of it he was told the kitchen did not have those items. Resident #5 said he was often hungry after meals because the portion sizes were too small or the quality and taste of the food was so bad he did not eat it. Resident #5 said he received spaghetti the other day that was dried and crusted over. Resident #37 and Resident #11 were interviewed on 5/23/23 at 9:35 a.m. Resident #37 said the food was terrible and no residents ate it. Resident #37 said the food had no taste to it. Resident #11 said she agreed with Resident #37. Resident #37 said her family brought in snacks for her and Resident #11, so if they were hungry after meals they had something to eat. Resident #1 was interviewed on 5/23/23 at 9:39 a.m. Resident #1 said the food did not look good or taste good. Resident #1 said there were no choices or alternatives. Resident #6's son was interviewed on 5/23/23 at 11:33 a.m. He said he visited the facility at meal times three to four times a week. He said the food was often terrible and he had noticed most residents did not eat his food. He said Resident #6 was often served foods that were too hard to cut. Resident #6 said he had voiced his concerns about the food quality to the nursing home administrator (NHA), but nothing had been changed. IV. Observations On 5/23/23 at 12:25 p.m. Resident #37 was observed in the dining room for lunch. She said she had received some sort of chicken enchilada casserole that had very little chicken in it, Mexican corn and chicken noodle soup with nothing in it. Resident #37 took a few bites of her meal and said she did not want anymore because it did not taste good. The chicken casserole did not appear to have chicken in it and was slopped onto the resident's plate. The corn looked dry and the chicken noodle soup had no chicken or noodles in it. A test tray for a regular diet was evaluated by three surveyors immediately after the last resident had been served their room tray for lunch on 5/24/23 at 1:00 p.m. The test tray consisted of meatloaf, a roll, mashed potatoes, carrots and a lemon bar. -The meatloaf was extremely dry and gritty. It had no flavor. -The roll was a Hawiian sweet roll versus the poppyseed roll that was on the menu. -The mashed potatoes were bland with no taste. There was no gravy on the mashed potatoes. -The glazed carrots were overcooked, had no texture and did not require chewing. V. Record review The 1/18/23 food committee notes revealed the residents voiced the following concerns: -Residents were reminded that if food come out burnt or not edible to return it to the kitchen immediately; -The burritos served yesterday (1/17/23) were cold; -The vegetables were too salty; and, -The residents did not like the allspice on the spiced fruits. A concern form dated 1/18/23 documented the burritos that were served on 1/17/23 were cold, the toast was burnt at breakfast, the food was too salty, especially vegetables and they did not like allspice on the fruit. The housekeeping manager (HM) conducted the investigation on 1/19/23. The summary of the resolution and action plan was to inservice all kitchen employees (again) on how to properly take the temperature of all foods. The burritos were new to the kitchen and needed a recap on how to cook them. The form documented the kitchen rarely used salt in the recipes, but the concern was discussed with the cooks again. The spiced apples and spiced pears called for allspice in the recipe, but they made note to decrease the amount the recipe calls for and the toaster would be turned down to a lower setting. -The concern form did not have a follow-up date or a resident signature for approval. A request was made for the education that was provided to the staff in response to the 1/18/23 concern form on 5/25/23. The DDM said there were no documented in-services (see interview below). The 2/23/23 food committee notes revealed the residents voiced the food was too salty. A concern from dated 2/23/23 documented the residents would like a list of all always available menu items on the tables. The residents felt this would be helpful when they are sick to see what other items may help their stomachs. The DDM documented the summary of the resolution and action plan was the always available menu was printed below the daily menu; however, she could create a laminated large print of the always available menu. The dietary manager (DM) signed the concern form on 2/28/23. -The concern form was not approved by any residents. Another concern form dated 2/23/23 documented the residents said the barbeque crusted pork chop was too tough. The summary of the resolution and action plan was the kitchen would be looking at the time and temperatures to make sure the pork was not over cooked and would be served juicy. The DM signed the concern form on 2/28/23. -The concern form did not reveal the resolution was reviewed with a resident. Another concern form dated 2/23/23 documented the residents said the food was too salty, especially the vegetables and soup. The summary of the resolution and action plan documented the DM would do a training with the cooks on not having salty foods. The concern form documented that the dining department would enhance the soup, so it was not salty. The DM signed the concern form on 2/28/23. -The concern form did not reveal the resolution was reviewed with a resident. A request was made for the education provided to staff in response to the 2/23/23 concern forms 5/25/23. The DDM said there were no documented in-services (see interview below). The 3/15/23 food committee notes revealed the residents voiced the following concerns: -The food was still very salty; -There was too much rice being served and they would like to have a different type of rice; and, -They would like to see more sandwiches served at lunch. The food committee notes documented a concern from was generated for the concerns brought forward. A request for the concern form was made on 5/23/23; however, it was not received (see interview below). The 4/19/23 food committee notes revealed the residents voiced the following concerns: -The meat was not cooked well, the pork was often too tough and dry when served; -The grilled cheeses were served without the cheese melted; -They would like to see less rice served and more noodles; -The kielbasa and turkey soups were very salty and have hardly any noodles; -The lemonade had no flavor; and, -The would like to see more snacks at the nurses stations at night. A concern form dated 4/20/23 documented the following concerns: -The pork served on 4/18/23 was touch and dry; -The grilled cheese being served did not have the cheese melted; -The meatloaf was very greasy; -The residents would like to have more noodles and less rice; -The kielbasa and turkey noodle soups were very salty and the residents would like to have more noodles in the soups; and, -The residents would like a low-sodium soup base to be used. The summary of the resolution and action plan was documented by the DM on 4/21/23. It revealed the following resolutions: -The cooks would be retrained on cooking pork; -Before grilled cheese sandwiches were served the cooks would ensure the cheese was melted; -The cooks would be trained to cook the meatloaf with a drip pan to prevent greasy meatloaf; -When the menus called for rice, they would substitute noodles; -The cooks would be retrained on proper steps to making soups hearty and flavorful; -The DM would look into purchasing a low sodium soup base; and, -Rice was a part of a well balanced meal and was generated by the menu program. -The concern form did not reveal the resolution was reviewed with a resident. A request was made for the education provided to staff in response to the 4/20/23 concern form on 5/25/23. The DDM said there were no documented in-services (see interview below). Another concern form dated 4/20/23 documented the following concerns: -The residents would like to have more snacks available at night; -The residents would like to have chips always available; and, -The residents would like to have tamales served at meals. The summary of the resolution and action plan was documented by the DM on 4/21/23. It revealed the following resolutions: -The cooks could offer more snacks being placed in the refrigerator at nights; and, -A vote would be taken to see what menu item they would like to remove to have chips and tamales replace. -The concern form did not reveal the resolution was reviewed with a resident. Although the concerns were reviewed in the next food committee meeting, several of the concerns were still brought up and not addressed to the residents' satisfaction. The 5/17/23 food committee notes revealed the residents voiced the following concerns: -The meat continued to be tough and dry; -The residents wanted the soup of the day listed on the menu; -Too much rice was being served; -There were not enough snacks for the residents at night; -Meals were being served late; -The oven baked vegetables were too hard to chew for residents with dentures, they would prefer to have steamed vegetables; -The items on the always available menu were not available to order; and, -The cheesesteak dinner served on 5/13/23 was not good, it was a thin piece of meat with two to three peppers, the cheese was dry and half the residents received the correct buns while the other half received their meals on hamburger buns. A concern form dated 5/18/23 documented the following concerns: -The residents still felt the meat was dry and touch; -The residents would like to see the soup of the day listed on the menu; -The residents still felt there was too much rice being served; -The lemonade still had no flavor; -The ice tea was too strong; -There were not enough snacks at the nurses station at night; -The meals were not being served on time; -The Mother's day meal did not taste good; -The oven baked vegetables were too hard for residents to chew and they would like to have their vegetables steamed; -The cheesesteak served on 5/13/23 was not good, it was once piece of meat that only had one to two peppers and no melted cheese. The sandwich was dry with crumbled cheese. Some residents received their sandwich on the correct bread, while others received it on a hamburger bun; and, -The items on the always available menu were not always available. The summary of the resolution and action plan was documented by the DM on 5/23/23. It revealed the following resolutions: -The cooks would prepare meats like chicken and pork in a broth to prevent meat from drying out and cook meats to the proper temperatures; -The soup of the day was not posted on the menu; -Obtain preference for residents who want pasta over rice; -Have a vendor come look at the juice machine; -Use less tea to brew the ice tea; -The kitchen will provide snacks at night; -Educate staff on proper internal cooking temperatures for proteins and vegetables; -The soup of the day will be on the resident's meal tickets; -The dietary department would follow up with the lemonade and ice tea to ensure the directions were followed; -Ensure residents have choices for snacks throughout the night; and, -The DM would follow up with the dietary staff every meal to ensure the meals were served on time. -The concern form did not reveal the resolution was reviewed with a resident. A request was made for the education provided to staff in response to the 5/18/23 concern form on 5/25/23. The DDM said there were no documented in-services (see interview below). VI. Staff interviews The DM and the DDM were interviewed on 5/24/23 at 3:35 p.m. The DM said she attended food committee meetings monthly. The DM said the activities director (AD) filled out grievance forms for any concerns brought up. The DM said she frequently educated staff to help with the concern. The DM said all of the education was done verbally and was not documented. The DM and the DDM were interviewed again on 5/25/23 at 10:02 a.m. The DDM said he would look into catering in food once a month for the residents since they were concerned the staff received catered food. The DDM said he would review the last 30 days of food committee notes and begin implementing changes. The DDM said he would educate all staff. The DDM said he would implement holding food committee meetings twice a month, until they were able to make the food better for the residents. The AD was interviewed on 5/25/23 at 12:10 p.m. She said she attended the food committee meeting monthly. The AD said she was responsible for filling out concern forms for any concerns brought up by the residents. The AD said she then gave the concerns forms to the social services director to distribute to the correct department. The AD said she has noticed the same food concerns being brought up month after month. The AD said next month they were going to hold a food committee twice to help address the food concerns. The AD said at times she noticed that some of the concern forms she filled out during the food committee were not returned. The NHA and the corporate regional director of operations (CRDO) were interviewed on 5/25/23 at 1:34 p.m. The NHA said the food services department was contracted through an outside agency. The NHA said she had raised the concerns to the outside agencies' corporate level. The NHA said the DDM was recently assigned this facility and would be visiting more frequently. The NHA and the CRDO said they were aware of the residents' ongoing food concerns. The NHA said she would keep a closer eye on the resolutions of the concern forms. 12905 32259 48412

Based on interviews and record review, the facility failed to take timely action to identify, investigate, address and resolve grievances of the resident group. Specifically, the facility failed to take action regarding ongoing resident concerns about food quality and lack of sufficient transportation for outings because the second facility van was not operational. Findings include: I. Facility policy The Resident and Family Grievances policy, dated 2/17/23, was provided by the nursing home administrator (NHA) on 5/25/23 at 5:24 p.m. It revealed in pertinent part, It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. Prompt efforts to resolve include facility acknowledgement of a complaint/grievance and actively working toward a resolution of that complaint/grievance. II. Resident group interview A resident group interview was conducted on 5/24/23 at 9:30 a.m. with 10 residents (#20, #39, #4, #21, #8, #42, #32, #37, #35 and #11), who were resident council officers or actively participated in resident council and were assessed and identified by the facility as interviewable. During the group interview, residents said the facility did not consider the views of the resident group, act promptly upon grievances and recommendations, respond to concerns or provide a rationale for not doing so. The residents voiced multiple concerns about the quality of the food. Several residents said they had special diets and were served things they could not eat and their food preferences were not honored. Residents said their orders were not taken and food was just served to them or their orders were taken the day before and they had no idea what they wanted to eat the next day. Residents said the facility offered alternates through an always available menu, but the facility ran out of food items. They call it 'always available' but it's not. Residents said the kitchen ran out of lemons for iced tea, crackers for the soup, tamales, corn dogs and chef salad. Residents said they were told, This isn't available until Wednesday when the next food shipment was to arrive and the food service staff would not go to the local grocery store to replenish items they needed. Residents said it had been mentioned multiple times that the soup of the day was never identified. If it's not eaten a lot of food is wasted. Residents said they did not like the quality and flavor of the food served at the facility. They said the dark gravy was too runny, sometimes foods were too salty, the meat was tough and overdone, dry and tasteless and very hard. They said the oven-baked vegetables like cauliflower were tough and residents could not cut through it with a knife and they could not chew it. They felt the vegetables should be cooked in a manner that would preserve the flavor and nutrients. Sometimes the vegetables were dry and tasteless. Sometimes the lettuce was wilted and had black spots. Residents said they were told there was not enough money in the budget for fresh fruits. They never received the fresh fruits that were seasonal and locally grown. Residents said the food temperatures were sometimes not hot enough, which affected different foods at different times. Portions served were inconsistent, sometimes too much and sometimes too little and not consistently measured. They said it would be nice to have fried chicken occasionally. Some residents said the chicken and pork were sometimes undercooked, or the chicken was overcooked and dry. Residents said they were concerned with the lack of outings; the facility had two buses but only one was functional. They said they saw staff writing down notes in resident council meetings, but there was a lack of follow-up on resident concerns. We've been asking why the second bus doesn't work and they say they're working on it. If they had both buses working they could take all the residents out. They said residents got upset when they lined up for outings and they were told not everyone who wanted to go would fit on the bus. It's crazy the facility has two buses and only one that they run. III. Record review Review of resident council and food committee meeting minutes for the past six months revealed repeated resident concerns about food quality (cross-reference F804 food palatability) and the inoperable second facility van. Although the facility generated grievances on most of the residents' concerns, the follow-up involved staff education but insufficient evidence of the training conducted, actions taken or resolutions. IV. Staff interviews The maintenance director was interviewed on 5/25/23 at 11:51 a.m. He said he had no idea the residents were concerned with the lack of access to the second van, which was fine but needed to be licensed and insured. He said they did only have one van driver who took the residents where they wanted to go. The activity director (AD) was interviewed on 5/25/23 at 12:10 p.m. She said the management team responded verbally immediately to the residents' concerns voiced during the meetings. She said she filled out concern forms from the resident council and turned them in to the social services director (SSD), who followed up with the appropriate manager for follow-up. They read the old minutes at each meeting and discussed what was addressed. The AD said they were having the same, repeated concerns being brought up about food. She said those concerns were sent directly to the nursing home administrator (NHA). She said they originally combined the food committee with the resident council, but they started having separate food committee meetings and were now holding two food committee meetings per month because there were so many concerns. That had started around 5/10/23. She said she and the residents had noticed that when the corporate and district team were in the facility, the food got better and then dropped off again. The AD said she was aware of the concern about the inoperative second van. She said only one wheelchair would fit on their van and she had been hearing concerns more recently because the weather had been nice. She said they created a sign-up sheet for outings and tried to involve the residents who were unable to get out very much. She said they had to wait a long time to get the second van, waited a long time to get it repaired and were not having to wait a long time to get it licensed. The residents were excited about getting a second van. The AD said when she reviewed the grievances generated by the resident council, she did notice some grievances were missing. I thought I had more concern forms than this. She said she knew residents felt there was no follow-up on their food concerns. She said the residents were frustrated and she was frustrated too. The NHA and corporate operations director were interviewed on 5/25/23 at 1:35 p.m. The NHA said the facility did have repeated concerns about food quality and tried to get corporate involvement through their dietary contracting company leadership and their corporate dietitian, to ensure the residents' concerns were addressed and resolved. She said their contractor and corporate leadership staff were evaluating the appropriateness of the staff in the kitchen, ensuring they had the appropriate training and followed up to hold staff accountable to ensure the residents received good quality food and their concerns were responded to. She said they would implement change. She said they had another registered dietitian before and she would let their new RD know the residents needed to feel they had access to him. Regarding the van situation, she said while they continued to work on the van project, the activities department was mindful of alternating residents who went on outings so it was not always the same residents and to ensure everyone had the opportunity for outings. She said the second van had been there for a couple of months. She said they would consider increasing the frequency of outings until they could get a resolution. She said the second facility van was a work in progress, definitely a project.

Based on interviews, observations, and record review, the facility failed to take steps to protect three (#145, #22 and #32) of 10 residents reviewed for abuse out of 33 sample residents. Specifically, the facility failed to: -Ensure Resident #145 was free from physical abuse from Resident #21; -Ensure Resident #22 was free from physical abuse from Resident #35; and, -Ensure Resident #32 was free from physical abuse from Resident #16. Findings include: I. Facility policy and procedure The Elder Justice Act and Reporting Suspected Crimes Against Residents policy and procedure, dated October 2017, was provided by the nursing home administrator (NHA) on 5/22/23 at approximately 11:00 a.m. It revealed in pertinent part, Purpose: to facilitate efforts to prevent, detect, treat, intervene in, and prosecute elder abuse, neglect, and exploitation and to protect elders with diminished capacity while maximizing their autonomy and their right to be free of abuse, neglect, and exploitation. Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish. Injuries of unknown origin may occur as a result of abuse. Physical abuse: includes, but is not limited to, hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. All negative interactions involving residents can potentially be abuse and the administrator must be notified. II. Incident of physical abuse between Resident #145 and Resident #21 on 2/25/23. The 2/20/23 SBAR (situation, background, assessment and recommendation) communication assessment documented in Resident #145's electronic medical record (EMR) had entered Resident #21's room. Resident #145 was hit in the nose by Resident #21. The assessment documented Resident #21's primary diagnosis was dementia and he was admitted for long term care. Resident #21 did not have a change in mental status, function status, respiratory, abdomen or urine. The family and physician were notified of the resident-to-resident interaction. The 2/21/23 weekly head to toe skin check documented in Resident #145's EMR documented Resident #145 had minimal redness and excoriation to his bottom and had a laceration to his nose from an incident that was already noted. The 2/20/23 SBAR communication assessment documented in Resident #21's EMR documented another resident wandered into Resident #21's room. Resident #21 became upset and hit the other resident in the nose. The nursing note in the assessment documented the other resident was removed from Resident #21's room. Police, family and the physician were notified. The 2/19/23 nursing progress note documented in Resident #21's EMR documented Resident #145 wandered into Resident #21's room. Resident #21 became upset and hit Resident #145 on the nose. Resident #145 sustained a laceration to the nose with minimal bleeding. Resident #145 had no complaints of pain. The 2/20/23 incident note documented in Resident #21's EMR documented Resident #145 was removed from Resident #21's room after he was hit on the nose. The 2/21/23 nursing progress note documented in Resident #21's EMR documented Resident #21 would like a stop sign placed on his door as a preventative measure. The 2/20/23 abuse investigation documented the staff heard residents arguing. Upon arrival to Resident #21's room they discovered Resident #145 had entered Resident #21's room and had sat on the bed. Resident #21 had asked Resident #145 to leave, but Resident #145 was hard of hearing and did not leave. Resident #21 became upset and hit Resident #145 in the face with a shoe causing an abrasion to Resident #145's nose where his glasses were. The staff immediately serrated the residents. Resident #145 received first aide care after being removed from Resident #21's room. Resident #21 was offered a stop sign and he agreed to have the stop sign placed on his door. Resident #21 was interviewed and said Resident #145 had entered his room and would not leave upon asking. Resident #21 said he hit Resident #145 with a whole. Resident #21 said he wanted a stop sign for his door. The abuse investigations conclusion documented the event was isolated and a stop sign was placed on Resident #21's door to prevent future occurrences. A. Resident #145 1. Resident status Resident #145, age 82, was admitted on [DATE] and discharged on [DATE]. According to the April 2023 computerized physician orders, the diagnoses included vascular dementia, delusional disorders, depression and bilateral hearing loss. The 4/26/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status with a score of three out of 15. He required extensive assistance for bed mobility, transfers, locomotion on and off the unit, dressing, toileting and personal hygiene. He required limited assistance for walking in his room and in the corridor. 2. Record review The elopement care plan, initiated on 1/19/23 and revised on 4/7/23, documented Resident #145 was an elopement risk related to his diagnosis of vascular dementia. Resident #145 had a wander guard. The interventions included: distracting the resident from wandering, giving medications as ordered, monitoring the placement of the wander guard, identifying patterns of wandering, redirecting the resident, intervening if the resident become agitated or upset, observing the resident for his location frequently, offering emotional and psychological support, orienting the resident to his environment, providing structured activities, reorienting and validating as needed and approaching the resident in a calm manner when he becomes exit seeking. The cognitive impairment care plan, initiated on 1/23/2020 and revised on 4/7/23, documented Resident #145 had impaired cognitive function and impaired thought process related to his diagnosis of vascular dementia. The interventions included: allowing the resident extra time to respond as needed, facing the resident and speak clearly when communicating and offering yes or no choices. B. Resident #21 1. Resident status Resident #21, age 69, was admitted on [DATE]. According to May 2023 CPO, the diagnoses included Wernicke's encephalopathy (degenerative disease of the brain), severe protein-calorie malnutrition, auditory hallucinations, anxiety disorder, cognitive communication deficit and disorientation. The 3/3/23 MDS assessment the resident had severe cognitive impairment with a BIMS score of five out of 15. He required limited assistance of one person bed mobility, transfers, dressing, toileting and personal hygiene. He required supervision with set-up assistance for locomotion on and off the unit and eating. The MDS assessment documented the resident did not have behaviors during the review period. 2. Record review The behavior care plan, initiated on 2/23/23, documented Resident #21 was uncomfortable with other residents in his room and could react aggressively if the residents did not leave when asked. Resident #21 had a stop sign attached to his door frame with velcro to deter others from entering his room. Resident #21 was able to remove the stop sign without assistance. The interventions included: educating Resident #21 to notify staff with conflict or if another resident were to enter his room, encouraging Resident #21 to utilize the stop sign when he was in his room and ensure that the stop sign was in place upon exiting Resident #21's room. The stop sign care plan, initiated on 2/25/23 and revised on 5/24/23 (during the survey process), documented Resident #21 had a stop sign as needed as he did not always desire to have it on his door to prevent unwanted visitors. Resident #21 was in agreement with the placement as needed. The intervention was to ensure that the stop sign was placed on the door when the resident was in his room as needed or desired. The intervention was initiated on 3/20/23 and revised on 5/24/23 (during the survey process). -However, the facility did not have the the stop sign in place so it could be used as needed, until it was brought up for disucssion during the survey. The cognitive impairment care plan, initiated on 9/10/22 and revised on 2/23/23, documented Resident #21 had impaired cognitive function ir impaired thought process related to encephalopathy (brain disease that alters brain function). The interventions included: asking yes or no questions to determine the residents needed, cuing and reorienting the resident as needed and reducing distractions as needed. 3. Observations On 5/25/23 -At 10:59 a.m. a stop sign was not placed on Resident #21's door. -At 2:14 p.m. a stop sign was not placed on Resident #21's door. C. Staff interviews Registered nurse (RN) #1 was interviewed on 5/25/23 at 10:59 a.m. RN #1 said she had worked at the facility for approximately five months. RN #1 said she was not aware Resident #21 had any negative resident-to-resident altercations. RN #1 said she did not know of any interventions in place for Resident #21 to prevent negative resident-to-resident altercations. Certified nurse aide (CNA) #14 was interviewed on 5/25/23 at 11:11 a.m. She said she was contracted through an agency. CNA #14 said she was not notified of any resident-to-resident altercations for Resident #21. CNA #14 said she was not aware of any interventions in place for Resident #21 to prevent negative resident-to-resident altercations. The NHA and the corporate regional director of operations (CRDO) was interviewed on 5/25/23 at 1:25 p.m. The NHA said she was the abuse coordinator. The NHA said Resident #145 had entered Resident #21's room. The NHA said Resident #21 became upset and hit Resident #145 with a shoe causing a laceration on his nose. The NHA said Resident #21 agreed to have a stop sign placed as needed to his door frame. The NHA said RN #1 and CNA #14 were agency staff members, so they might not be aware of all interventions for residents. The NHA said care plans should be updated timely with any current interventions. The NHA said when new interventions were put into place, she would verbally tell staff on the units of the new intervention. The NHA said the care plan was in place for staff to refer to for interventions. -However, the abuse investigation intervention documented the stop sign was to be placed to Resident #21's door and the care plan intervention documented to ensure the stop sign was in place prior to leaving Resident #21's room this was not observed to be in place during the survey. III. Incident of physical abuse between Resident #22 and Resident #35 on 4/29/23. The 4/29/23 abuse investigation documented Resident #22 and Resident #35 were found in the dining room slapping at each other and were separated immediately. One resident was upset that the other resident was reportedly wearing a shirt that was not his. The two residents were separated and the Resident #22 was placed on frequent checks. The investigation documented: Resident #35 had a historical pattern of being irritated by Resident #22 and lashed out at him at times. Resident #35 had a recent behavior of pouring beverages on other residents when he was upset or yelled at other residents. Resident #35 had two previous physical altercations on 1/20/23 and 2/12/23. Resident #22 was interviewed and said Resident #35 had accused him of doing things he did not do and called him names. Resident #22 said he was going to stay away from Resident #35. Resident #35 was interviewed and said he approached Resident #22 and told him to take off his shirt, because it did not belong to him. Resident #35 said Resident #22 swung at him and hit his arm. Another resident was interviewed during the investigation as a witness and said Resident #35 told Resident #22 he was wearing my shirt. Resident #35 started the fight, but she was not sure if Resident #35 hit Resident #22. The follow-up action taken was to monitor the residents proximity to one another and keep separated, remove the resident if others were becoming frustrated with him and redirect with foods, fluids or activities, educating Resident #35 to ask for staff assistance when bothered or upset by others and staff were to monitor the two residents and keep them separated. The abuse investigation concluded the intention to initiate and altercation was substantiated, but the intention to harm was unsubstantiated. The 4/30/23 SBAR communication assessment documented in Resident #22's EMR documented Resident #22 was in a physical altercation on 4/29/23. The assessment documented at approximately 7:10 p.m the nurse was notified that Resident #22 was involved in a physical altercation with another resident that resulted in Resident #22 being hit on his left arm. The resident did not have any injury. The family, police, management and physician were notified of the altercation. The 4/30/23 SBAR communication assessment documented in Resident #35's EMR documented Resident #35 was in an altercation with another resident, which resulted in Resident #35 striking another resident on the left arm. The family, police, management and the physician were notified of the altercation. The 4/30/23 behavior progress note documented in Resident #22's EMR revealed Resident #22 was in a physical altercation with another resident that resulted in him being hit on his left arm. No injuries were noted and all parties were notified of the incident. The 4/30/23 behavior progress note documented in Resident #35's EMR revealed at approximately 7:10 p.m. the nurse was notified that Resident #35 was involved in a physical altercation that resulted in Resident #35 striking another resident on his left arm. No injuries were noted. The family, police, management and the physicians were signed. The 5/1/23 late entry social services progress note effective on 5/24/23 (during the survey process) documented by the NHA revealed the executive director followed up with Resident #35 after an altercation with another resident over the weekend. Resident #35 was reminded to ask for staff assistance when he became upset or bothered by others. The progress note documented the resident expressed understanding and agreement. The 5/1/23 late entry social services progress note documented the executive director followed up with the resident after an altercation with another resident. The resident was unable to recall the event and was at baseline. The 5/2/23 behavior progress note documented in Resident #35's EMR revealed the AD (activities director) met with Resident #23 to discuss interactions with fell ow residents. The note documented Resident #35 had a tendency to get easily irritated with another male resident and was aware his actions were inappropriate at times. Resident #35 was encouraged to ask for assistance if other residents were causing him frustrations. Resident #35 acknowledged understanding and agreed to rely on staff for assistance for future interactions. A. Resident #22 1. Resident status Resident #22, age 90, was admitted on [DATE]. According to the May 2023 CPO, the diagnoses included Alzheimer's disease, dementia with agitation and cognitive communication deficit. The 3/13/23 MDS assessment revealed the resident had severe cognitive impairment with a BIMS with a score of four out of 15. He required extensive assistance of one person for bed mobility, transfers, locomotion on and off the unit, dressing, toileting and personal hygiene. 2. Record review The behavior care plan, initiated on 11/30/23 and revised on 5/23/23 (during the survey process), revealed Resident #22 had a history of calling our 'help' frequently, although most of the time he was just attempting to say hello to staff and did not need help. This behavior negatively affected other residents. The interventions initiated on 11/30/23 included: encouraging the resident to participate in the activities of his choice, redirecting the resident to other areas if he became disruptive, ensuring the residents needs were met, monitoring if the resident needs something when yelling help or if he was just saying hello and providing medications as ordered. The interventions initiated on 5/23/23 (during the survey process) included: removing the resident if other residents were feeling frustrated with Resident #22 and monitoring for signs or symptoms of fear or psychosocial trauma related to an altercation and providing support as necessary. The wandering care plan, initiated on 8/2/23 and revised on 5/9/23 documented Resident #22 wandered in the facility and was at risk for elopement. The interventions included: distracting the resident from wandering by offering pleasant diversions, identifying a pattern of wandering, observing for fatigue and weight loss,offering emotional and psychological support and reorienting and redirecting resident as needed. The impaired cognition care plan, initiated on 5/2/22 and revised on 5/22/23 documented the resident had impaired cognitive function or impaired thought process related to dementia. The interventions included: allowing the resident to make daily decisions, approaching the resident in a gentle manner, asking yes or no questions to determine the residents needs, using the residents preferred name, cuing and reporting as needed, monitoring for changes in cognitive function and presenting one thought at a time and using task segmentation to support short term memory deficits. B. Resident #35 1. Resident status Resident #35, age 86, was admitted on [DATE]. According to the May 2023 CPO, the diagnoses included depression and dependence on a wheelchair. The 4/1/23 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS with a score of 11 out of 15. He required supervision with set-up assistance for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toileting and personal hygiene. 2. Record review The behavior care plan, initiated on 2/18/23, documented Resident #35 had a new behavior of pouring beverages on other residents when he became upset with them. Resident #35 was aware this was not a reasonable or acceptable way to respond to others, but may forget at times. The interventions included: anticipating and meeting the residents needs, providing positive interactions and educating the resident on successful coping and interaction strategies. The cognitive impairment care plan, initiated on 7/4/22 and revised on 4/25/23, revealed Resident #35 had impaired cognitive function and impaired thought process. The interventions included: asking yes or no questions, using the residents preferred name, cueing and reorienting as needed and checking on the resident. The MDS assessment documented the resident did not have behaviors in the review period. C. Staff interviews RN #1 was interviewed on 5/25/23 at 10:59 a.m. RN #1 said Resident #35 attempted to stay away from Resident #22. RN #1 said Resident #35 and Resident #22 were doing alright with each other recently. CNA #14 was interviewed on 5/25/23 at 11:11 a.m. CNA #14 said she was not aware of any resident-to-resident altercations for Resident #35. The NHA and the CRDO were interviewed on 5/25/23 at 1:25 p.m. The NHA said Resident #35 often became upset with Resident #22. The NHA said Resident #22 often yelled out help instead of saying hello to the staff. The NHA said Resident #35 and Resident #22 with each other had two previous physical altercations prior to 4/29/23. The CRDO said the resident's care plans should be updated immediately with any new interventions following a physical altercation. The CRDO said typically the resident's care plans would be updated during the investigation or if other identified opportunities thereafter arose to implement safety or oversight. 12905 IV. Abuse incident involving Resident #16 against Resident #32 on 5/21/23 A. Facility investigation Review of facility investigative reports revealed on 5/21/23 at 5:00 p.m., female Resident #32 was in the dining room with male Resident #16. Resident #16 became frustrated with Resident #32 and bumped his walker into her legs. The certified nurse aide (CNA) who witnessed the incident said the residents were sitting at a small table. The male resident (#16) spread his legs causing the table to move; the female resident (#32) asked that he not move the table and moved it back. Resident #16 was offered a different table and he declined. Resident #32 moved to an alternate chair. When Resident #16 got up, he bumped into Resident #32 with his walker and proceeded to walk away. No injuries or behavioral changes were identified. Resident #32 was involved in another abuse incident on 5/30/22, about a year before. Resident #16 had not been involved in other abuse incidents. The family representative, local police and State Agency were notified. Eight other residents were interviewed; they denied threats or fear of other residents. The facility investigation was still in process at the time of the survey exit on 5/25/23. B. Record review 1. Resident #32 Resident #32, age 75, was admitted in 2/18/22. According to the May 2023 CPO, diagnoses included neurocognitive disorder with Lewy bodies; traumatic ischemia of muscle, sequela; major depressive disorder and anxiety disorder. According to the 4/21/23 MDS assessment, Resident #32 had severe cognitive impairment with a BIMS score of three out of 15. She had no behavioral symptoms. She needed supervision, oversight and set-up assistance for most ADLs. Her diagnoses included dementia. (Cross-reference F744, dementia care.) Resident #32's 5/22/23 care plan identified cognitive impairments due to a dementia/Alzheimer's diagnosis. She enjoyed being around others and socializing with friends in the common areas and at the dining table. She participated in all group activities offered. She received physical aggression from another resident and the goal was no fear or trauma related to aggression. Interventions included assessing for injury, fear, anxiety or psychosocial trauma related to the incident, provide support if fear or other signs/symptoms were noted; and provide routine check-ins and refer to external agencies if appropriate. Review of social services progress notes revealed documentation on 5/21/23 at 5:30 p.m. that Resident #32 had an altercation with another resident. Resident #32 said she was fine, was not upset or scared, but annoyed. She did not recall the entire event, but expressed that she had no injury and no further concerns. 2. Resident #16 Resident #16, age 80, was admitted on [DATE]. According to the May 2023 CPO, diagnoses included cognitive communication deficit and other symptoms and signs involving cognitive functions and awareness. According to the 4/13/23 MDS assessment, Resident #16 had severe cognitive impairment with a BIMS score of three out of 15. (Cross-reference F744, dementia care.) He had delirium indicators of inattention and disorganized thinking, and a behavioral symptom of care rejection. He was independent with set-up assistance needs for most ADLs, and used a walker for ambulation. Resident #16's care plan, initiated 10/30/2020 and revised 5/22/23, identified when he got angry, he sometimes would curse and throw things at staff. He had poor impulse control when frustrated. He had run into another resident with his walker. The goal was he would not harm himself or anyone else. Interventions included: encourage him to involve staff with conflict or times or frustration, remove him from the source of frustration, he preferred to cool off in his room, encourage and validate his feelings, he enjoyed going outside, it helped to use humor with him as he liked to joke with staff, use a calm approach, if agitated let him be and re-approach later, and when I get angry, it helps me if you sit and talk with me. -There were no social services or nursing notes regarding the 5/21/23 abuse incident in Resident #16's medical record. C. Staff interview The NHA was interviewed on 5/25/23 at 2:10 p.m. She said when the above incident occurred, Residents #32 and #16 were at a table, became annoyed, and Resident #16 came back and ran his walker into Resident #32. She said there were no injuries to Resident #32 and there was no intent by Resident #16 to harm Resident #32. The NHA said to avoid further conflicts in the common areas, they had implemented more activities, music, impromptu dance parties, and a little more staff engagement when residents were out at the common area. -There was no documentation of an interview or statement from Resident #32 at the time of the incident. -The facility investigation documented Resident #16's physical abuse against Resident #32 was willful, indicating that abuse was substantiated.

Based on record review and interviews, the facility failed to provide adequate dementia care and services to ensure the highest practicable psychosocial well-being for three (#22, #32 and #16) of 10 residents reviewed for dementia care out of 33 sample residents. Specifically, the facility failed to provide dementia care and services to ensure Residents #22, #32 and #16 were free from abuse from their peers. Cross-reference F600, free from resident-to-resident abuse Findings include: I. Resident #22 A. Resident status Resident #22, age 90, was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia with agitation and cognitive communication deficit. The 3/13/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. He required extensive assistance of one person for bed mobility, transfers, locomotion on and off the unit, dressing, toileting and personal hygiene. B. Record review The behavior care plan, initiated on 11/30/23 and revised on 5/23/23 (during the survey process), revealed Resident #22 had a history of calling our 'help' frequently, although most of the time he was just attempting to say hello to staff and did not need help. This behavior negatively affected other residents. The interventions initiated on 11/30/23 included: encouraging the resident to participate in the activities of his choice, redirecting the resident to other areas if he became disruptive, ensuring the resident's needs were met, monitoring if the resident needs something when yelling help or if he was just saying hello and providing medications as ordered. The interventions initiated on 5/23/23 (during the survey process) included: removing the resident if other residents were feeling frustrated with Resident #22 and monitoring for signs or symptoms of fear or psychosocial trauma related to an altercation and providing support as necessary. The impaired cognition care plan, initiated on 5/2/22 and revised on 5/22/23, documented the resident had impaired cognitive function or impaired thought process related to dementia. The interventions included allowing the resident to make daily decisions, approaching the resident in a gentle manner, asking yes or no questions to determine the resident's needs, using the resident's preferred name, cueing and reporting as needed, monitoring for changes in cognitive function, presenting one thought at a time and using task segmentation to support short term memory deficits. C. Incident of physical abuse between Resident #22 and Resident #35 on 4/29/23 The 4/29/23 abuse investigation documented Resident #22 and Resident #35 were found in the dining room slapping at each other and were separated immediately. One resident was upset that the other resident was reportedly wearing a shirt that was not his. The two residents were separated and the Resident #22 was placed on frequent checks. The investigation documented Resident #35 had a historical pattern of being irritated by Resident #22 and lashed out at him at times. Resident #35 had a recent behavior of pouring beverages on other residents when he was upset or yelled at other residents. Resident #35 had two previous physical altercations on 1/20/23 and 2/12/23. Resident #22 was interviewed and said Resident #35 had accused him of doing things he did not do and called him names. Resident #22 said he was going to stay away from Resident #35. Resident #35 was interviewed and said he approached Resident #22 and told him to take off his shirt, because it did not belong to him. Resident #35 said Resident #22 swung at him and hit his arm. Another resident was interviewed during the investigation as a witness and said Resident #35 told Resident #22 he was wearing my shirt. Resident #35 started the fight, but she was not sure if Resident #35 hit Resident #22. The follow-up action taken was to monitor the residents' proximity to one another and keep separated, remove the resident if others were becoming frustrated with him and redirect with foods, fluids or activities, educating Resident #35 to ask for staff assistance when bothered or upset by others and staff were to monitor the two residents and keep them separated. The abuse investigation concluded the intention to initiate an altercation was substantiated, but the intention to harm was unsubstantiated. D. Staff interview The nursing home administrator (NHA) was interviewed on 5/25/23 at 2:10 p.m. She said interventions for Resident #22 involved trying to redirect him from calling out, sitting with him, spending time, providing food, being mindful of location and monitoring him in the presence of other residents. The NHA said the facility updated care plans accordingly and discussed any changes in approach with staff. -The facility failed to provide adequate dementia care for vulnerable Resident #22 to meet his psychosocial needs and keep him safe from resident-to-resident abuse by assessing and implementing approaches to mitigate the root cause of the resident's behavioral symptoms that were disturbing to other residents. II. Resident #32 A. Resident status Resident #32, age 75, was admitted on [DATE]. According to the May 2023 CPO, diagnoses included neurocognitive disorder with Lewy bodies; traumatic ischemia of muscle, sequela; major depressive disorder and anxiety disorder. According to the 4/21/23 MDS assessment, Resident #32 had severe cognitive impairment with a BIMS score of three out of 15. She had no behavioral symptoms. She needed supervision, oversight and set-up assistance for most ADLs. Her diagnoses included dementia. B. Record review Resident #32's 5/22/23 care plan identified cognitive impairments due to a dementia/Alzheimer's diagnosis. She enjoyed being around others and socializing with friends in the common areas and at the dining table. She participated in all group activities offered. She received physical aggression from another resident and the goal was no fear or trauma related to aggression. Interventions included assessing for injury, fear, anxiety or psychosocial trauma related to the incident, provide support if fear or other signs/symptoms were noted; and provide routine check-ins and refer to external agencies if appropriate. Review of social services progress notes revealed documentation on 5/21/23 at 5:30 p.m. that Resident #32 had an altercation with another resident. Resident #32 said she was fine, was not upset or scared, but annoyed. She did not recall the entire event, but expressed that she had no injury and no further concerns. C. Abuse incident involving Resident #16 against Resident #32 on 5/21/23 Review of facility investigative reports revealed on 5/21/23 at 5:00 p.m., female Resident #32 was in the dining room with male Resident #16. Resident #16 became frustrated with Resident #32 and bumped his walker into her legs. The certified nurse aide (CNA) who witnessed the incident said the residents were sitting at a small table. The male resident (#16) spread his legs causing the table to move; the female resident (#32) asked that he not move the table and moved it back. Resident #16 was offered a different table and he declined. Resident #32 moved to an alternate chair. When Resident #16 got up, he bumped into Resident #32 with his walker and proceeded to walk away. No injuries or behavioral changes were identified. Resident #32 was involved in another abuse incident on 5/30/22, about a year before. Resident #16 had not been involved in other abuse incidents. The family representative, local police and State Agency were notified. Eight other residents were interviewed; they denied threats or fear of other residents. The facility investigation was still in process at the time of the survey exit on 5/25/23. -The facility failed to provide adequate dementia care for vulnerable Resident #32 to ensure her highest practicable psychosocial well-being and keep her free from abuse by other residents, by intervening effectively before the negative interactions occurred and assessing and implementing measures to identify and address root causes when Resident #32 was in the common areas with Resident #16 and other residents. III. Resident #16 A. Resident status Resident #16, age 80, was admitted on [DATE]. According to the May 2023 CPO, diagnoses included cognitive communication deficit and other symptoms and signs involving cognitive functions and awareness. According to the 4/13/23 MDS assessment, Resident #16 had severe cognitive impairment with a BIMS score of three out of 15. He had delirium indicators of inattention and disorganized thinking, and a behavioral symptom of care rejection. He was independent with set-up assistance needs for most ADLs and used a walker for ambulation. B. Record review Resident #16's care plan, initiated 10/30/2020 and revised 5/22/23, identified when he got angry, he sometimes would curse and throw things at staff. He had poor impulse control when frustrated. He had run into another resident with his walker. The goal was he would not harm himself or anyone else. Interventions included: encourage him to involve staff with conflict or times or frustration, remove him from the source of frustration, he preferred to cool off in his room, encourage and validate his feelings, he enjoyed going outside, it helped to use humor with him as he liked to joke with staff, use a calm approach, if agitated let him be and re-approach later, and when I get angry, it helps me if you sit and talk with me. The resident's impaired cognitive function care plan, initiated 8/15/2020 and revised on 3/31/23, identified a goal of being able to communicate basic needs on a daily basis. Approaches included he was easily redirected with positive reassurance and needed frequent reminders, stop and return if agitated. -There were no social services or nursing notes regarding the 5/21/23 (see above) abuse incident in Resident #16's medical record. -There were no dementia care plan revisions after 5/21/23 with specific details on positive reassurance and ensuring his psychosocial well-being needs were met and to prevent further altercations with other residents by assessing and developing approaches to be mindful of and mitigating Resident #16's behavioral symptoms to keep him and other residents safe and treated respectfully. IV. Staff interview The NHA was interviewed on 5/25/23 at 5:15 p.m. She said to address dementia care needs and prevent resident-to-resident altercations, they were trying to alleviate some of the residents' idle time by providing more outside time, dog visits and other opportunities for engagement. She said they would be providing dementia care classes for facility staff through the National Council of Certified Dementia Practitioners (NCCDP) in June 2023.

Based on observations, record review and interviews, the facility failed to ensure menus were followed to meet the resident's nutritional needs. Specifically, the facility failed to: -Ensure residents were served the correct diets; and, -Follow the correct portion sizes to ensure adequate nutrition was provided to the residents. Findings include: I. Professional reference Dysphagia indicates difficulty swallowing. According to The Nutrition Care Manual website, Transitioning Texture-Modified Diet Terminology and Definitions to IDDSI (International Dysphagia Standardization Initiative) Framework, https://www.nutritioncaremanual.org/auth.cfm (Retrieved 8/6/23), Dysphagia Level 3: Advanced or mechanical soft diet: no hard sticky, or crunchy foods, foods should be moist, mixed-consistency foods are allowed if tolerated and should be assessed by clinician (Speech language pathologist), food particles are served in bite-sized pieces (less than 1 inch), meats are cut up, chopped or ground (moist), crusty dry breads not allowed, most other moist breads are bread products allowed, salad, raw vegetables, and most fresh fruit are not allowed, adequate dentition and chewing ability expected. II. Facility policy and procedure The Food: Quality and Palatability policy, dated September 2017, was provided by the dining district manager (DDM) on 5/25/23 at 3:36 p.m. It revealed in pertinent part, The Dining Services Director and Cook(s) are responsible for food preparation. Menu items are prepared according to the menu, production guidelines, and standardized recipes. III. Failure to ensure residents were served the correct therapeutic and mechanically altered diets. A. Observations and record review During a continuous observation during the lunch meal on 5/24/23 beginning at 11:19 a.m. and ended at 12:55 p.m. the following was observed: -Dietary aide (DA) #2 placed lemon bars on the resident's meal trays who were on a carbohydrate controlled diet. The menu extensions documented that residents on a carbohydrate controlled diet should have received a sugar cookie. -At 12:30 p.m. cook #1 cut off a piece of meatloaf and used two spatulas to chop the meat up. The meatloaf was variable in size, some pieces were over one inch. It was served to the resident in room [ROOM NUMBER]-2, who was on a dysphagia advanced diet with ground meat. Cook #1 continued this method for residents in room [ROOM NUMBER]-1, 11-1 and 45-1 who were on a dysphagia advanced diet with ground meats according to their meal tickets. -The resident in room [ROOM NUMBER]-1 requested a cookie with his lunch. The menu specified residents on a dysphagia advanced diet should receive a sugar cookie. The resident in room [ROOM NUMBER]-1 received an M&M cookie. -The resident in room [ROOM NUMBER]-1 was prescribed a therapeutic lifestyle diet. The menu specified he should have received a 3 ounce (oz) hamburger steak instead of the meatloaf. Cook #1 served the resident in room [ROOM NUMBER]-1 the meatloaf. IV. Failure to follow correct portion sizes to ensure adequate nutrition was provided to residents. A. Observations and record review During a continuous observation during the lunch meal on 5/24/23 beginning at 11:19 a.m. cook #1 used the following scoop sizes: A three ounce (oz) spoodle for the carrots for the regular and mechanically altered diets; Tongs for the alternative chicken; A spatula for the dysphagia advanced ground meatloaf; and, A #16 (four tablespoons) scoop for the pureed meat. The three oz spoodle was one oz less than the four oz portion size specified on the meal tickets for the sliced carrots for the regular and mechanically altered diets. Cook #1 weighed the chicken breast upon prompting and it weighed two oz. The chicken breast was two oz less than the four oz that was specified on the resident's meal tickets for the alternative menu item. After prompting cook #1 began serving two pieces of chicken to the residents. The menu revealed residents who were prescribed a dysphagia advanced diet with ground meat should have received a #8 scoop (four oz) of ground meatloaf. The meatloaf was not measured by cook #1 prior to serving the meatloaf. The #16 scoop (0.25 cup), measuring two oz, was three oz less than the 0.5 cup (four oz) specified on the recipe sheet for the pureed meatloaf. The residents on the pureed diet received meatloaf, bread and carrots. They did not receive four ounces of mashed potatoes that was listed on their meal tickets. B. Resident interviews Resident #20 was interviewed on 5/22/23 at 2:09 p.m. He said the portion sizes were too small sometimes. He said at times he did not get enough to eat and left the meal hungry. Resident #5 was interviewed on 5/22/23 at 4:32 p.m. He said the portion sizes were often too small, so he was hungry after meals. V. Staff interviews Cook #1 was interviewed on 5/24/23 at 12:00. He said he knew what items to serve each resident based on their meal ticket. Cook #1 said the portion sizes and diets were on the meal tickets. Cook #1 said the chicken was only two oz. He said the chicken that had been delivered lately had been smaller and he could not control the size of the chicken. The dietary manager (DM) and the DDM were interviewed on 5/25/23 at 10:02 a.m. The DDM said the cooks followed the meal tickets to ensure the correct portion sizes and diets were followed. The DDM said cook #1 should have utilized the food processor to grind the meatloaf to ensure all pieces were even and did not vary in size and then utilized a scoop to ensure the residents received the correct portion size. The DDM said the residents diet order was physician ordered and should be followed. The DDM said the resident in room [ROOM NUMBER]-1 should have received the cookie that was on the menu. The DDM said the M&M cookie could have been a choking hazard. The DDM said the meal tickets should have been followed to ensure the residents received the correct menu items. The DDM acknowledged the residents on a carbohydrate controlled diet received the wrong dessert. The DDM said it was important for the cooks to use the correct portion sizes to ensure the residents received adequate nutrition. The DDM said the residents on a pureed diet should have received mashed potatoes. The DM said she would look into purchasing bigger pieces of chicken to ensure the residents received adequate nutrition. The DDM said he would put together education to staff on diet types and portion sizes. The nursing home administrator (NHA) and the corporate regional director of operations (CRDO) were interviewed on 5/25/23 at 1:25 p.m. The NHA said the DDM would be visiting the facility more frequently to ensure the issues were addressed. 12905 32259

Based on observation, record review and interviews, the facility failed to ensure four (#2, #3, #4, #12) of five residents reviewed for skin and pressure injuries, out of 13 sample residents, received care consistent with professional standards of practice to prevent and heal pressure injuries. Systematic failures were identified in the facility's pressure ulcer prevention and care practices, increasing the risk and worsening of facility acquired pressure injuries. The facility did not consistently provide ongoing monitoring of pressure ulcers, accurately assess and document skin conditions, pressure ulcers and interventions. The facility failed to show consistent oversight in pressure ulcer prevention and treatment. Specifically, the facility failed to prevent a skin tear to her sacrum/coccyx from worsening to a unstageable pressure ulcer for Resident #4. The skin tear identified on 5/13/22, was not monitored between 6/3/22 and 6/10/22. There was inconsistent documentation identifying the onset of pressure ulcer with inconsistent follow up with treatment and preventative measures. Nursing documentation indicated, the nurse believed the resident had a pressure ulcer on 6/11/22. According to the nursing home administrator (NHA), Resident #4's condition was misidentified on 6/11/22. The resident was confirmed to have a stage two pressure injury on 6/17/22. Between 6/20/22 and 7/5/22, the wound team did not review Resident #4 weekly. Between 6/25/22 and 7/2/22 the nursing staff did not identify the pressure ulcer or its condition. On 7/5/22, the stage two pressure injury was unstageable. The facility relied on staff to reposition Resident #4 every two hours to prevent the development and the worsening of a pressure injury. The wound determined additional pressure relieving intervention were needed after Resident #4 acquired the pressure ulcer to her hip. The facility an ordered air mattress for Resident #4 but was not available until 6/29/22, two weeks after the pressure ulcer was identified. Resident #3 had inconsistent documentation identifying existing and new resident's pressure ulcers, the onset date, the location of existing pressures, the condition and monitoring of the 6/17/22 pressure ulcer. Resident #3 had redness to his bilateral hips as of 5/7/22 which worsened to a stage two pressure on his right hip and potentially to his left hip as identified on the 7/9/22 weekly head to toe skin check. The skin condition documentation was inconsistent in its description, condition and or measurements of a skin concern/pressure injury. In addition, the facility failed to ensure residents identified at risk for skin injuries and pressure ulcers, interventions were documented timely and with professional standards of practice. Record review and staff interview identified it was common practice for the certified nurse aide (CNA) to chart she completed a pressure reducing task, repositioning, hours prior to completing the task. The practice limited the credibility and confidence that the task was completed as documented. The practice affected three residents (#2, #4, and #12), who were at risk or had current pressure ulcers. Findings include: I. Professional reference The NPUAP Pressure Injury Stages,The National Pressure Ulcer Advisory Panel, was retrieved on 8/2/22 at http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages read in pertinent part: A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear. The updated staging system includes the following definitions: -Stage 1 Pressure Injury: Intact skin with a localized area of non-blanchable [CONDITION(S)]. -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. -Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar was removed, a Stage 3 or Stage 4 pressure injury will be revealed. II. Facility policy The Pressure Injury Prevention and Management policy, dated 2021, was provided by the nursing home administrator (NHA) on7/21/22 via email. The policy indicated the facility was committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. The policy defined avoidable pressure ulcer injury was when the failed to do one or more of the following: -Evaluate the resident's clinical condition and risk factors; -Define and implement interventions that are consistent with the residents needs, goals, and professional standards of practice; -Monitor and evaluate the impact of the interventions; or, -Revised the interventions as appropriate. The policy read in pertinent part: The facility shall established and utilize a systematic approach four pressure injury prevention and management, including prompt assessment and treatment, intervening to stabilize, reduce or remove underline and risk factors; monitoring the impact of interventions; and modifying the interventions as appropriate. Licensed nurse will conduct a full body skin assessment on all residents upon admission/readmission, weekly and after a newly identified pressure injury. Findings will be documented in the medical records RN (registered nurse) unit manager, or designee, will review all relevant documentation regarding skin assessments, pressure injury risk, progression towards healing, and compliance at least weekly, and document a summary of findings in the medical record. The Wound Treatment and Management policy, dated 2021, was provided by the nursing home administrator (NHA) on 7/21/22 via email. The policy read: To promote wound healing a various types of wounds, it is the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Pressure your injuries will be differentiated from non pressure injuries, such as arterial, venous, diabetic, moisture or incontinence related skin damage. Treatment decisions will be based on characteristics of the wound including the stage, size, amount of exudate and presence of pain, infection and or non-viable tissue. The effectiveness of treatments will be monitored through ongoing assessments of the wound. Consideration for needed modifications include: -Lack of progression towards healing; -Changes in characteristics of the wound; and -Changes in Residence goals and preferences, such as end of life or in accordance with his or her rights. III. Resident #4 A. Resident status Resident #4, age 79 , was admitted on [DATE]. According to the July 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/12/22 minimum data set (MDS) assessment indicated Resident #4 had severe cognitive impaired with a brief interview for mental status (BIMS) score of one out of 15. The resident required extensive assistance of more than two persons for bed mobility, dressing, and personal hygiene. The MDS identified the resident had total dependence on staff for toileting. According to the MDS, the resident had an unhealed, unstageable pressure ulcer. The MDS identified the resident was in hospice. B. Observation The pressure ulcer treatment was observed on 7/19/22 at 11:30 a.m. The pressure injury to the resident's coccyx (buttocks at the base of the spine) was observed to have slough and red tissue. The pressure injury appeared to have healing healthy red tissue granulation tissue present. There were no odors or signs or symptoms of infection. The resident was not complaining of pain or discomfort. The surrounding skin did not appear to be broken down or showing signs of infections. The wound appeared to be healing. RN #2 cleansed wound with wound cleanser and applied Santyl (topical wound medication) to the wound bed. The RN placed alginate (wound dressing) around the edges in the wound. The RN applied the foam dressing over the wound bed. C. Record review The CPO identified the Resident #4 had active orders since 7/31/21 directing staff to cleanse the resident's bilateral lower extremities with wound cleanser and observe for abnormalities to wound beds and surrounding skin. According to the orders, staff should document if the resident had abnormalities or no abnormalities. The orders requested staff to provide additional documentation if abnormalities were identified, on every shift for wound care. The CPO identified the Resident #4 had active orders since 12/30/21 directing staff to apply barrier cream mixed with [MEDICATION(S)] after each incontient episode. The 5/13/22 weekly head to toe skin check identified Resident #4 had a skin tear to her sacrum/coccyx area. There were no new interventions noted on the skin check to treat the skin tear. -The skin check did not identify the size, or describe the condition of the skin tear. The 5/13/22 hospice notes identified the resident had been on hospice since 12/2/21. The 5/20/22 weekly head to toe skin check did not identify the resident had a skin tear or note its condition. The check referred reader to see weekly wound assessment. The 5/27/22 weekly head to toe skin check noted the resident continued to present with a skin tear to her sacrum/coccyx area. No new interventions noted on the skin check to treat the skin tear. -The skin check did not identify the size, or describe the condition of the skin tear. The 6/2/22 Braden scale assessment for Resident #4 identified the resident was at a very high risk for pressure ulcers. According to the Braden scale assessment, the resident was bedfast and had a very limited ability to change and control her body position independently. The 6/3/22 and 6/10/22 weekly head to toe skin check did not identify the skin tear or note its condition of her sacrum coccyx area or interventions to treat. The 6/11/22 weekly head to toe skin check identified the resident had a new pressure ulcer. The skin check revealed the open area was on her sacrum, measuring 2 centimeters (cm) x 1.5 cm. The open area was described as red with a graduating wound bed. According to the skin check, staff applied barrier cream to treat. The skin check did not include the stage of the pressure ulcer. The 6/13/22 weekly pressure log read Resident #4 had blanchable denuded skin to her sacrum. According to the 6/13/22 log entry, the sacrum would be reviewed again at the end of the week. The 6/13/22 weekly pressure log entry for Resident #4 identified the resident had a 6/17/22 (however, this was three days after the entry) facility acquired a pressure ulcer on her sacrum with slough measuring 1.2 cm x 1 cm. -The log entry did not identify the stage of the pressure ulcer, however the slough was now present. The 6/14/22 new pressure ulcer incident form read Resident #4's previous reddened coccyx, now had a 2 cm x 1.5 cm open area on her sacrum. The area was described as blanchable, denuded skin. Interventions included to apply barrier cream as ordered and continue to reposition the resident for comfort and pressure reduction. According to the form the interdisciplinary team (IDT) recommended to continue with her current plan of care. -The incident form did not include a stage for the identified pressure ulcer. The 6/18/22 weekly head to toe skin check read the resident had an existing pressure ulcer. No additional information was noted regarding the pressure ulcer. The 6/20/22 weekly pressure ulcer record read the resident had a stage two pressure ulcer measuring 1.5 cm x 1 cm on her coccyx. The record identified the pressure ulcer acquired at the facility on 6/17/22. The record noted the resident was to use pillows and a pressure reducing mattress. The review of the resident's medical record, did not identify a weekly pressure ulcer record or document the resident was seen by the wound team between 6/20/22 and 7/5/22. The 6/25/22 weekly head to toe skin check did not identify the resident had a pressure ulcer, the condition of the pressure ulcer or interventions to treat the pressure ulcer. The 7/1/22 CPO read the resident had orders for an air mattress. (Two weeks after the pressure was identified.) The 7/2/22 weekly head to toe skin check did not identify the resident had a pressure ulcer, the condition of the pressure ulcer or interventions to treat the pressure ulcer. The skin identified the resident had a new skin tear. -The skin check did not clearly identify where the skin tear was located. The 7/5/22 weekly pressure ulcer record read the resident an unstageable pressure ulcer measuring 1.5 cm by 1.5 cm. According to the record, the resident's response to the provided treatment deteriorated. The unstageable pressure ulcer had an increase in size and had 100% slough to the wound bed. The record identified the air mattress arrived and was implemented on 6/29/22 (at least two weeks after the onset of the pressure ulcer). The 7/9/22 weekly head to toe skin check identified the resident had a new skin tear on her elbow and bruising on her upper extremity related to a 7/8/22 fall. -The skin check did not identify the pressure ulcer, the condition of the pressure ulcer or interventions to treat the pressure ulcer. The 7/11/22 CPO identified the resident had orders to cleanse the sacrum pressure ulcer twice a day, apply santyl to the wound bed and calcium alginate over the santyl. Skin prep should be applied to the surrounding skin. A foam dressing should then be applied. According to the order, staff should document if the resident had abnormalities or no abnormalities. The orders requested staff to provide additional documentation if abnormalities were identified, on every shift for wound care. The 7/11/22 weekly head to toe skin check identified the resident had a new skin tear on her elbow and bruising on her upper extremity related to a 7/8/22 fall. -The skin check did not identify the pressure ulcer, the condition of the pressure ulcer or interventions to treat the pressure ulcer. The 7/11/22 weekly pressure ulcer record read the pressure ulcer had a small reduction in size, with some depth noted in the center of the wound. The pressure ulcer measured 1 cm x 1.5 cm x .2 cm. According to the record, there were no signs of infection and the resident continued on hospice. The 7/16/22 weekly head to toe skin check identified the resident had a new skin tear on her elbow and bruising on her upper extremity related to a 7/8/22 fall. -The skin check did not identify the pressure ulcer, the condition of the pressure ulcer or interventions to treat the pressure ulcer. The July 2022 care plan revealed the resident had the potential for skin issues related to immobility, chronic stasis ulcers, [CONDITION(S)], venous insufficiency, potential breakdown secondary to incontinence. -The care plan did not include the resident's current pressure ulcer. D. Staff interview Registered nurse (RN) #2 was interviewed on 7/20/22 at 11:30 a.m. She said the wound team saw the resident's wound on Monday (7/18/22). There were no new orders made. The RN said the wound team staged it unstageable, but now it was open and the wound could be seen. The RN said it was the facility policy stage the pressure ulcer staging did not decrease even if it was healing. The NHA was interviewed on 7/20/22 at 4:46 p.m. with the director of operation (DO). The NHA said she was the facility wound nurse and part of the wound team. She said the wound team documented their findings on the weekly pressure ulcer record. The NHA said the she was aware Resident #4 had an identified open area on her sacrum/coccyx on 6/11/22 and the wound team looked at it on the following Monday, 6/13/22. The team identified the open area was more of a shearing instead of pressure ulcer. She said it was pink and blanching, denuded and shallow. She said she did not document the wound team's 6/13/22 observation. The NHA said on 6/17/22 she looked at the open area and felt the wound was a pressure related injury and identified 6/17/22 as its onset date. She said she ordered an air mattress and was waiting for it to arrive. The air mattress did not arrive until 6/29/22. She said she relied on staff to continue to reposition the resident to alleviate the pressure. She said the form dressing was implemented. She identified a change in condition that should have been done at the time. The wound team's weekly pressure ulcer record was reviewed with the NHA and the DO. The NHA acknowledged there was no wound team documentation indicating Resident #4 was seen between 6/20/22 and 7/5/22 when the pressure injury worsened. The NHA said she was on vacation during that time and the former director of nursing (DON) should have conducted the observations and documented the pressure injury findings. The DO said the wound team should have seen the resident weekly. The NHA said she would conduct a full house audit to ensure residents with identified skin concerns are seen routinely and appropriate documentation was in place. She said would provide additional education on wound monitoring and documentation. IV. Resident #3 A. Resident status Resident #3, age 83, was admitted on [DATE] and passed away on 7/10/22. According to the July 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/17/22 minimum data set (MDS) assessment indicated Resident #3 had severe cognitive impaired with a brief interview for mental status (BIMS) score of three out of 15. The resident required extensive assistance of one person for most of his activities of daily living (ADLs). Resident #3 was identified on the MDS to be at risk for pressure ulcer, however the resident did not trigger for actual pressure ulcers. B. Record review The 10/1/22 CPO read Resident #3 was admitted to hospice. The 5/7/22 weekly head to toe skin check read Resident #3 had redness to his bilateral hips. The 5/14/22 weekly head to toe skin check read Resident #3 had existing pressures to his bilateral on his hips. The 5/21/22 weekly head to toe skin check read Resident #3 had a tumor on his left cheek. -The skin check did not indicate there was redness or pressure ulcers to his bilateral hips. The skin check did not identify the resident's hips were checked to determine the resident's 5/21/22 skin condition. The 5/28/22 weekly head to toe skin check marked Resident #3 had an existing pressure ulcer. -The skin check did not identify where the pressure ulcer(s). The weekly head to toe skin check noted the resident had redness to hips and buttocks. The 6/13/22 Braden scale for Resident #3 identified the resident was at high risk for pressure ulcers. According to the Braden scale assessment, the resident had a slight limited ability to change and control his body position independently. The 6/4/22 weekly head to toe skin check read Resident #3 had redness to his face. -No additional information related to the resident's hips were noted. The 6/11/22 weekly head to toe skin check read Resident #3 had redness to his bilateral hips. The 6/17/22 weekly non-pressure condition record read Resident #3 had a new non pressure skin condition to his right hip. Record described the skin condition as red with a small opening area measuring 1 cm x 1cm. The wound bed was yellow with slough present. The wound was not staged. The surrounding skin around the open area was bright red. An air mattress was noted as intervention. According to the record the wound nurse/NHA, the nutritionist, and the resident's family was notified on 6/18/22. The 6/17/22 situation, background, assessment, recommendation (SBAR) communication form, identified the wound as pressure related over the bony prominence of the right hip. The form read the condition had not occurred before. The wound was covered with dressing. According to the SBAR, offer to reposition and offer pillows and attempted to alleviate the pressure from his hip. The physician was notified on 6/17/22. -The SBAR did not indicate the stage of the pressure ulcer. The 6/18/22 weekly head to toe skin check read Resident #3 had an existing pressure ulcer to his right hip. The skin check read the pressure injury was covered with a padded dressing and staff attempted to reposition the resident. -The skin check did not describe or identify the condition of the pressure ulcer. The 6/20/22 weekly pressure ulcer record the resident had a right hip pressure injury with an onset date of 6/17/22. The pressure injury measured 1.2 cm x 1 cm and was referred to the physician and the wound nurse. According to the record, the interdisciplinary team (IDT) recommended to continue the current treatment and interventions. -The record did not include staging of the pressure ulcer. The 6/25/22 weekly head to toe skin check read Resident #3 had a pressure ulcer to his right hip, treatment in place. -The skin check did not describe or identify the condition of the pressure ulcer. No additional information was identified on the skin check pertaining to his pressure ulcer. The 7/2/22 weekly head to toe skin check read Resident #3 had an existing pressure ulcer on his right hip. According to the skin check, wound orders were in place. -The skin check did not describe or identify the condition of the pressure ulcer. No additional information was identified on the skin check pertaining to his pressure ulcer. The 7/5/22 weekly pressure ulcer record read the resident had a stage two pressure injury to his right anterior hip which increased in length and reduced in width, measuring 1.7 cm by .06 cm. The pressure was described as macerated (softening of breakdown of skin as a result of prolonged moisture.) According to the record, the resident had a change in treatment. The dressing would be changed more frequently, noting the dressing would be changed to BID (twice a day) and PRN (as needed), for moisture management. The record indicated the resident preferred to lay on his right side. The 7/9/22 weekly head to toe skin check identified the resident had two pressure injuries. Resident #3 had a stage two pressure ulcer to his right hip and a stage one pressure ulcer to his left hip. The 7/10/22 nursing note identified Resident #3 passed on 7/10/22. According to the note, the resident only had one pressure ulcer (on his right hip) when he passed. The note did note identify the second pressure ulcer to his left hip as described in 7/9/22 weekly head to toe skin check. The 7/19/22 CPO read the resident had orders for Pro Stat at 30 milliliters (ml), twice a day. The 7/20/22 CPO read the resident had orders to consume one packet of [MEDICATION(S)] daily mixed with water for wound healing. The July 2022 care plan for potential for skin impairment/skin integrity care plan related to fragile skin, poor intake, and end of life. According to the care plan, the resident would often decline to reposition to his right side. The care plan read that the resident would tolerate to lay on his back for short periods at a time, but would often return to his right side. The care plan directed staff to turn and reposition the resident frequently to decrease pressure. C. Staff interview The NHA was interviewed with the DO on 7/20/22 at 1:35 p.m. The NHA said nurses should complete weekly checks on residents. She said if they identify a skin concern, they should immediately report the concern to the wound team, complete an SBAR, and risk management. The staff should also document the resident had a change in condition. She said interventions should then be put in place including the implementation of pressure relieving devices. She said all in house mattresses were pressure reducing and were rated up to a stage three. The NHA said the 6/17/22 non-pressure injury form was a mistake. She said staff should have completed the correct pressure ulcer form after a pressure ulcer was identified. She said the wound team observed Resident #3 on 6/20/22 and confirmed the pressure ulcer. The NHA said prior to 6/17/22, the resident only had redness to his hips. The DO said staff encouraged the resident to reposition off his right side but he had a tumor to the left side of his face. The resident would often want to lay on his right side related to the tumor on his left side. The NHA said the resident should have been seen by the wound team weekly. The NHA said the resident did not have pressure ulcers as on 5/14/22 and nursing should not have documented he did as of 5/14/22. The NHA said there was alot of back and forth on the documentation related Resident #3's skin condition. The NHA said staff should know redness did not mean the resident had a pressure ulcer/injury. She said should have also completed the necessary documentation and staff notification if the nurse believed the resident had a pressure injury. The NHA said the former DON should have provided more staff oversight. She said the identified documentation concerns were an opportunity to educate staff on the importance of documentation accuracy. The NHA said the resident did not have a stage one pressure ulcer to his left hip as identified on 7/9/22 weekly skin check. She said it might have been a little red on his left hip. She said she needed to review staging with the nursing staff. The NHA said the identification of a new pressure ulcer depended on its blanching. She said she would review staging of pressure ulcers in the education. The NHA said staff received training on our systems during orientation and receive training on skin conditions annually and needed. The DO said there was a breakdown in the supervision of the system. She said there should have been spot checks with appropriate follow up. She said the facility needed to make sure during orientation and annual trainings. The NHA and the DO agreed the above issues were due to a lack of training and oversight. According to the DO and NHA, they would conduct immediate staff education and review nurse competencies. They said they would also review the orientation training and make sure all needed education components were included related to the identified concerns. V. Accuracy of intervention documentation A. Residents 1. Resident #2 a. Resident status Resident #2, age 83, was admitted on [DATE] and readmitted on [DATE]. According to the July 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/17/22 minimum data set (MDS) assessment indicated Resident #2 had moderate cognitive impaired with a brief interview for mental status (BIMS) score of eight out of 15. The resident required extensive assistance of more than two persons for her activities of daily living (ADLs) of bed mobility, transferring, dressing and toileting. The MDS indicated the resident was at risk for pressure ulcers. b. Record review The 7/19/22 Braden scale for Resident #2 identified the resident was at risk for pressure ulcers. According to the Braden scale assessment, the resident had a very limited ability to change and control her body position independently. The July 2022 care plan for skin breakdown read the resident had potential for skin breakdown related to incontinence of bowel and bladder. According to the care plan the resident needed staff assistance with positioning and support for comfort and pressure reduction. The care plan directed staff to turn and reposition the resident frequently to decrease pressure. 2. Resident #4 a. Resident status Resident #4, age 79 , was admitted on [DATE]. According to the July 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/12/22 minimum data set (MDS) assessment indicated Resident #4 had severe cognitive impaired with a brief interview for mental status (BIMS) score of one out of 15. The resident required extensive assistance of more than two persons for bed mobility, dressing, and personal hygiene. The MDS identified the resident had total dependence on staff for toileting. According to the MDS, the resident had an unhealed, unstageable pressure ulcer. b. Record review The 6/2/22 Braden scale assessment for Resident #4 identified the resident was at a very high risk for pressure ulcers. According to the Braden scale assessment, the resident was bedfast and had a very limited ability to change and control her body position independently. The July 2022 care plan for potential for skin issues related to immobility, chronic stasis ulcers, [CONDITION(S)], venous insufficiency, potential breakdown secondary to incontinence. -The care plan did not include the resident's current pressure ulcer. 3. Resident #12 a. Resident status Resident #12, age 81, was admitted on [DATE]. According to the July 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/26/22 minimum data set (MDS) assessment indicated Resident #12 had severe cognitive impaired with a brief interview for mental status (BIMS) score of six out of 15. The resident required extensive assistance of one person for bed mobility, personal hygiene, and dressing. She needed extensive assistance from more than two persons for toileting. The MDS indicated the resident was at risk for pressure ulcers. b. Record review The 5/24/22 Braden scale for Resident #12 identified the resident was at risk for pressure ulcers. According to the Braden scale assessment, the resident was bedfast (confined to a bed), and had a very limited ability to change and control her body position independently. The July 2022 care plan for skin breakdown read the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included directing staff to provide encouragement and assistance to turn/resposition at least every two hours, or more often as needed or requested. B. Facility record review The reposition tracking daily log for residents was revi[TRUNCATED]

Based on interviews and record review, the facility failed to ensure one (#1) of six residents reviewed was free from significant medication errors out of 24 sample residents. Resident #1 was symptomatic and diagnosed with a urinary tract infection ([CONDITION(S)]) and prescribed an antibiotic on 3/17/22. However, she did not receive the first dose of her antibiotic until seven days later on 3/23/22. The resident experienced discomfort, burning and delayed treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident expressed right now I have a [CONDITION(S)] and the infection feels like it's eating my skin, and said she felt discomfort, burning, and if I sit in a wet diaper for very long my skin starts burning and I punch the light immediately. Findings include: I. Facility policy The Unavailable Medications policy, undated, was provided on 3/23/22 at 5:17 p.m. by the corporate nurse consultant (CNC). It included the following: The facility maintains a contract with a pharmacy provider to supply the facility with routine, prn (as-needed), and emergency medications. -A STAT (immediate) supply of commonly used medications is maintained in-house for timely initiation of medications. -Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that the medication is unavailable: a. Determine reason for unavailability, length of time medication is unavailable, and what efforts have been attempted by the facility or pharmacy provider to obtain the medication. b. Notify physician of inability to obtain medication upon notification or awareness that medication is not available. Obtain alternative treatment orders and/or specific orders for monitoring resident while medication is on hold. -If a resident misses a scheduled dose of the medication, staff shall follow procedures for medication errors, including physician/family notification, completion of a medication error report, and monitoring the resident for adverse reactions to omission of the medication. II. Resident status Resident #1, under age 65, was admitted on [DATE]. According to the March 2022 computerized physician orders, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 12/22/21 minimum data set (MDS) assessment, Resident #1 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. No mood or behavioral symptoms were documented. There was no evidence of care rejection. Resident #1 needed extensive two-plus-person assistance with transfers, dressing, toilet use, personal hygiene, and bathing. She took antibiotics and diuretics, and had a [CONDITION(S)] within the last 30 days of the assessment. III. Interviews Resident #1 was interviewed on 3/21/22 at 4:15 p.m. She said she had a real bad (urinary) incontinence problem, and right now I have a [CONDITION(S)] and the infection feels like it's eating my skin. She said antibiotics were ordered for her Thursday (3/17/22) after a physician visit and the pharmacy told the nursing staff they don't deliver on the weekend. Resident #1 said she discussed this with her nurse (licensed practical nurse #3) this morning (3/21/22). Resident #1 said she had discomfort, burning, and if I sit in a wet diaper for very long my skin starts burning and I punch the light immediately. Resident #1 was interviewed a second time on 3/22/22 at 8:45 a.m. She said she still had not received her antibiotic and she was burning. Licensed practical nurse (LPN) #3 was interviewed on 3/22/22 at 8:50 a.m. She said Resident #1's antibiotic had not come in yet from the pharmacy. She said she was not sure what the process was, they had just changed pharmacies, she was off Friday, Saturday and Sunday, and came back yesterday to find the resident had not received her antibiotic. She confirmed the resident saw her doctor on Thursday and needed the antibiotic. She said the pharmacy was on her list of calls to make that day. LPN #3 said she did not know the facility policy for acquiring medications from the emergency kit or from a local pharmacy, if residents did not have their medications available. The nursing home administrator (NHA) and corporate nurse consultant (CNC) were notified on 3/22/22 at 9:00 a.m. The CNC reported on 3/22/22 at 11:45 a.m. that she had just talked with and educated LPN #3. The CNC said they had the medication in the emergency kit. The resident will get the medication now. The CNC said she would follow up with the pharmacy to find out the reason for the delay on their end, and would do a full house audit to ensure other residents had not missed their medications. Resident #1 was interviewed again on 3/22/22 at 4:14 p.m. She said she got her antibiotic today, which they took from the emergency kit, but the prescription still had not arrived from the pharmacy. The resident's antibiotic was delayed for six days. IV. Record review Review of nursing progress notes and the March 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/17/22 at 4:17 p.m., LPN #3 documented, res(ident) in to see provider, main issues discussed were concerns over possible [CONDITION(S)], [MEDICATION(S)] 100 mg cap, 1 cap by mouth every 12 hrs with food for 7 days, drink plenty of fluids, OTC (over the counter) [MEDICATION(S)] (analgesic to relieve [CONDITION(S)] symptoms) PRN (as needed) for painful urination, will add new orders. The resident's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] was not added to the MAR. On 3/17/22 at 5:30 p.m., LPN #3 documented the antibiotic had not yet arrived from the pharmacy. There was no documentation that [MEDICATION(S)] was offered or given, and it was not added to the MAR. There was no documentation of a call to the physician. On 3/18/22 at 5:56 p.m., another nurse documented waiting on pharmacy to deliver the antibiotic. There was no documentation [MEDICATION(S)] was offered and no call to the physician. On 3/19/22 at 5:01 a.m., a third nurse documented medication pending from pharmacy. There was no documentation [MEDICATION(S)] was offered and no call to the physician. On 3/19/22 at 5:01 p.m., a fourth nurse documented the [MEDICATION(S)] was unavailable not delivered. There was no documentation [MEDICATION(S)] was offered and no call to the physician. On 3/20/22 there was no nursing note about the [MEDICATION(S)]. On 3/21/22 at 7:30 a.m., LPN #3 documented they were waiting on pharm (pharmacy) to deliver the [MEDICATION(S)]. On 3/22/22 at 7:09 a.m., LPN #3 documented they were waiting on pharm to deliver the [MEDICATION(S)]. On 3/22/22 at 8:00 p.m., the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The last dose was scheduled to be given at 8:00 a.m. on 3/29/22. -There was no documentation the resident was monitored for symptoms such as painful urination, that [MEDICATION(S)] was provided for the burning symptoms she experienced (see resident interview above), that the pharmacy was contacted, or that nursing management or the physician were notified that the medication was not received and instructions requested for how to acquire the resident's medications. The care plan, initiated on 3/23/22, identified a urinary tract infection. The goal was resolution without complications. Interventions were: encourage adequate fluid intake; give antibiotic therapy as ordered, monitor/document for side effects and effectiveness; monitor/document/report to physician as needed for signs/symptoms of [CONDITION(S)]: frequency, urgency, malaise, foul smelling urine, dysuria (painful urination), fever, nausea and vomiting, flank pain, suprapubic pain, hematuria (blood in urine), cloudy urine, altered mental status, loss of appetite, behavioral changes; obtain and monitor lab/diagnostic work as ordered, report results to physician and follow up as indicated. V. Facility follow-up On the morning of 3/23/22, the CNC reported that no other residents had missed critical medications. She provided an undated medication error report and process improvement plan which included the following: One resident with antibiotic ordered 3/17/22 and as of 3/22/21, medication had not been received by pharmacy or administered to resident. Corrective action: Medication removed from StatSafe and administered to resident. Resident assessed and physician notified of delay and assessment findings. (Name of pharmacy) pharmacy contacted with concern of delay. Pharmacy representative researched the issue and the pharmacy had not received the order for the antibiotic due to the computer systems not being integrated at this time. The order would have to be called in or faxed. The order was entered, and the med was dispensed to the resident 3/22/22. ID (identification) of others: An audit of medication orders x 2 weeks was completed 3/22/22 to assess for missing medications. One order for Oragel received by the facility on 2/21 was found to not have been administered. Central Supply notified and medication will be purchased for use 3/23. Licensed nurse education was provided to six nurses regarding use of the StatSafe (emergency kit) and what to do when a new order was received. Education was ongoing for each oncoming nurse to their shift.

Based on interviews and record review, the facility failed to ensure residents were treated with respect and dignity. Residents reports that staff did not consistently: -Respond to their call lights in a timely manner; -Treat them and speak to them in a dignified manner; and, -Respond appropriately and timely when concerns were brought to their attention. Residents said it was wrong the way they were sometimes disrespected by staff and treated like children. As a result, residents used the words angry, aggravated, ridiculous and hurt to describe how they felt. Findings include: I. Resident interviews Interviews with residents who were cognitively capable and interviewable revealed the following concerns regarding dignity and respect. Residents #1 and #27, who were roommates, were interviewed on 3/21/22 at 4:05 p.m. Resident #27 mentioned a fall off the bedside commode on 2/25/22 (cross-reference F689). Resident #1 said she rang the call light to get help, but staff didn't come, didn't come, didn't come, to answer the call light. Resident #27 said she had fallen on both her stumps and it hurt. Resident #27 said if she waited for transfer assistance to the toilet there would've been a big mess. She said the fall scared the heck out of me. Resident #1 said she had to use the sit-to-stand lift for transfers and cares, but there's a wait because it takes two people. Resident #1 said, and it was observed, that she had [CONDITION(S)] to her lower legs and ankles which were wrapped, but her feet were not elevated. She said the only solution they had offered was to have her lie down in bed, but she said no because if they put her to bed she would have to stay there because call light response took so long. Resident #1 further stated she had a urinary tract infection ([CONDITION(S)]), probably from sitting in urine for too long due to her incontinence and delayed call light response, which meant delayed incontinence care, which made her skin burn. She said call light response sometimes took 25 minutes to an hour. If I sit in a wet diaper for very long my skin starts burning and I punch the light immediately. She said having to wait for call light response and care felt uncomfortable and wrong. Cross-reference F760 for significant medication errors related to treating her [CONDITION(S)]. A group of residents (#27, #1, #31, #140, #6 and #21) who were active in resident council were interviewed on 3/23/22 at 3:10 p.m. Residents said call light response had been a problem discussed in resident council meetings several times, and it was still a problem. Resident #1 said she had recently had to wait 45 minutes for assistance to the bathroom because they had a find a second staff person to come, and ended up having an accident. I get so upset when I have an accident. The other day an aide got really nasty at me, and said 'You should've held it. 'I was pissed and I felt bad. Resident #1 said the night her roommate, Resident #27, fell (cross-reference F689) and nobody answered the light, she hollered and they fussed at me for hollering and asked, 'Why are you yelling? Because (Resident #27's) on the floor.' Resident #27 said, Then they told me to calm down. I felt just as bad as (Resident #1). I felt ridiculous and (the fall) hurt really bad. Resident #1 said staff sometimes placed residents' call lights out of reach when they made their beds, and you can't get to it. They need to put it back down on the bed. Resident #1 said she and Resident #27 got grippers so they could access their call lights from behind the beds. Resident #1 said, If they're short staffed, I put myself to bed using the slide board, which doesn't feel safe. Resident #6 said she agreed. Resident #1 said staff gripe about having to help and move things around, just to move my fan and my scooter, and they ask 'Why didn't you do that before you got back into bed?' Resident #1 said this type of staff treatment made her feel aggravated and like she was being treated like a child. Residents #27 and #6 nodded their heads in agreement. II. Resident council minutes Review of resident council minutes for the past six months revealed the resident council group had complained about call light response and dignity for several months. Specifically, minutes documented in pertinent part: On 12/29/21: Group concern for call lights in the evening. On 1/26/22: CNAs (certified nurse aides) are slow to answer call lights. CNA will come ask the resident what they need then leave without helping. Residents hear CNAs complaining about answering call lights when they are sitting in the common area. On 2/23/22: Nursing staff not asking to come in (to resident rooms) or announcing themselves. Staff on phones while in residents' rooms. Answering call light times become longer, 15-30 minutes. Need more aides. On 3/23/22 (just before the resident group interview above): The DON addressed old concerns regarding nursing and floor staff. She let residents know we have hired a new set of traveling staff. DON provided education to staff about dignity, respect, and cell phone policies. Call light response time is low (still a problem). Additional RA (resident assistant) staff hired for morning and evening, and managers will do call light audits and follow-ups. Status: ongoing. -However, call light audits and follow-up were not noted previous to 3/23/22 until identified on survey, to show the facility was actively addressing long call light times when residents expressed concern in December 2021, and January and February 2022. III. Staff interviews The therapy director was interviewed on 3/22/22 at 4:39 p.m. about some of Resident #1's concerns. She said she would visit with Resident #1 about options to help her elevate her legs, like an up/down schedule, alleviating her concerns about call light response. She said Resident #1 should be able to get up and down per her choice and request. CNA #2 was interviewed on 3/24/22 at 10:30 a.m. She said Resident #1 was probably one of our most understanding residents because she's been a nurse. Once in a while she'll have a bowel incontinence issue but she's pretty good about letting us know when she's got to go to the toilet. She said delayed call light response could be a problem sometimes, but not often on the day shift, although it could get very busy at times and the nurse was not always able to help with call lights. CNA #6 was interviewed on 3/24/22 at 11:00 a.m. She said he recalled hearing concerns from Residents #1 and #27 about call light response and staff responses to them. She said she had overheard a couple of other residents talking between themselves about staff saying 'Don't call me.' She said she had also heard stories about residents not getting their dinner or not getting to bed timely, and that's really bad. She said she had also overheard contract staff raising their voices to residents and had intervened and reported them, and she did not see them in the facility after that. She said that was a month or two before. The nurse manager (NM) and social services director (SSD) were interviewed on 3/24/22 at 12:18 p.m. The NM said she recalled one of the former agency CNAs had raised her voice at a resident. She reported to the DON and it was investigated and the agency staff did not return. The SSD said they reviewed resident grievances as an interdisciplinary team and it was turned in to the appropriate department for investigation. The results were reported to the residents. The activity director was interviewed on 3/24/22 at 12:42 p.m. about follow-up on resident council concerns. She said residents requested more staff and they responded by adding more agency staff. A new corporation was newly on board and they had halted admissions until they were able to hire and retain stable staff. The director of nursing (DON) was interviewed on 3/24/22 at 1:30 p.m. She said she had investigated concerns about former agency staff, and their contracts were not reviewed and the concerns were reported to the agency manager. She said she was in the process of investigating resident concerns. She said so far, all but three of the residents she interviewed had told her they were satisfied with their care and the way staff treated them. She said they would proceed with investigations and staff training to address the residents' concerns regarding dignity, call light response and care provision.

Based on observations, interviews and record review, the facility failed to ensure two out of six residents reviewed for abuse out of 24 residents were kept free from abuse. Resident #32 and #3 expressed fear and anxiety about a situation that occurred with Resident #4 on 1/11/22. Resident #4 entered their room while they were inside, blocked the door, and began to yell at them. She told them she was going to shoot them and they were afraid she was going to start throwing items at them that were near the sink. Residents #32 and #3 both turned on their call lights for help but they were unable to get staff assistance during the situation and felt like they were being held hostage. They were scared and did not feel safe. There was one intervention implemented after the event, which was to place a Velcro stop sign in the doorway entrance in an attempt to deter Resident #4 from entering the room again. However, the stop sign was not monitored for placement consistently and was not present during the survey. A. Facility policy and procedure The Abuse, Neglect and Exploitation policy, dated 3/1/22, was provided by the corporate nurse consultant (CNC) on 3/24/22 at 4:51 p.m., and included in pertinent part: Involuntary seclusion referred to the separation of a resident from other residents or from their room or confinement to their room against the resident's will. The facility would establish a safe environment and monitor residents with needs and behaviors, which might lead to conflict or neglect. B. Resident #4 status Resident #4, age 73, was admitted [DATE]. According to the March 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/28/21 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of five out of 15. [CONDITION(S)] behaviors present included hallucinations and delusions with physical behavioral symptoms directed toward others that occurred one to three days, and verbal behavioral symptoms that occurred four to six days. She required extensive assistance with activities of daily living (ADL) and used a wheelchair for mobility. She received antipsychotic medication on a routine basis. The care plan, initiated 11/5/21 and revised 12/28/21, identified Resident #4 received antipsychotic medication related to a psychiatric condition that caused her to act in ways that were inappropriate for her setting and situation. This was evidenced by distressing auditory and visual hallucinations, continuous wandering and exit seeking with increased anxiety and agitation. The approaches included going outside with staff, wandering around the facility and people watching, and reminiscing about her family. When she acted in ways that were inappropriate for her setting and situation, it helped if staff sat and talked with her. C. Resident #32 status Resident #32, age 89, was admitted [DATE]. According to the March 2022 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/15/22 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. She had no [CONDITION(S)], [CONDITION(S)] or behavioral symptoms, and no rejection of care. She required extensive assistance with ADLs. D. Resident #3 status Resident #3, age 89, was admitted [DATE]. According to the March 2022 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/27/21 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. She had no [CONDITION(S)], [CONDITION(S)] or behavioral symptoms, and no rejection of care. She required extensive assistance with most ADLs. E. Resident #32 and #3 interviews Resident #32 and #3, who were roommates, were interviewed on 3/21/22 at 11:55 a.m. They were asked if they had any confrontations with any other residents, and they described the following situation: Resident #32 said approximately two to three months ago, Resident #4 entered their room, uninvited, while they were in there. Resident #4 blocked the door with her wheelchair and prevented them from leaving. Resident #4 began screaming and yelling at them, which scared them and made them feel like they were being held hostage. Resident #4 told them she was going to shoot them. They both turned on their call lights for assistance, but said no one came to help them. They were afraid Resident #4 was going to start throwing things at them that were near the sink area. Resident #4 remained in their room for approximately 15 minutes until she decided to leave on her own. Resident #3 said they told the nurse or certified nurse aide (CNA) who was working that day, and told the nursing home administrator (NHA) about the incident. However, they were unable to remember the names of the staff members they had informed. She said a Velcro stop sign had been placed across the door entrance to their room after the incident occurred. On 3/24/22 at 11:17 a.m., Residents #32 and #3 were interviewed again and asked if they were still afraid of Resident #4. Resident #32 said, It makes me very uncomfortable and I don't know what she is capable of. If she came in here again I would not like it at all. I wouldn't feel safe. Resident #3 said Resident #4 returned to their room approximately three weeks ago and asked if she could use their bathroom. Resident #3 told her someone else was using the restroom so she could not use it, and Resident #4 removed the Velcro stop sign from the door entrance, wadded it up and took it with her as she left. She said the staff did not replace the stop sign, and they preferred to keep their door open because it got warm in their room. Resident #3 said they did not know what Resident #4 was capable of and did not know if they should be afraid of her or not. F. Resident #4 observations On 3/22/22 at 12:00 p.m., Resident #4 was sitting in her wheelchair at the Telluride Street unit doors that were closed because they led to the COVID-19 isolation neighborhood. She attempted to propel herself down the hallway and was yelling the name of a housekeeper and cursing at her loudly when she was not allowed to enter the hallway. CNA #7 approached the resident and attempted to distract her, but the resident continued to yell and curse loudly for approximately six minutes. At 12:10 p.m., registered nurse (RN) #5 approached the resident and informed her she was not allowed to enter the isolation neighborhood. Resident #4 yelled at the RN to leave her alone, and the RN walked away. The resident was left alone and not within line of site of any staff members, and became quiet and calm for a few minutes. She was then was assisted to her room by RN #5, who propelled her backwards in her wheelchair down the hallway to her room. On 3/22/22 at 4:14 p.m., Resident #4 was propelling herself independently around the common area of the progressive care unit (PCU). She went to the window and looked outside for a few minutes, then approached the nurses' station briefly, then propelled herself down the hallway towards the dining room. She was able to move about the area independently. On 3/23/22 at 3:03 p.m., Resident #4 was sitting alone in the common area of the PCU. She became agitated and said she wanted to go home, repeating the request loudly multiple times. RN #4 spoke with her briefly, and then walked away. A CNA approached her a few minutes later and offered her a baby doll to hold, but the resident did not want it. The resident was left alone for a few minutes, and then suddenly propelled herself across the common area to another resident who was sitting quietly holding another baby doll. Resident #4 asked the other resident to give her the baby doll and when the resident did not hand it over, Resident #4 grabbed the doll out of the other resident's hands, and then propelled herself back across the common area. Resident #4 went over to where another resident was talking with a visitor and told him or her, I'm not going anywhere. I'm giving you the same treatment I'm getting. CNA #8 was able to encourage Resident #4 to move away from the visitor and back to her room. G. Record review The behavior tracking for Resident #4 was reviewed from 3/1/22 through 3/22/22, and revealed the following: There were a total of three days when she exhibited distressing behaviors of agitation, hallucinations, wandering and exit seeking; There were a total of three days when she exhibited tearfulness, hopelessness and withdrawing from activities of interest. -There was no interdisciplinary team review of the incident that occurred with Residents #4, #32 and #3 documented in any of the residents' electronic medical records. On 3/24/22 at 10:20 a.m., the DON provided documentation of the incident that occurred among Residents #4, #32 and #3 on 1/11/22, and included the following information: Resident #4 entered the room of Residents' #32 and #3, closed the door and threatened to shoot them. Resident #4 left the room independently and staff were aware of the incident and were to keep Resident #4 within line of sight. The police were notified and the victims were interviewed, Resident #4 was assessed and no weapon was found in her room or on her person, and during the investigation, nursing staff monitored her. The report documented that during the interview with Residents #32 and #3, both expressed fear of Resident #4 in relation to her threat. The investigation revealed no other residents had any concerns or fear, and the psychoactive medications for Resident #4 would be reviewed. The facility was unable to substantiate abuse because Resident #4 had advanced dementia and was unaware of her actions. There were no other interventions put in place to help prevent a recurrence. Call light audits were reviewed from January 2022 through March 2022, but there were none completed on 1/11/22 to check the length of time Resident #32 and #3's call light was going off. H. Staff interviews CNA #3 was interviewed on 3/24/22 at 12:30 p.m., and she said she was an agency worker who had worked at the facility for 10 days. She said Resident #4 was able to propel herself in her wheelchair independently and had moments when she got upset. She said if Resident #4 did not get her way, she became agitated, and that happened quite often, in the mornings. She said it helped her to de-escalate if she was allowed to propel herself around the building and she liked to go from place to place. CNA #4 was interviewed on 3/24/22 at 3:36 p.m., and he said he routinely worked with Resident #4. He said she had verbal outbursts or aggressive behavior frequently and sees a lot that is not there. He said he was not at the facility when the incident happened among the three residents on 1/11/22, but said it really scared Residents #32 and #3. He said the facility placed a Velcro stop sign up to deter Resident #4 from entering their room again and stated, we as CNAs have to keep a better eye on her. He said he thought the stop sign was still across their doorway but he did not think it would stop Resident #4 from entering their room again and said, the real intervention is us keeping a better eye on her. He said they could not keep her from roaming, but they could redirect her. The SSD was interviewed on 3/24/22 at 1:19 p.m., and she said the facility was trying to maintain her safety and the safety of others. She said the facility was not aware of the extent of her aggressive outbursts when they accepted her (to the facility), and when they learned more about her behaviors after she was admitted , she began working with Resident #4's husband to transfer her to a secured unit. However, they had not been able to find a facility that would accept her. The facility had tried a combination of medication management and one on one interventions to calm her down when needed, and said it was successful at times and at other times, it was not, because of her dementia process. She said Resident #4 was delusional and it was important to meet her where she was in her memory. She said they had tried offering task-oriented activities like folding towels, puzzles and coloring, but found that validation and reminiscing worked best with her. The SSD said Resident #4 was not aware of her aggressive outbursts so she was not sure how the facility would be able to prevent her from doing something like that again as she did with Residents #32 and #3. RN #2 was interviewed on 3/24/22 at 3:16 p.m., and she said she routinely worked with Resident #4. She said Resident #4 did not like to be engaged with other people, but liked to be directing and telling them what to do-mostly staff. She said most of the other residents usually ignored her, but she needed attention. She said the staff would talk about stories with her, what it was like when she was young, and the clothes her mother used to make for her. The RN said they tried to keep her in the PCU, which was a calm, predictable environment, rather than going down the hallway to other units. RN #2 explained the location of Residents' #32 and #3's room was near a glass exit door, and she thought the incident occurred earlier in her stay at the facility when she was doing more exit seeking. She said she would look out the door, see the cars in the parking lot, and think she needed to leave. RN #2 said put a stop sign barrier up to try to keep her away from that area, and was not aware the stop sign was no longer there. The RN said she was not working the day the incident occurred, but did not believe their call light was going off for 15 minutes and explained in a situation like the one they experienced, three minutes might seem like a much longer period of time. RN #2 said Residents #32 and #3 were wary and watch her (Resident #4) RN #2 said the medication changes the facility had made had helped tremendously and she was not aware of any more incidents that had occurred with Resident #4. The DON was interviewed on 3/24/22 at 2:30 p.m., and she said she was working in the PCU as a CNA on 1/11/22, the day the incident happened. She recalled there were three call lights going off at the same time, including Resident #32 and #3's, and she prioritized answering the call light of a resident who was at high risk for falls and needed assistance with toileting. She said when she finally arrived at Resident #32 and #3's room, approximately 10 to 12 minutes later, Resident #4 was already leaving, and they were very upset about it. She said she offered them reassurance that they were safe and that Resident #4 had left on her own. She said she informed the former NHA immediately and he assumed responsibility for the investigation and interventions from there, including putting up a stop sign to deter Resident #4 from entering again. The DON said since that episode occurred, they have been able to steer Resident #4 away from that hallway. The DON explained when the incident occurred, Resident #4 was in the process of a medication change at that time and they were waiting for a therapeutic level to take effect. She said once the medications had been changed, Resident #4 had become calmer and had fewer aggressive outbursts. The DON was not aware the Velcro stop sign was no longer across the entrance to Resident #32 and #3's room and said it was never reported to her that Resident #4 had ripped it off the wall. She said she was not aware Resident #4 had returned to their room again three weeks ago and had asked to use their restroom. The DON said she would find out where the stop sign had gone and get another one placed across their door immediately.

Based on observations, record review and interviews, the facility failed to provide supervision and assistance to prevent falls with injuries for two (#10 and #11) of five residents reviewed for falls/accidents out of 23 sample residents. The facility failed to observe and supervise, anticipate needs and implement fall prevention measures for Resident #10. The facility was aware the resident was vulnerable, impulsive, had a history of [REDACTED]. The resident fell and fractured her pelvis on 12/28/2020 at 5:00 a.m., and as a result suffered pain, an emergency department (ED) visit, physical decline and experienced another fall on 1/6/21 at 7:50 a.m. Resident #11 was vulnerable and weak from a hospitalization upon facility admission, and was assessed at high risk for falls. He experienced six falls after his admission; four were unwitnessed and one occurred during a transfer. One of his unwitnessed falls during February 2021 resulted in pain, bruising and abrasions, and a visit to the ED for assessment of elbow pain. Findings include: I. Resident #10 A. Resident status Resident #10, age 91, was admitted on [DATE] with [DIAGNOSES REDACTED]. According to her 11/17/2020 minimum data set (MDS) assessment (before her fall with fracture), she had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident needed extensive assistance with transfers, ambulation with a wheelchair and toilet use. She had pain medications, scheduled and as-needed, and no current pain. Her 1/18/21 significant change MDS assessment (after her fall with fracture) documented a BIMS score of two out of 15. She needed extensive two-plus person assistance with transfers and toilet use. She had occasional pain that she rated at three out of 10, which limited her daily activities, and was treated with scheduled and as-needed pain medications, and other methods. She had had a fall with major injury since her prior assessment. She was receiving hospice services. B. Record review 1. Fall risk assessments The resident's fall risk assessments dated 8/25/2020, 11/26/2020 and 2/23/2020 rated her at high risk for falls. 2. Falls Review of fall investigation reports and interdisciplinary progress notes revealed the following documentation of the resident's falls: Fall #1 - 4/4/2020 at 7:00 p.m.: The resident's roommate turned on her call light at 7:00 p.m. after the resident fell out of her wheelchair while propelling across her room. The resident was lying on her back but stated she fell out of the chair and landed on her buttocks on the floor by her sink. I just fell out of my chair, I'm not sure what happened. The resident denied any loss of consciousness, or hitting her head. Upon assessment there were no complaints of pain. Tylenol was given at 7:15 p.m. for complaints of aching in her buttocks. The resident had a history of [REDACTED]. She also had a history of [REDACTED]. -It was not documented when the staff had last checked on the resident. Fall #2 - 4/21/2020 at 9:30 a.m.: The resident was found sitting on the floor in front of her wheelchair, in her gown, no shoes on, call light not engaged. She had been incontinent of bowel at the time of fall, and had a skin tear to her right elbow, a raised area to her right forehead with bruising. She was unable to verbalize how she fell , but may have fallen forward from her wheelchair striking her head on her roommate's wheelchair or the floor, or may have been ambulating without assistance. The resident was noted as confused with poor safety awareness. Therapy would evaluate for antiroll back brakes to wheelchair, continue to assist and anticipate needs. There were no witnesses. -It was not documented when staff had last checked on the resident. -No new person centered interventions were added or attempted to prevent future falls or injuries. Fall #3 - 12/28/2020 at 5:00 a.m.: The resident was found lying on the floor at the foot of her bed, complaining of pain to left shoulder and a large hematoma over her left eye with laceration, bed at safe anatomical height, call light in reach on bed, unable to verbalize how the fall occurred. The resident was sent to the ED for evaluation due to pain to the left shoulder and decline of allowing nurse to complete full assessment related to pain and poor cognition. The resident returned from the ED to the facility at 12:15 p.m. with a [DIAGNOSES REDACTED]. The facility documented placing a low bed with mat, lamp on in room at night for increased visibility, resident has soft touch call light in place, staff to continue to anticipate needs, continue all other current interventions. On 12/31/2020 the resident was sent to the ED again in severe pain; she returned with medication orders to treat a urinary tract infection. Review of nursing notes surrounding the resident's 12/28/2020 fall with injury revealed no documentation about the resident since 12/25/2020 (three days before the fall, and only regarding a shower given), minimal documentation of post-fall monitoring after the resident returned from the ED, and no IDT fall review meeting until 12/31/2020 (four days after the resident's fall with fracture and head injury). No neurological checks were completed after this fall. No new interventions were added to the fall care plan until 12/29/2020 after the resident fell and was sent to the ED, where she was diagnosed with [REDACTED]. See care plan section below. Fall #4 - 1/6/21 at 7:50 a.m.: The resident was found on the floor in her room, bed in low position and call light in reach and on. The resident was unable to state what happened. It appeared she had rolled out of her low bed onto her fall mat. She was assisted back into bed and neuros initiated. Resident declining since fall with fracture. Position of comfort is on right side, but staff assisting with turning and positioning. Appears resident turned from left to right and rolled off the bed. Resident currently on air mattress with low bed and fall mat. Will continue current interventions and educate staff to ensure positioned in center of bed. Also working with physician on better pain control to allow for positioning on both sides of body. 3. Care plan The resident's care plan, initiated 7/8/18, documented high risk for falls related to history of falls, poor safety awareness related to dementia, and impaired mobility related to [MEDICAL CONDITION]. Interventions were: -Anti-rollbacks on wheelchair (8/6/18) -Anticipate and meet needs (7/8/18) -Soft call light strategically placed for ease of calling for assistance (7/18/18) -Often forgets to call for assistance due to cognition. Remind and redirect as needed, ensure call light is in reach (12/29/2020) -Offer and encourage the toilet frequently (7/27/18) -Therapy evaluate and treat as ordered or as needed (7/8/18, revised 8/20/19) -Low bed with fall mat in place (7/18/18, revised 12/29/2020) -Keep a lamp light on in room at night to help with visibility if I attempt to get up without assistance and forget to use my call light (12/29/2020) -Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Education resident/family/caregivers/IDT as to causes (7/8/18) C. Observations The resident was observed on 2/23, 2/24, 2/25 and 3/1/21, spending most of her time in her room in bed or sitting up in her wheelchair alone in her room, when not in the dining room for lunch or dinner. Her door was often completely closed or halfway closed where she could not be easily observed from the hallway. On 2/25/21 at approximately 8:30 a.m., the resident's light was on, and her door was closed. Several minutes passed before a CNA walked down the hall with a meal tray cart. She saw the resident's light, said the resident's name and quickly entered her room and stayed with her, asking her if she was ready to get up. When the resident was observed in bed, her bed was in the low position and a fall mat was next to her bed. D. Interviews The resident's daughter was interviewed by phone on 2/24/21 at 10:45 a.m. She said she worried about her mother falling so much. She does seem to be alone long enough to where she can fall out of her chair, and that worries me a little bit. She's fallen off the bed. They've got a pad down. She does have a lot of little stumbles and last time she broke her pelvis. She's just now recovering to where she's not in pain. We also know she gets up all at once and takes off like she can walk. She thinks she walks all the time. She used to be quite the walker, walked for miles when she was younger. She was always an active woman and thinks she still is . (now) it's hard to get her engaged in anything. CNA #1 was interviewed on 3/1/21 at 1:30 p.m. She said they checked on residents regularly when their doors were closed, to ensure they were safe. She said Resident #10 was not as impulsive about getting up unassisted since she fell and broke her pelvis, which she thought happened during the night shift. The unit manager (UM) was interviewed on 3/1/21 at 3:30 p.m. She said Resident #10's fracture happened after a self-transfer, as she was unaware of safety, and her falls usually occurred while trying to get in or out of bed, and if she was tired. She said the resident's fall with fracture happened early in the morning, and she couldn't remember if she was trying to get up or lie down. She definitely has no safety awareness so we try to keep her out and about, and when she's tired or says she's tired, we definitely lay her down. She said they tried to lay eyes on high-risk residents every hour if not more often: nurses, CNAs, herself. She said if the resident was lying down, and with COVID we were supposed to have the doors closed, Resident #10 has a pressure pad call light as well. She likes to sleep in in the mornings. We'll go in and offer to get her up and we just kind of check on her and if the call light's on we know we need to go in. She's able to propel herself around a little bit. When she first fell she had a little bit more pain but now she's getting back to baseline. II. Resident #11 A. Resident status Resident #11, age 90, was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the resident's 1/18/21 MDS assessment, he had severe cognitive impairment with a BIMS score of five out of 15. He needed extensive two-plus person assistance for bed mobility, transfers and toilet use. He used a wheelchair for mobility. B. Record review 1. Falls The resident's admission assessment dated [DATE] documented he was at high risk for falls. His fall risk assessment on 3/1/21 also documented high risk. The resident experienced six falls during February 2021; four of his falls were unwitnessed and one occurred during a transfer. Fall investigative notes and IDT progress notes documented the following. Fall #1-12/28/2020 at 9:00 a.m.: The resident slid from his bed to a sitting position on his fall mat. There was no evidence of an investigation after this fall. Fall #2-2/8/21 at 5:15 p.m.: The resident was found sitting on the floor beside the bed that was in the lowest position. He was confused and unable to give a full description of the fall. There was a small skin tear on his left knee. The resident was educated about using the call light and fall risks. The resident had a noted decline, a fall mat was placed and staff were educated to ensure he was positioned to the center of the bed away from the edge. He needed more assistance with all activities of daily living, and staff were to anticipate needs. Fall #3-2/12/21 at 7:00 p.m.: The resident was found on the floor at bedside, bed in low position, mat in place, call light in reach, pain and limited range of motion to right elbow and complaint of pain to the head. He was sent to the ED for evaluation, and returned with no injury noted. The resident was educated to call staff for assistance and verbalized understanding. Evaluate for perimeter defining mattress. Fall #4-2/16/21 at 8:30 a.m.: The resident was witnessed sitting up and starting to transfer himself to his wheelchair, when he slid from his bed to the floor. There was no evidence of follow-up or an investigation regarding this fall. Fall #5-2/19/21 at 10:45 a.m.: The resident was found in a kneeling position on the floor mat next to his bed with his elbows resting on the bed. He had previously been sitting in his wheelchair facing the door, eating his breakfast. He was unable to verbalize how the fall occurred. He had a small abrasion to his left ear. No other new visible areas of redness or bruising were found. He was assisted to bed, mat placed next to bed, call light in reach. He denied discomfort. Staff were educated to not leave the resident up in his wheelchair in his room, and to try to bring him to the common area or activities. He remained on therapy services. Fall #6-2/24/21 at 8:00 a.m.: The resident's legs gave out during a transfer and he was assisted to the floor without injuries. (See MDS above, the resident required two-plus person assistance for transfers.) There was no evidence of an investigation after this fall. 2. Care plan The resident's fall prevention care plan identified moderate risk for falls related to weakness. Interventions included: -Anticipate and meet the resident's needs. -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. -Encourage to sit in the lobby at times for increased socialization and monitoring by staff (resident declines at times). -Ensure the resident is wearing non-skid socks. -I have been educated that I am weak due to recent illness and need to call for assistance when transferring or ambulating. I have been shown how to use my urinal without standing. -I will have a perimeter defining mattress. My bed will be placed in low position and fall mat next to bed. -Therapy as indicated and tolerated by resident. -When I am sitting up in my wheelchair, I will be out at the common area for supervision. C. Observations The resident was observed on 2/23, 2/24, 2/25 and 3/1/21 spending most of his time lying on his back in bed. He had dark blue bruises covering his hands and forearms. The door to his room was often closed. D. Staff interviews CNA #1 was interviewed on 3/1/21 at 1:30 p.m. She said they knew the resident tried to get up on his own and they had to constantly go in and check on him. She said if they were busy helping another resident we can't put them on hold to go check him. She said there were not enough nursing staff to provide two-person assistance for one resident and keep an eye on residents who were at high risk for falls at the same time (cross-reference F725). The unit manager was interviewed on 3/1/21 at 3:15 p.m. She said the resident's falls involved unassisted transfers, as he was confused and forgot he could not get up. She said, We try not to leave them in their room alone, and instead take residents at high risk to the commons area, activities, ask if they want to go back to bed and if they do, help them get back to bed. For (Resident #11) he usually wants to get back in bed. We check on residents every hour: the nurse rounds one hour, CNA another, we're up and down the halls, try to help until we can get him back in bed. When he first came back from the hospital he didn't realize how weak he was, so he thought he could get up and get to his chair or go to the bathroom, and his blood pressure and oxygen levels drop when he starts moving around and he doesn't take the time to sit and wait, so he'd fall . He's not trying to get up anymore. One night they did send him to the ED because he complained of pain to his arm, so I'm sure when he came back the bruising (to his hands and arms) may have come about after he returned. The nursing home administrator (NHA) and director of nursing (DON) were interviewed regarding quality assurance and process improvement on 3/1/21 at 7:10 p.m. The NHA said they had identified issues regarding falls, and developed action plans which were in process regarding pain and fall assessments with each fall, and ensuring neurological checks were complete and accurate for each resident.

Based on interviews and record review, the facility failed to ensure sufficient nursing staffing to meet resident needs in keeping with their comprehensive plans of care, with two of two neighborhoods, for six of nine residents reviewed. Interviewable residents who resided throughout the facility said in interviews that due to insufficient nursing staffing they experienced delayed call light response, waited too long for pain medication, were left on the toilet until they were numb, and waited too long for assistance to get out of bed in the morning, and for assistance with incontinence care and personal hygiene. Staffing failures contributed to the residents feeling as they stated, degraded, neglected, disrespectful and unsafe, and resulted in a resident suffering a fall with fracture. (Cross-reference F689, failure to provide supervision and assistance to prevent a fall with injury) Findings include: I. Facility policy and procedure A policy related to sufficient nursing staffing was requested from the facility. On 3/1/21 at approximately 4:00 p.m., the district director of clinical services (DDCS) stated the facility did not have a policy related to sufficient nursing staffing. The director of nursing (DON) was interviewed on 3/1/21 at 4:22 p.m. and said the facility did not have a policy related to sufficient staffing. II. Resident interviews A. Resident #184 Resident #184 was initially interviewed on 2/25/21 at 9:27 a.m. This resident had a brief interview for mental status (BIMS) cognition score of 14 out of 15, which meant she was cognitively intact to make daily decisions related to her care. She said she had been awaiting her pain pill for 15 minutes. She voiced no other concerns other than she often had to wait for her pain medication to be administered. This resident had undergone a recent [MEDICAL CONDITION] and was in a significant amount of pain. She said she felt the facility did not have enough nursing staff to address residents' needs in a timely manner. Resident #184 was interviewed again on 3/1/21 at 9:45 a.m. She said she was moved into her permanent room from the isolation wing on 2/26/21. She said it still took staff 10 to 15 minutes to answer a call light on the new hall, just as it had on the isolation hall. She reiterated she felt the facility did not have enough staff, as on 2/26/21, while she remained on the isolation wing, an unidentified certified nurse aide (CNA) left her on the bedside commode for 20 minutes. She said her bottom had become numb before someone arrived to assist her off the commode. (Cross-reference F677.) B. Resident #7 Resident #7, with a BIMS score of 11 out of 15, said his only concern was the facility not having enough staff and that call lights were being answered slowly. C. Resident #16 Resident #16, who had a BIMS score of 15 out of 15, was interviewed on 2/23/21 at 9:50 a.m. He stated facility staffing had really gone downhill. He said his call light took anywhere from 10 to 60 minutes to be answered, depending on the time of day and which staff were working. D. Resident #23 Resident #23, who had a BIMS score of 15 out of 15, was interviewed on 2/23/21 at 10:27 a.m. She said the facility did not have enough staff and it was difficult for her to get up in the mornings before breakfast due to insufficient staffing. She said she required total care and was dependent on staff to get her ready for breakfast. She said she had continued concerns about long waits for her call light to be answered at night because they only had one CNA on duty scheduled for her hall and often had to wait for the nurse to become available to assist, as this resident required a two-person transfer. Resident #23 was interviewed a second time on 2/25/21 at 8:15 a.m. She said she had been trying to get up and ready for the day since 6:30 a.m. that morning. She said staff were just now sitting her up for breakfast. The resident said she felt staff were more concerned about turning off the call light than meeting her needs, because as soon as they responded to the call light, they turned it off before even asking her what she needed. She said if staff needed to find extra help to assist with her care, they would leave the room, but not turn the call light back on. The resident said she would wait awhile, then hesitantly turn the call light back on as her needs had not yet been met. She said because of this, staff would accuse her of always being on her call light. She said when contracted traveling staff were working in the building, they focused on the resident first, then worried about turning the call light off after her needs were fully met, which she appreciated. The resident said current staff were more concerned about turning the call light off because they were being audited rather than working together as a team to provide timely resident care. Resident #23 was interviewed a third time on 3/1/21 at 10:25 a.m. She said over the weekend they had two CNAs scheduled. She said she did not get out of bed on Saturday because she felt bad about asking staff to assist her since she needed two-person assistance. The resident said that due to short staffing, she did not receive timely assistance to get out of bed, personal hygiene (deodorant, lotion), shampoos and timely incontinence care. She said she had to lie in urine or bowel longer because they were short staffed. She said she felt degraded and neglected when that occurred. I know they're going to be in a hurry so I don't feel like I should even be asking. When I have to lay in my bowel or urine it feels disrespectful. She said the night CNA assisted her with the care by himself because it's just him and the nurse (on duty). If they're both in here nobody else is out there to help other residents. It feels unsafe. E. Resident #15 Resident #15, who had a BIMS score of 14 out of 15, was interviewed on 2/24/21 at 9:35 a.m. She said sometimes she pushed the call button and it took 45 minutes or so before someone came to address her needs. She said she just had to wait and wait. F. Resident #32 Resident #32, who had a BIMS score of 14 out of 15, was interviewed on 3/1/21 at 10:00 a.m. She said sometimes the facility did not have enough staff and she waited about half an hour to have her brief changed. She said it happened a couple of days ago on the day shift, and it felt not too good. She said when she pressed her call button sometimes she comes. III. Family interviews A. Family interview for Resident #5 A family member of Resident #5 was interviewed on 2/24/21 at 11:13 a.m. She said, I don't feel like they have enough staff. For example, when I call the phone rings and rings, and then when I go to visit there, I have to ring the doorbell over and over and wait for someone to come when I am dropping off personal items for my dad. B. Family interview for Resident #10 A family member of Resident #10 was interviewed on 2/24/21 at 11:07 a.m. The family stated, I just worry about Mom falling so much. She does seem to be alone long enough to where she can fall out of her chair and that worries me a little bit. She's fallen off the bed. They've got a pad down. She does have a lot of little stumbles and last time she broke her pelvis. She's just now recovering to where she's not in pain. (Cross-reference F689.) The family stated she and the facility were aware that her mother would just get up impulsively all at once and took off like she could still walk. The family stated her mother was confused and still thinks she can walk on her own. She said Resident #10 used to be quite the walker and was able to walk for miles when she was younger. The family said Resident #10 was always an active woman and the resident thinks she still is. IV. Record review A. Resident council minutes The resident council group meetings were not held during November and December of 2020 and January of 2021. This was due to the COVID-19 pandemic. The minutes of 10/28/2020 documented one resident complained of call lights not being answered in a timely manner. The minutes documented untimely call lights were a trend. B. Call light audits The random call light audits were reviewed from 12/21/2020 through 2/19/21. The following was documented: 12/21/20: room [ROOM NUMBER]: It took 11 minutes to answer this resident's call light 12/23/20: room [ROOM NUMBER]: 15 minutes room [ROOM NUMBER] and 52: Five minutes 12/24/20: room [ROOM NUMBER]: 30 minutes room [ROOM NUMBER]: Five minutes 12/26/20: room [ROOM NUMBER]: 13 minutes room [ROOM NUMBER]: 18 minutes room [ROOM NUMBER]: Five minutes room [ROOM NUMBER]: 11 minutes 12/28/20: room [ROOM NUMBER]: Five minutes 12/29/20: room [ROOM NUMBER]: Five minutes room [ROOM NUMBER]: Five minutes room [ROOM NUMBER]: 15 minutes. It documented staff was educated and the certified nurse aide and nurse were sent into the resident's room. room [ROOM NUMBER] and 57: 10 minutes 12/30/20: room [ROOM NUMBER]: Eight minutes 12/31/20: room [ROOM NUMBER]: Six minutes room [ROOM NUMBER]: 12 minutes 1/4/21: room [ROOM NUMBER]: Seven and a half minutes room [ROOM NUMBER] and 48: Five minutes 1/5/21: room [ROOM NUMBER]: Five minutes 1/6/21: room [ROOM NUMBER]: Five minutes 1/8/21: room [ROOM NUMBER]: Six minutes 1/15/21: room [ROOM NUMBER]: Eight minutes room [ROOM NUMBER]: Eight minutes 1/16/21: room [ROOM NUMBER]: Five minutes 1/18/21: room [ROOM NUMBER]: Five minutes 1/19/21: room [ROOM NUMBER]: Five minutes 1/20/21: room [ROOM NUMBER]: Eights minutes 1/21/21: room [ROOM NUMBER]: 14 minutes and it documented staff was verbally educated about the lengthy call light response time. 1/22/21: room [ROOM NUMBER]: Six minutes room [ROOM NUMBER]: Five minutes room [ROOM NUMBER]: Seven minutes 1/25/21: room [ROOM NUMBER]: Five minutes 1/27/21: room [ROOM NUMBER]: Five minutes room [ROOM NUMBER]: Five minutes 1/28/21: room [ROOM NUMBER]: Six minutes 1/29/21: room [ROOM NUMBER]: Five minutes room [ROOM NUMBER]: Five minutes room [ROOM NUMBER]: Six minutes 2/2/21: room [ROOM NUMBER]: Eight minutes room [ROOM NUMBER] 36, and 38: Five minutes 2/5/21: room [ROOM NUMBER]: 15 minutes 2/9/21: room [ROOM NUMBER]: Six minutes room [ROOM NUMBER]: Ten minutes room [ROOM NUMBER]: Seven minutes room [ROOM NUMBER]: Eight minutes 2/12/21: room [ROOM NUMBER]: Six minutes room [ROOM NUMBER]: 13 minutes 2/13/21: room [ROOM NUMBER]: Eight minutes room [ROOM NUMBER]: Seven minutes room [ROOM NUMBER]: Nine minutes room [ROOM NUMBER]: Five minutes 2/19/21: Room31 and 47: Five minutes room [ROOM NUMBER]: 14 minutes room [ROOM NUMBER]: Ten minutes C. Daily nursing staff schedules 1. January 2021 schedules 1/1/21: Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 4.5: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/2/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 5.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/3/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 4.5: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/4/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 5.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 4.5: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/5/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 1.5: Total required 3.0 1/6/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 3.9: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/7/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 5.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/8/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/9/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 5.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 5.0: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/10/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 4.5: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/11/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 4.5: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/12/12: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 5.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 4.5: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/13/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/14/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 4.5: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/15/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 4.5: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/16/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 5.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 4.5: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/17/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 5.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 5.5: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 1.8: Total required 3.0 1/18/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/19/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 4.1: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/20/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/21/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/22/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/23/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 5.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/24/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 5.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/25/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/26/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 5.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/27/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 5.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/28/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 5.0: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/29/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/30/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 4.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 5.0: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 1/31/21: Shift 6:00 a.m. to 2:00 p.m. Total CNAs assigned 5.0: Total required 6.0 Shift 2:00 p.m. to 10:00 p.m. Total CNAs assigned 5.0: Total required 6.0 Shift 10:00 p.m. to 6:00 a.m. Total CNAs assigned 2.0: Total required 3.0 2. February 2021 schedules The facility changed their daily nursing schedule format this month. The following was documented: -2/15/21: One CNA called off for the 2:00 p.m. to 10:00 p.m. shift on the extended care unit (ECU) -2/16/21: One CNA called off for the 2:00 p.m. to 10:00 p.m. shift on the ECU -2/23/21: One CNA called off for the 10:00 p.m. to 6:00 a.m. shift on the ECU -2/27/21: One resident assistant (RA) called off for the 8:00 a.m. to 5:30 p.m. shift on the ECU -2/28/21: One CNA called off for the 2:00 p.m. to 10:00 p.m. shift on the ECU 3. Resident Census and Conditions The Resident Census and Conditions form was provided by the DON on 2/23/21 at 8:55 a.m. It documented that of 35 current residents, 21 were incontinent of bladder and 14 were incontinent of bowel. All residents with incontinence were on a scheduled toileting program. Twenty-two residents had issues with mobility, eight residents had a [DIAGNOSES REDACTED]. Five residents were on hospice, 18 residents required respiratory treatments, five residents received injections, and 26 residents received pain management care. V. Staff interviews CNA #8 was interviewed on 2/24/21 at 8:20 a.m. She said the facility could use more staff. She said the residents' basic needs were being met, just not in a timely manner. She said the issues with providing residents their baths and showers per their choice was slowly getting better. Registered nurse (RN) #2 was interviewed on 2/24/21 at 11:00 a.m. She said the facility was a little short with nursing staff right now in the mornings, but the residents were not doing without anything. She said it just took staff a bit longer to provide the services and attend to the residents' needs. CNA #7 was interviewed on 2/25/21 at 9:49 a.m. She said she felt staffing was short at times, but the residents were not doing without anything. She said it was just taking a bit longer to provide the care. She said at times it took her 20-30 minutes just to find a peer to help her with a transfer or the nurse if needed. She said facility communication should be better with either radios or walkie-talkies in order to locate help much quicker. She said the facility had less staffing issues at night and the facility atmosphere did not feel so tense in the evenings. The minimum data set director (MDSD) was interviewed on 3/1/21 at 10:29 a.m. She said she assisted with the call light audits on hall 4 frequently and had recently observed the call lights going off for six or seven minutes on average before the call light was answered. She said the longest wait she had seen recently was approximately 10 minutes. She said nursing staff would come to get her to assist with resident transfers on a frequent basis if they could not find another nursing staff to assist. The MDSD said, in her opinion, call lights should be answered in under three minutes. CNA #1 was interviewed on 3/1/21 at 1:30 p.m. She said, Neglect might be getting to the lights when you're busy with one resident and can't get to another. This past weekend there were just two CNAs. That's not fair to the residents . If we're busy with someone we can't put them on hold to go check (another resident who is a high fall risk). She said she knew the DON was trying, but they needed more staff. The director of nursing (DON) was interviewed on 3/1/21 at 11:30 a.m. She said she created the nursing daily staffing schedules. She said, prior to 2/26/21, due to facility census, the expectation was to have one nurse and three CNAs working on the ECU halls during the day and evening shifts. This decreased to one nurse and one to two CNAs for the night shift. She said the progressive care unit (PCU) hall was only staffed with one nurse on all shifts, who also performed the CNA duties on that hall. She said, after the residents were moved back to their regular rooms following their time in COVID-19 isolation, the expectation would be changed to one nurse and two to three CNAs on the day and evening shifts on ECU. The PCU would be staffed with one nurse and one CNA on the day and evening shifts. For the night shift, the expectation was for one nurse to work the PCU hall and one nurse and one to two CNAs to man the ECU hall. The DON said of 35 residents, the facility had 11-12 residents who required frequent checks. She said there were two residents on ECU and two residents on PCU that required two-person transfers. The nursing home administrator (NHA) was interviewed on 3/1/21 at 3:00 p.m. She said with COVID-19, staff education had been provided in small, socially distanced groups for the most part during this past year, depending on the COVID-19 status in the building. She said it was her expectation to have call lights answered in less than five minutes. She said anytime it took longer than five minutes to answer a call light, it should be an exception to the rule rather than standard practice.

Based on observations, record review and interviews, the facility failed to prevent pressure ulcers from developing for two (#21 and #11) of three residents reviewed out of 23 sample residents. The facility failed to ensure Resident #21 who was admitted on [DATE] with bilateral deep tissue injuries to her heels and was a known high risk upon admission for developing pressure ulcers did not develop pressure injuries to her heels. Moreover, the facility failed to consistently monitor and implement interventions put in place per the resident care plan. Furthermore, the resident did not like wearing the booties as evidenced by some interviews, however, as evidenced by observations they were not offered by staff to the resident. Resident #21 right heel pressure injury healed in December 2020 which indicated she had the ability to heal further confirming she sustained preventable pressure injuries. Additionally, Resident #11, who was at high risk for skin breakdown, developed bilateral heel blisters. The interventions implemented to float heels and heel protectors were not consistently implemented according to record review and observations during the survey. Due to the facility failures, the resident developed pressure injuries while in the facility to both heels that were avoidable. Findings include: I. Facility policy and procedures The Wound Care/Treatment policy, revised February 2018, was provided by the nursing home administrator (NHA) on 3/1/21 at 3:35 p.m. The policy documented in part that the purpose was to provide wound care and treatments to promote healing in accordance with the facility's skin management systems, a weekly assessment will be completed on all wounds requiring treatment. This should include measurement and a description. There must be a specific order for the treatment and the care plan should reflect the current status of the wound and appropriate goals. The Skin Management policy, revised July 2017, provided by the NHA on 3/1/21 at 3:35 p.m., documented in part residents receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed and provided treatment to promote healing, prevent infection, and prevent new ulcers from developing. Ongoing monitoring and evaluation are provided for optimal resident outcomes. Practice guidelines: upon admission or readmission residents are assessed for skin integrity from head to toe, a Braden scale for predicting pressure sore risk was completed in conjunction with the Nursing admission data collection set. Appropriate preventive surfaces (e.g., beds, wheelchairs, etc.) would be implemented for residents identified at risk with interventions documented on the care plan. Ongoing skin assessments: a weekly skin check will be completed using the head to toe skin check. Note: alterations or changes in skin integrity, breaks in the resident's skin including skin tears and bruises are recorded on the head to toe skin check. II. Resident #21 A. Resident status Resident #21, age 83, admitted [DATE]. According to the February 2021 computerized physicians orders (CPO), [DIAGNOSES REDACTED]. According to the minimum data set ((MDS) dated [DATE], the resident had severe cognitive impairment with a brief interview of mental status (BIMS) of five out of 15. She required extensive assistance for bed mobility, transfers and toileting. She did not reject care. Initial review of the MDS on 2/24/21 at 4:06 p.m. revealed under section M, skin conditions (M0300) E, an upward arrow ^ and no identifiable, unhealed, unstageable pressure ulcer. The facility provided a copy of the resident's MDS section M on 3/1/21 and this was reviewed on 3/4/21. The section now documented the resident with 1 unhealed, unstageable pressure ulcer. The skin and ulcer/injury treatments included in part, pressure reducing device for bed. B. Observations of resident heels and interviews On 2/23/21 at 4:00 p.m. the resident was lying in bed awake and watching television. She had red skid resistant socks on and her feet were crossed. She had green soft booties on both of her feet as ordered per her care plan to prevent pressure wounds (see below). On 2/24/21 at 4:43 p.m. the resident was observed lying in bed. She had red skid resistant socks on. She did not have a pillow under her legs to float her heels. She had both her knees bent and she was sliding both of her heels back and forth on the mattress. She was asked if she was supposed to have her soft boots on her feet and she said she did not like them and they were uncomfortable. Her green soft booties were sitting on top of her wheelchair cushion. On 2/25/21 at 8:42 a.m. the resident was in her wheelchair in the common area. She was wearing red skid resistant socks and gray slippers. She did not have her green soft booties on her feet as ordered to prevent heel pressure. On 2/25/21 at 9:16 a.m. the resident was lying in bed resting. Her feet were not floated on pillows as ordered to prevent heel pressure and she did not have her soft booties on. The booties were sitting on top of a chair next to her nightstand. On 2/25/21 at 3:14 p.m. the resident was in her wheelchair in the dining room participating in an activity. She did not have her soft booties on. On 3/1/21 at 9:18 a.m. the resident was sitting at a table in the common area. She was wearing red skid resistant socks and gray slippers. She did not have her green soft booties on her feet as ordered to prevent heel pressure. C. Observations of wound care to left heel On 3/1/21 at 12:46 p.m. wound care observations were made with licensed practical nurse (LPN #1). Cross-reference F880 for failure in infection control. LPN #1 pulled the resident's blankets back to expose her feet. The resident did not have her feet floated with a pillow and she did not have her soft booties on. The resident did not have a dressing on her left heel. She then removed the resident's sock on her left foot and placed her foot back on top of the bed mattress. She then raised the resident's left foot, took the clean saturated gauze and cleansed the wound on her left heel. She described the wound as having eschar. She then took a second dry gauze and dried the heel and sat the resident's clean heel back on top of the bed mattress. Next LPN #1 measured the wound with a measuring tool located on the outside of the gauze packaging. The wound measured 2cm (centimeters) x 3cm (centimeters). She then applied [MEDICATION NAME] to the heel as ordered and replaced her sock. She then took a pillow and placed it under the residents legs to float her heels. The LPN was interviewed immediately following the observation above. She said she had not seen the wound in about a month and she remembered it being larger in size, however; she believed it was getting better. She also confirmed that the resident did not have her soft booties on or her heels floated as ordered. She said the resident was lying on a lipped mattress used for fall prevention and that it was not an air mattress. D. Record review A nurse note dated 10/23/2020 documented in part that the resident had a skin tear present on admission but did not have any pressure injuries. An SBAR (situation, background, assessment and recommendation) note, dated 10/24/2020, documented the resident had deep tissue injuries to the bilateral heels. The physician and family members were notified. A care plan, initiated 10/23/2020 and revised on 1/18/21 identified the resident with potential/actual skin issues related to potential breakdown and risk for bruising related to aspirin use. The goal was the resident's skin would remain intact without signs of breakdown by the next review. Interventions included in part, heel protectors or float heels while in bed, pressure reduction mattress to bed, wound care/preventative skin care per order and skin checks weekly per facility protocol and document findings. -The resident did not have an air mattress in place as care planned. She had a lipped mattress used for preventing falls. A care plan, initiated 10/24/2020 and revised on 12/16/2020 documented the resident with a pressure sore on her left heel. The goal was she wanted her pressure sore to heal. Interventions included in part, encourage and assist the resident to sit in my chair in the lobby. The resident kept her heel protectors in place better while I am up in my chair and this assists her to reduce and change pressure to her heels. Ensure the resident had pressure reducing heel protectors on while in bed and while in her chair. The resident often kicked the heel protectors off, please help her to replace them as needed. The resident could tolerate a pillow to float her heels at times when she was restless and kicking off her heel protectors. Paint the resident's left heel with [MEDICATION NAME] (antiseptic), and leave open to air. Float heels. A nutritional admission assessment dated [DATE] identified the resident with increased nutritional needs related to pressure sores to her left and right heels. Nutrition interventions recommended were a vitamin and mineral supplement and protein supplements and to see the care plan for additional information. The October 2020 physician's orders [REDACTED].>-[MEDICATION NAME] packet, one packet one time a day for supplement. Start date 10/26/2020. -Multivitamin, give one tablet one time a day for supplement. Start date 10/26/2020 -Med pass 2.0 (supplement) three times a day. Start date 10/23/2020. 11/12/2020 nurse note: documented that the resident's air mattress was to be switched out for a regular mattress due to a fall out of bed. 12/10/2020 telemedicine NP (nurse practitioner) progress note: reviewed heel wound .new supplements; vitamin D and calcium ordered .continue current wound interventions. 12/29/2020 nurse note: heel boots off, nurse asked if she could reapply them and she said she wanted them off for awhile. -There was no follow-up documentation to show they were reapplied. 1/1/21 nurse note: had booties on until wakened early am .replaced every hour by nursing staff. Left heel wound drying with no surrounding [DIAGNOSES REDACTED]. 1/2/21 nurse note: noted to have heels floated throughout the am. Did not want the booties in bed. 1/5/21 nurse note: non-adherent to skin interventions, kicks off heel protectors and rubs heels on bed . 2/25/21 nurse note: Resident refused bilateral boots this shift. -There was no further documentation found to demonstrate what further interventions were tried, and; no other documented refusals of the foot booties or of elevating feet with a pillow while in bed. A physician's visit note dated 2/5/21 documented in part that the resident was to continue with physical therapy for ambulation and to continue the heel precautions. A 2/11/21 Braden skin assessment documented the resident with a score of 16 which indicated she was at risk for developing a pressure sore. The January 2021 and February 20/21 treatment administration record (TAR) was reviewed and revealed the nurses documented that the above order was being followed although observations revealed that her heels were not floated while in bed and her soft protective boots were not on while up in her wheelchair (see resident observations above). The March 2021 CPO documented the following orders in part: Paint the left heel with [MEDICATION NAME] Q (every) shift, leave OTA (open to air) and ensure heels are floated at all times. Observe for abnormalities to the wound bed, surrounding skin, or pain associated with wounds .every shift for wound healing. ordered on [DATE]. The Weekly assessment notes documented: 10/24/2020- Right heel 1cm (centimeter) x1cm (centimeter), DTI. Left heel 2cmx3cm, Stage two clear blister pressure ulcer intact. 11/5/2020-Left heel 4cmx4cm, stage two. Right heel 1.5cmx1.2cm, stage two intact blister. 11/11/2020-Right heel 1.5cmx1.5cm blister intact. Left heel 4cmx4cm. 11/19/2020-Left heel 3.5cmx4cm, stage two. Right heel 1.5cmx1.8cm. 11/25/2020-Left heel 3cmx2cm, reduced, dry, dark tissue has sloughed revealed healthy intact skin. 12/2/2020-Left heel; 3cmx3.5cm area has become black,discussed with family that resident often rubs heels on floor or bed. 12/17/2020-Left heel 2cmx2cm unstageable dark, intact eschar. 2/10/21-Left heel 2cmx2cm; unstageable area reduced in size, surrounding tissue calloused and lifting revealing healthy intact pink skin .resident continues to kick off heel protectors at times, will tolerate pillow placed to float heels at times. 2/17/21-Left heel 2cmx2cm (no change in interventions from the 2/10/21 note. And, the wound is described exactly as it was above on 2/10/21). Wound measurements reviewed from the months of 10/2020-2/2021 revealed the weeks were inaccurately and inconsistently documented with weeks missing. The left and right heel were both documented. The right heel was documented to be healed the month of December 2020. It was documented the resident often rubbed her heels on the floor or bed. -No additional intervention was documentation to prevent or assist in the prevention of this action from occurring. E. Interviews Certified nurse aide (CNA) #3 was interviewed on 2/25/21 at 1:11 p.m. She said that the staff were supposed to put booties on Resident #21 when she got up in the wheelchair. CNA #3 said the resident did not like her booties and would take them off herself. She said the resident did not need to have the booties on while she was in bed. She said the booties were used to relieve pressure so that her sores did not get worse. She said that if the resident refused to wear them she would re-approach her and try again. She said if the resident continued to refuse she would let the nurse know so that the nurse would document it. She said she did not know about the resident's feet being floated while she was in bed CNA #5 was interviewed on 2/25/21 at 3:49 p.m. He said that the resident was supposed to have her green heel boots on when she was in bed only. He said he was not aware if she had any wounds. He said the resident did not want to wear them today so he let the nurse know. He said he was not told by anyone that she needed to have the boots. He figured it out on his own because he saw the boots in her room on her chair. The director of nursing (DON) was interviewed on 3/1/21 at 1:07 p.m. She said that Resident #21's heel wound was acquired in the facility. She said she had skin breakdown on admission and it was not properly noted on the admission assessment. She said the resident had heel protectors in place upon admission. She said the pressure wounds were initially identified as deep tissue injuries (DTI ' s) and her heels went from pink to purple and then blisters developed. She said the wound doctor came in once a week to see other residents, however; the in-house wound team saw her wounds weekly. The DON said Resident #21 was not being seen by the wound specialist because she felt the facility staff could handle the residents wounds. She said the healing of her left heel wound had stalled but was improving. She said the interventions that were in place were helpful to reduce pressure and improve healing. She said the resident kicked off her heel protectors at times because she got hot and if she did that then staff should use a pillow while the resident was in bed. She confirmed the soft booties should be on when she was out of bed and in her wheelchair. She said staff should be following the interventions as the resident tolerated and if she declined the interventions the staff should re-approach and try again. She said that no staff had reported to her the interventions were not effective. She said if the resident was refusing the interventions, the nurse should write a progress note and then report it to her. She said the resident was usually compliant. III. Resident #11 A. Resident status Resident #11, age 90, was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the resident's 1/18/21 MDS assessment, he had severe cognitive impairment with a BIMS score of five out of 15. He needed extensive two-plus person assistance for bed mobility, transfers and toilet use. He was frequently incontinent of urine and occasionally incontinent of bowel. He had no pressure ulcers, and was at risk. B. Record review The resident's admission assessment, dated 1/13/21, documented his skin was intact, and he was at very high risk for skin breakdown. Physician orders [REDACTED]. Observe for and document abnormalities to wound bed, surrounding skin, or pain associated with areas. Physician orders [REDACTED]. There were documentation blanks five times during the evening shift, indicating the resident's heels were not floated (2/13, 2/14, 2/14, 2/18 and 2/19/21).The order was discontinued on 2/20/21. Review of Weekly Pressure Ulcer Records revealed the resident developed new pressure ulcers, acquired in the facility, to both heels on 2/10/21. His left heel had a 3 x 4 cm unstageable pressure ulcer, and his right heel had a 0.8 x 3 cm unstageable pressure area. The wound descriptions documented drained blisters to both heels, skin folded up and dry over wound bed, skin noted at edges of open blister pink and blanchable, no infection, resident had a recent fall (cross-reference F689 for falls/accidents) and was noted to be pushing heels down and rubbing them on floor at time of fall, heel protectors had fallen off during fall, but in place while in bed prior to fall, appears to be superficial blister with dry dark tissue covering as blister has drained. Review of the resident's 2/12/21 emergency department report (for assessment after a fall) revealed the resident had bilateral heel decubitus ulcers. Review of the resident's fall documentation revealed none of his falls were documented as consistent with causing heel injuries. No heel injuries or heel rubbing were noted in fall investigative reports or nursing notes. On 2/17/21, the left heel unstageable wound measured 2.5 x 3.5 cm, and the right heel unstageable wound measured 1 x 3 cm. The description documented the areas were stable in size, surrounding skin improved, pink and blanchable, no infection, heel protectors in place, resident does kick them off at times and verbalizes that he does not want them on, heels floated on pillows at times when resident removes heel protectors. The most recent record, dated 2/26/21, documented the right heel was 1 x 2.2 cm and the left was 1.5 x 2 cm. Both wounds were still unstageable. The care plan identified actual skin issues related to bilateral heel wounds, with the following interventions: -Pressure reducing mattress, able to make frequent positioning adjustments for comfort, able to call staff for assistance as needed. -Encourage good nutrition and hydration. -Pressure reducing heel protectors in place as tolerated, at times the resident will kick them off, use pillows to float heels during times of heel protector refusals. -Wound care/preventive skin care per orders. -Skin checks weekly, document findings. The nursing home administrator (NHA) provided documentation the resident was repositioned every two hours; however, the resident was never observed during the survey (2/23, 2/24, 2/25 and 3/1/21) in a position other than on his back (see observations below). C. Observations Resident #11 was observed on 2/23, 2/24, 2/25 and 3/1/21 spending most of his time in bed, lying on his back, when his door was not closed. On 3/1/21 at 2:23 p.m. wound care was observed for Resident #11 with licensed practical nurse (LPN) #1. Upon removing his skid resistant socks from both feet, she began with the right heel. The right heel wound had a circular, flat, no longer intact blister. There was no drainage. It was dry, with a discolored center that was brown in color. There was no depth to it. The peri-wound was dry and scaly. The LPN stated that it appeared like the discolored area could turn into eschar. She cleansed the wound, then applied [MEDICATION NAME] to the heel and let it air dry, then left it open to air. LPN #1 then began to clean the resident's left heel wound. It was a large, no longer intact blister, circular, and covered the entire heel. There was no depth to it. There was no drainage. It was dry and discolored, slightly brown with red around the edges. It was peeling near the back of the heel. She cleansed the wound and applied the treatment and left it open to air. D. Staff interviews The unit manager was interviewed on 3/1/21 at 3:30 p.m. Regarding the resident's bilateral heel pressure ulcers, she said the CNA who found him on the floor after a fall said he was rubbing his heels back and forth on the floor. They looked like blisters that had popped and the skin was peeled back so we treated them like pressure. He won't keep the booties on sometimes, but we'll try to float them. (After the fall) he had the fall mat under his bottom but his feet were on the tile floor. Their skin is so thin it seems any kind of trauma can do just about anything. They looked like popped blisters but I'm not a wound expert. The NHA and DON were interviewed on 3/1/21 at 7:10 p.m. regarding quality assurance/process improvement. They said they had developed an action plan to address pressure sores, and were still monitoring their plans of correction, were conducting ongoing audits, and had not achieved sustained compliance. The facility failed to prevent unstageable pressure ulcers from developing to both of Resident #11's heels.

Based on observations, record review and interviews, the facility failed to maintain acceptable parameters of nutritional status for one (#10) of three residents reviewed for nutrition out of 13 sample residents. The facility failed to timely address the Resident #10's weight loss and initiate additional nutritional interventions and evaluate current nutritional interventions that were implemented. The registered dietitian (RD) ordered a house supplement to be consumed at meals which was not consistently implemented and evaluated his supplementation when it was known by facility staff he disliked the house nutritional supplement. Furthermore, weekly weights were not consistently obtained based on his nutritional risk due to his [DIAGNOSES REDACTED]. Occupation therapy (OT) recommended adaptive equipment during meals to help with his independence with eating that were not consistently implemented. The resident fluid intakes were not consistently monitored with a previous [DIAGNOSES REDACTED]. The facility's failures contributed to Resident #10 sustaining a significant weight loss of 15 pounds which is 8.8% in 37 days since his readmission from the hospital to the facility on [DATE]. Findings include: I. Facility policy and procedure The Weight Management policy and procedure, dated July 2017, was provided by the director of nurses (DON) on 9/9/20 at 4:23 p.m. It revealed the resident's nutritional status would be monitored on a regular basis to aid in the maintenance of acceptable parameters, such as body weight. Accurate weights were obtained by having staff follow a consistent approach to weighing and by using an appropriately services and functioning scale. Residents were offered a therapeutic diet when there was a nutritional concern and when the health care provider ordered a therapeutic diet. The measurement of weight is a guide in determining nutritional status. Therefore, the evaluation of the significance of weight gain or loss is a part of the assessment process. Significant unintended changes in weight (loss or gain) or insidious weight loss may indicate a nutritional problem. II. Resident #10 A. Resident #10 status Resident #10, age 49, was admitted on [DATE] and readmitted on [DATE]. According to the September 2020 computerized physician orders (CPO), [DIAGNOSES REDACTED]., pneumonitis due to inhalation of food and vomit, dysphagia, gastro-[MEDICAL CONDITION] reflux disease (GERD), cognitive communication deficit, generalized muscle weakness and lack of coordination. The 7/29/2020 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. He required extensive two-person physical assistance with bed mobility, transfers, and extensive assistance of one person eating.He was assessed to have no possible swallowing disorder and he had no or unknown loss of five percent or more weight loss in the last month or loss of 10 percent or more in the last six months. He received [MEDICATION NAME]/IV feeding while not a resident and did not receive it while in the facility. He was assessed to be at risk of developing pressure injuries and did not have any unhealed pressure injuries. He was not currently receiving nutrition or hydration intervention to manage skin problems. He had an indwelling urinary catheter and no [MEDICAL CONDITIONS], or rejection of care. B. Record review The care plan, initiated 7/28/2020 and revised 8/20/2020, identified the resident had the potential for a fluid deficit related to poor intake. The interventions included ensuring he had access to fluids whenever possible, offering and assisting with fluids as needed, and to notify the physician if persistent symptoms of output exceeding intake occurred in the past 48 hours. The care plan, initiated 7/28/2020 and revised 8/20/2020, identified the resident had a swallowing problem secondary to [MEDICAL CONDITION]. The interventions included to instruct him to eat in an upright position, to eat slowly, and to chew each bite. All of the resident's weights were reviewed from 7/23/2020 through 9/3/2020 and included the following: 7/23/2020 = readmitted from hospital, no weight obtained on admission 7/24/2020 = 171# 7/27/2020 = 168# (three pound weight loss) 7/28/2020 = 166# (two pound weight loss) 8/4/2020 = 168# 8/17/2020 = 160# (eight pound weight loss, which was 5.0% and 12 days since last weighed) 8/26/2020 = 159# (in about one month since the resident's readmission weight on 7/24/2020, he had 12 pound weight loss which was 7.0%.) 8/31/2020 = 156# (three pound weight loss in one week, 15 pound weight loss since his readmission weight on 7/24/2020 which was 8.8% overall weight loss.) There was no weight measured during the week of 8/7/2020 (third week after admission) and had an overall 15 pound weight loss in 37 days since his readmission from the hospital. The RD's Nutrition Data Collection form was reviewed and was effective 7/30/2020, which was seven days after the resident was admitted . The document revealed the resident had a change in weight that included a weight loss but was not significant, and his usual body weight was 168#. He was able to feed himself with supervision and did not use adaptive feeding equipment. The following sections of the form were void of documentation: dentition, skin status, dehydration risk factors, and pertinent lab values. The narrative summary included the following: Initial assessment: (Resident #10), height 70 inches, weight 166#, BMI (body mass index) 23.8. Medical history included [MEDICAL CONDITION] with dysphagia, pneumonitis due to inhalation of food and vomit. On a regular diet, regular textures and cleared safe by speech therapy. Meal intakes are adequate so far at 50-75% meals. admitted to (name of facility) for strengthening with PT (physical therapy), OT (occupational therapy) and ST (speech therapy) and plan is to return home. BMI is within normal limits. Will monitor routinely. The Nutrition RD Assessment form, dated 7/30/2020, documented no nutritional [DIAGNOSES REDACTED]. The RD estimated Resident #10's calorie needs between 1886-2037 kcal (calories) per day and fluid needs between 1886-2037 mL (milliliters) per day. -The resident had had a five pound (2.9%) weight loss since his readmission from the hospital on [DATE]. His meal intakes were 50-75% and no interventions were started despite his insidious weight loss and meal intakes. The RD assessment form did not document if it met his calorie and fluid needs and what percentage of meal intake was required to meet those needs (see calculated above). The care plan, initiated 7/30/2020 and revised 8/20/2020, identified the resident had a significant weight loss of 6.5% over 30 days. He had a history of [REDACTED]. He did best with finger foods due to hand tremors although sometimes requested main entrée, which required extensive feeding assistance by staff. The interventions included to assist him to eat as needed because at times he could eat finger foods independently but at other times he needed extensive assistance; occupational therapy to screen and provide adaptive equipment for feeding as needed; observe intake and record every meal, and RD to evaluate and make diet change recommendations as needed. A progress note, dated 8/20/2020, was written by the RD that identified Resident #10 triggered for significant weight loss of 6.5% for 30 days. He was on a regular diet and ate mostly finger foods unless fed by staff. Intakes were fair with breakfast averaging approximately 50%, lunch 25-50%, and supper was 50-75%. The RD recommended adding a house supplement with breakfast and lunch meals for weight stability and would discuss his plan of care with the IDT in the weekly at risk meeting and follow weights weekly until stable for four weeks. -A supplement was started nearly one month after the resident's readmission from the hospital with a 11 pound weight loss (6.5%) with his meal intakes being documented as 50-75% which was fair on the 7/30/2020 assessment. The interdisciplinary team (IDT) progress note, dated 8/20/2020, documented the team met and reviewed Resident #10's plan of care due to his recent weight loss. They spoke with his family and received his preferences for snacks (peanut butter and apples), and sent them to the kitchen. The family was to order foods and have them sent to the facility and the resident would continue with speech therapy and other therapies. Resident #10 had fluctuating ability due to his disease process and staff was educated that he required assistance for all meals. The IDT recommended weekly weights at that time. -His care plan was not updated to reflect the resident snack preferences and the family was to order food. The IDT progress note, dated 8/27/2020, documented the team met and discussed Resident #10's weight loss and documented his weight was stable. The family provided the resident with pizza and the facility began providing apples and peanut butter every afternoon. Supplements for wound healing (Cross-reference F686 Pressure Ulcers) were added due to new wounds and the resident continued to require extensive assistance with meals. He continued to receive speech therapy and weekly weights. The RD attended and no additional weight loss interventions were implemented at that time. -The house supplement was not implemented as a physician's order with it being an RD recommendation for his poor intakes and weight loss. The house supplement was not offered at his meal on 9/3/2020 (see observation below). The IDT progress note, dated 9/4/2020, documented the team met and discussed Resident #10's recent weight loss and determined his weight was stable. The RD attended and no new interventions were implemented at that time. -The resident's weight was 156# on 8/31/2020, which was an additional three pound weight loss in one week from his previous weight obtained of 159# on 8/31/2020, which was a 15 pound weight loss since his readmission weight on 7/24/2020 (8.8% weight loss). The Medication Administration Record [REDACTED] The peanut butter and apples snack every afternoon, started on 8/20/20, was provided and he ate 100% most of the time until 9/5/2020, when he ate 25% on 9/5, 9/6 and 9/7/20. The MAR indicated [REDACTED]. There were no house supplements on the MAR for August or September 2020. A progress note, dated 8/26/2020, documented No apples available in facility. There was no further documentation to show if a substitute was offered or given. The meal intake records were reviewed from 7/23/2020 through 9/7/2020 and included the following: The resident ate 0-25% five times The resident at 26-50% seven times The resident at 51-75% 55 times The meal intake records were void of documentation for a total of 16 meals. Further, the facility did not document fluid intakes for meals or other activities. The resident refused meals four times during the review period and there was no documentation the resident was offered an alternative meal or other preference instead. The occupational therapy treatment encounter note, dated 7/30/2020, documented the skilled instruction provided to the resident included a discussion of using adaptive utensils and Resident #10 was interested due to his increased tremors and being dependent on staff for assistance for feeding on bad days. -There were no further orders or documentation to indicate the adaptive equipment was implemented or used. The CPO for 9/8/2020 was reviewed and included the following orders: Provide regular diet, started 7/23/2020; Provide snack: peanut butter and apples in the afternoon, started 8/20/2020; Occupational therapy evaluation and treatment, started 7/23/2020; and, Speech therapy evaluation and treatment, started 7/23/2020. -There were no physician orders to administer house supplements with breakfast and lunch, implement the use of adaptive utensils during meals, or to monitor urinary output. C. Observations On 9/2/2020 at 4:30 p.m., Resident #10 was lying in bed in his room. He was alert, wearing a purple shirt and was thin in appearance. On 9/3/2020 at 10:42 a.m., Resident #10 was sitting in his wheelchair in his room with his back to the door. The room was dark with closed blinds and he was awake. He was not engaged in any activity and the TV or music were not on. On 9/3/2020 at 11:00 a.m., Resident #10 was sitting in his tilt-in-space wheelchair at the nurses' station on the extended care unit. He was reclined back, leaning to the right and his head was not in alignment with the back headrest. He was able to straighten himself up slightly, but never fully upright. At 12:28 p.m., Resident #10's lunch tray was placed on a table to his right, but out of reach, and remained covered until a certified nurse aide (CNA) was able to sit down and assist him with the meal. The utensils on the tray were standard, not adaptive. At 12:30 p.m., CNA #3 sat down on his left side and began to assist Resident #10 with his meal of meatloaf, mashed potatoes with gravy, a roll, pudding, and an eight-ounce glass of ice water. He removed his hat and placed it on the table. The CNA did not raise the back of his tile-in-space wheelchair to an upright position. At 12:48 p.m., he told the CNA, Chair's too far back. The CNA stood up, raised the back of the chair to an upright position, and the resident nodded his head to indicate it was better. At 12:52 p.m., he had eaten most of his lunch and he did not have a house supplement with his meal. He drank approximately four ounces of the water and was not offered anything else to drink. On 9/8/2020 at 1:24 p.m., Resident #10 was lying in bed in his room. He was lying on his back and was frowning. He said he was thirsty and wanted a drink. His computer communication screen read, My butt hurts. I have . and nothing more was written. Licensed practical nurse (LPN) #6 assisted the resident to take a long drink from a cup on his bedside table until he had had enough. She asked him if he was okay and then asked him if he wrote the note on the screen. He nodded yes, confirmed he was having pain on his bottom, and she said she would follow up with his nurse, LPN #2, to find out about pain interventions. D. Staff interviews CNA #1 was interviewed on 9/8/2020 at 11:34 a.m. She confirmed she routinely worked with Resident #10 and he never refused care for her. She said he was not able to provide any care for himself and required total assistance to eat his meals. She explained he liked to eat fruit, Fruit Loops cereal, tea and he loved lemonade. She said he would drink water but did not like ice in it. She said she was not aware that he used adaptive utensils because she had never seen them sent on his breakfast or lunch trays. She said when he was eating a meal in his tilt-in-space wheelchair or in bed; he should be positioned as straight upright as possible. CNA #1 said meal intakes were recorded by each CNA for each neighborhood and entered into the medical record. She said approximately one year ago, the CNAs were instructed not to document fluid intake for meals because they were told they really did not know how much each resident had to drink. She said she felt confident she would be able to accurately estimate the percentage of fluids consumed at mealtimes. She said they had been instructed to document not applicable instead. The dietary manager (DM) was interviewed on 9/8/2020 at 12:00 p.m. He said the facility provided diets with fortified foods to five residents in the facility, but Resident #10 was not one of them. He said their fortified foods included adding creams, milk, protein powder, and butter to foods, and they had a fortified pudding with peanut butter and protein powder, Mighty Shakes or MedPass (nutritional supplements) they could provide for residents. The RD was interviewed on 9/8/2020 at 1:34 p.m. She said she was at the facility to see residents once per week, and participated in IDT staff meetings through virtual calls. She said the facility did not typically inform her of new residents, but instead, she would screen through her computer because she had remote access to the facility's records and find them that way. She said the facility notified her of high-risk residents who were admitted , such as a resident on a tube feeding or TPN (total [MEDICATION NAME] nutrition). She explained the facility flagged her if there was something they wanted her to pay attention to right away, but otherwise, she screened residents herself that were of nutritional risk. The RD said the facility did not inform her of residents' weight losses, and when she performed her screenings, she would look at the weights in the electronic medical record, which would trigger a resident who had a significant weight loss for her. She followed the significant weight loss parameters of five percent or greater in one month, 7.5% or greater in three months, or 10% or greater in six months. She clarified there were also residents who were admitted with a low body weight who might not trigger, but she followed them to establish their baseline weight and follow them in the at risk meetings. The RD said for residents with a downward trending weight, sometimes I will catch them based on their oral intake, and explained they would be flagged if they consumed less than 50% for two meals, and she kept an eye on them. She said if a resident was losing weight, the facility implemented nutritional interventions and followed them for four weeks or until their weight was stable. She said she was able to access the meal intake report remotely and looked at it weekly when she did her nutritional screenings. However, she clarified she did not look at every resident every day to see how they were eating, and relied on the facility to inform her if they had concerns. The RD said when a resident had a weight loss, the interventions she would like to implement included starting a nutritional supplement, fortified puddings, or providing the resident with more foods they like to eat, and make sure they were eating enough. She said she was not able to write orders for supplements, but if she made a recommendation, the DON would follow up and ensure it was implemented. The RD was not aware the facility was not documenting or tracking the residents' fluid intakes and said she thought the CNAs recorded that with the meal intakes. She said she reviewed fluid intakes if a resident was at risk for dehydration, on a tube feeding or on [MEDICAL TREATMENT]. She said if a resident was losing weight, malnourished, showing signs of dehydration, or at high risk for dehydration, then there was more of a clinical need for her to track it. The RD confirmed Resident #10 was admitted with a [DIAGNOSES REDACTED]. She said he required full assistance with all meals, he was not losing any more weight, and they were following him weekly. She said the challenge was to have staff available to help him at mealtimes and stated, I think they were looking at trying to get him some adaptive equipment but I'm not sure what the status of that is. She explained that even with adaptive equipment, he would still need someone to help him eat. She said they had to be consistent as a team and make sure he was getting the supervision, cueing, and help he needed at every meal and maybe that was not identified right away. She said she felt like he needed the assistance constantly, even with snacks. The RD said they discussed the house supplement at one of the weekly at risk meetings and it was attempted, but he did not like the supplement at all. She said the documentation for the IDT notes was written by the DON and did not know when the house supplement was implemented or discontinued. -The resident's disliking of the supplement was not indicated in the RD and IDT notes (see above) and additional interventions were not evaluated with his dislike of the supplement with his weight loss and meal intakes not being adequate to meet his nutritional needs. The RD said her documentation of a recent weight loss on her initial nutrition assessment was probably an error. She said when she completes the data collection form, if she had the information to complete the skin status and dehydration risk factor sections of the form, and then she could enter them. If not, she could enter the information within a few weeks, after reweights or pressure ulcers developed. The RD said Resident #10 should be upright while he ate his meals. Licensed practical nurse (LPN) #4 was interviewed on 9/8/2020 at 2:37 p.m., and confirmed she routinely worked with Resident #10. She said residents who had urinary catheters did not routinely have their urinary outputs measured, but the CNAs usually reported to the nurse how much they emptied during their shift. She said if there was a decrease in the amount, she thought they would know there was something going on. She said the residents were supposed to have ice water in front of them to drink, and for those who were not able to drink independently, they would be provided hydration whenever they were turned or repositioned. She said she thought CNAs would know to offer residents a drink when they were in their room and had not instructed them to do that. LPN #4 said Resident #10 was not able to provide much care for himself, but could push the call light purposefully to let staff know if he needed something. She said he preferred to drink lemonade instead of water and he did not refuse care. She explained he usually ate in his room and a staff member had to go in and help him. She said she had not been notified by the CNAs that he did not eat everything during his meals, but she hoped they would notify her if he did not. She was not aware of his apples and peanut butter snack he received each afternoon and thought maybe it was given to him before her shift started at 2:00 p.m. LPN #4 confirmed the resident did not have an order to monitor his urine output and did not know why the care plan intervention to notify the physician if persistent urine output exceeded input was in place. She stated, I would have to question, 'Why aren't we doing I (intake) and O (output) on him? She said when she gave him his medications twice during her shift; he drank quite a bit. LPN #4 said meal and fluid intakes were documented by the CNAs when they did their charting and should include what percentage of each meal the residents were eating. She clarified the facility did not currently have anyone on I&O and stated, He should be on it though. It would make sense. She was aware the CNAs were not documenting fluid intakes and said they had not been recording it for at least one year. She said, I don't think any of them drink enough. LPN #4 was not aware Resident #10 had had a recent weight loss and confirmed he did not receive a house supplement. She said he did not currently use adaptive utensils when he ate and said, He could probably benefit from those. She said when he ate, he should be sitting as upright as he could so he could swallow better, and the CNAs should know how to put him upright. The DON was interviewed on 9/8/2020 at 3:28 p.m. She said the CNAs and floor nurses obtained weights on residents who were newly admitted three times within the first week they were there in order to get an accurate weight. Then the residents were weighed weekly for four weeks after that, then monthly. If they identified a weight loss on a resident, they would revert to obtaining weekly weights so they could monitor interventions and see if they were effective. She said she was responsible for entering weights into the medical records, and if she noticed a drastic difference, she asked for a re-weigh. She explained she verified weight losses twice to make sure it was accurate. The IDT discussed it in the at risk meeting weekly and put interventions in place to address it, and track it. If a resident's weight continued to decline, they tried different interventions. The DON said their scales were re-calibrated on a regular basis, with the most recent done one week ago. She explained when a weight was entered into the medical record, if it was a significant weight loss, it triggered and showed her the resident's loss or gain. The DON confirmed the facility did not notify the RD of identified weight losses. She explained the RD had remote access to the medical records and was supposed to look at them several times a week. She said, If I catch it, I will give her a heads up. She said it should be discussed in the next at risk meeting. The DON confirmed the residents' fluid intakes were not routinely documented and stated, We chart by exception. She explained if a doctor ordered fluid intakes to be recorded, they would do that. However, she said, You are still not getting an accurate picture of their intake because they are still getting ice and drinks in activities. She said she was able to ensure the residents were well hydrated because they assessed the ice water at their bedsides every shift and ensured they were giving them plenty of fluids with meals. The DON said when Resident #10 was first admitted , his mother reported he was independent with finger foods, so that was what they ordered for him. She explained it depended on the time of day and level of medications in his system, and she said she has instructed the staff they needed to be with him and if he could not eat on his own; they must provide him total assistance with his meals. The DON did not know if the house supplements the RD had recommended on 8/20/2020 were implemented or if he was currently taking a house supplement. She said she thought Resident #10 had a significant weight loss because he was adjusting to the facility and really wanted to be at home. She said he had a urinary tract infection after he was admitted and was pretty sick. She said the facility staff were learning what they needed to provide for him. She said his weight had stabilized and he was due for a weight that day. The DON confirmed he needed to be positioned in an upright position when he ate his meals and confirmed he was not currently using adaptive utensils for eating. She stated, Watching how he was even with finger foods, I don't know if they would be that beneficial to him. She did not know if the facility had ever tried to use them.

Based on observations, record review and staff interviews, the facility failed to ensure one (#10) of three residents reviewed for pressure ulcers out of 13 sample residents received care and services necessary to prevent the development of pressure injuries. Resident #10 was admitted to the facility as a resident with a known risk for developing skin integrity issues due to some of his diagnoses to include [MEDICAL CONDITION], cognitive communication deficit, generalized muscle weakness and lack of coordination.The facility failed to monitor and ensure all interventions were attempted to prevent skin breakdown for Resident #10. Resident #10 had a pressure relieving device in place for his bed and wheelchair, however, no other method of pressure relieving was implemented consistently. Moreover, the facility came to the conclusion the air mattress (never implemented for Resident #10) was not appropriate for the resident due to safety reasons, however, the resident was dependent on staff for bed mobility and transfers, which would require alternating pressure relieving methods. Failures to ensure Resident #10 was consistently offloading weight to pressure areas, Resident #10 sustained two in house acquired Stage 3 pressure injuries, one to his coccyx and one to his left ischium. Furthermore, after Resident #10 developed the pressure injuries, the facility failed to consistently resposition frequently, failed to notify the registered dietitian (RD) in a timely manner and implement orders (cross-reference F692 for nutrition/hydration) to promote proper healing. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, retrieved 9/14/2020 from https://npiap.com/PressureInjuryStages, pressure injuries and stages were defined as follows: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or flactuance) on the heel or ischemic limb should not be softened or removed. II. Facility policy and procedure The Skin Management policy and procedure, dated July 2017, provided by the director of nurses (DON) on 9/9/2020 at 4:23 p.m., included the following: Residents receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed and provided treatment to promote healing, prevent infection, and prevent new ulcers from developing. Ongoing monitoring and evaluation are provided for optimal resident outcomes. III. In-house facility acquired stage 3 pressure ulcer A. Observations 1. The resident not off-loading pressure On 9/2/2020 at 4:30 p.m., Resident #10 was lying in bed in his room. He was lying on his back with the head of the bed elevated approximately 35 degrees. He did not have an air mattress on his bed and he denied pain in his coccyx or left ischium wound areas. On 9/3/2020 at 11:00 a.m., Resident #10 was sitting in his tilt-in-space wheelchair at the nurses' station on the extended care unit. He was reclined back, leaning to the right and his head was not in alignment with the back headrest. He was able to straighten himself up slightly, but never fully upright. -At 12:28 p.m., Resident #10's lunch tray was placed on a table to his right, but out of reach, and remained covered until a certified nurse aide (CNA) was able to sit down and assist him with the meal. -At 12:30 p.m., CNA #3 assisted Resident #10 with his meal and did not raise the back of his wheelchair to an upright position. - At 12:48 p.m., he told the CNA, Chair's too far back. The CNA stood up, raised the back of the chair to an upright position, and the resident nodded his head to indicate it was better. -At 12:52 p.m., he had eaten most of his lunch and he did not have a house supplement with his meal. 2. Wound care On 9/3/2020 at 2:54 p.m., wound care was observed for Resident #10 with the DON, who was also the facility's wound nurse. The following was observed: -At 2:54 p.m., entered Resident #10's room and found resident lying in bed on his back with the head and foot of the bed raised slightly. -At 2:56 p.m., the DON washed her hands and donned clean gloves. She used the bed remote control to lower the foot and head of the bed flat, removed the adhesive tape on his incontinence brief and lowered it, and assisted him to roll onto his right side. -At 3:00 p.m., the DON did not remove her dirty gloves or perform hand hygiene, and removed the current dressing from the wounds. She used wound cleanser and gauze to clean around the wounds, and then applied Skin Prep adhesive around the wound. She did not perform hand hygiene or change her gloves. (Cross-reference F880 Infection Prevention and Control) The DON applied Medi-honey into the pressure injuries and then covered them with an [MEDICATION NAME] dressing. The DON did not measure the wounds, but said the left ischial wound was getting better, but she did not have measurements to compare it to. She said the coccyx wound surface now had some depth to it, but did not measure it. 3. Additional observations of resident not off-loading On 9/8/2020 at 10:05 a.m., Resident #10 was lying in bed on his back. His room was dark and he was asleep. On 9/8/2020 at 11:19 a.m., Resident #10 was lying in bed on his back. The room remained dark and he was asleep. On 9/8/2020 at 1:24 p.m., Resident #10 was lying in bed in his room. He was lying on his back and was frowning. He said he was thirsty and wanted a drink. His computer communication screen read, My butt hurts. I have . and nothing more was written. Licensed practical nurse (LPN) #6 assisted the resident to take a long drink from a cup on his bedside table until he had had enough. She asked him if he was okay and then asked him if he wrote the note on the screen. He nodded yes, confirmed he was having pain on his bottom, and she said she would follow up with his nurse, LPN #2, to find out about pain interventions. B. Resident #10 status Resident #10, age 49, was admitted on [DATE]. According to the September 2020 computerized physician orders [REDACTED]. pneumonitis due to inhalation of food and vomit, dysphagia, cognitive communication deficit, generalized muscle weakness and lack of coordination. -No diagnoses of pressure ulcers was indicated from admission. The 7/29/2020 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. He required extensive two-person physical assistance with bed mobility, transfers, and toilet use, and extensive assistance of one person for dressing, eating, and personal hygiene. He had functional limitation impairment in range of motion in both upper and lower extremities. He was not currently receiving nutrition or hydration intervention to manage skin problems. He had an indwelling urinary catheter and was always incontinent of bowel. He had no [MEDICAL CONDITION], no [MEDICAL CONDITION] and no rejection of care. He was assessed to be at risk of developing pressure injuries and did not have any unhealed pressure injuries. He had a pressure-reducing device for his chair and bed, and was on a turning/repositioning program. -However, the turning and repositioning program was a part of bed mobility records and was not always followed by staff for Resident #10 (see under record review). C. Record review The care plan, initiated 7/28/2020 and revised 8/20/2020, identified a potential impairment to skin integrity related to impaired mobility. The goal was to maintain clean and intact skin. The interventions included the following: avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short; encourage good nutrition and hydration in order to promote healthier skin; identify/document potential causative factors and eliminate/resolve where possible; use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface, and weekly skin check and notify resident, responsible party and MD with changes or concerns. The weights were reviewed from 7/24/2020 through 8/31/2020 (Cross reference F692, Nutrition/Hydration Status Maintenance) revealed and indicated the resident weight went from 171lbs down to 156lbs. The medication administration records (MAR) were reviewed for August 1 through September 7, 2020, and there was no house supplement given or ordered as recommended by the RD. The MAR documented Pro Stat (liquid protein supplement) was started on 8/26/2020 and was given twice daily for wound healing. It was discontinued on 9/1/2020 because the resident refused to take it. -There were no additional supplements started to replace the Pro Stat. The Braden Scale (an evidence-based tool used to predict the risk for developing a facility acquired pressure injury); dated 8/16/2020, identified Resident #10 had a score of 16 out of 23, which indicated he was at mild risk. The head to toe skin check, dated 8/16/2020, documented Resident #10's sacrum was red, pink, and blanchable. Barrier cream was applied with each brief change. The daily skilled nursing charting from 8/17/2020 through 8/19/2020 documented the resident's skin was intact and there were no changes in integrity. The daily skilled charting for 8/20/2020 documented the skin was not intact; there was an abrasion on left buttock that appeared to be shearing. Barrier cream was applied. A progress note, dated 8/20/2020, was written by the RD that identified Resident #10 triggered for significant weight loss of 6.5% for 30 days. He was on a regular diet and ate mostly finger foods unless fed by staff. Intakes were fair with breakfast averaging approximately 50%, lunch 25-50%, and supper was 50-75%. The RD recommended adding a house supplement with breakfast and lunch meals for weight stability and would discuss his plan of care with the IDT in the weekly at risk meeting and follow weights weekly until stable for four weeks. -The supplement was never ordered or attempted for Resident #10 (cross-reference F692) The Weekly Pressure Ulcer Record, dated 8/26/2020, documented the date of onset for the wound was 1/20/2020. However, the date had been entered incorrectly, and subsequent records revealed it was identified on 8/20/2020. The new pressure injury measured 1.5 cm length (L) by 0.8 cm wide (W), zero depth (D) and was a Stage 3. The description included, Resident noted to have a pink, non-blanching area to coccyx. Area is superficial Stage 3, no signs or symptoms of infection. Supplements and treatment in place. Resident to be OTA (open to air) while in bed with frequent repositioning. Pale pink tissue was noted to 100% of the wound bed and there was no odor or drainage. Specialty interventions were marked, bed, wheelchair cushion and positioning device (pillows) in place. The wound team would follow weekly until the pressure injury was healed. The physician and responsible party were notified on 8/20/2020. -However, the nutrition notification for the RD was not completed until 8/27/2020, a week later. The care plan, initiated 8/26/2020 and revised 9/2/2020 (during survey), identified Resident #10 had a Stage 3 pressure injury to his coccyx and left ischium. The interventions included the following: administer medications and treatments as ordered; observe and document for side effects and effectiveness; complete a full body check weekly and document results; IDT (interdisciplinary team) referrals as indicated, i.e., RD, PT (physical therapy), OT (occupational therapy) or other; observe nutritional status, serve diet as ordered and observe intake record; pressure reduction mattress in bed and pressure reduction cushion in wheelchair; reposition resident in bed and chair frequently for comfort and pressure reduction, resident requires supplemental protein, vitamins, minerals as ordered to promote wound healing; and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. The risk vs. benefit of an air mattress was reviewed with the IDT, MD and resident, and the following was decided: the resident would be at high risk for injury, falls, serious injury or entrapment with air mattress due to [MEDICAL CONDITION] and mobility limitations. Resident not appropriate for air mattress use at this time due to risk. Will continue pressure reduction mattress. -The care plan did not specify what the pressure injury was related to or indicate when an air mattress was attempted before concluding the air mattress risk for entrapment out weighed the benefits for the resident to prevent the development or worsening of pressure ulcers. (see bed mobility care plan below-resident would need an alternating pressure relieving device due to being dependent on staff) The care plan, initiated 7/28/2020 and revised 8/11/2020, identified the resident required help with everyday tasks to take care of himself including getting in and out of bed, hygiene, and toilet use. The interventions documented required extensive assistance with bed mobility, dressing, bathing and toileting, and total assistance and a mechanical lift to get in and out of bed. The Weekly Pressure Ulcer Record, dated 9/4/2020, documented the corrected date of onset as 8/20/2020 and measured 1.9 cm L by 0.5 cm W by zero D. The narrative note documented the following: Small increase in length noted, reduced in width, continues with no noted depth. Wound bed noted to have pale yellow slough, with some hair follicles noted scattered throughout. The skin surrounding the area was noted to be red. No noted drainage, no noted signs or symptoms of infection and resident encouraged to remain open to air while in bed, continue with supplements and positioning. Resident declined protein supplements. Continue all others. No additional interventions were started and note documented the wound was stable in appearance and stable overall. The Weekly Pressure Ulcer Record, dated 9/4/2020, documented the corrected date of onset as 8/20/2020 and measured 0.5 cm L by 0.5 cm W by zero D. The narrative note documented the wound had improved and decreased in size. There were no signs or symptoms of infection and the plan was to continue with the supplements and repositioning as the resident would tolerate. The CPO for 9/8/2020 included the following orders: -Regular diet, started 7/23/2020 -Snack: peanut butter and apples in the afternoon, started 8/20/2020 -Sacrum abraded area: Cleanse, barrier cream with pericare, monitor for healing every shift for skin abrasion, started 8/21/2020 -Apply moisture barrier cream to coccyx and left ischium with all peri care every shift after cleansing. Observe for abnormalities to wound bed, surrounding skin, or pain associated with wounds, started 8/26/2020 -Vitamin C tablet 500 mg, give one tablet by mouth two times a day for wound healing, and started 8/26/2020 -[MEDICATION NAME] packet (nutritional supplement), give one packet by mouth one time a day for wound healing, started 8/27/2020 -Fish oil capsule 1000 mg (Omega-3 fatty acids); give one capsule by mouth one time a day for wound healing, and started 8/27/2020 -Cleanse pressure injury to coccyx and left ischium BID (twice daily), apply Medi-honey to wound bed and cover with foam dressing. Observe for abnormalities to wound bed, surrounding skin, or pain associated with areas, started 9/4/2020 The turning and repositioning documentation for Resident #10 was requested on 9/8/2020 at 12:05 p.m. The nursing home administrator (NHA) said the facility did not document turning and repositioning because it was their expectation that every resident was turned every two hours, so it was considered charting by exception, rather than documenting each turn. She explained the bed mobility documentation included all of the turning and repositioning documentation they had. (see below) The bed mobility documentation was reviewed from 7/23/2020 through 9/3/2020, and revealed Resident #10 was turned and repositioned at the following times: -Once on 7/23, 8/2, 8/9, 8/17 and 9/3 -Twice on the remainder of the days -There is no documentation that Resident #10 was turned and repositioned more than twice each day, or frequently as indicated on the care plan. There were no refusals documented. IV. Staff interviews CNA #1 was interviewed on 9/8/2020 at 11:34 a.m., and she confirmed she routinely worked with Resident #10. She said he was not able to provide any care for himself and he had never refused care for her. She said he was not able to reposition himself in his wheelchair or the bed and the staff had to do it for him. She said during her eight-hour day shift, she would reposition him a couple times, and explained she turned him just before his breakfast and lunch, and then just before she went home for the day. She said Resident #10 did not like to turn onto his side and would rather be on his back. She said his refusals should be documented in their CNA charting, and she did not know how the pressure injuries developed. She said he had not gotten up out of bed yet that day because he had not requested to get up. She said she did not think he wanted to. On 9/8/2020 at 2:00 p.m., LPN #6 said she had checked the MAR and orders for Resident #10 and he did not have any orders for PRN (as needed) pain medications. She said she had placed a phone call to his doctor in order to inform him of his pain and the response was pending. She said she went back into Resident #10's room and repositioned him by lowering his legs down and adjusting his hips. She said he remained on his back and thought he felt better. LPN #4 was interviewed on 9/8/2020 at 2:37 p.m. She said she had worked at the facility for a little over one year and knew Resident #10 well. She said he was unable too much for himself or move himself, but he was able to push the call light purposefully and let staff know if he needed something. She said he never refused care for her. She said she did not know he had pressure injuries and it had not been reported to her during shift report that he had any. She said he had a standard mattress and did not know if he had a pressure-reducing cushion in his wheelchair or of any additional interventions that were put in place to address the pressure injuries. She said the CNAs were supposed to be turning and repositioning him every two hours and keeping him clean and dry. The DON was interviewed on 9/8/2020 at 3:28 p.m., and said the facility did wound rounds weekly with a physician. During the current pandemic, the physician was not entering the facility, but they had a dedicated electronic tablet so he could see the wounds. She said the standard skin precautions put in place for all residents upon admission included initial and weekly skin checks and monitoring weights weekly for four weeks to ensure their nutritional status was stable. She explained all of their mattresses were therapeutic and pressure reducing. She said they identified how mobile they were, and if they were immobile, they received heel protectors and staff would round on them every two hours. If they were independent, they made sure they were able to reposition themselves. The DON said all of the above interventions were in place for Resident #10 prior to his development of the two pressure injuries. She said the first time she looked at his pressure injuries they looked like excoriation, but they progressed, and the second time she looked at them they had a thin film on them, which made them a pressure injury because she could not see the wound bed any more. She said his wounds were caused by shearing and being left in one position for too long. The DON said after his pressure injuries were identified, they ordered barrier cream to be applied to the areas and tried to keep him open to air as much as possible. They would reposition him on his sides as he tolerated because he moved around a lot with his [MEDICAL CONDITION] tremors, but he was not resistant to care. She said once she identified them as pressure injuries, she notified the dietician, arranged for nutritional supplements to be started, and instructed the staff to keep him open to air as much as possible. The DON said the staff should reposition Resident #10 before meals, after meals, at hour of sleep, and as needed throughout the day. During the night shift, they did rounds every two hours and he would be repositioned at those times. She confirmed the turning was not being documented every two hours and said she was able to ensure it was being completed by, a lot of follow-up. She said they did not have many residents in the facility who had wounds, so she believed the turning was being done.

Based on record review and interviews, the facility failed to ensure three sample residents (#21, #152, and #68) of 53 sample residents received the care and services necessary to attain or maintain their highest practicable physical, mental and psychosocial well-being. Cross refer tag F 279 and F323. Resident #21: The facility failed to ensure resident #21 received medications necessary to control her heart rate and to prevent the development of [MEDICAL CONDITION] emboli. Record review and interview revealed the facility had a list of resident #1's medications when she was admitted which revealed she had been on medications to control her diabetes and heart rate and to prevent blood clots. Staff interview and documentation by the facility revealed that after an initial fax to the resident's primary care physician (PCP) requesting orders for these medications on 2/8/17, when there was no response, staff waited four days, then another three days, and then another six days in their attempt to obtain the orders. The facility's failure to ensure resident #21 received her ordered medication to control heart rate contributed to the resident's admission to a hospital intensive care unit (ICU) for treatment of [REDACTED]. Resident #152: The facility failed to ensure resident #152 was free of medication error, had a comprehensive care plan that evidenced collaboration with hospice and private caregivers, had changes in condition properly documented in his record and received proper care and services following a fall with fracture. Resident #68: The facility failed to ensure resident #68 received medications as ordered. The findings included: I. Resident #21 - Failure to obtain necessary medications. A. Resident status 2/8/17 to 2/23/17 Resident #21's record was requested for initial review on 5/1/17. Resident #21, age 76, was admitted on [DATE]. [DIAGNOSES REDACTED]. Per the admission minimum data set assessment ((MDS) dated [DATE], resident #21 required assistance of one to two staff for activities of daily living (ADLs) and was frequently incontinent of bladder and always incontinent of bowel. An admission nursing assessment, dated 2/8/17, documented the resident's oxygen saturation was 90% on room air; pulse was regular at 92 beats per minute , some non-[MEDICAL CONDITION] of only the right lower extremity, the resident was continent, was TTWB (touch toe weight bearing) with an immobilizer on the right lower extremity. -The last nursing assessment, dated 2/14/17 documented a pulse of 102 and no [MEDICAL CONDITION]. -The last recorded blood pressure and oxygen saturation (both within normal limits) was on 2/19/17, four days prior to her hospitalization on [DATE] (see below). The care plan, initiated on 2/10/17, identified resident #21 required extensive assistance with ADLs from two staff. She had alteration in mobility and required assistance with toileting. She was at risk for falls and required safety checks. She had potential for pain. The resident's undated food preference interview documented the resident was on a regular diet. The February 2017 Medication Administration Record [REDACTED]. B. Resident decline 2/23/17 to 2/27/17 Review of physician progress notes [REDACTED].#21 was transferred to the hospital on [DATE] for treatment of [REDACTED]. A physician's office Progress Note, dated 2/23/17, read in part: She is here today alone (from LTC facility). Apparently none of (resident #21's) chronic meds were continued when she was d/c'd (discharged ) to (LTC facility). They contacted us 2/9 and a list of her medications was faxed but apparently never received. (LTC) says they sent another fax requesting an order for [REDACTED]. (LTC) facility sent no record of vitals or any report of how the pt is doing. Past medical history included the above and mental [MEDICAL CONDITION]. The resident's heart was very [MEDICAL CONDITION] (rapid) and she was sent to the ED (emergency department) for rate control. According to hospital records, received at the Department on 4/27/17, resident #21 was seen for follow-up at her physician's office on 2/23/17 and found to be in [MEDICAL CONDITION] with RVR (rapid ventricular response), and hypoxic (low oxygen). Tests in the ED revealed [MEDICAL CONDITION] embolism in the right and left [MEDICAL CONDITION] arteries. Her heart rate on admission was 171 with an oxygen saturation of 75%. She had 2+ [MEDICAL CONDITION] (swelling) of both lower extremities. Her urine was amber colored and foul smelling. Lab results, dated 2/23/17 included a blood glucose level of 158, (normal range of 65 - 99). Her oxygen saturation was in the 70's. (Normal oxygen saturation is 90% and above). The ED report read the resident described a fast heart beat that started several days (ago) and is still present. It was gradual in onset and has been constant. She has had difficulty breathing. Patient was discharged to the (LTC) on 8 February. She apparently did not subsequently receive her medications including [MEDICATION NAME], Eliquis, [MEDICATION NAME] (antiarrythmic, anticoagulant, antidiabetic and antihypertensive medications, respectively). An Admission and History record (H & P) dated 2/23/17 read in part: Resident #21 fell and had a distal femur fracture on the right side on 2/7/17. The resident was discharged on [DATE] to the LTC facility. There was some confusion as to what happened with her discharge medications when she went back to (LTC) facility. She was off of her (heart) rate control medicines as well as her anticoagulation medicines for history of chronic [MEDICAL CONDITION]. It is unclear why this happened or why it persisted as she has been off the medicines for approximately 2 to 2-1/2 weeks. During that time she did develop rapid ventricular rate with her [MEDICAL CONDITION] and was seen by her PCP in the clinic today. She was directed over here to the emergency room because of the [MEDICAL CONDITION] During workup here, she was found to have bilateral [MEDICAL CONDITION] emboli as well as hypoxemia into the 70s. Past medical history included chronic [MEDICAL CONDITION], hypertension and type 2 diabetes. The assessment and plan included: 1. Chronic [MEDICAL CONDITION] with acute rapid ventricular response. The patient has been off of her rate control for approximately a couple of weeks now. 2. Bilateral [MEDICAL CONDITION] emboli. She has also been off of her anticoagulation since her fracture. With her known history of chronic [MEDICAL CONDITION] she was at elevated risk for [MEDICAL CONDITION] emboli. 3. [MEDICAL CONDITION] hypertension. This is noted on the patient's most recent echo (cardiogram) last year. She does have evidence of right heart strain that has likely worsened given her clot burden from [MEDICAL CONDITION] emboli. A hospital discharge summary, dated 2/27/17, read in part: Patient is a [AGE] year old who has a history of MR (mental [MEDICAL CONDITION]), [MEDICAL CONDITIONS] and hypertension who had recently been admitted on ,[DATE] with a right nondisplaced femur fracture. She was discharged to (LTC) for inpatient rehab. Upon discharge (LTC) did not receive orders for her maintenance medications and patient went 2 weeks without any anticoagulation or rate controlling medications for her [MEDICAL CONDITION]. In the ED the patient was found to have bilateral [MEDICAL CONDITION] emboli with a moderate to large clot burden and right heart strain. It also appeared that she had an acute [MEDICAL CONDITION] exacerbation with vascular congestion seen on chest x-ray. Urine was also suggestive for infection. She was admitted to the ICU. treatment for [REDACTED]. C. Facility failure to ensure resident #21 received medications necessary to control heart rate and to prevent development of [MEDICAL CONDITION] emboli. 1. Facility record review revealed references on and after admission to the resident's chronic medical conditions, as well as the medications necessary to manage them. Interview confirmed the facility received a list of the resident's medications to address her medical condition on admission. a. Record Review Although the hospital Facility Handoff Sheet, dated 2/8/17, Medication Administration Record [REDACTED]. Handwritten notes included not making needs known, DMII, [MEDICATION NAME] (antidiabetic medication). Discharge diet was diabetic. A history and physical, dated 2/8/17, with a faxed date of 2/17/17, included a medication list: Fish oil, Folic acid, [MEDICATION NAME], Zinc, Atorvastatin, [MEDICATION NAME], Red rice yeast and Eliquis. An undated, unsigned handwritten note also in the resident's record read: A.M. [MEDICATION NAME] 25 mg, [MEDICATION NAME] CD 240 mg, Zinc 50 mg; P.M. Atorvastatin 40 mg, [MEDICATION NAME] ER 25 mg, Red Rice Yeast 600 mg; Both A.M. and P.M. Eliquis 5 mg, [MEDICATION NAME] 500 mg. b. Interview A family member was interviewed on 5/11/17 at 1:20 p.m. She said she had provided the undated, unsigned handwritten list of the resident's home medications to staff at the facility on the day of the resident's admission. She said another family member had taken the resident's home medications to the facility by accident and they were left in the bottom drawer of the medication cart as they could not be administered without physician orders. Licensed practical nurse (LPN) #21 was interviewed on 5/15/17 at 3:05 p.m. She said the handwritten notes found with the hospital Facility Handoff Sheet, dated 2/8/17, referencing the resident's diabetes and use of [MEDICATION NAME] were notes by the facility nurse who took the transfer information from the hospital by phone. She confirmed a family member had provided the list of home medications the day resident #21 was admitted . 2. Facility record review revealed the facility failed to obtain medications to treat resident's known, chronic medical conditions. Staff attempts to obtain the medications were inadequate and untimely. A facility fax completed by LPN #21, dated Wednesday 2/8/17, read: Resident admitted to facility (without) orders for the following home meds. The medications and administration times in the unsigned, undated handwritten note provided by the family member on admission were listed on the fax. LPN #21 documented at the top of the fax, Faxed 2nd time 2/12/17; called 2/15/17 as well; 2/21/17 Sent to appt 2/21/17; 3rd time faxed 2/21/17; Called 2/22/17 LM (left message) (with a personal name); sent 2/22/17. Review of nursing progress notes on the above dates included in pertinent part: - 2/8/17 (Wednesday) - (Family member) gave a list of medications that (resident) took at home. No orders received from (hospital) for these meds. PCP contacted via fax requesting orders for her home meds. - 2/12/17 - no documentation of the refax on Sunday 2/12/17, four days after admission. - 2/15/17 (one week after admission) LPN #21 - Telephone MD (medical doctor) office to inquire on the 2 faxes sent to clarify orders from admit. Left a message for return call to facility on VM (voice mail), unable to speak to a live person. - 2/22/17 (two weeks after admit and one week after voice mail of 2/15/17) - LPN #21 documented she called the physician office to follow up on orders for the resident's medications, after refaxing yesterday and sending med list to appt with ortho(pedic) (physician) for orders for home meds. Ortho MD referred it to PCP. Received voice mail at PCP office and was transferred multiple times. Finally reached the receptionist who transferred me to (physician's) nurse. (Receptionist) states that (a family member of resident #21) was in the office attempting to get orders for the meds as well. A nurse said she was looking for the items and had called the nurse for (PCP). (Nurse) has a call out to (PCP) to inquire about the orders and she is currently looking on (PCP's) desk. A second note, of the same date by LPN #21, read the nurse called back to state she could not locate any faxes on PCP's desk. Requested they be sent again. - 2/23/17 LPN #21 documented at 17 minutes after midnight. No return call from (PCP's) office in regards to request for orders for meds resident took at home. Spoke to (former) DON (director of nursing) earlier in the day about the multiple calls and faxes sent to the office about orders for her meds. She agreed that we should contact the Medical Director. (Medical Director) faxed to ok orders for resident's meds that she took at home. - 2/23/17 registered nurse (RN) #17 documented resident #21 went to a medical appt, driver later reports that MD called him to take resident to (hospital) ER. On 5/1/17, the facility was asked to write up a timeline of their efforts to obtain orders for resident #21's medications. On 5/9/17, a second review of the record included an undated, unsigned handwritten timeline. The current DON, interviewed on 5/9/17, said the timeline was completed by the assistant DON (ADON). Review of the timeline revealed it mirrored the faxes, calls and electronic notes by LPN #21 and confirmed staff's efforts to obtain the resident's medications were inadequate and untimely. The ADON documented: - LPN #21 notified the ADON of her efforts, including the orthopedic physician referring the facility to the PCP for orders. I told her to keep calling the office until she was able to get to talk to a live person. Don't fax or leave messages. - LPN #21 went to the DON, who told her to send an urgent fax to the medical director with attention to his nurse. No call back or fax was received. -On 2/23/17, (resident #21) was transferred to (hospital). She was diagnosed with [REDACTED]. Found on H & P (by two physicians) that they had put her meds in her notes, so somebody was aware. Reviewed vs (vital signs) and they were stable since admission and her weight was also stable . 3. Interviews confirmed the resident's decline and an inadequate facility response to ensure the medications were obtained and administered. A family member was interviewed on 5/11/17 at 1:20 p.m. and said LPN #21 told her she faxed and faxed the PCP; however, the family member was under the impression the supply of medications was getting low and the facility was requesting refills. -She said she told another family member to go to the PCP's office (on 2/22/17) because LPN #21 said the PCP's office was not accepting the paperwork the facility was sending over. -She said on 2/23/17, another family member had gone to the facility to visit resident #21 and found out the bus driver had dropped her off at the hospital. When the family member arrived at the ED, they were telling me her resting heart rate was 150 and her lungs were full of clots and her bladder had two liters of fluid in it. The doctor said she wasn't getting her meds. -She said (2/23/17) was the first time she was aware resident #21 had not been getting her meds and no one told any of the three family members they had not been administering any of resident #21's routine medications. LPN #21 was interviewed on 5/15/17 at 3:05 p.m. She confirmed the dates she made on the fax form (2/8, 2/12, 2/15/17, 2/21/17 x 2, and 2/22/17) were the only days she had attempted to contact the PCP for orders, although she said she had passed on in report to the other nurses that the facility was waiting for orders. She said the original fax would stay in the Fax book and if other nurses made attempts to contact the PCP, they should have made a note on her fax or attached their confirmations if another fax was sent. -She said she spoke with a family member about the lack of orders and the family member offered to administer the medications herself; however, LPN #21 acknowledged she was not aware there were medications in the bottom drawer of the medication cart. She said another family member had gone to the PCP's office trying to get other documents signed. I went to (ADON) first and she told me to keep trying to call and then I went to (former DON) and ADON and I asked if we could get a hold of (medical director) and they said 'yes.' The current DON was interviewed on 5/16/17 at 2:25 p.m. She said she began duties on 3/6/17; therefore, she was not present when resident #21 resided in the facility. She said besides LPN #21, the ADON and Registered Nurse (RN) #19 had made efforts to obtain signed orders. She was not aware there was no documentation in the resident's record or in the timeline prepared by the ADON that anyone had made efforts to obtain the resident's medication orders besides LPN #21. 4. Interview with administration revealed an inadequate facility response to prevent a recurrent failure to obtain medications necessary to treat a resident's medical condition. At the quality assurance interview, on 5/17/17 at 4:45 p.m., the administrator stated she was out of town when the events took place related to resident #21. -She said something should have been done sooner (to obtain the orders); however, she felt it was addressed when the facility met with the hospital regarding issues the facility had with new admissions. She referred to a letter written by the hospital in April 2017 that read the hospital acknowledged a few patient handoffs were not as thorough or complete as they should have been. The hospital said they had provided some education to their staff and physicians on patient discharge/transition process. -She did not state what steps had been taken by the facility to address how staff should respond and who should be notified to prevent a delay in a resident receiving the medications necessary to address his/her chronic medical conditions. II. Resident #152 - Failure to ensure freedom from medication error and proper care and services, including coordination and documentation of care. A. Resident status Resident #152, age 84, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. The resident was admitted to hospice palliative services on admission. According to the MDS assessment, dated 3/15/17, the resident had severe cognitive impairment with a BIMS score of one out of 15. B. Failure to ensure freedom from medication error A physician progress notes [REDACTED]. A hospice note, dated 2/15/17, read in part: Met patient and (spouse) at (physician) appointment. Spouse talked about episode of 2/14 when (s/he) thought that patient had a TIA ([MEDICAL CONDITION]). (Physician) suggested may have also been from [MEDICATION NAME], was given a dose of this inadvertently by facility nurse on 2/13 and then later in the evening had [MEDICATION NAME] (sedative). There was no documentation in the nursing progress notes of the medication error or of the resident's condition following the error or documentation of resident's monitoring thereafter. On 5/15/17, evidence the facility had conducted an investigation of the medication error was provided by the DON. The Medication Variance Report, dated 2/13/17 at 3:10 p.m., read the error occurred on 2/13/17 at 2:00 p.m. Wrong resident, wrong medication was marked. Vital signs were taken at 3:30 p.m. and 4:30 p.m. The report read [MEDICATION NAME] 50 mg, belonging to another resident, was administered in error for the intended medication [MEDICATION NAME]. C. Failure to provide proper care after fall with fracture Cross reference F323; accidents. A late entry nursing note, dated 4/23/17, and signed by a licensed practical nurse, read in part : Previous note not found but was previously saved by nurse on 4/18/17. Resident was found on floor by evening shift CNA. Writer found resident in supine position on the floor with his pajama pants around his ankles. The nurse contacted the resident's spouse and hospice with recommendation the resident be transferred to the hospital for suspicion of serious injury. Emergency services was contacted at 8:23 p.m. for transport. At 2:30 a.m. (on 4/18/17) the resident and his spouse returned to the facility. The spouse said she had paperwork from the hospital but did not provide it to the nurse. The only thing (spouse) told writer is, 'He has a small fracture in his left hip.' -An x-ray report, dated 4/17/17 and received 5/19/17 after survey exit, confirmed Femoral neck fracture of left hip. Review of an emergency medical services report, also received 5/19/17 after survey exit, revealed the facility failed to ensure resident #152 was not moved prior to an assessment of the resident's condition by a Registered Nurse and prior to the arrival of emergency services. Specifically: An EMS Care Report, dated 4/17/17, documented EMS received a call at 10:30 p.m. They arrived at the facility at 10:41 p.m. Facility staff told EMS personnel Pt (patient) was found on the floor and had fallen onto the floor onto his buttocks, after they examined him the caretaker stated that the pt was complaining of pain to his left hip/pelvis area. Pt was lying in his bed. Pt was back in his bed and the pt fell at approximately 10:30 p.m. this evening. Review of the resident's record revealed no documentation that prior to EMS's arrival and prior to being returned to bed, the resident had been assessed by a licensed nurse. D. Failure to ensure collaboration with hospice on the plan of care Resident #152's record included hospice notes from 12/21/16 through 4/12/17. He was on hospice palliative services until 3/28/17, when he was transitioned to full hospice services. The care plan, with problems initiated on 12/27/16 and revised last on 4/12/17, did not identify resident #152 was receiving any hospice services in order to ensure coordination of services between the hospice agency and the facility. This failure resulted in the potential for lack of, or duplication of, services. For example, a hospice note, dated 4/7/17, read in part: Hospice Aide comment: Almost had patient in bathhouse when a Nurse informed me he had just got one. Poor guy almost had a repeat. E. Failure to coordinate services with private caregivers through a comprehensive care plan. The care plan, referenced above, did not include documentation the resident received any services from private caregivers. A social services note, dated 3/29/17, documented a family care conference was conducted at the request of a family member to include hospice and facility staff. The note read a private caregiver would work Monday through Friday from 7-8:30 (a.m.) and another caregiver from 5-730 (p.m.) and they trade weekends. A social services note, dated 2/28/17, documented a quarterly conference conducted with hospice, family member and a private caregiver. The current DON said on 5/10/17 at 3:45 p.m., I have identified a problem with care plans. On admission I started an admission checklist and make sure the assessment is done and note the height, weight, meds, psych(otropic) meds, Braden assessment and skin assessment. Then I have a care plan check list and everything has been done. We observe the room, assess the resident and any special equipment. We are in the process of updating the care plans. She said the unit managers and ADON were responsible for developing and updating the care plans. The social services director said on 5/16/17 at 9:18 a.m., private caregivers sent by resident #152's spouse, would show up and get him ready for the day and get him ready and take him to breakfast. They sometimes came at lunch and did come for dinner, usually but I don't know how late they stayed. The customer service coordinator said, on 5/15/17 at 5:00 p.m., . He had the sitter (private caregiver). She had no idea what hours the private caregiver was present. She saw people here on and off throughout the day. A young lady helped him eat breakfast. She thought they were present until about 2 p.m. The ADON said on 5/17/17 at 1:34 p.m., hospice helped with the resident's medications, and provided a volunteer that came in and visited with the resident. She said the facility would include any services provided by private caregivers. She was aware resident #152 had private caregivers, as well as hospice services. She said It varied when they (private caregivers) would come in, I mostly saw them during the day. They sat with him, visited with him. We did all the ADLs for him, even dressing. F. Failure to document changes of condition A hospice note in resident #152's record, dated (Thursday) 1/12/17 at 9:45 a.m., read in part that a private caregiver was with the resident at breakfast when he became shaky and was unable to hold onto fork or feed himself. The caregiver could see his teeth chattering. Private caregiver contacted the family member, who went to facility and took resident's blood pressure, which she recorded initially as 184/159, then 134/72. The hospice nurse called facility and spoke to RN #17. Asked her about earlier incident, she acknowledged the incident, stated that patient had the 'shakes,' asked her if these were like fine tremors and she stated they were. She has no information to add, states she was present on Saturday (1/7/17) when patient's blood pressure was elevated, states patient was less responsive and his face was flushed during that incident, today was alert during incident. Review of facility nursing progress notes, included no notes of the incident on 1/12/17. A note on 1/7/17 read in part, In dining room chair leaning back, while scooted forward in seat, (spouse) concerned when this happened before it just looks like a stroke. BP as noted sitting, standing BP 90/61. The resident was able to ambulate unsteadily after drinking juice. The note did not reflect the elevated blood pressure, flushed face, and less responsive state, as stated by the RN to the hospice nurse. The administrator was interviewed about the lack of documentation for the resident's change of condition, on 5/17/17 at 10:30 a.m. She said resident #152's spouse would come in with all of her investigations about things like his [DIAGNOSES REDACTED] or she would talk about his TIAs, but they were nothing that was witnessed by the nurses. III. Resident #68 - Failure to ensure that the medications were administered per physician's orders [REDACTED].>A. According to Clinical Nursing Skills & Techniques, by Perry, Potter & Ostendorf, 8th Edition (copyright 2014), page 480-489: Safe Medication Administration: To prevent medication errors follow the six rights of medication administration consistently every time you administer medications. Many medication errors are linked in some way to an inconsistency in adhering to the six rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation B. Resident #68's status Resident #68, age 88, was admitted on [DATE] and readmitted on [DATE]. Review of the face sheet revealed a [DIAGNOSES REDACTED]. According to the 3/8/17 MDS assessment, the resident had moderate cognitive impairment with a BIMS score of nine out of 15. No mood or behavior symptoms were noted. The resident required extensive assistance of two persons with bed mobility, transfers, dressing, and toileting. The resident was not steady and needed human assistance during transitions and walking to stabilize. The care plan, initiated 3/2/17 and revised 4/12/17, identified the resident was able to make decisions as to her care. The interventions included she could make decisions of her preferences at any time. Review of the computerized physician's orders [REDACTED]. The resident's Medication Administration Record [REDACTED]. C. Observations and Interview On 5/10/17 at 8:45 a.m., the staff nurse (#19) was observed during a medication administration for resident #68. The nurse was observed to place [MEDICATION NAME] 1200 mg into the small medication cup with other medications. The nurse said the [MEDICATION NAME] was a stock bottle of medication that the facility orders with other over-the-counter stock medications and it was the only choice for this medication. The business office manager, who was in charge of ordering stock medications, was interviewed on 5/16/17 at 2:55 p.m. She said the nurses let her know what dosage of a medication is needed. She said she orders from one company and if they do not have what is needed, she goes to the store in town to get what is needed. The stock medication closet was observed with the business office manager. The medication closet had two bottles of stock [MEDICATION NAME] 1200mg, no other dosage was in the medication closet. On the evening of 5/17/17 the administrator and the DON were interviewed. They were informed of observations of staff's administration of the wrong dose of [MEDICATION NAME] during the medication pass. The administrator said the staff nurse had not informed them of the observations above and she said she would follow up on the issue.

Based on observation, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible; and each resident received adequate supervision and assistance devices to prevent accidents for two of three residents (#109 and #152) reviewed for accident hazards of 55 sample residents. Specifically, the facility failed to: - Address resident #152's known risks for falls and take steps to intervene, including to increase supervision after the resident fell ,[DATE], 3/28, 3/29, and 4/14 and 4/16/17. The resident fell again 4/17/17 and sustained a femur fracture. - Accurately assess resident #109's fall risk and update his care plan after a self-reported fall. - Safely store chemicals. - Ensure safe hot water temperatures. The findings included: I. Resident #152 A. Resident Status Resident #152, age 84, was admitted to the facility on [DATE] from the hospital. On 4/19/17, resident #152 was transferred to the hospice care center for pain management following a fall with fracture 4/17/17, and he did not return to the facility. According to the face sheet, [DIAGNOSES REDACTED]. According to the significant change minimum data set (MDS) assessment of 3/15/17, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of one out of 15. He required set-up assistance with dressing, eating, personal hygiene and bathing. He was independent with bed mobility, transfers and toilet use. A hospital document titled, Facility Handoff Sheet, dated 12/21/16, had Fall Risk circled, with Falls/Balance and Elopement/Wandering checked. Diabetes was also marked on two pages. admission orders [REDACTED]. A History and Physical report dated 12/21/16 identified diet controlled diabetes and dementia - the patient has been labeled possible Parkinsons or [DIAGNOSES REDACTED]. The record included consents for psychotropic medications that included Xanax (sedative), Lorazepam (sedative), and Zoloft, Trazodone and Celexa (antidepressants) with orders initiated on 3/22/17,12/28/16, 4/8/17, 4/11/17, and 12/21/16, respectively. Warnings on each consent included: sedation, drowsiness, dizziness, and blurred vision. A Care Conference Attendance Record, dated 12/27/16, noted the resident gets up and down, doesn't use call light to get help. The care plan, with problems initiated on 12/27/16 and revised last on 4/12/17, identified the resident needs assistance with his ADL (activities of daily living) care related to severe Alzheimer's disease with loss of short term and long term memory and poor cognition. Interventions included one person assistance or supervision with bed mobility, transferring, bathing, dressing, personal hygiene, toileting and eating. (Resident) is independent with ambulation but does have an unsteady gait and needs to be supervised. B. Review of fall risk records and fall reports provided by the director of nurses (DON) on 5/9/17, along with post-fall reviews, nursing and physician progress notes [REDACTED].#152 had five falls, including a fall with fracture. 1. Fall risk review the resident was identified at high risk for falls. - 12/21/16 - score 10 - a 10 or higher is High Risk - 3/2/17 - score 21 - 3/15/17 - score 10 - 3/28/17 - score 21 - 3/29/17 - score 16 - 4/14/17 - score 14 - 4/16/17 - score 20 2. Fall reports - 3/2/17 at 11:15 a.m. - caregiver reported to staff that resident fell while out on pass at home. No injury noted. - 3/28/17 at 9:55 p.m. - resident went to sit on a 4 wheel walker. Item kept going and he sat on his butt. No injuries noted. - 3/29/17 at 6:15 a.m. - Patient stood up from the couch in the commons area, started to walk away, lost his balance and fell on the tile floor. Witness by (certified nursing aide/CNA) who states, I'm not sure if he hit his head, but I think he did. - 4/14/17 at 7:00 a.m. - Resident was found lying under bed. Resident stated he did not fall, however, (there) was a lump on head - hospice confirmed it was not a bump from hitting his head, resident also c/o (complained of) left hip pain. - 4/16/17 at 10:00 a.m. - Resident was found in room on floor by bed, between the bed and wall. Although the resident fell again 4/17/17 (see post fall review and hospital record below), a fall record for 4/17/17 was not provided by the facility. 3. Post Fall Reviews included the following intervention notes: - 3/2/17 - Resident has unsteady gait. High fall risk. Family to take resident out in w/c (wheelchair) when out of facility. Pharmacy consultant and dietary consult done. Indicate all intervention recommendations. Care plan revision was marked. - 3/28/17 - Has history of frequent falls. Has a PT (physical therapy) evaluation from a Hey Therapy referral (a form completed when staff see something they want to refer to the therapy department) for either using a walker or w/c. Meds have been reviewed with no changes and dietary has been referred. Care plan revision was marked under recommendations. - 3/29/17 - Have implemented a Hey Therapy to have PT screen for balance and use of either walker or w/c. Pharmacy and Dietitian also have screened for any problems. Care plan revision was included under recommendations. - 4/14/17 - Resident confused stated he was working on bed. Increase staff supervision. Attempted to redirect. Assisted back to bed. - 4/16/17 - Bed in low position. Monitored frequently by staff. Hospice informed of fall. Social Services continues to explore other placement for a locked unit. Assessed mattress. Treatment to monitor left rib area every shift for three days. Care plan revisions were not recommended on the last two post fall reviews. A physician progress notes [REDACTED]. The note read, He has had several falls this week, he has fallen on the floor but has not had any injuries. He has continued on Xanax as needed and this helps. (Family member) reports he has needed it a lot more due to increased aggressiveness and combativeness. (Family member) is requesting a wheelchair to help prevent falls for the patient. A late entry nursing note, dated 4/23/17, read in part: Previous note not found but was previously saved by nurse on 4/18/17. Resident was found on floor by evening shift CNA. Writer found resident in supine position on the floor with his pajama pants around his ankles. The nurse contacted the resident's spouse and hospice with recommendation the resident be transferred to the hospital for suspicion of serious injury. Emergency services was contacted at 8:23 p.m. for transport. At 2:30 a.m. (on 4/18/17) the resident and his spouse returned to the facility. The spouse said she had paperwork from the hospital but did not provide it to the nurse. The only thing (spouse) told writer is, 'He has a small fracture in his left hip.' An x-ray report from the hospital, dated 4/17/17 and received 5/19/17 after survey exit confirmed Femoral neck fracture of left hip. C. Facility failure to address resident #152's known risk for falls and supervision needs after repeat falls. 1. Review of the resident's care plan revealed the resident's risk for falls, including his use of psychotropic medications which had potential side effects of sedation, drowsiness, dizziness, and blurred vision, was not care planned. In addition, the care plan failed to address the resident's need for supervision because he gets up and down, doesn't use call light to get help. No interventions were documented on the care plan after the resident's falls despite notations in the post fall reviews on 3/2, 3/28 and 3/29/17. 2. The Assistant DON (ADON) was asked what interventions were put in place to keep resident #152 safe, as the care plan was void of interventions. She said, on 5/17/17 at 1:34 p.m., After he started falling, it was more trend and track, when was the most (frequent) time for him (to fall). We did more one on one with him. One thing I did notice, it seemed like his abilities, his gait, was more unsteady and he did not want to use the wheelchair. She said one intervention was moving the resident to a room closer to the nurses' station. However, there was no documentation of one on one with the resident, no directive for how frequently staff was to monitor the resident and what if any interventions were recommended after PT evaluated the resident for balance. II. Resident #109 A. Resident status Resident #109, age 46, was admitted on [DATE] with a readmitted on 12/29/16. According to the face sheet, the [DIAGNOSES REDACTED]. The admission type was the resident was a short term stay. According to the May 2017 computerized physician's orders [REDACTED]. According to the 4/3/17 minimum data set (MDS) assessment, the resident had a brief interview for mental status (BIMS) score of 14 out of 15. No mood or behavior symptoms were noted. The resident required supervision and set up help with bed mobility, transfers, locomotion on the unit, and locomotion off the unit, dressing, and toileting. The care plan, initiated 7/21/16 and revised 4/5/17, identified a potential/actual safety and or fall risk related to alteration in mobility, amputee, and a current infection process. The interventions included extensive assistance of two staff members for transfers. The facility communication form and progress note, also known as SBAR form, revealed the resident reported on 4/27/17 that he had a fall at home before returning to the facility from a pass out of the building. Things that make the condition or symptoms worse, according to the SBAR form, was left below the knee amputee. Things that make the condition or symptoms better, listed none. The SBAR revealed the resident was in the nursing home for long-term care. Other pertinent history included diabetes. The registered nurse (RN) suggested the problem might be the resident was self-transferring at home and fell . The physician was notified about the fall on 4/27/17. The nurse noted a 1 cm laceration/abrasion to the left knee, cleansed, antibiotic ointment applied, covered with a dressing. The resident denied hitting his head. B. Failure to accurately assess the resident's risk for falls Review of the resident's two fall risk assessments, dated 4/1 and 4/27/17, revealed both assessments failed to address the resident's known functional limitations/fall risk. The facility fall risk assessment dated [DATE] revealed the resident had not had a fall in the past three months. The resident was chair bound and required assistance with elimination. The evaluation for gait/balance, standing on both feet without holding onto anything was not applicable due to the resident being unable to perform the function. The question related to predisposing disease, such as loss of limb, was documented as none present, although the resident had a left leg amputation. The assessment rating with a score of less than 10 indicated the resident was at a low risk for falls. The licensed practical nurse/licensed vocational (practical) nurse signed the fall risk assessment dated [DATE]. Although the resident had self-reported a fall at home on 4/27/17 (see SBAR above), the facility fall risk assessment dated [DATE] revealed the resident had no falls in the past three months, ambulation status as ambulatory, although the resident had a left leg amputation, and continent, the gait/balance standing with both feet indicated his gait/ balance was normal, and required assistive devices. The assessment rating for a fall indicated the resident was at a low risk category. The RN signed the fall risk assessment on 5/10/17. C. Observation and Interviews Observations and interviews revealed the resident had sustained several falls since his admission while out of the facility, contrary to the above fall assessments. The resident was interviewed on 5/9/17 at 10:50 a.m. The resident had a bandage on his left stump and said he had injured his stump during a fall he sustained while out of the facility. He said that he had fallen multiple times in the past. He said he was prone to falls and usually wears prosthesis on his left stump but could not wear it until his stump healed up. The nurse assigned to care for resident #109 was interviewed on 5/9/17 at 10:19 a.m. She said the resident had two falls in the past 30 days and she did not remember the dates. She said both falls happened out of the facility while the resident was on leave/pass. D. Failure to ensure the resident's safety from falls Record review revealed the resident's care plan (see above) failed to address the resident's falls and progress notes failed to include any evidence the resident was educated on how to remain safe from falls when out the facility. Record review further revealed no evaluation or intervention by therapy following the resident's self-report of a fall, in order to prevent the resident from sustaining additional falls. The therapy director was interviewed on 5/16/17 at 11:10 a.m. She said the resident was no longer on therapy services and had been discharged on [DATE]. She said the therapy department could do screenings when a resident had a fall but that nursing services would have to let them know it was needed. She said she had not heard from nursing that the resident had fallen. The DON was interviewed on 5/16/17 at 1:58 p.m. She said the resident already had proper footwear as an intervention on his care plan. The administrator and DON were interviewed on 5/17/17 at 1:27 p.m. The administrator said the resident was assessed for safety and he had a high BIMS score so he is cognitive. She said the resident has only had one fall from the time of his admission and that fall was out of the facility while he was on pass. The DON said all falls are discussed in a group meeting and changes to the care plan are made as necessary. She said she would review the resident's care plan and make changes as needed. When informed there was no screening or therapy after his reported fall on 4/27/17, the administrator said she would fill out a Hey Therapy form and have physical therapy or occupational therapy do a screening of the resident. The administrator and DON also said they would review the fall risk assessment for possible mistakes. III. Hot Water Temperatures A. Professional Reference According to the American Burn Association's Scald Injury Prevention Educator's Guide, 2/11/16, in pertinent part: The older adults are at high risk for burns due to thinner skin, which means that hot liquids cause deeper burns even with brief exposure. Additionally, an increase in medical conditions may decrease their ability to sense heat. Hot water at 120 degrees Fahrenheit can cause a third degree burn with five minutes of exposure time. Hot water at 124 degrees Fahrenheit can cause a third degree burn with three minutes of exposure time. Hot water at 127 degrees Fahrenheit can cause a third degree burn with one minute exposure time. According to the Consumer Product Safety Commission, Document #5098, dated 5/12/00, Most adults will suffer third degree burns if exposed to 150 degree water for two seconds. Burns will also occur with a six second exposure to 140 degree water or with a thirty-second exposure to 130 degree water. Even if the temperature is 120 degrees, a five minute exposure could result in third-degree burns. B. Facility Expectations The facility's Work Schedule Tasks, dated 1/29 through 2/4/17, included water temps - test and log the hot water temperatures. C. Initial Observations On 5/8/17 during the initial tour and resident observations, the following were observed: -Room 57 sink water temp was taken with a thermometer, which indicated a temperature of 128 degrees Fahrenheit (F). -Room 53 sink water temp was taken with a thermometer, which indicated a temperature of 130 F. -Room 14 sink water temp was taken with a thermometer, which indicated a temperature of 134.3 F. -Room 12 sink water temp was taken with a thermometer, which indicated a temperature of 134.5 F. -Room 11 sink water temp was taken with a thermometer, which indicated a temperature of 135.1 F. -Room 7 sink water temp was taken with a thermometer, which indicated a temperature of 122 F. D. Additional Observations On 5/9/17 at 9:05 a.m., room 11 sink water temp was taken with a thermometer, which indicated a temperature of 131.1 F and verified by activity assistant #13. On 5/16/17 at 11:01 a.m. room 11 sink water temp was taken with a thermometer, which indicated a temperature of 117 F. E. Record review Water temperature log sheets dated 5/9, 5/10, 5/11, 5/12, and 5/15/17 were provided with date, time, room numbers and varying temps ranging from 62 F up to 114.9 F. There was one time the temp was 137 F in room 11 on 5/9/17 at 10:00 a.m. A Service Invoice dated 5/11/17 was provided recording the work provided by a local plumbing company. Computerized Test and log hot water temperatures were provided for 1/31 through 5/8/17 for various, ECU and Summit areas. The log revealed 14 rooms were randomly selected and water temperatures tested weekly. -On 5/8/17 temps ranged for 14 rooms from one room at 103 F, one room at 108 F, one room at 111 F, four rooms at 113 F and seven rooms at 114 F. -On 5/3/17 temps ranged for 14 rooms from 12 rooms at 107 F and two rooms at 108 F. -On 4/26/17 temps ranged for 14 rooms from 11 rooms at 107 F and three rooms at 108 F. -On 4/17/17 through 1/31/17 the 14 rooms ranged from 106 F one time one room and 109 F one time one room. -The other logs revealed documented temps were 107 F and 108 F. On 5/17/17 at 5:55 p.m. the maintenance supervisor provided updated water temp log sheets for the following rooms, checked on 5/17/17: At 11:43 a.m. Room 53 - 114.8 F At 11:45 a.m. Room 57 - 114.2 F At 12:01 p.m. Room 42 - 109.2 F At 12:11 p.m. Room 7 - 114.8 F At 12:12 p.m. Room 11 - 108.4 F At 12:14 p.m. Room 12 - 113.7 F At 12:15 p.m. Room 14 - 112.4 F At 12:16 p.m. Room 24 - 114.2 F At 5:20 p.m. Room 10 - 113.8 F F. Staff Interviews On 5/9/17 at 9:05 a.m. the maintenance supervisor was interviewed and notified of the hot water temperatures above. He said he used a thermometer from the kitchen to measure the water temps because he did not have one. At 9:25 a.m. he brought a digital thermometer from the kitchen and the thermometer measured 135.7 F and 134.9 F in room 11. He said he had noticed the last couple of days there was a problem with the water and yesterday the water temps were really low so he had called the plumber. The plumber came in yesterday and they went through the system. We figured out the thermostats are built up in the machines and so we had to order some new ones from Denver. The plumber thought the water temps issue is due to the fact with the snow no longer on the roof and the thermostats had went into overtime and they were not shutting off, which resulted in the water temps staying hot. The water temps are checked once a week and then I input them into the computer. On 5/10/17 at 10:40 a.m. the district director of clinical services was interviewed and said the thermostats were bad, and that two of them were overnighted from Denver and should be here today. The staff was complaining the water was too cool so they turned the other tank on and then maintenance ran out and turned both tanks off and put a lock on them. The maintenance supervisor will be checking the switches and water temps every hour. The staff will be doing assessments on each resident to make sure no burns have occurred. The environmental tour was conducted on 5/17/17 at 9:00 a.m. with the nursing home administrator (NHA), maintenance supervisor, assistant supervisor, and the housekeeping manager. The above findings were observed and discussed during the environmental tour. The NHA, maintenance supervisor, assistant supervisor, and the housekeeping manager confirmed and acknowledged the findings. They said the areas of concern that were discussed would be addressed and monitored. IV. Chemical Storage A. Facility Policy The facility's policy and procedure titled, Hazardous Materials Management Plan, last revised October 2013, was reviewed and documented the following: The facility maintains an inventory of hazardous chemicals in the workplace .Facility trains all employees, including supervisors, and informs vendor employees/contractors .on controlled materials and the Globally Harmonized Labeling and Classification System, including .Handling and storage .Supervisors and Administrators conduct a periodic job hazard analysis on non-routine tasks to determine chemical or other hazards . B. Observations On 5/9/17 at 5:33 p.m., an unlabeled door with a key pad was unlocked and able to be pushed open on the extended care unit. It was the bath/shower room located on the west wing of the building and there were no staff present. (Cross-reference F441) The following was observed: -A pair of sharp scissors located in an unlocked metal cabinet -AIRX 75 Antibacterial Heavy Duty Cleaner and Odor Counteractant one-quart bottle x two, which included the warning: Keep out of reach of children; Caution. -Two packages of personal disposable razors; one package with 10, and one package with five -One tub of extra-large CaviWipes cleansing cloths, one pound 15 ounces, which included the warning: Keep out of reach of children. -A second door to the room was noted to have a sign that read: For the safety of our residents please keep door closed. On 5/16/17 at 5:32 p.m., the unlabeled door with the key pad to the bath/shower room was again unlocked and there were no staff present. The same items listed above were still in the room and accessible to anyone who passed by it. On 5/8/17 at 10:20 a.m., the kitchenette near the progressive care unit was inspected. The cupboard below the counter top was observed to have a 32-fluid ounce spray bottle with the label One Up Mega-Buff Gloss Restorer and Remoisturizer. The cupboard door was not locked and was accessible to anyone who passed it. The spray bottle was still there on 5/16/17 at 8:11 a.m. C. Record Review The Material Safety Data Sheet (MSDS) for CaviWipes, prepared 7/14/15, documented the following: Harmful if absorbed through the skin. Inhalation of concentrated vapors may cause irritation of the eyes, nose and throat and dizziness and drowsiness. Prolonged overexposure to ethylene glycol monobutyl ether may affect liver, kidneys, blood, lymphatic system or central nervous system. The MSDS for AIRX, prepared 9/20/05, documented the following: Prolonged or repeated contact of concentrated product with eyes may cause irritation and reddening. Ingestion of this product may cause exposed person to vomit and may result in some diarrhea. D. Staff Interviews The director of nurses (DON) was interviewed on 5/17/17 at 5:15 p.m. and she confirmed that all chemicals should be locked up and stored safely when not in use.

Based on record review, family interview and staff interviews, the facility failed to ensure one (#5) of 16 sample residents was free from unnecessary drugs. Specifically, the facility failed to: -Assess and identify the root cause of the resident's behavioral symptoms; -Assess the effectiveness of the anti-psychotic/anti-anxiety medications provided for resident #5; -Document and monitor behaviors and medication side effects; -Obtain a physician order before administering [MEDICATION NAME] for resident #5; and -Consistently document [MEDICATION NAME] administration. The failures contributed to decline in the resident's condition and hospitalization in an acute behavioral facility. The findings included: I. Facility Standard According to the [MEDICAL CONDITION] management policy provided by the director of nurses (DON) on 12/13/16 at 2:48 p.m., revised 2/11, An unnecessary drug is any drug when used: in excessive dose .without adequate monitoring . II. Professional References According to the 2014 Saunders Nursing Drug Handbook: -[MEDICATION NAME], an antipsychotic medication, has the following black box alert: Elderly with dementia related [MEDICAL CONDITION] are at increased risk for death. Caution should be taken for diabetes. Side effects include frequent drowsiness and dizziness. -[MEDICATION NAME] ([MEDICATION NAME]), an anti-anxiety, sedative-hypnotic medication, recommends caution for depression. Frequent side effects include drowsiness and dizziness. Considerations for the elderly include, Use small initial doses with gradual increases to avoid ataxia, excessive sedation. Dosage: Elderly: 0.5-1mg (milligram)/ day. May increase gradually. Range 0.5-4mg. -[MEDICATION NAME] ([MEDICATION NAME]), an antidepressant medication, has side effects including drowsiness and dizziness. -[MEDICATION NAME], a narcotic [MEDICATION NAME], has side effects including, Those not in severe pain may experience dizziness, nausea, vomiting, [MEDICAL CONDITION]. III. Resident Status Resident #5, age 72, was admitted on [DATE] and discharged on [DATE]. According to the 11/16 Medication Administration Record [REDACTED]. According to the 10/23/16 admission minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of one out of 15. She required limited assistance with dressing and personal hygiene. She was independent for transfers, toilet use, and walking in her room and in the corridor. She required supervision/setup for locomotion on and off the unit. No mood or behavior symptoms were identified. No pain symptoms were identified. She received antipsychotic and antianxiety medications during the last seven days. No antidepressant was noted. The care area for [MEDICAL CONDITION] drug use was triggered for a care planning decision. Record review and interviews revealed the resident was admitted into the facility from her home through adult protective services after her husband was hospitalized with a stroke. He was her primary care giver. On admission, the resident was on aspirin, [MEDICATION NAME] (oral diabetic medication), [MEDICATION NAME] (antihypertensive), [MEDICATION NAME] (antidepressant) and [MEDICATION NAME] (antihypertensive). Although the resident had been administered [MEDICATION NAME] in the hospital in response to behaviors, a hospital progress note, dated 10/15/16, from the resident's physician read the physician wished to avoid initiating antipsychotic on admission to the facility. Record review further revealed the following information regarding the resident's stay: -The facility documented the resident was pleasant with dementia, resulting in some agitation and confusion. She was able to talk with staff and she was able to complete some independent activities of daily living such as combing her hair. According to staff, she was upset and was taken to see her husband. According to the social services assessment note, dated 10/19/16, the resident had no hallucinations or delusions. -While at the facility, the resident would get anxious and had some loss of consciousness. Several episodes occurred at the facility. When the resident was unconscious for a longer period of time, about 14 minutes, the facility sent her to the hospital on [DATE]. Her [MEDICATION NAME] was decreased on return to the facility. -The resident's husband passed away 10/16/16. This resulted in increased behaviors with more exit seeking. She was started on [MEDICATION NAME] ([MEDICATION NAME]) on 10/20/16 and [MEDICATION NAME] on 10/24/16. -The resident's behaviors continued to increase, and included tearfulness, agitation, hallucinations, fear and anger. She was combative with staff and was observed dragging furniture. Staff observed her behaviors increased after the [MEDICATION NAME] was given; however, [MEDICATION NAME] was increased every two to nine days to a maximum order of [MEDICATION NAME] 2mg every four hours, scheduled. The nursing staff documented waking up the resident to give her the medication. [MEDICATION NAME] was increased on 11/9/16 and the last medication change was completed on 11/12/16 after the on-call physician discontinued [MEDICATION NAME] and increased the [MEDICATION NAME]. She was transported out of the facility in an unconscious state on 11/15/16. -Throughout her time at the facility, the resident was receiving [MEDICATION NAME] for pain without a physician order for [REDACTED]. III. Facility Failures A. Failure to develop a comprehensive care plan The care plan, initiated 11/1/16, identified the resident was difficult to redirect when attempting to leave. Becomes very angry and combative, striking staff with hands or any object within reach. Intervention included: Offer activities, food or drink; Resident had demonstrated [MEDICAL CONDITION] behaviors to get her way. Protect from harm until she arouses; Use medication prescribed by physician for resident's safety. There was no care plan regarding the resident's behavioral symptoms and staff attempts to understand the resident and meet her needs, the root cause of the resident's behaviors, and detailed non-pharmacological interventions. There was no specific care plan related to anti-psychotic medication use, although [MEDICATION NAME] and [MEDICATION NAME] were started shortly after the resident's admission. B. Failure to acquire a physician order for [REDACTED].>1. Physician Orders According to the 11/16 medication review report, physician orders included: -10/24/16: [MEDICATION NAME] tablet 50mg; Give one tablet by mouth at bedtime for agitation, anger, combative, threatening staff and residents. -10/27/16: [MEDICATION NAME] concentrate 2mg/ml (milliliter); Give 0.5ml by mouth every one hour as needed (PRN) for anxiety/panic/agitation. -10/10/16: [MEDICATION NAME] HCL ([MEDICATION NAME]) tablet 100mg; Give one tablet by mouth one time a day for depression. The above orders were signed by the physician on 11/10/16. [MEDICATION NAME] was not on the medication review report. 2. Medication Administration Records (MARs) MAR review [REDACTED] Although there was no physician order for [REDACTED]. -[MEDICATION NAME] was given eight times in November 2016 per the MAR. -There was no documentation of [MEDICATION NAME] on the October MAR. However, the narcotic sheet documented the resident was receiving [MEDICATION NAME] in October and November. 3. Hospital documentation See above; the resident was transferred to the hospital on [DATE] when she was unconscious for about 14 minutes. The 10/15/16 hospital transfer orders did not have [MEDICATION NAME] listed. C. Failure to identify resident needs, assess root cause of resident behaviors, develop nonpharmacological interventions, and identify adverse effects of medications before adding and increasing medications 1. Review of the resident's MARs revealed [MEDICAL CONDITION] medications were added and increased as follows: [MEDICATION NAME] -Order date- 10/24/16; Discontinue date- 11/9/16: [MEDICATION NAME] tablet 50mg; Give one tablet by mouth at bedtime. -Order date- 11/9/16; Discontinue date- 11/12/16: [MEDICATION NAME] tablet 50mg; Give one tablet by mouth two times a day. (Increased) [MEDICATION NAME] -Order date- 10/20/16; Discontinue date- 10/25/16; [MEDICATION NAME] concentrate 2mg/ml; Give 0.25ml by mouth every 12 hours as needed. -Order date- 10/25/16; Discontinue date- 10/27/16; [MEDICATION NAME] concentrate 2mg/ml; Give 0.5ml by mouth every 5 hours as needed. -Order date- 10/27/16; Discontinue date- 11/3/16: [MEDICATION NAME] concentrate 2 mg/ml; Give 0.5ml by mouth every one-hour PRN. -Order date- 11/3/16; Discontinue date- 11/12/16: [MEDICATION NAME] tablet 1mg; Give one tablet by mouth four times a day (QID). (Actual order: 11/3/16: [MEDICATION NAME] 0.5mg oral tablet, one tablet by mouth 4 times a day for anxiety and agitation) -Order date- 11/12/16; Discontinue date- 11/12/16: [MEDICATION NAME] tablet 1mg; Give one tablet by mouth every four hours. -Order date- 11/12/16: [MEDICATION NAME] tablet 2mg; Give one tablet by mouth every four hours. [MEDICATION NAME] ([MEDICATION NAME]) -Order start 10/10/16: [MEDICATION NAME] HCL tablet 100mg; Give one tablet by mouth one time a day for depression. [MEDICATION NAME] (see administrations above) 2. According to the nursing facility progress notes, the resident became anxious, fearful, confused, sad, and combative after admission. There was no evidence in the progress notes and nursing daily skilled charting that staff attempted to identify the needs the resident was expressing, to develop nonpharmacological resident-specific interventions, or consider adverse effects of medications before adding and increasing medications Progress notes: 10/10/16: Resident arrived from home .She was upset on arrival, but calmed after some conversation with the social worker .She was in good spirits . 10/13/16: Resident is pleasant but confused. 10/14/16: Unresponsive on bed in supine position. Arouses to touch and voice after 2 minutes. Becomes anxious and unresponsive again. In and out of consciousness over a period of 15 minutes .Arouses once again and then unresponsive greater than 7 minutes. This nurse returned to room to find resident on floor, unresponsive, resting on left side .Paramedics present. 10/14/16: Orders: [MEDICATION NAME] tablet 100mg; Give tablet one tablet by mouth two times a day for hypertension. 10/15/16: Order: [MEDICATION NAME] tablet 50mg; Give tablet one tablet by mouth two times a day for hypertension. (Order change from the hospital) 10/17/16: She is a pleasant woman with significant dementia at times that can put her in a state of agitation and confusion. 10/21/16: Orders: [MEDICATION NAME] concentrate 2mg/ml; Give 0.25ml by mouth every 12 hours as needed. 10/22/16: Behaviors- resident got upset this morning (AM), that she could not see her husband that passed last Sunday. Started to run to every door to get out. She did get out . 10/24/16: Agitated, angry, combative, assaulting staff, exit seeking. 10/25/16: Anxious, worried, wants to leave. 10/26/16: Anxious, agitated, packing to leave. 10/27/16 at 13:22: Gradual dose reduction (GDR)- [MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME]). Will monitor trying to place resident in a secure unit. 10/27/16 at 14:18: Calm, walks with nurse holding hands. Denies pain. States she is bored. No evidence of pain or anxiety at this time. 10/27/16 at 15:50: Resident is tearful and stated feels sad and helpless. [MEDICATION NAME] 0.5ml order of tears and personal anxiety. 10/29/16: Orders: [MEDICATION NAME] 2mg/ml; Give 0.5ml by mouth every one hour as needed. 10/30/16: Anxious, agitated, packing up to leave. 11/1/16: Anxious, tearful, agitated, pacing, packing up, exit seeking. 11/2/16: Order: Aspirin tablet 81mg; Give one tablet by mouth one time a day for anticoagulation. 11/3/16 at 0045: Pacing. 11/3/16 at 08:08: Order: [MEDICATION NAME] HCL concentrate 10mg/0.5ml; Give 0.5ml by mouth every one hour as needed for pain- moderate; pain-severe. Hip and knee pain. 11/3/16 at 09:16: The system has identified a possible drug allergy for the following order: [MEDICATION NAME] HCI concentrate 10mg/0.5ml. (Allergy in chart: [MEDICATION NAME]) 11/8/16: Woke resident up for 0000 scheduled [MEDICATION NAME] ([MEDICATION NAME]) and went back to bed. Later came down hall, unable to say what she needed. Redirected back to bed. Throughout shift resident was awake and out in common area. Gave scheduled doses of [MEDICATION NAME] without any effect. Towards morning became weepy and exit seeking. Will monitor. 11/11/16 at 16:47: Writer has spoken with guardian and has begun process for referral to .behavioral health. 11/11/16 at 19:25: Hallucinations: This nurse has noticed that each evening times two that resident has responded to the [MEDICATION NAME] with tears, fear, hallucinations and anger. (See nurse interview below) 11/11/16 at 21:02: Continues angry, hallucinating, laying on the floor then up again more than 35 times over a period of three hours. Ambulates in the hall and around the outside of the building with this nurse. Takes offense when touched or redirected. Verbal outburst, small shoving. 11/12/16 at 11:38: Resident's behaviors have increased; called into medical doctor (MD). The on call doctor discontinued the [MEDICATION NAME] thinking this may be the cause on increased agitation and changed the [MEDICATION NAME] ([MEDICATION NAME]) to 2mg every 4 hours and take the first dose now and call after one hour if the behaviors continue. Order to send to .behavioral health. 11/12/16 at 12:33: The system has identified this order as being outside of the recommended dose for this drug. [MEDICATION NAME] tablet 2mg; Give one tablet by mouth every 4 hours for agitation. 11/12/16 at 13:02: Resident continues to have behaviors. Call back to doctor. He ordered to give another dose of 2mg [MEDICATION NAME] now and that with this type of agitation, this is only a small dose and if she continues call him back. 11/14/16 at 00:27: Resident sleeping soundly. 11/14/16 at 03:14: Resident awake and wondering hallways and lobby. At times will just lay down on floor and the get up. Finally fell asleep at around 0030. Slept until 0300. Awake and restless. Will give scheduled [MEDICATION NAME]. 11/14/16 at 07:20: Resident is lethargic and tired. 11/15/16 at 07:02: Have been awaiting [MEDICATION NAME] to be delivered. [MEDICATION NAME] 0.25ml/ml given 2x this shift for generalized pain. This did help resident to where she could sleep approximately 3 hours. 11/15/16 at 13:55: Resident went via ambulance transport to .behavioral health. Sent all belonging and one 2mg [MEDICATION NAME]. Time left 1300. Daily skilled charting: According to the nursing daily skilled charting, dated 10/11/16: -Mood/Behavior: Wanders -Pain: No pain marked; Does resident have sleep issues related to pain? No. According to the nursing daily skilled charting, dated 10/12/16: -Mood/Behavior: Angry -Pain: No pain marked According to the nursing daily skilled charting, dated 10/14/16: -Mood/Behavior: Sad, resistive to care, disorganized thinking, wanders -Pain: No pain marked D. Failure to track behaviors and identify increased behaviors with increase in [MEDICATION NAME] According to the pharmacist consultation report dated 10/25/16, Behavior monitoring documentation appears to not be maintained completely . missing the following items: behavior monitoring sheets missing for [MEDICATION NAME] and [MEDICATION NAME] use. The narcotic sheets and the behavior tracking sheets were reviewed showing an increase in behaviors corresponding with the increase in [MEDICATION NAME] dosages. According to the behavior tracking sheets and the narcotic sheets: Order: [MEDICATION NAME] concentrate 2mg/ml; give 0.25ml by mouth every 12 hours as needed from 10/20/16 through 10/25/16. -10/20/16: 0600: 0.5ml given -10/21/16: 0630: 0.5ml given -10/22/16: 0800: 0.5ml given -10/23/16: NONE -10/24/16: 0800: 0.5ml given; 1750: 0.5ml given -10/25/16: 0.5ml given; 0900: 0.5ml given; 1520: 0.5ml given Order: [MEDICATION NAME] concentrate 2mg/ml: Give 0.5ml by mouth every 5 hours as needed from 10/25/16 through 10/27/16. -10/26/16: 1100: 0.5ml given; 1230: 0.5ml given; 1845: 0.5ml given (2 behavior episodes) -10/27/16: 1120: 0.5ml given; 1545: 0.5ml given (1 behavior episode) Order: [MEDICATION NAME] concentrate 2mg/ml; Give 0.5ml by mouth every hour as needed from 10/27/16 through 11/3/16. -10/28/16: 0830: 0.5ml given -10/29/16: 0700: 0.5ml given; 1720: 0.5ml given -10/30/16: 0700: 0.5ml given; 1100: 0.5ml given; 1850: 0.5ml given -10/31/16: 0700: 0.5ml given; 0900: 0.5ml given; 1100: 0.5ml given -11/1/16: 0700: 0.5ml given; 1740: 0.5ml given (3 behavior episodes) -11/2/16: 0700: 0.5ml given; 1340: 0.5ml given (2 behavior episodes) -11/3/16: 0045: 0.5ml given; 0545: 0.5ml given; 0830: 0.5ml given; 1800: 0.5ml given (6 behavior episodes) Order: [MEDICATION NAME] tablet 1mg; Give one tablet by mouth four times a day from 11/3/16 through 11/12/16. (The narcotic sheet has 0.5mg four times a day) -11/4/16: 0545: 0.5ml given; 1200: 0.5mg given; 1800: 0.5ml given; 2100: 0.5ml given (7+ behavior episodes) -11/5/16: 0000: 0.5mg given; 0600: 0.5mg given; 1200: 0.5mg given; 1800: 0.5mg given (8 behavior episodes) -11/6/16: 0000: 0.5mg given; 0600: 0.5mg given; 1200: 0.5mg given; 1800: 0.5mg given (7 behavior episodes) -11/7/16: 0000: 0.5mg given; 0600: 0.5mg given; 1200: 0.5mg given; 1800: 0.5mg given (8 behavior episodes) -11/8/16: 0000: 0.5mg given; 0600: 0.5mg given; 1200: 0.5mg given; ;1800: 0.5mg given (5+ behavior episodes) -11/9/16: 0000: 0.5mg given; 0600: 0.5mg given; 1200: 0.5mg given; 1800: 0.5mg given (9+ behavior episodes) -11/10/16: 0000: 0.5mg given; 0600: 0.5mg given; 1200: 0.5mg given; 1900: 0.5mg given (15 behavior episodes) -11/11/16: 0000: 0.5mg given; 0600: 0.5mg given; 1200: 0.5mg given; 1830: 0.5mg given (58 behavior episodes) -11/12/16: 0000: 0.5mg given; Order: [MEDICATION NAME] tablet 2mg; Give one tablet by mouth every four hours from 11/12/16. -11/12/16: 1630: 0.5mg; 1130: 0.5mg x4 given; 1300: 0.5mg x4 given; 1600: 0.5mg x4 given; 2045: 0.5mg x4 given (4 behavior episodes) -11/13/16: 0000: 0.5mg x4 given; 1200: 0.5mg x4 given; 1600: 0.5mg x4 given (many behaviors) -11/14/16: (4+ behavior episodes) According to the narcotic sheet for [MEDICATION NAME]: 10/22/16: 0.25 ml given 10/25/16: 0.25 ml given No date: 0.25 ml given 11/2/16: 0.25 ml given 11/3/16: 0.25 ml given 11/6/16: 0.25ml given 11/8/16: 1630: 0.25 ml given; 2330: 0.25 ml given 11/9/16: 0900: 0.25 ml given; 1100: 0.25 ml given 11/11/16: 0900: 0.25 ml given; 2200: 0.25 ml given 11/12/16: 0.25 ml given 11/13/16: 0.25 ml given 11/14/16: 0300: 0.25 ml given; 0620: 0.25 ml given; 0830: 0.25 ml given; 1100: 0.25 ml given; 2315: 0.25 ml given. 11/15/16: 0.25 ml given (There was no physician order in the chart for the [MEDICATION NAME]) IV. Staff Interviews Staff interviews confirmed the resident's condition declined after admission and with the administration of certain [MEDICAL CONDITION] medications. The registered nurse (RN) #1 was interviewed on 12/8/16 at 2:47 p.m. She said resident #5 was changing. When she first came in, she looked and talked normal. She did not enter the building on [MEDICATION NAME] or [MEDICATION NAME]. They started after she had behaviors. She came in with a total of five to six medications. She developed panic attacks and would lose consciousness. When she was out for about 14 minutes, they sent her out. She was admitted to the nursing facility as normal and left (with psychiatric symptoms). She appeared to be having a paradoxical effect with the medications. The more [MEDICATION NAME] she was given, the more behaviors she had. She talked to her boss and her co-workers about it. She wrote a fax to the doctor. He discontinued the [MEDICATION NAME] and increased the [MEDICATION NAME]. He thought her behaviors may have been coming from the [MEDICATION NAME]. She got worse every time she was given the [MEDICATION NAME]. Within 30 minutes of giving the [MEDICATION NAME], her behaviors accelerated. It was a chemical restraint.I thought the medication was appropriate before the paradoxical effect . The woman who left here was a different person. Social worker #13 was interviewed on 12/8/16 at 3:20 p.m. She said when the resident was first admitted , she dressed herself and did her own hair. She said she did not have a lot to do with the medications but she questioned them a lot. She said the resident was more confused with the medications; that morning on the day the resident was discharged , she saw the resident and she could tell she was heavily medicated. She was not talking. She was non-responsive when they got her over to the behavior health center. Her behaviors were strong when her husband passed away. She was delusional three to four days before transport. She felt they had her on the wrong medications. She said she was not aware of any [MEDICAL CONDITION] meetings. They would go through medication changes in the mornings. When the resident first came in, she was happily confused. She was talking and she wanted to engage. She was more delusional after her husband's death and with the medications. By the time she left, she stopped dressing herself. The assistant director of nurses (ADON) was interviewed on 12/9/16 at 10:56 a.m. She said this resident was confused when she got here. After her husband passed away, she was exit seeking more often. She would sometimes faint. She did that at home, so it was nothing new. The medical director was interviewed on 12/9/16 at 12:15 p.m. He said there needed to be an order for [REDACTED]. The director of nurses (DON) was interviewed on 12/9/16 at 12:50 p.m. She said she knew the [MEDICATION NAME] was up and down. She knew general information about the resident. She said she was not aware the resident's behaviors increased after [MEDICATION NAME] was given. It was not on the 24-hour report. She said they did try some non-pharmacological approaches such as one-on-ones, activities and listening to music. V. Family Interview The family of resident #5 was interviewed on 12/7/16 at 11:50 a.m. The family said this resident was unresponsive when she arrived to the behavioral health facility on 11/15/16. She really needed a secure unit. The facility thought they could manage her with medications. The resident became so out of it. She was having an adverse effect from the medications. They decided it was not working and sent her out to behavioral health. She never did recover. The resident passed away 11/30/16.

Based on resident and staff interviews and record review, the facility failed to have evidence that all allegations of abuse and mistreatment involving three of 49 sample residents (#61, #85 and #159) were thoroughly investigated, timely reported, and steps were taken to protect these residents and other facility residents from further abuse and mistreatment. During an interview on 6/1/16 at 11:36 a.m., resident #61 reported that certified nurse aides (CNAs) #21 and #33 were verbally and physically rough with her and grabbed her arm during transfers. The resident said she had reported this to her ambassador, the Minimum Data Set (MDS) coordinator, a long time ago. She said they had been rough with her for approximately six months. During an interview on 6/1/16 at 11:46 a.m., resident #85 reported that CNA #21 and #33 had verbally abused him, were really nasty to him, pointed their fingers at him and ordered him around, refused to change him when he was incontinent at night, made him walk to the bathroom and told him to clean himself up, and yelled at him. He said their behavior was demeaning, felt threatening, and made him feel like less than a man. The resident said he had reported this to CNA #1 within the past week, and CNA #1 said she would take care of it. On the morning (time not documented) of 6/5/16, resident #159 reported to the facility that registered nurse (RN) #39 had been verbally abusive and gestured that she intended to strike him. During an interview on 6/6/16 at 1:45 p.m. resident #159 said, (RN #39) raised her hand to me as if she was going to hit me. The above incidents were determined by the facility to be unsubstantiated. However, record review and interviews revealed none of the above incidents was thoroughly investigated and CNA #21, #33 and RN #39 were allowed to return to work following brief suspensions without evidence of training, counseling and a supervision plan. Moreover, although residents #61 and #85 had reported allegations of staff mistreatment to other facility staff, their allegations were not reported to the Nursing Home Administrator (NHA) or Director of Nurses (DON). The facility's failures created a situation for residents of immediate jeopardy with the potential for serious harm. The findings included: I. Imposition of Immediate Jeopardy On 6/17/16 at 5:05 p.m., the NHA and DON were informed by the Colorado Department of Public Health and Environment (CDPHE) that the facility's failures in investigating, reporting and resident protection during allegations of abuse/mistreatment left facility residents vulnerable to further abuse and created a situation of immediate jeopardy for potential serious harm. II. Facility Response and Removal of the Immediate Jeopardy. On 6/17/16 at 7:22 p.m., an interim plan was submitted by the facility to CDPHE. It read: (RN #39) will not be working the weekend of 6/18 and 6/19 or 6/20/2016. -(CNA #33) is off work until Monday night when she is to return. -(CNA #21) is not working 6/17-19th of June. On 6/20/16 at 4:42 p.m., a plan was submitted by the facility to CDPHE. It read: Effective immediately, the RN is not working June 17. 18, or 19, first Night RCS is off work until 6/20/2016, second Night RCS is off until 6/20/2016. - Staff members have received appropriate disciplinary action and further education around facilities abuse policy. - Ongoing, staff members will be monitored by DON/Designee during shifts worked to ensure staff is providing care in a professional and dignified manner. QA Committee to meet weekly for one month and then monthly for 3 months and then quarterly or as needed to ensure plan remains effective. - The NHA and DON attended the state abuse training in Denver, CO on June 9, 2016. - Staff currently working at San Juan Living center received in-servicing on 6/05/16 that when they see, hear or are made aware of an allegation of abuse or neglect or any resident concern around safety and or fear, they are to first make sure all residents are safe in any situation then report to the administrator. Remaining staff not in-serviced on 6/5/2016 will be in-serviced on the same process before they work another shift. - The District Clinical Director interviewed the three identified residents on 6/20/16 about their concerns. All three residents denied having received care from the persons that their allegations were pertaining to, since the reporting of the incidents. All three residents denied having been treated disrespectful, rudely, of roughly in any way since their allegation. Each resident stated to the District clinical director that they feel safe, and are not fearful, or intimidated by anyone at the facility. The administrator and or designee will review concern forms, 24 hour report and the clinical dashboard in Point Click Care in each morning meeting to identify any potential resident concerns or statements in which abuse may be perceived. - The administrator will bring all abuse related concerns to QA weekly for one month then monthly for 3 months and then quarterly or as needed to review all outcomes and applicable action plans. On 6/20/16 at 4:45 p.m., the NHA, DON and two corporate consultants were notified that the above plan was accepted and the immediate jeopardy was removed effective 6/17/16 at 7:22 p.m. However, based on interviews and record review, deficient practice remained at an E level, a pattern with the potential for more than minimal harm. III. Expectations According to the abuse and neglect prohibition policy provided by the DON on 6/7/16 at 9:39 a.m., revised on 6/2013, Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin and misappropriation of property .The facility will conduct an investigation of any alleged abuse/neglect . in accordance with state law. Any employee alleged to be involved in an instance of abuse and /or neglect will be suspended immediately and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated . The facility will investigate all patterns, trends, or incidents that suggest the presence of abuse, neglect . The facility will protect the residents from harm during the investigation. IV. Allegations of Abuse - Reporting and Investigation Failures A. Resident #61 Resident #61, age 57, was admitted on [DATE]. According to the 6/16 medication review report, [DIAGNOSES REDACTED]. According to the 5/2/16 annual minimum data sheet (MDS) assessment, the resident had intact cognition with a brief interview for mental status (BIMS) score of 15 out of 15. The resident mood interview revealed a score of zero. Behaviors were not exhibited. The resident's care plan, initiated 10/20/14 and revised 5/17/16, identified a behavior problem related to personality disorder. Interventions included: Approach in a calm manner to discuss . concerns. Listen to find a solution . 1. Resident Interviews Resident #61 was interviewed a number of times to clarify and confirm her allegations involving CNA #21 and #33. The resident alleged she had reported the staff's abuse/mistreatment to facility staff. Resident #61 was interviewed on 6/1/16 at 11:36 a.m. She said two certified nurse aides (CNAs #21 and #33) were rough with her. They are not going to be gentle with me. She said she told her ambassador a long time ago. (This incident was reported to the NHA after the resident interview, early afternoon of 6/1/16.) Resident #61 was interviewed a second time on 6/2/16 at 10:00 a.m. She said CNA #21 and #33 worked last night. Only the nurse was allowed in her room. That was the best night sleep. She said when the two CNAs cared for her they were rough when she was not moving fast enough for them. One of the CNAs had grabbed her arm and said come on, you need to do this now. She said they had been rough for approximately six months. Resident #61 was interviewed a third time on 6/7/16 at 2:07 p.m. She said CNA #33 and CNA #21 needed re-training on how to take care of people. The resident said when she got ready for bed, it was sometimes after 10:00 p.m. and the CNAs would grab her arm and tell her that she had to learn to move faster, or they would say she could move faster than she was moving. The resident said she had reported her concerns to her ambassador/MDS coordinator, who took the concerns to a morning meeting and tried to have the situation rectified. She said the CNAs were no longer allowed in her room without a nurse being present to supervise what they were doing. 2. Staff Interviews Interviews revealed staff failed to report the resident's allegations to the NHA and/or DON, to ensure the allegations were seriously considered, and to ensure a timely and thorough investigation was conducted. a. NHA The NHA was interviewed several times, with and without the RN corporate consultant, about the investigation of resident #61's allegations. The NHA was interviewed on 6/2/16 at 7:45 a.m. She said they stayed up until 10:00 p.m. last night to investigate resident #61's allegations. (See above; the resident's allegations were reported to the NHA in the early afternoon of 6/1/16.) The NHA said they educated the staff and split up CNA #21 and #33 who continued to work in the building on the night shift. The NHA was interviewed on 6/2/16 at 12:10 p.m. She clarified the two CNAs had been suspended following the allegation, but when it was determined resident #61's allegations could not be substantiated, the CNAs worked the night shift starting at 10:00 p.m. The NHA said the CNAs were suspended again the next day, however, when an incident involving the same two CNAs was reported by another resident (on different hall). The NHA explained only residents on the one hall where resident #61 resided had been interviewed on 6/1/16. She said they now understood they needed to interview everybody. The RN corporate consultant #31 and the NHA were interviewed on 6/2/16 at 1:13 p.m. The NHA said she felt like the investigation of resident #61's allegations of abuse had been thorough, stating they interviewed ten residents on that resident's hall. She felt like her investigation regarding resident #61 was finished so the CNAs, suspended upon notification of the allegation early afternoon on 6/1/16, were brought back for the night shift 6/1/16. She said that was her mistake and they were doing more interviews. When asked if she should have included all residents under the care of the two CNAs, she said Yes. On night shift 6/1/16, they were assigned to the whole facility. Not just that one hall. The NHA was interviewed a third time on 6/2/16 at 2:50 p.m. She confirmed they needed a new system in place to ensure the allegations were thoroughly investigated. The RN corporate consultant #31, the DON and the NHA were interviewed again on 6/7/16 at 5:38 p.m. about their investigation of resident #61's abuse allegations. They said the CNA #21 and #33 always worked on all four halls. They explained they had 'unsubstantiated' resident #61's allegations of abuse/mistreatment because resident #61 disliked the CNAs and she had a clear skin check. Further,the investigation revealed the resident did not want to be woken up at night. They said moving forward, resident #61's care would be provided by the nurse and other CNAs. b. DON The DON was interviewed on 6/7/16 at 2:44 p.m. She said resident #61 visited with her ambassador daily and would tell her things sometimes. She said they (administrative staff) had not heard anything about CNA #21 and #33 and resident #61. She said resident #61 had tried to get staff into trouble in the past and said, She can be unpleasant with staff. She said the two CNAs told her they would change the resident quickly without disturbing her sleep. c. Ambassador/MDS coordinator The ambassador/MDS coordinator #24 was interviewed on 6/7/16 at 3:41 p.m. She said resident #61 had told her about her interactions with CNA #21 and #33 a couple of times. One time, the resident said she was just complaining and no concern form was written up, but it was brought up in morning meeting. Another time, just before survey, the resident said the staff was rough with her when putting her to bed. I wrote it up on a concern form.She said that was the only time the resident had presented it to her as serious. She said she knew this resident very well; she said the resident exaggerates and is easily triggered, characteristics that are noted in the resident's care plan. 4. Record Review a. A concern form was provided by the MDS coordinator on 6/7/16 at 4:30 p.m.: -Date concern came to your attention: 6/1/16 -Date this form was completed: 6/6/16 b. Review of the facility abuse investigation revealed the investigation lacked resident interviews from additional halls under the care of the two CNAs (see resident #85's allegations below). The time the physician was notified was blank. According to the abuse investigation dated 6/1/16, provided by the NHA on 6/2/16 and on 6/6/16: -Date of incident: 6/1/16 -Date investigation initiated: 6/1/16; Time investigation initiated: 1:30 (p.m.) -Staff involved: CNA #33 and CNA #21 -Date suspended: 6/1/16; Time suspended: 2 p.m. -Physician notified; Date: blank; Time: blank -Staff interviewed: nine staff documented -Residents interviewed: ten residents documented (residing on the same hall as complainant) -No allegation was substantiated. The investigation was completed by 9 p.m. 6/1/16. (Interview results present for four staff members and for ten residents, one non-interviewable) c. Progress notes revealed issues with resident #61's cares and interactions with staff during the night (See above; the resident had complained about night staff mistreatment). According to the progress notes: -5/31/16 at 07:14 (7:14 a.m.): Resident in bed at 2200 (10 p.m.). Allowed staff to change and clean and reposition each round. -5/30/16 at 04:42 (4:42 a.m.): Resident in bed at this time. CNAs have attempted to provide incontinence care x4 between 0100 (1 a.m.) and current time. Resident has refused all offers and attempts. -5/25/16 at 04:41 (4:41 a.m.): Awake at 2200 (10 p.m.) until 0400 (4 a.m.). Allowed staff to change brief once even though staff asked if she would like to change again or to go to bed. Agreed at 400 (4 a.m.) to go to bed. Care given and asleep. -5/23/16 at 03:50 (3:50 a.m.): Before going to bed at 0300 (3 a.m.) resident was asked several times if she needed changed or toileted. Resident stated no. Put resident on toilet prior to being put to bed. Rechecked again end of shift. -5/22/16 at 01:49 (1:49 a.m.): Res is up in her wheelchair at this time. CNAs attempted to provide incontinent care and offered to assist resident into bed. Resident refused all care at this time. -5/18/16 at 03:17 (3:17 a.m.): Resident went to bed at 0000 (12 midnight). Was put on toilet then to bed. Rechecked and gave care. -5/17/16 at 04:05 (4:05 a.m.): Resident awake most shift. Staff approached resident to change brief but resident refused. Went to bed at 0245 (2:45 a.m.). Sat on toilet, cleaned and then put to bed. Resident wanting to refuse but did comply. -5/10/16 at 07:09 (7:09 a.m.): Resident was given care with each check and change. Did need to arouse from sleep. Was not happy with being woke up but staff proceeded to give care. B. Resident #85 Resident #85, age 61, was admitted to the facility on [DATE]. According to the face sheet, his [DIAGNOSES REDACTED]. According to the 3/14/16 MDS assessment, the resident was moderately impaired with daily decision making with a brief interview for mental status (BIMS) score of eight out of 15. The resident needed supervision with set up for eating. He required limited assistance of one for transfers and dressing. He required limited to extensive assistance of one for ambulation with his walker or wheelchair. The resident needed extensive assistance of one for bed mobility, personal hygiene, bathing and toileting. The care plan, initiated 10/22/14 and revised on 3/16/16, identified a communication problem related to cognitive changes. The goal read, (PREFERRED NAME) will be able to make basic needs known by (SPECIFY) on a daily basis through the review date. The interventions included: Encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense or responds to the feeling resident is trying to express. Observe/document for physical/nonverbal indicators of discomfort or distress and follow-up as needed. The care plan was not completed or individualized to identify resident-specific needs or approaches. 1. Resident and Staff Interviews The resident, over several interviews, alleged staff verbal abuse/mistreatment and had reported his concerns to facility staff; however, staff failed to report to the NHA and/or DON, to ensure the resident's allegations were seriously considered, and to ensure a thorough investigation was conducted. a. Resident #85 The resident was interviewed on 6/1/16 at 11:46 a.m. The resident said staff in the facility had verbally abused him. He said two night shift CNAs were really nasty to him. He said there were two CNAs with the same first name, and the one he was referring to wore a little hat. He stated this CNA (CNA #33) and the CNA who typically worked with her (CNA #21) had verbally abused him. The resident said he reported this to another CNA (CNA #1) last week or perhaps the week before that (sometime between 5/15/16 and 5/28/16). The resident said he did not want anything to do with either CNA #33 or CNA #21 who were verbally abusive towards him. He said, They're nasty. They point their fingers at me and order me around. Resident #85 said the two CNAs refuse to change him when he is incontinent at night. The resident said the two CNAs tell him to get into the bathroom and clean himself up. He stated they yell, Get up! and make him walk into the bathroom. The resident said that was all he wanted to say about the two CNAs but later said one time he was standing up and holding onto a grab bar in his bathroom and his pants were down around his ankles. He stated he reached out to touch CNA #33 while she was assisting with cleaning him up and CNA #21 yelled out, Don't you dare touch her! The resident said he did not fear either CNA, but they made him feel like less than a man. The resident stated the two CNAs had demeaning personalities. The resident stated that following the incident above, his interactions with the two CNAs did not improve. The resident said, I want them (the two CNAs) to leave me alone. I want them to do no service to me whatsoever. The resident said when the two CNAs worked on his hall, he tried to just ignore them and tried to stay away from them. He stated he needed some extra staff assistance at night with wipes and peri-care after bowel movements and he tried to get help from the evening shift before that shift went off duty; that way, he did not have to deal with either CNA #21 or #33 for his care. The resident stated he had told CNA #1 how CNA #21 and #33 made him feel and CNA #1 told him she would take care of it and talk to someone about the situation. The resident stated that he still saw CNA #33 and CNA #21 every night and reiterated he would rather have someone different taking care of him at night. The resident said CNA #33 told him, I shouldn't have to change you, and threatened to write him up as no longer being independent. The resident stated these comments felt threatening. He stated CNA #33 made him get up and go to the bathroom and refused to assist him with his peri-care and wipes. Resident #85 was interviewed again, in the presence of the NHA and the DON on 6/2/16 at 8:30 a.m. Both the NHA and the DON said this was the first they had heard about resident #85's complaints of abuse, even though the resident said that he told CNA #1 about his concerns three times already. Resident #85 said he was tired of answering the same questions over and over and nothing being done about his complaints. He repeated that CNA #33 refused to change him during night shift and told him that he was too lazy to get up. The resident said his interactions with CNA #33 do not make him feel like a man. The resident acknowledged the DON was his personal ambassador and he had not told her of his complaints of abusive treatment by CNA #21 and #33. b. DON The DON was interviewed on 6/2/16 at 11:30 a.m. The DON stated that following the interview above with resident #85, she had spoken with CNA #1 who admitted resident #85 mentioned to her once that some CNAs were rough with him. CNA #1 told the DON said she told the resident he needed to report his concerns to his ambassador, the DON. The DON stated the CNA should have also told the DON about the resident's concerns so that his issues could go up the chain of command and be thoroughly investigated. When asked about protecting the resident from further abuse, given that CNA #21 and #33 were scheduled to work that night (6/2/16), the DON said she would speak to the NHA. She said on 6/1/16, the facility had been unable to substantiate abuse allegations by another resident (#61), but since resident #85's allegations had been brought to the facility's attention this morning, the plan was to continue to investigate all the allegations of abuse and then seriously discuss what the facility would put into place for the residents' safety from this point and ongoing. c. NHA and RN corporate consultant The NHA was interviewed on 6/2/16 at 11:45 a.m. The NHA said CNA #21 had been on the schedule for that evening, but the NHA had called her, took her off the schedule for the evening, and suspended her for the duration of the abuse investigation. She stated that CNA #33 had not been on the schedule for the evening, but she also was suspended. The NHA said both CNAs had worked the evening/night shift 6/1/16 after being educated and nothing happened to her knowledge. The NHA and the RN corporate consultant were interviewed on 6/2/16 at 1:13 p.m. They said they had interviewed resident #85 and he had identified CNA #21 and #33, denied they verbally abused him, and reported they were rude to him. The corporate consultant said that he felt that the facility had conducted thorough investigations when attempting to rule out staff to resident abuse when it was brought to their attention. The NHA said the facility had interviewed ten residents who resided on resident #85's hall. She said that interviewing only a few residents who resided on only one hall in response to an earlier allegation of abuse by resident #61 was a mistake she made and the facility needed to continue to interview more residents. The corporate consultant said the facility had definitely established a pattern about what the residents were saying about CNA #33 and CNA #21. The NHA acknowledged she had not interviewed any other CNAs, but that she could do it that evening. She stated she was willing to go back and re-investigate the situation and ask some different questions to get to the root of what the perceived abuse with the two CNAs actually involved. The corporate consultant confirmed the facility was suspending CNA #1, as well as CNA #33 and CNA #21. He said the facility would go back and redesign their questions to the residents and staff and keep investigating. The NHA said the facility had just provided education to the staff about abuse on 5/11/16. She said the facility provided that education annually at a minimum, and said that anytime something comes up, the facility tries to in-service and re-educate staff. 2. Record review of the investigation of resident #85's allegations of verbal abuse/mistreatment. The NHA provided records on 6/6/16 at 5:34 p.m. of the facility's investigation of resident #85's allegations of abuse/. Review of these records revealed the facility's investigation was incomplete. The facility failed to interview all residents residing on the same hall with resident #85 who also were provided cares by CNA #33 and #21. In addition, even though his treatment by the two CNAs had been misconstrued by CNA #1, the facility failed to investigate why the resident, in his 6/1/16 interviews, detailed several ways the CNAs had verbally abused and mistreated him. The facility records included: a. A Disciplinary Action Record for CNA #1, dated 6/2/16 and signed by the staff member. The recommended action was a written warning, including suspension/termination. CNA #1's statement read resident #85 had told the CNA that the night shift had said to him, he could do what he needed to do himself. The CNA said she told the nurse, who told her to tell the resident to speak with the NHA or DON. The DON interviewed CNA #1 on 6/2/16 and said resident #85 reported he told CNA #1 the night aides made him stand up and walk to the bathroom. CNA #1 stated the resident never told her he was fearful and the CNA did not feel the resident had indicated the night shift had been abusive. CNA #1 stated that she did report the resident's complaints to licensed practical nurse (LPN) #6. b. An interview with LPN #6 conducted by the DON on 6/2/16 LPN #6 did not recall CNA #1 telling her anything about this situation. c. A Disciplinary Action Record for CNA #33 dated 6/2/16 and signed by the staff member. It stated this was the CNA's second written warning and the staff member was to be suspended pending the abuse investigation. d. A Disciplinary Action Record for CNA #21 dated 6/2/16 and signed by the staff member. It stated the staff member was to be suspended pending the abuse investigation. e. A handwritten summary, provided by the NHA. The summary read in part, (Resident #85) made allegation . that two CNAs made him get up and told him if he could get up and go smoke, then surely he could get up and go to the bathroom . They told him he was lazy and he was upset by their words . Police were notified, physician and ombudsman . All three CNAs were suspended pending investigation. Findings include that (CNA #1) didn't receive clear communication, making it a care issue instead of abuse issue. Training was given to (CNA #1) on abuse training. Spoke with (CNA #33) and (CNA #21) separately and both substantiated that they always went together and they were always polite and not rough. However, (CNA #33) said she did use the word lazy because he could get up to smoke and should be able to go to the bathroom . Conclusion: After a thorough investigation, facility finds the allegation of abuse unsubstantiated. Resident demeanor is to become increasingly agitated when issues arise in his cares to the point of tears and physical signs of anxiety, tachypnea (abnormally rapid breathing) and embracing self . Staff will receive customer service training/behavior training/ abuse training. Resident's care plan will be updated to reflect resident needs. 3. Staff Interviews 6/7/16 The NHA, DON and RN corporate consultant were interviewed together in relation to the above report of abuse and subsequent facility investigation on 6/7/16 at 5:30 p.m. The RN corporate consultant confirmed the facility failed to substantiate the report of abuse from resident #85 and had concluded that, while there had been failures in the reporting of resident #85's allegations, the resident had not been verbally abused by the CNAs. The corporate consultant said the facility did determine that additional training was needed for the staff in question, including customer service, concerns/grievances and how staff spoke to the residents. They acknowledged they heard from CNA #1 that resident #85 statements to her represented a complaint that he was not receiving enough care at night. The corporate consultant said the facility would begin to meet his needs by going back to reassess what his real needs were. They said CNA #1 would return to the facility for education, including abuse/neglect training and reporting occurrences. They said CNA #33 and #21 would return to the facility for the above education plus the additional customer service education and education regarding residents who require or desire more care. They said the plan was to have the social services director and the management team members speak with the residents about receiving care from the two CNAs prior to their return to the facility. If residents had concerns, arrangements could be made to have cares provided by other staff members. Neither the documentation provided by the facility of their investigation nor the interviews with the NHA or the corporate consultant indicated there were plans for oversight of the CNAs' provision of resident care. C. Resident #159 Resident #159, age less than 55, was admitted on [DATE]. According to the 5/5/16 admission MDS assessment, [DIAGNOSES REDACTED]. According to the 5/5/16 MDS assessment, the resident had clear speech, vision and hearing; and was able to understand others and be understood. The resident was cognitively intact with a BIMS score of 15 out of 15, and had no mood or behavioral symptoms. The resident needed limited physical assistance for activities of daily living except eating, used a wheelchair for ambulation, and was unable to walk. 1. Interviews and record review revealed the facility failed to thoroughly investigate resident #159's allegations of abuse. a. Staff Interview The NHA was interviewed on the morning of 6/6/16. She said she was in the process of investigating an abuse allegation from resident #159 from the previous day (6/5/16). The resident had reported that RN #39 had been verbally abusive and gestured she intended to strike him. The NHA said she had suspended RN #39 pending the investigation. She had called the police who had investigated by interviewing individuals in the vicinity when the alleged abuse occurred. She said the police officer had counseled the resident about false reporting. The NHA said she would provide the investigative report as soon as she sorted out the numerous abuse allegations she was in the process of investigating. b. Record Review On the afternoon of 6/6/16, the NHA provided a copy of the investigation, which was combined with another allegation from the same resident, which he had mentioned during interview on 6/1/16 and had filed on 5/21/16. Most of the abuse investigation documents were handwritten, undated and unsigned. Most of the documents did not include the names of the interviewers or the full names of the persons interviewed; and did not include whether the persons interviewed were residents or staff. Specifically: (1) Allegation #1 Investigative Report A Resident Interview Questions and Answers form dated 6/1/16 listed the name and room number of resident #159. The interviewer's last name was not listed. The resident answered yes when asked if he had been abused, and said staff ignored me when asked where the nurse was. The person who did this was identified as a night shift CNA (CNA #40), and by first name and last initial, and had occurred 7-10 days ago. Asked if the incident was reported, the resident said yes, to the agency and Office of Civil Rights. A corporation Customer Satisfaction Line document dated 5/22/16 at 12:36 a.m. The document included caller stated a CNA ignored a patient . The caller stated on 5/21/16 at 10:25 p.m. (CNA #40's first name, last name unknown) ignored a patient's (name withheld) request by not even acknowledging the patient. The caller became frustrated with the reporting process, used pr

Based on resident and staff interviews and record review, the facility failed to ensure residents, including two of 49 sample residents, (#93 and #69) were free from verbal, physical and mental abuse from residents #115 and #114. Specifically: -The facility failed to take adequate steps to limit resident #115's [MEDICAL CONDITION] and ensure resident #93 was protected from abuse when resident #115 was intoxicated, contributing to resident #93's eye injury and feelings of fear and frustration; -The facility failed to take adequate steps to limit resident #115's [MEDICAL CONDITION] and ensure resident #69 was protected from abuse when resident #115 was intoxicated, contributing to resident #69 being hit in the head and held down on the ground; -The facility failed to ensure adequate supervision of resident #114 to prevent his aggressive behaviors towards resident #93, which contributed to resident #93's leg injury and creating the potential for other residents and staff to feel harassed and fearful; and -The facility failed to respond in a timely manner to resident #114 and #115's abuse and mistreatment of [REDACTED]. The findings included: I. Facility Policy On 6/7/16 at 9:39 a.m., the director of nurses (DON) provided the facility's policy and procedure titled, Abuse and Neglect Prohibition, revised 6/2013, which included: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property . Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the administrator and/or director of nursing . Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish. Injuries of unknown origin may occur as a result of abuse . Mental abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation . Physical abuse includes, but is not limited to, hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment . Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability . The facility will screen for potentially abusive residents . II. Resident #115 and Resident #69 A. Resident #115 Status Resident #115, age less than 55, was admitted on [DATE], readmitted on [DATE] and discharged on [DATE]. According to the face sheet, diagnoses included fracture of left forearm, fracture of right forearm, fracture of one right rib, fracture of right ilium (pelvic bone), left ankle fracture, right ankle fracture, fracture of left talus (ankle bone), major [MEDICAL CONDITION], and anxiety disorder. According to the 2/22/16 minimum data set (MDS) assessment, the resident had a brief interview for mental status (BIMS) score of 15 out of 15, which indicated he was cognitively intact. He had adequate hearing, speech and vision, and no rejection of care or mood symptoms were present. He had other behavioral symptoms not directed towards others that occurred one to three days and the behavior impact on the resident or others was void of documentation. He was independent with bed mobility, transfers, walking, dressing, toilet use, personal hygiene and eating, and used a walker and wheelchair for mobility. He had occasional pain that he received a PRN (as needed) pain medication for, and he received an antidepressant medication seven times during the last seven days. The care plan, initiated 12/31/15 and revised 3/1/16, identified that the resident frequently exited the facility without telling anyone or signing out, going to unknown locations and returning to the facility inebriated; was very rude, loud and obnoxious to staff and others. The goals and interventions included to encourage and remind resident #115 to sign out when wanting to exit, explain the risks to him in regard to his behavior, and on his return to encourage him to remain in the facility and encourage safety. The care plan, initiated 12/2/15 and revised on 3/1/16, identified that the resident had depression related to his injuries and decrease in his abilities. The interventions included to arrange for a psychiatric consult and to follow up as indicated, arrange for his clergy or spiritual leader of choice (not specified on the care plan) to visit (frequency not specified) and as requested, to assist him in developing/providing him with a program of activities that was meaningful and of interest. (However, the care plan did not identify his specific areas of interest). Also, to discuss with the resident/family/caregivers any concerns, fears, issues regarding health or other subjects; encourage individual confidence and comfort with staff by attempting to establish continuity of care as much as possible; to observe/document/report as needed any signs or symptoms of depression and observe/record/report to medical doctor (MD) as needed risk for harming others. This included increased anger, labile mood or agitation, feelings of being threatened by others or thoughts of harming someone, or possession of weapons or objects that could be used as weapons. B. Resident #69 Status Resident #69, age 63, was admitted to the facility on [DATE]. According to the face sheet, diagnoses included diabetes and [MEDICAL CONDITION]. According to the 3/15/16 MDS assessment, resident #69 had a BIMS score of 15 out of 15, which indicated he was cognitively intact. He had adequate hearing and speech and highly impaired vision. He had no [MEDICAL CONDITION], mood or [MEDICAL CONDITION] behaviors and no rejection of care. He required supervision with bed mobility, transfers, walking, dressing and toilet use; and limited assistance with personal hygiene. The care plan, dated 12/28/15 and revised 2/5/16, identified sensory deficits as a problem, but did not specify what the impaired sense was or what the deficit was related to. The goal and interventions documented that the resident would have his needs anticipated and met due to his sensory impairments and that staff were to ensure appropriate visual aides were available as necessary. There were no additional interventions documented. C. Resident #115 Record Review and Resident #69 Interview The progress notes for resident #115 dated 2/10/16 through 2/11/16 included the following entries: -2/10/16 at 1:05 p.m.: Out on pass -2/10/16 at 9:19 p.m.: Resident smells of alcohol and exhibits behaviors of being intoxicated. Meds held related to condition. -2/11/16 at 2:27 a.m.: Resident at 7:00 p.m. was found by staff to be staggering down hall 2 and into room [ROOM NUMBER]. Male staff escorted resident by arm down hall and back to room. Noted by evening and night nurse to smell of alcohol and having an unsteady gait. Face red, eyes red. Resident into wheelchair and outside to smoke. Staff that was on break overheard this resident talking about taking 'Molly Powder' (Ecstasy). As noted, evening nurse held scheduled meds related to condition. Made administrator aware . Behaviors were exaggerated and not baseline. Resident went to bed. Nurse checked on resident and not able to arouse. Sleeping soundly . Res was checked on several times after .12:45 a.m. Resident awake and requesting pain meds. This nurse did neurological check and noted that pupils were still dilated and reluctant to give pain meds. Resident became angry. Made administrator aware. Call into (name of MD) .and gave order to get UA (urinalysis) toxicology and to give resident PRN (as needed) meds. UA obtained before pain meds given and sent . The urine drug screen toxicology results from the local area hospital laboratory, dated 2/11/16, documented that the resident tested positive for THC (marijuana), benzodiazepines and [MEDICATION NAME]. (He received scheduled [MEDICATION NAME], a benzodiazepine, and [MEDICATION NAME] PRN). The Incident/Accident Report dated 2/10/16-2/11/16 documented that the resident was Showing signs of being intoxicated. Making comments that he had taken 'Molly Powder.' Pupils dilated to 0.8 with very little reaction. Resident acting euphoric. Not baseline then becoming angry when requesting pain meds. The form documented that the physician was notified. The progress notes for resident #115 dated 3/1/16 through 3/3/16 included the following entries: -3/1/16 at 12:36 p.m.: Resident out on pass -3/1/16 at 2:28 p.m.: Patient was scheduled for MD appointment in (nearby town) today and decided that family could take him and also signed out to go out on pass until 3/2/16 at 10:00 p.m. at the same time. In the past, the client has returned from his passes intoxicated with alcohol. Therefore, a call was placed to the patient's primary care physician to inquire about the release of narcotic medications while out on pass. (Name of MD) stated that the patient is only to take enough narcotic meds for today and needs to pick up additional meds in person tomorrow if he needed them. This was communicated to the patient and he verbalized understanding. -3/2/16 at 7:13 p.m.: Patient came back into the building from outside after spending some time outside near the building. He had signs and symptoms of [MEDICAL CONDITION] as evidenced by slurred, incoherent speech, inability to walk independently, unsteady gait when standing, unsteady gait when sitting, dark red skin color to face and neck. He was not able to follow directions unless repeated multiple times. A call was placed to (name of MD), order received to send patient to ER (emergency room ) for altered mental status, request for toxicity screen and blood alcohol level. Patient was transported by ambulance at 5:20 p.m -3/3/16 at 1:04 a.m.: Resident returned to facility at approximately 10:30 p.m. via facility van. Appeared to not be intoxicated. The serum ETOH (ethyl alcohol) toxicology results from the local area hospital laboratory, dated 3/2/16, documented that the resident's alcohol level was 315 milligrams per deciliter (mg/dL), which was considered a toxic level on the lab report. (A normal or negative result would range from 1-10 mg/dL). Also, the urine drug screen toxicology results, dated 3/2/16, documented that the resident tested positive for THC. The progress note dated 3/7/16, written by the social worker, included the following documentation from the quarterly care conference: We met with (resident #115) on 3/3/16 . We were there to answer questions about therapy, smoking, Medicaid and his housing situation. He is eating well and likes to order a breakfast 'McMuffin' for breakfast. He is sleeping well. (Ombudsman) went over his personal goals with him. I went over his 'choices' interview with him and he does not wish to change anything . He is signed up with 'Transitions' with Region 10 (a program to assist Medicaid clients moving out of nursing homes and back into the community with support and services) . There were no other concerns. The documentation did not address the resident's episodes of intoxication or anger issues related to his narcotics being decreased. The progress notes for resident #115 dated 3/8/16 through 3/9/16 included the following entries: -3/8/16 at 8:09 a.m.: Out on pass -3/8/16 at 9:42 p.m.: Patient returned to facility at 9:00 p.m. Patient was stumbling and slurring his speech. Smelled like marijuana. At 9:30 p.m. he called from his room requesting his HS (hour of sleep) meds and his pain pill. Patient was approached and asked if he had been drinking this evening. Patient denied. Asked if he had been smoking marijuana this evening. Patient denied. Patient was assessed. Smelled like he had alcohol on his breath. Informed that while under the influence he would not be receiving any narcotic medications per physician order [REDACTED]. -3/8/16 at 10:44 p.m.: Patient called requesting to speak to RN (registered nurse). Was very angry that he was not getting narcotics. Patient states he 'has the right to take his meds.' Discussed risk of taking narcotics with alcohol. Patient aware of risks. States he 'is an adult and can drink if he wants to.' States he 'has been taking these pills and drinking for years' and he 'can manage himself just fine.' Reminded patient of incident six days prior where he was sent to the emergency department minimally responsive with a slowed respiratory rate related to [MEDICAL CONDITION] and serum ETOH in toxic range. Patient says he 'was not that drunk' and 'y'all overreacted.' . Patient did admit to drinking and marijuana use this evening. Reports that he is angry that his meds were decreased . Patient became very emotional, apologetic, 'needs help, can't cope with [MEDICAL CONDITION],' is 'in pain from [MEDICAL CONDITION] and falling off a cliff, drinks too much, knows he shouldn't be drinking while taking his meds.' Ended conversation with patient stating he understands why he will not be getting narcotics while intoxicated. (There was no [DIAGNOSES REDACTED]. -3/9/16 at 5:09 a.m.: Patient called at 4:30 a.m. requesting to speak with RN. Stated he is 'Firing his (expletive) doctor,' is 'getting his old doctor back. None of you (expletive) idiots care about me at all.' Stated he wants to speak with administrators. Patient would not allow any response to statements. Patient cussed me out of the room. The progress note dated 3/18/16, written by the social worker, included in pertinent part: Informational note. I gave a pamphlet/application for the Vocational Rehabilitation and gave it to (resident #115) Wednesday 3/16/16. He voiced that he would return it completed to me the next day/yesterday morning but was not in the building. I was able to catch him this morning and reminded him of the application-which he returned it to me completed. I then got a message phone on the number to the vocational rehab and left a message to make a future appointment with them. The social worker did not document that any conversation was had with the resident related to his intoxication, marijuana use, mixing narcotics and alcohol together, or cursing at staff. Further, the resident's medical record was reviewed in its entirety and there were no additional progress notes or documentation by the social worker that would indicate that she had helped him with these issues. The Behavior Monthly Flow Sheet for 3/16 documented that the resident was being monitored for target behaviors that included Depressed/Withdrawn and [MEDICAL CONDITION]. The day and night shift staff all documented zeros to indicate that none of the target behaviors were exhibited. The Behavior/Intervention/Outcome antianxiety medication monitor form for 3/1-3/3/16 documented that the resident was receiving [MEDICATION NAME] and was being monitored for target behaviors that included [MEDICAL CONDITION] and Acting out/Aggressive. For the three day period, there were only two evening entries documented on 4/1/16 and 4/3/16. On the evening shift of 4/3/16, there were 11 events of acting out/aggressive behavior and the intervention included adjusting the environment was ineffective. The progress notes for resident #115 dated 4/2/16 at 3:03 p.m. through 4/3/16 at 12:50 a.m. included the following entries: -4/2/16 at 3:03 p.m.: OOP (out on pass) -4/3/16 at 12:50 a.m.: 10:30 a.m. police called due to this patient and (resident #69) acting verbally aggressive towards each other (and) another nurse, ending in blows to the head. The pair remained verbally abusive to police. Each issued with a citation for disorderly conduct. Each went to sleep. The local county police department case report was reviewed for the incident that occurred on 4/2/16 and included in pertinent part: Two residents . had been in a physical altercation but were separated at this time. I was told there was alcohol involved . According to staff, (resident #115) and his roommate, (resident #69) got into an argument because (resident #115) came in the room and woke (resident #69) up. (Resident #69) got mad . After they were separated, (resident #115) went back in the room and (resident #69) and (resident #115) got into a physical fight. I spoke with (resident #69), he told me (resident #115) came in the room and woke him up because he was drunk again . (Resident #69) said (resident #115) came across the room and he got up and hit (resident #115). (Resident #115) hit (resident #69) back, knocked him down and got on top of him hitting him. I observed a bruise on the left temple area of (resident #69's) head. I went back and spoke with (resident #115) and (resident #69) together. I asked if they could get along for the rest of the night. They both began to argue and interrupt me. I told them they were getting a summons for Disorderly Conduct . NHA Interview: On 6/6/16 at 5:18 p.m., the NHA was interviewed and she said there was no incident or accident report created for the incident that happened between residents #115 and #69 on 4/3/16. Resident #69 Interview: On 6/6/16 at 3:38 p.m., resident #69 was interviewed and he explained that on 4/2/16, resident #115 started arguing and he got up and I got up and the fight was on. I hit him first. I swung at him but I missed him because I can't see. He held me down. He said that resident #115 was always drunk and they told him to quit drinking. He explained that resident #115 was intoxicated frequently and stated, The drinking was ever since he came in the door. He wanted to quit drinking. The progress notes for resident #115 dated 4/3/16 included the following entries: -4/3/16 at 12:56 p.m.: Resident behaviors: He had moved over to hall 4 . and started harassing the CNA to change his pants. This nurse went to him and said to stop harassing the CNA (and) she is busy at this time . He said that he was only giving the CNA a bad time and went outside to smoke. III. Resident #115 and #93 A. Resident #93 Status Resident #93, age 56, was admitted on [DATE]. According to the 6/16 computerized physician orders, the diagnoses included diabetes, coagulation deficit, [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION], anxiety disorder, [MEDICAL CONDITION] and major [MEDICAL CONDITION]. According to the 4/11/16 MDS assessment, the resident had a BIMS of 15 out of 15, which indicated he was cognitively intact. He had adequate hearing, vision and speech and had no [MEDICAL CONDITION], mood or [MEDICAL CONDITION] behaviors or physical or verbal behavioral symptoms directed toward others. He required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. He had functional limitation in range of motion in his left upper and lower extremities and used a walker and wheelchair for mobility. The care plan, initiated 3/6/16 identified pain related to his history [MEDICAL CONDITION] and alteration in mobility as a problem. The interventions included observing for signs and symptoms of verbal and non-verbal indicators of pain at each medication pass and periodically, notify the MD of unrelieved pain, provide diversion activities such as positioning, music and television, and provide medication as ordered and document the effectiveness results of the medication administration. B. Record Review and Resident Observation/Interview: The Incident/Accident Report dated 4/3/16, documented that at 4:30 p.m. the resident (#115) was outside next to the smoking area and got in a fist fight with another male resident after he grabbed other resident's wheelchair and was spinning him around in the parking lot. On 5/4/16 (during a complaint investigation initiated prior to survey) at 1:45 p.m., resident #93 was lying in bed in his room and was observed to have a black, circular bruise under his right eye. The resident was interviewed and asked how he got the black eye and he stated, I got beat up. A guy stole an electric wheelchair and was pushing me around the parking lot, and I lost the wheels off my wheelchair and I tried to slap him. He said the resident who pushed him and hit him was resident #115. He said he was fearful of resident #115 when he was still a resident in the facility, but was not afraid of him anymore because he had been taken to jail and was no longer in the facility. The local county police department deputy report was reviewed for the incident that occurred on 4/3/16 at 4:30 p.m. and included: Two male parties had received a summons relative to an incident occurring the previous evening . and one of the involved male parties was now giving a supervisor at the residence a hard time . (Resident #115), who evidenced signs of intoxication including slurred speech, slow affect, glassy and bloodshot eyes, relayed that he had been involved in a physical altercation with a roommate the previous day and had just been notified by (NHA) that he would be relocated to a separate wing by administration as a preventative safety measure . (Resident #115) who became overtly agitated, uncooperative and belligerent stated that he adamantly objected to the relocation of his room . (Resident #115) was served a 30-day notice by (NHA) on behalf of (name of facility), warned of the possible consequences should he return and commit any crimes and subsequently walked away. -4/3/16 at 8:25 p.m.: Away from facility -4/3/16 at 10:54 p.m.: Resident has a problem with alcohol which has worsened and created more problems with his behavior. The police were called and he was taken to jail. Resident was not able to be redirected prior to this interaction with the other male resident. He cursed and made threats to the staff when we tried to help him get in control. C. Additional Resident Interview Resident #88, who was cognitively independent per facility assessment, was interviewed on 6/1/16 at 12:35 p.m. When asked if anyone in the facility had ever abused him, he said, Yes. Verbal abuse. The problem - I don't know his name - a resident. Well, he was drunk in the building. When asked if he had seen any other resident being abused he said, Yes. (Resident #93). Same thing. Another resident got drunk and slammed on him. This is a new resident that got drunk and he's in jail (resident #115). D. Staff Interviews The social worker was interviewed on 5/4/16 at 3:18 p.m., and she said she did not have any challenges in dealing with resident #115 and stated, I had none. We had a mutual respect. He had a lot of issues . His issues were social service issues but they were bigger than me. She explained that he was not very punctual when he would have appointments and he would flake it off and was not responsible. -She said they had a care conference meeting with the resident because, We felt like he needed direction. She explained that the facility was trying to help him with vocational rehabilitation, but she said he did not go to the first appointment. -She explained that on occasion he would leave the facility and come back at 2:00 a.m. drunk, which was disturbing. Then he would say things that I heard about after he left, like sexual innuendos to multiple aides and it was kind of disgusting. She said the issues with him coming into the facility intoxicated were taken care of by (name of NHA). CNA #20 was interviewed on 6/2/16 at 2:39 p.m. and he said he worked with resident #115 regularly when he was still a resident in the facility. He confirmed that he'd observed the resident's verbally abusive behaviors that included, Cursing down the hallway laughing like he was in a bar, making rude comments about the girls and sexually provocative comments about the girls . inappropriateness, being loud . being overly disruptive and making the whole environment uneasy. He said his behavior would go on throughout each day, every day during the days that CNA #20 worked, which was every Thursday, Friday and Saturday. -The CNA said that on the days resident #115 would come in intoxicated or high, he didn't listen to anybody. The CNA said that would occur at least two of my days (I worked) he would come in red-faced and a few times I could smell it. He explained that the odor smelled of alcohol and marijuana and I could smell it on him like it was a cologne. -The CNA said he did not remember the staff receiving any specific type of education on abuse or related to resident #115's behaviors. CNA #16 was interviewed on 6/2/16 at 2:48 p.m. and she said she'd worked with resident #115 regularly when he was still a resident at the facility. She confirmed that she'd observed his verbally abusive behaviors and stated, When he started buying alcohol for everybody (residents) that was able to walk and they would all get together and drink and it was a constant thing with the cops being called . I kept my distance from people like that. She said he was aggressive when he was drunk and the staff was instructed to take him to his room and ask him not to be mean to the other residents and would ask him to stop. When he was drunk, he wouldn't stop the bad behaviors; it was impossible. The behaviors went on for weeks. Maybe a month before he went to jail and was kicked out of here. Licensed practical nurse (LPN) #6 was interviewed on 6/2/16 at 3:00 p.m., and she confirmed that she'd worked with resident #115 when he was still living at the facility. She said he was inappropriate, and described one Saturday night when she was working and another resident was drunk to the point of falling down and the NHA had been called three times and come into the facility. She said resident #115 was sitting outside of the facility near the smoking area and the other resident had tried to go back outside again but was unsteady and ready to fall, so the LPN went to the door and asked him to stay inside. She said resident #115 was screaming at me because I'm not a police officer and I was trying to protect him. She said resident #115 kept yelling at me and he kind of came at me and at that point I called (the NHA) again. The LPN said that resident #115 was an inappropriate resident to have admitted to the facility because of his behaviors. RN #2 was interviewed on 6/2/16 at 3:12 p.m. and she said she'd worked with resident #115 when he was still a resident in the facility and confirmed that she'd observed his verbally and mentally abusive behaviors. She stated, He wanted what he wanted, when he wanted it. If he didn't get it he would become verbally abusive at times towards staff. She said he told her, You are a stupid little (expletive). Get the (expletive) out of here. She said she also heard him say, That stupid (expletive) on night shift doesn't know what the (expletive) she's doing. She said his behaviors made her feel uncomfortable to be around him. Licensed practical nurse (LPN) #4 was interviewed on 6/2/16 at 3:13 p.m. and she said she'd worked with resident #115 when he was still a resident in the facility and confirmed that she'd observed his verbally and mentally abusive behaviors. She said his behavior made her feel uncomfortable and explained that he had made sexual remarks to me telling me to come get in bed with him. He was stumbling drunk once and approached me at the front door and I felt uncomfortable so I had to go around. -The LPN described another incident where resident #115 stood up out of his wheelchair, drunk, and was walking towards me so I just kind of backed up and told him he needed to back up because I was going home and I'd clocked out. She said she did not feel that resident #115 was appropriate for this facility. LPN #3 was interviewed on 6/6/16 at 1:15 p.m. and she confirmed that she'd taken care of him when he was a resident at the facility. She said that he had a cocky young man attitude, and said that he was rude to staff. She said that she'd observed him be rude to residents and stated, He would make what he wanted known. He would say 'move' to other residents. She thought his behaviors escalated over time and she confirmed that she'd also observed him to be intoxicated. She said during those times he would get more flirtatious and loud. She explained that his behaviors made other residents and staff in the facility uncomfortable and stated, You could feel an edge around here. The DON was interviewed on 6/6/16 at 2:53 p.m. and said, Many times when he would come in if he'd been drinking he would just go to bed and sleep it off. Once in a while he could be verbally aggressive, more than anything else with staff or his roommate. -The DON explained that he was not nice to staff whether he was drunk or sober and became verbally nasty to the staff and other residents. -She explained that the facility arranged for the Ombudsman to come in and meet with resident #115 to help him accept some responsibility for his actions. She said in the presence of the Ombudsman, he was very docile, but explained that by the next day that was all forgotten and he didn't follow through on anything that she'd asked him to do. -The DON said that other residents in the facility did not complain about resident #115 and stated, They felt like (resident #115) was causing trouble and was out of line . and just tried to stay out of his way. I don't think they were fearful of him . He was destroying the even tenure of the building environment that (name of facility) usually has by keeping things so stirred up. -The DON said she felt that the resident was an appropriate admission at the time he was admitted because he needed help and he needed care and therapy. She explained that after he got better that he stated he knew he was not going to be reviewed for eligibility to stay on Medicaid until June and he was planning to stay in the facility until then, even though he refused to go to therapy and wasn't staying in the building a lot of the time. -The DON explained that when they got the Ombudsman involved with him, it was because they wanted to try to get her assistance on Where do we go from here? Can we give him a 30-day notice? She said they were talking with their regional and division team to see if there was a way they could get him discharged . She stated, His mom wouldn't take him, and his girlfriend wouldn't take him so he technically had no place to go. He hadn't been set up with disability yet. The NHA was interviewed on 6/2/16 at 3:45 p.m. She said, He just wanted to drink . He would go out and get drunk and come back in the door and stagger and we would put him to bed and I spent the night a lot because the aides couldn't take care of him. She said, We had families complaining because he was running up and down the hall. He threatened me and I called the police. -The NHA was asked what was done to ensure that the other residents in the facility were kept safe when resident #115 was intoxicated and she said, We watched him. She said that they did 15-minute checks but did not document them. She said, He would go to his room and sleep it off. -The NHA agreed that the resident was having inappropriate behaviors as far back as December and she explained that was when he started drinking. She said, It wasn't every month that it was bad . and it wasn't horrible all the time. -The NHA explained that a psychiatric consult was completed but the resident didn't want to talk to the psychologist. She stated, In my opinion, he didn't feel or perceive that he needed mental health help. -The NHA was asked how often the staff contacted the resident's physician with concerns that he had threatened or harmed other residents or staff, and she said she did not know and would have to look in the chart. -The NHA said she was not aware of any sexual innuendos the resident made toward staff, but said she was aware that the staff wanted her in the building when he came back drunk. She said she didn't think the staff were afraid of him, But staff was tired of his behaviors. She said she was surprised that the staff were uncomfort

Based on family, staff and resident interview and record review, the facility failed to ensure one of four sample residents (#1) was free from neglect. The facility failed to provide toileting assistance, incontinence care, repositioning, oral care, and eating and drinking assistance to resident #1, who needed extensive assistance from staff. These failures resulted in resident #1 lying in bed unattended for several hours in his own incontinence, without food, fluids, toileting, repositioning, oral care, personal hygiene, or linen changes. Cross-reference F312, failure to provide activities of daily living assistance for a resident who needed extensive assistance. The findings included: 1. Facility Policy The facility's "Abuse & Neglect Prohibition" policy/procedure, dated ,[DATE], provided in pertinent part the following: "Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property." - "Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Injuries of unknown origin may occur as a result of neglect." - "Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect ... is at risk for occurring." - "Staff will be instructed to report any signs of stress from family and other individuals involved with the resident that may lead to abuse, neglect ... and to intervene as appropriate." - "The facility supervisory staff will integrate into the supervisory process monitoring staff members and residents for behavior indicative of high stress levels that may lead to abuse/neglect or may escalate a continuum of aggression." 2. Resident #1 Closed record review revealed resident #1, a [AGE] year-old male, was admitted to the facility, on [DATE], for respite care. He was discharged to home with hospice care, on [DATE], and died on [DATE]. His [DIAGNOSES REDACTED]. Minimum Data Set (MDS): Although the resident had been in the facility more than 14 days, his MDS was incomplete. Care Area Assessment Review Reports identified care planning needs in the following areas: cognitive loss/dementia, communication, ADL function, fall risk, urinary incontinence ("frequently incont of urine secondary to cog loss/Parkinson exacerbation episodes, always cont of bowel at this time"), nutritional status, pressure ulcer risk (Braden scale score 21), and [MEDICAL CONDITION] drug use. Care Plan: The resident's undated initial plan of care identified problems as follows: pain potential, skin breakdown potential, requires assistance with ADLs, history and potential for falls, safety - wandering and elopement, vision and hearing deficits, and bladder incontinence. - The [DATE] care plan for incontinence identified medications and impaired cognition as factors, with the following instructions to nursing staff: provide perineal care daily and as needed, encourage fluids, observe for signs of infection, observe for incontinence episodes at regular and frequent intervals and as needed, observe resident for worsening mental or functional status. - The [DATE] ADL care plan identified the resident needed limited assistance of one staff member. Goals were for the resident to wash his own face and hands, brush his own teeth and brush his hair independently daily. Staff were to gather and provide needed supplies, encourage active participation in tasks, praise all efforts, provide cueing with tasks as needed, and ensure effective pain management prior to ADL activities. Pressure Sore Risk Assessment: The resident scored as follows on the Braden Scale assessments for predicting pressure sore risk: On [DATE] and [DATE], he scored 21 (low risk); on [DATE], he scored 12 (high risk). - The pressure sore risk assessment, on [DATE], revealed the resident needed extensive assistance with ADLs, but his care plan (above) was not updated to reflect his deterioration in ADL status or his increased care needs. 3. Facility Failures regarding Resident #1: Cross-reference F312 for further details On [DATE], interviews revealed that resident #1's family members found him lying in his own incontinence, with a dried urine ring on his bed sheet extended from his shoulders to his knees. The facility's investigation and interviews with staff members revealed the resident had not received care for several hours, possibly at least one entire shift, before his family discovered him and nursing staff observed his condition and provided ADL care. Resident #1's family member was interviewed by phone, on [DATE] at 2:30 p.m., and on [DATE] at 12:45 p.m. The family member said she and two other family members had visited the resident on mid-afternoon, on [DATE], and found him lying in incontinence, with dried, brown urine rings on the sheets underneath him, extending from his shoulders to his knees. - She said she feared the resident had not been changed or repositioned for 16 hours. She said, "(Resident #1 had) laid in that condition for hours, more than one shift. ... They fired a CNA. What about the nurse on the offgoing and oncoming shift? ... I asked when he'd last had oral care and they said Friday - this was Sunday. ... (Three family members) were there. We all work in health care. We know he was in that same condition for more than one shift. His whole kneecap was discolored from being pressed against the wall. We know this isn't an isolated incident." - The family member said she and another family member had visited the resident the previous evening, [DATE], and helped him to bed at about 7:30 p.m. "The reason we put him to bed the night before - he was parked at the aviary. We took Dad to bed ourselves - his brief was wet - we changed him and transferred him to bed. He was really tired ... We know he was not moved (at least from) mid-morning to 3:30 p.m. on [DATE]. He was in the same position (mid-afternoon of ,[DATE]) as 7:30 p.m. (on ,[DATE]), except the pillow was not between his legs." - The family member said they visited the resident around 10 a.m. on ,[DATE], then again at 1:30 or 2 p.m., and again at around 3:30 p.m. on [DATE] with a family member who had just flown in to visit. "The ladies were sitting at the nurses' station talking." The family member said that was when they first observed the odor of urine. "My sister said she thought he needed to be changed. He was reaching down towards his knee." She said they pulled back his covers and observed he was wet and surrounded by a large dried urine ring. He had no pillow between his knees, and his knees were drawn up, pressed against the wall, and bruised from lack of repositioning. He had not received oral care and appeared to have thrush at the back of his throat. "He was only there two weeks and five days...Mom was crying, saying, 'I knew better; I've got to take him home,'" said the family member. CNA #2 said she got report from CNA #1 at 2 p.m. on ,[DATE], and at 2:30 p.m., answered a call light from resident #1's roommate. "(Resident #1's) family was in the room with (resident #1); I didn't want to interrupt. It was about 3 p.m., and the family asked me to change and reposition (resident #1). ...I felt horrible. He was lying on his side facing the wall. You could tell by the spit on the side of his face, like he'd been lying there for hours. The urine on his pad was dry like it had been there a long time. He was still in his night gown - hadn't been gotten up for breakfast or lunch. His dentures were in and hadn't been cleaned since the ,[DATE] shift. He was facing the wall; his knees had developed bruising and were red; his face was red on that side from being on that side for a long time. His daughter said it looked like he had thrush. His mouth was full of phlegm and hadn't been swabbed. He hadn't been drinking any water ..." - CNA #2 said, "He was soaked clear through the pads, blanket, and bottom sheet. There was no pillow between his knees; his knees were against the wall. The nurse (LPN #2) observed all of this - I called her in. She looked at his skin, and saw the bruise and redness." CNA #2 said she thought the previous ,[DATE] p.m. shift had provided oral care for resident #1, but she doubted that the night shift (10 p.m. to 2 a.m.) did oral care. Asked how often she toileted resident #1, she said typically three times during a shift. Facility Investigative Report: The investigation was initiated, on [DATE], with a concern form completed by the social services director (SSD). Her description of the concern read as follows: "Family reports resident found wet. Investigation started [DATE]." The following information was documented by the director of nursing (DON) under action taken: ",[DATE] - will cont. investigation but information gathered so far shows that res was left in bed and was not changed for approx 8 hrs. Staff member responsible for care at this time was disciplined. Will meet (with) family at 9 am on [DATE] to discuss findings/outcome." In her "Investigation of (Resident #1) report, the DON documented: - [DATE], "Spoke (with LPN #1) - nurse on duty hall 1 ECU on [DATE]. Asked her about her interaction (with resident #1) on the time in question. She said she gave him his AM meds and milk shake at approx 9 am. Stated he did wake up and take meds from her. She said she sat him up in his bed to take meds and didn't notice if he was wet. States she did not see any brown ring on linens at that time. She said she later asked the aide caring for res on that hall to make rounds to assure his res were dry, etc. She stated he failed to do so and she gave me a write up for him." - "Spoke (with CNA #3) - worked night shift. She says that she and the other aide did rounds at 12, 2 am & 4 am. She said (resident #1) was changed at each rounds (with) the last time being around 4:45. Stated he was turned and repositioned at each round. Did not take any nourishment or water from her." - "Spoke (with CNA #1). Interviewed (CNA #1 with) ADON (Assistant DON). Asked him about his care of (resident #1) on Sun, [DATE]. He stated he thought res was 'actively dying' so he 'didn't bother him.' I asked him if he had discussed (resident #1's) health state (with) the nurse and he said no. I reminded him that it was beyond his scope to assess if res was actively dying and even if he was, he still needed to do care for him. Discussed the way resident was found, way family felt etc. After long discussion I told (CNA #1) he was suspended until I finished my investigation. After (follow-up) with Admin and HR, was decided to terminate." - "Res was moved to PCU at family request on Sun 13th. Spoke (with) staff on PCU to assure that res was receiving proper care. Family are in building most of the time. No other care issues have been brought forward. 2 head to toe assessments done to determine if there are any injuries from being in a wet bed. No redness or skin breakdown noted - has multiple bruises - some from a fall a few days ago." Included with the investigative report were the following written statements from two additional other nursing staff, CNA #2 and LPN #2: - LPN #2 wrote in a statement, dated [DATE] at 3 p.m.: "Family reported to this nurse that (resident #1) appeared to not have been changed all day. When I went in I saw brown rings up at his shoulders, and past his knees. The wife and daughter had found him this way and were in tears." - CNA #2 wrote the following in pertinent part: "When I asked (CNA #1) about hall 1 ... his report was 'Hall 1 is good.' When I asked him about (resident #1) his response was that, 'he is pretty much dying.' I asked if he had got him up for meals, he responded no. ...His report to me was very poor but I got tired of interrupting his conversation so I left it at that. At 2:30 pm I answered (resident #1's roommate's) call light and I noticed that (resident #1's) family was in the room so I did not have the opportunity to check if (resident #1) was dry and I had intended to as soon as they left. At 3:00 pm (resident #1's) family called us into his room because his pad and entire bedding was covered in dry urine. He had been positioned facing the wall. (Resident #1) had saliva dried on his face and the side of his face that had been facing down was red. He looked as if he had not been repositioned all day because the family said that's how he was laying when they positioned him the night before. He did not have pillows in between his knees, so where his knees were rubbing against another was red. His knees were also against the wall and were bruised. The family did not remember the bruising on his knees and asked if they were from his prior fall or from his knees being against the wall. I had no response. The family was also greatly displeased when they took out his dentures and swabbed his mouth. It was very clear that the dentures had not been cleaned and that no oral care had been given. (Another CNA) and (I) did all we could do to comfort the family. We did a complete bed change and brought the family supplies such as wipes, swabs and fresh wash cloths. - "On Saturday, [DATE], I worked hall 1 on the ,[DATE] day shift. (Another CNA) and I got (resident #1) up that morning and cleaned his teeth before breakfast. (Resident #1) was up for the entire shift. Before I left at 2 pm (another CNA) helped me toilet him and then she took over hall 1 for the ,[DATE] evening shift." Staff Interviews: The licensed practical nurse (LPN #1) who worked with CNA #1, both of whom were assigned to provide care for resident #1 during the day shift, on [DATE], was interviewed at approximately 12:15 p.m. on [DATE]. She said (in pertinent part) that on ,[DATE], "I told (CNA #1) to check his people." - Asked if she checked on resident #1 herself, she said, "I checked on (him); he'd be repositioned - he'd done it himself. I recall blankets being twisted up. I'd rearrange the covers - I didn't smell anything or see wetness. I gave him [MEDICATION NAME] around 10 a.m. - he was very agitated." - Asked if she checked on the resident at the end of her shift, she said, "I didn't check on him right at 2 p.m., but I told (CNA #1) around one-ish to go ahead and check on his people." LPN #2, the nurse who was assigned to provide care to resident #1 on the [DATE] evening shift, ,[DATE] p.m., was interviewed at 3:55 p.m. on [DATE]. She said, "Around 3 or 3:30 p.m. (on ,[DATE]) the family told my aide (resident #1) was wet. Before I could find her (the CNA), they came back (to the nurses' station). It was horrible - I was very upset, too. My aide changed him; I think another new aide assisted her." Asked if she assessed the resident at that time, and what she observed, she said, "Other than lack of care, he was okay - no skin breakdown. His skin was red and bruised, with a 4x4 cm bruise inside his knee. Other than his knee and hip, he was good. Vital signs were normal. He was lethargic, but he'd been that way." - Asked if she completed an incident report, she said, "The manager on duty and upper manager do that (incident report and investigation). I wrote a statement, who reported to me, etc. We do it that way so we can keep all the information together." Asked if she documented her assessment of the resident, LPN #2 said, "Charting? I can't remember. I was pretty upset." Asked if she checked the resident's condition when she came on duty, including incontinence care, she said, "It shocked me about that aide (CNA #1)." - Asked if she checked residents herself to ensure they were receiving incontinence and ADL care, she said, "I check residents but don't check them for incontinence care. I went in around 2:30 or 2:45 p.m. and resident #1 was resting - I checked his vitals. He wasn't strong smelling enough, I guess, for me to smell him. I have allergies [REDACTED]. I think I was with staff giving him pain meds with his change so it wouldn't hurt to check the MAR for the time. He had pain with repositioning, I gave him [MEDICATION NAME] around 6 a.m., and he was cleaned and turned at that time. I guess the nurse has responsibility too, but we depend on our aides. The aides found a couple more residents wet (on the ,[DATE] p.m. shift who were assigned to CNA #1), but not that bad." CNA #3, who provided care for resident #1 on the 10 p.m. to 6 a.m. night shift ,[DATE]-[DATE], was interviewed by phone on [DATE] at 10:15 p.m. She said, "The night I worked we'd go in, make sure he was turned, and check to see if he was wet. We do rounds at 12 p.m." She said she recalled changing resident #1 on the "first round" at 12 p.m., her co-worker CNA checked him at 2 a.m., and at 4 a.m., they both checked and he was changed. She said he was checked at 6 a.m., but she did not recall by whom, or if he was wearing dentures or a gown. She said he was up and awake at 10:30 p.m., and she "believed he got laid down" by her co-worker CNA but she did not recall if oral care was done. Asked if she did rounds to check on her residents upon arrival for her shift and immediately before her departure, she said, "Some people do." However, she had already indicated that her first rounds were done at 12 midnight. Resident Assessments during and after [DATE]: There was no evidence in nursing notes to describe how the resident was found on [DATE]. There was no documentation in nurses' notes that the resident was having difficulty swallowing. There was no evidence of a thorough nursing assessment. Vitals were not documented in nurses' notes. Assessments documented elsewhere were as follows: (1) The vital sign & weight flow sheet documented on [DATE] that vitals were taken, but no time was noted. Vitals were listed as follows: blood pressure ,[DATE], temperature 97, pulse 60, and respiration 17. (2) The incident/accident report was dated [DATE], and was completed by the assistant director of nursing, not by the nurse on duty or the nurse from the previous shift. The time of the incident was noted as "p.m.," but no exact time was documented on the incident report. The resident's vital signs were listed as follows: temperature 97, pulse 60, respiration 16, blood pressure ,[DATE], and oxygen saturation levels 92 on room air. The resident outcome listed "redness" under "other," but the location of the redness was not drawn on the body map. The physician was notified at 4 p.m., according to the incident report, that the resident was "left wet in bed - family upset." (3) A head to toe skin check was not documented until [DATE]. Bruising was documented to both the resident's inner knees, and over the entire front of his left knee. Otherwise his skin was noted as intact with the exception of a rash labeled as "dermal staining" to both his lower legs, which had been documented on the resident's admission skin assessment. - Of note, the resident's family said (see family interview) he was found lying on his side with no pillow between his knees, reaching toward his knee, and his knees were pressed against the wall. (4) The resident's post-discharge plan of care, dated [DATE], documented, "Skin intact, bruises on knee." (5) A speech therapy evaluation was conducted on [DATE] at approximately 3:,[DATE] p.m. according to speech therapist notes. Her evaluation revealed the following in pertinent part: - "Nursing reported that pt stopped swallowing over the weekend. Family says he swallows, but then the food comes back out the oral cavity." - "Pt (patient) had dramatic medical decline. All food/drink leaked out the oral cavity. Pt. was ordered an NPO (nothing by mouth) diet." - "Pt having severe dysphagia. Most likely aspirating. 20% of fluids are not swallowed & leak out the anterior oral cavity. All solids, even puree texture, leak out the oral cavity. Pt has some sensation in & around the oral cavity. Pt coughed consistently on thin juice (with) a non-productive cough. Wet respiratory sounds & vocal quality were heard after swallowing thin liquids and pudding. Clear vocal quality after nectar-thick liquids are swallowed. Verbal cues helped the pt to swallow." - "Discharge summary: D/C pt from ST - family decided to take pt home (with) hospice." Summary of Facility Failures: The facility failed to ensure resident #1 received incontinence care, oral care, feeding assistance, hydration, and repositioning. The resident had been assessed at high risk for skin breakdown. As a result of facility failures, he lay in urine for hours, suffered discomfort, bruising to his knees, and redness to his skin. Although there was evidence the resident's vital signs were checked, there was no evidence the resident was thoroughly assessed after he was found lying in urine for so long. The nurse did not document the resident's condition in the chart. The day shift nurse did not adequately supervise the CNA and assess the resident's condition, and the oncoming evening shift nurse failed to do the same. The nurses and CNAs who were interviewed did not state they made a point to immediately do rounds to check the condition of the residents they were to provide care for, upon arrival for their shifts, and prior to leaving at the end of their shifts. Instead, the nurses said they relied on their CNAs.

Based on observation, record review, and resident, family and staff interview, the facility failed to ensure three of four sample residents (#1, #2, #3) and several additional residents who needed extensive to total assistance with activities of daily living (ADLs), received adequate assistance with toileting, incontinence care, eating, oral care, and personal hygiene. Specifically: The facility failed to provide adequate ADL care and assistance for residents. Facility management staff and nursing staff failed to provide sufficient monitoring, supervision and action to ensure residents received adequate ADL care. These failures contributed to resident #1 lying in urine for extended periods, and not receiving assistance with toileting, linen changes, eating, oral care, hydration, turning and repositioning, for extended periods. The findings included: 1. Resident #1 Closed record review revealed resident #1, a [AGE] year-old male, was admitted to the facility, on [DATE], for respite care. He was discharged to his home with hospice care, on [DATE], and died on [DATE]. His [DIAGNOSES REDACTED]. a. Respite Stay Admission According to a progress note from a Care Coordinator, dated [DATE], resident #1 was admitted to the long term care facility for a respite stay under the following circumstances: "Increasing patient dementia with exhausted caregiver (spouse) who is scheduled to have (surgery) on [DATE]. (Spouse) feels she will be hospitalized 4 days for ... surgery, then in a rehab facility for about 5 days before she can resume caring for her husband. She states the patient is up & about most of the night, he is incontinent of bowel & bladder, and incapable of cleaning himself or requesting assistance." b. Minimum Data Set (MDS) According to his [DATE] MDS, the resident had unclear speech, sometimes understood others, and could sometimes make himself understood. He had short- and long-term memory problems and moderate cognitive impairment. No behavioral symptoms were noted. The resident needed limited, one-person physical assistance with bed mobility, transfer, ambulation, dressing, toilet use and personal hygiene. He needed extensive one-person assistance with dressing, and supervision and one-person physical assistance with eating. He used a walker and wheelchair for mobility. He was frequently incontinent of urine and continent of bowel. He was at risk for developing pressure ulcers. He had no identified skin issues, and was to have the following treatments: pressure reducing devices for bed and chair, turning/repositioning program, nutrition or hydration intervention to manage skin problems. He was taking a diuretic medication. - Care Area Assessment Review Reports identified care planning needs in the following areas: cognitive loss/dementia, communication, ADL (activities of daily living) function, fall risk, urinary incontinence ("frequently incont of urine secondary to cog loss/Parkinson exacerbation episodes, always cont of bowel at this time"), nutritional status, pressure ulcer risk (Braden scale score 21), and [MEDICAL CONDITION] drug use. c. Evaluation for Bowel and Bladder Training The admission assessment, dated [DATE], identified incontinence and the need to "offer toileting" every ,[DATE] hours, "needs assistance, will drink fluids placed in reach, feeds self - may become distracted - confused - unable to locate BR (bathroom) in new surroundings, assist as needed, poor cognition, unsure of ability to feel need to void ... Will offer toilet every ,[DATE] hours and change PRN (as needed)." Neither the initial care plan nor the revised care plan (see below) included the plan from the bowel/bladder evaluation to toilet the resident every two to three hours and change PRN. d. Care Plan The resident's undated initial plan of care identified problems as follows: pain potential, skin breakdown potential, requires assistance with ADLs, history and potential for falls, safety - wandering and elopement, vision and hearing deficits, and bladder incontinence. - The [DATE] care plan for incontinence identified medications and impaired cognition as factors, with the following instructions to nursing staff: provide perineal care daily and as needed, encourage fluids, observe for signs of infection, observe for incontinence episodes at regular and frequent intervals and as needed, observe resident for worsening mental or functional status. - The [DATE] ADL care plan identified the resident needed limited assistance of one staff member. Goals were for the resident to wash his own face and hands, brush his own teeth and brush his hair independently daily. Staff were to gather and provide needed supplies, encourage active participation in tasks, praise all efforts, provide cueing with tasks as needed, and ensure effective pain management prior to ADL activities. e. Changes in ADL needs per assessments - According to the fall risk evaluation, updated [DATE], the resident was disoriented x3 at all times, had ,[DATE] falls in the past 3 months, was chair bound and needed assistance with elimination, was not able to ambulate, took ,[DATE] medications that caused lethargy or confusion, and had 3 or more predisposing diseases that contributed to fall risk. - According to the Braden scale, updated [DATE], the resident's condition deteriorated in the following areas: could not always communicate discomfort or the need to be turned, his skin was often moist and linen must be changed at least once a shift, chairfast and unable to bear weight, very limited mobility and unable to reposition independently, very poor nutrition, and potential problem with friction and shear. The resident's risk score was upgraded to 12, high risk, on [DATE] (from 21, mild risk, on [DATE] and [DATE]). The resident's care plan (above) was not updated to reflect his increased ADL assistance needs or increased pressure ulcer risk. f. Additions of restraints and benzodiazepine/psychoactive medications - According to the pre-physical restraint and reduction assessment, dated [DATE], a self releasing seat belt was applied "due to res. standing up & falling - added Wanderguard." - According to physician telephone orders (TOs) and medication administration records (MARs), two medications were added after the resident's admission: [MEDICATION NAME] on [DATE] which was increased on [DATE] and [DATE], and [MEDICATION NAME] on [DATE]. (Cross-reference F329, unnecessary drugs.) - On [DATE], a TO was provided for a self-releasing seat belt, and on [DATE] a TO was provided for a Wanderguard. The resident's care plan was not updated to reflect additional care and monitoring needs and risks of added restraints and potential medication side effects. g. Nurses' Notes There were no nurses' notes on [DATE]. - On [DATE], there was one note, no specific time indicated, documented on the ,[DATE] p.m. shift: "Alert at times (with) agitation toward staff. Drowsy and sleeping off & on, ate some ice cream only for meal. Family in to visit and put him to bed. Alarm on bed for safety. Neuros (and) vitals WNL (within normal limits). [MEDICATION NAME] 2 mg po given @ 1600 for (increased) agitation (with) good results." - On [DATE], 6a-2p, "Res. in bed (with) eyes closed. Unable to arouse for bkfst. (increased) agitation @ 10:00 (10 a.m.). [MEDICATION NAME] 1 mg po given (with) good results. Res. turned self from (right) side to (left) side. Repositioned & blankets put on res. several times this shift." -On [DATE], no time noted, a different nurse wrote, "Family requesting res to be moved back to his former room on PCU. S.S. (social service) and DON (director of nurses) approved so move was accomplished. Res very sleepy at this time. Reports of agitation earlier." h. Social Services Notes On [DATE], no time noted, the social services director (SSD) documented, "Came in to investigate families reports of concerns. Resident moved to ECU [DATE] which family agreed to. Concerned found resident in wet bed. Spoke to family, nurses, CNAs (certified nurse aides). Family expressed wishes to have res moved back to PCU. Call to DON - arranged move, moved back to PCU today. Family happy with this." - This SSD note was the only documentation in the medical record of the family's concerns and of resident #1's condition on [DATE]. i. Family Interview Resident #1's family member was interviewed by phone, on [DATE] at 2:30 p.m., and on [DATE] at 12:45 p.m. The family member said she and two other family members had visited the resident on mid-afternoon on [DATE] and found him lying in incontinence, with dried, brown urine rings on the sheets underneath him, extending from his shoulders to his knees. -She said she feared the resident had not been changed or repositioned for 16 hours. She said, "(Resident #1 had) laid in that condition for hours, more than one shift. ... They fired a CNA. What about the nurse on the offgoing and oncoming shift? ... I asked when he'd last had oral care and they said Friday - this was Sunday. ... (Three family members) were there. We all work in health care. We know he was in that same condition for more than one shift. His whole kneecap was discolored from being pressed against the wall. We know this isn't an isolated incident." - The family member said she and another family member had visited the resident the previous evening, [DATE], and helped him to bed at about 7:30 p.m. "The reason we put him to bed the night before - he was parked at the aviary. We took Dad to bed ourselves - his brief was wet - we changed him and transferred him to bed. He was really tired ... We know he was not moved (at least from) mid-morning to 3:30 p.m. on [DATE]. He was in the same position (mid-afternoon of ,[DATE]) as 7:30 p.m. (on ,[DATE]), except the pillow was not between his legs." - The family member said they visited the resident around 10 a.m. on ,[DATE], then again at 1:30 or 2 p.m., and again at around 3:30 p.m. on [DATE] with a family member who had just flown in to visit. "The ladies were sitting at the nurses' station talking." The family member said that was when they first observed the odor of urine. "My sister said she thought he needed to be changed. He was reaching down towards his knee." She said they pulled back his covers and observed he was wet and surrounded by a large dried urine ring. He had no pillow between his knees, and his knees were drawn up, pressed against the wall, and bruised from lack of repositioning. He had not received oral care and appeared to have thrush at the back of his throat. "He was only there two weeks and five days...Mom was crying, saying, 'I knew better; I've got to take him home,'" said the family member. j. Staff Interviews (1) The DON and nursing home administrator (NHA) were interviewed at 10:50 a.m. on [DATE] about what occurred with resident #1. -The DON said the resident was admitted for respite care with "very advanced [MEDICAL CONDITION], a shuffling gait, using a walker." They started seeing a decline, and an increase in behaviors. ... We asked family if we could move him to the other end of the facility ... He became lethargic, we started talking to hospice. On ,[DATE], family came in around 3:30 p.m. and found him very wet, found some dried rings of urine. They talked to the nurse, who called in the SSD (manager on duty), and we investigated." -The DON said they interviewed the certified nurse aide (CNA #1) who was to provide care for resident #1 during the 10 a.m. to 2 p.m. shift on [DATE], who had not worked for the facility for very long. "On Monday morning I called him in and talked to him about the complaint. He said he thought the resident was actively dying. I asked him why he wouldn't report that to the nurse and provide care, thinking that was the case. I talked with other staff. The nurse said she went in twice with meds and a supplement, and covered (the resident) up, but didn't notice he was wet. The CNA's story didn't match the nurse's. (CNA #1) admitted no care on an eight hour shift, no mouth care, no changing. The oncoming CNA said a couple of other residents were wet, and she had a difficult time getting a complete report from (CNA #1). The family was really upset. (CNA #1) was terminated." -The NHA had been on vacation and was not in the facility when the incident was reported. The DON said the SSD looked at the resident's bed when she was called in to investigate, but she did not know if the urine ring was still there because the nursing staff were in the process of cleaning the resident and his bed. The DON said, "On rounds things look good; linens are dry. This was a one-time thing. We've never found a resident in that condition before. It was wrong, it happened, and I dealt with it." - Asked if they had taken other quality assurance steps to ensure residents were receiving adequate care, the DON said she and two assistant DONs were conducting "spot checking" to see if residents were wet. The DON said they had no documented toileting tracking, and instead they wanted to do more spot checking to ensure for themselves that residents were receiving care. The surveyor requested a copy of the facility's investigation of the incident, and the NHA and DON said they would have to request permission from their corporate office. When asked why nothing was documented in nurses' notes about the incident, the resident's condition, or an assessment of the resident after he was found in this condition, the DON said they were instructed by their corporate office to document their investigations as part of quality assurance, and not in the medical record. (Cross-reference F514, accurate and complete medical record.) (2) The SSD was interviewed, on [DATE] at 11:50 a.m. She said she received a call from a nurse on Sunday, [DATE]. The nurse told her "the family was upset about (resident #1) being left wet. One of the daughters had flown in to visit. It was around 3 p.m. They wanted to move him back to rehab and we made that happen. He was in bed, comfortable, getting care from the nurses when I arrived. I went down the rest of the hall to see if any of the other residents had problems. We determined the night shift had provided care, calmed the family down, got him moved back to the other side, got him settled and comfortable. This happened on a Sunday and I think he went home Tuesday. I heard he passed away on hospice care." (3) The licensed practical nurse (LPN #1) who worked with CNA #1, both of whom were assigned to provide care for resident #1 during the day shift on [DATE], was interviewed at approximately 12:15 p.m. on [DATE]. She said that on ,[DATE], "I told (CNA #1) to check his people. Family complained, I wrote up (CNA #1) that day and never saw him again. It seemed he was short with the residents; I had to remind him to do everything; I had to be on him. That was the only day I worked with (CNA #1)." - Asked if she checked on resident #1 herself, she said, "I checked on (him); he'd be repositioned - he'd done it himself. I recall blankets being twisted up. I'd rearrange the covers - I didn't smell anything or see wetness. I gave him [MEDICATION NAME] around 10 a.m. - he was very agitated." - Asked if she checked on the resident at the end of her shift, she said, "I didn't check on him right at 2 p.m., but I told (CNA #1) around one-ish to go ahead and check on his people." (4) The "oncoming" CNA (CNA #2), who worked ,[DATE] p.m. on ,[DATE] and was assigned to care for resident #1 was interviewed during mid-afternoon on [DATE]. She said, "I worked morning two shifts before ,[DATE] - the whole day (resident #1) was fine. I'd toileted him and he was fine. The next day I worked a different hall." -CNA #2 said she got report from CNA #1 at 2 p.m. on ,[DATE], and at 2:30 p.m., answered a call light from resident #1's roommate. "(Resident #1's) family was in the room with (resident #1); I didn't want to interrupt. It was about 3 p.m., and the family asked me to change and reposition (resident #1). ...I felt horrible. He was lying on his side facing the wall. You could tell by the spit on the side of his face, like he'd been lying there for hours. The urine on his pad was dry like it had been there a long time. He was still in his night gown - hadn't been gotten up for breakfast or lunch. His dentures were in and hadn't been cleaned since the ,[DATE] shift. He was facing the wall; his knees had developed bruising and were red; his face was red on that side from being on that side for a long time. His daughter said it looked like he had thrush. His mouth was full of phlegm and hadn't been swabbed. He hadn't been drinking any water ..." -CNA #2 said, "He was soaked clear through the pads, blanket, and bottom sheet. There was no pillow between his knees; his knees were against the wall. The nurse (LPN #2) observed all of this - I called her in. She looked at his skin, and saw the bruise and redness." CNA #2 said she thought the previous ,[DATE] p.m. shift had provided oral care for resident #1, but she doubted that the night shift (10 p.m. to 2 a.m.) did oral care. Asked how often she toileted resident #1, she said typically three times during a shift. (5) LPN #2, the nurse who was assigned to provide care to resident #1 on the [DATE] evening shift, ,[DATE] p.m., was interviewed at 3:55 p.m. on [DATE]. She said, "Around 3 or 3:30 p.m. (on ,[DATE]) the family told my aide (resident #1) was wet. Before I could find her (the CNA), they came back (to the nurses' station). It was horrible - I was very upset, too. My aide changed him; I think another new aide assisted her." Asked if she assessed the resident at that time, and what she observed, she said, "Other than lack of care, he was okay - no skin breakdown. His skin was red and bruised, with a 4x4 cm bruise inside his knee. Other than his knee and hip, he was good. Vital signs were normal. He was lethargic, but he'd been that way." - Asked if she completed an incident report, she said, "The manager on duty and upper manager do that (incident report and investigation). I wrote a statement, who reported to me, etc. We do it that way so we can keep all the information together." Asked if she documented her assessment of the resident, LPN #2 said, "Charting? I can't remember. I was pretty upset." Asked if she checked the resident's condition when she came on duty, including incontinence care, she said, "It shocked me about that aide (CNA #1)." - Asked if she checked residents herself to ensure they were receiving incontinence and ADL care, she said, "I check residents but don't check them for incontinence care. I went in around 2:30 or 2:45 p.m. and resident #1 was resting - I checked his vitals. He wasn't strong smelling enough, I guess, for me to smell him. I have allergies [REDACTED]. I think I was with staff giving him pain meds with his change so it wouldn't hurt to check the MAR for the time. He had pain with repositioning, I gave him [MEDICATION NAME] around 6 a.m., and he was cleaned and turned at that time. I guess the nurse has responsibility too, but we depend on our aides. The aides found a couple more residents wet (on the ,[DATE] p.m. shift who were assigned to CNA #1), but not that bad." (6) CNA #3, who provided care for resident #1 on the 10 p.m. to 6 a.m. night shift ,[DATE]-[DATE], was interviewed by phone on [DATE] at 10:15 p.m. She said, "The night I worked we'd go in, make sure he was turned, and check to see if he was wet. We do rounds at 12 p.m." She said she recalled changing resident #1 on the "first round" at 12 p.m., her co-worker CNA checked him at 2 a.m., and at 4 a.m., they both checked and he was changed. She said he was checked at 6 a.m., but she did not recall by whom, or if he was wearing dentures or a gown. She said he was up and awake at 10:30 p.m., and she "believed he got laid down" by her co-worker CNA but she did not recall if oral care was done. Asked if she did rounds to check on her residents upon arrival for her shift and immediately before her departure, she said, "Some people do." However, she had already indicated that her first rounds were done at 12 midnight. (7) CNA #1 was interviewed by phone at 4:30 p.m. on [DATE]. He had been assigned to provide care for resident #1 on the day shift of [DATE] from 6 a.m. to 2 p.m. He said, "I did provide care for (resident #1); they wouldn't listen to me. I changed his brief and (incontinence pad) once, and tried to reposition him. When I came to work (at 6 a.m. on ,[DATE]) he wasn't doing well. He kept throwing off his covers, leaning toward the wall. All I know is when I came in (the morning of ,[DATE]), I walked in, changed his brief, brought in his food for breakfast. I let the nurse know he didn't eat and was unresponsive. I may not have told her right away. I tried to feed him breakfast (a room tray), but he wouldn't eat." -During a follow-up interview on [DATE] at 11:40 a.m., CNA #1 said, "I know I messed up... (At 6:30 a.m. on ,[DATE]) I checked his brief, he was dry ... I don't recall if he was wearing dentures; he wore a blue brief, no clothes - he always slept like that." The CNA said he tried to feed resident #1 breakfast and lunch, but the resident "didn't eat - pocketed everything ... I had to go in with a glove and get the food out of his mouth." Asked if he reported this to the nurse, CNA #1 said, "They weren't listening to what I said ... When I tried to reposition him he would roll back over to his right side in a fetal position ... I attempted to feed him - he wouldn't eat. I told the nurse he wasn't eating but they say I didn't. I know I changed his brief." -Asked what times he saw the resident and what care he provided, CNA #1 said he could not recall exact times, but thought he saw the resident at 6:30 a.m., then when he passed room trays and came back to feed the resident, then tried to feed him lunch, and checked him before he left for the day. -When asked the facility's expectation for how often to check in on a resident, CNA #1 said, "Every 10 to 20 minutes, but I didn't do it with him that day. He was declining rapidly. ... I reported his condition to the nurse after breakfast and lunch - she said 'okay.' ... It was a bad day - there was too much going on. I didn't agree with what they wrote up." - To summarize, CNA #1 said, "He ate no breakfast or lunch; I charted it in the computer. He wouldn't take fluids either but I tried. I tried to give him water - I should've grabbed some swabs and swabbed his mouth. He wasn't able to use the straw. I talked to the nurse about breakfast and lunch - no fluids or food. I thought he was actively dying and I told the nurse that. I changed him two times - both times he was wet. He kept throwing off the covers - he didn't want me touching him. I didn't want to get hit. I thought he may have been in pain because of his face - eyes closed, frowning, lips moving. I didn't tell the nurse that. He looked that way every once in awhile." - Asked what he would have done differently for resident #1, the CNA said, "Lots of things ... got him up, gave him more attention, try harder. I'm not a horrible CNA." Review of the CNA's statements revealed he gave conflicting reports about the care he provided for resident #1, whether or not he changed the resident, whether the resident was wet or dry, and how often he attempted to provide care, checked on the resident, and reported to the nurse. Review of the nurses' documentation and statements revealed inconsistencies about the care the resident received, the supervision they provided for the CNAs, and the care they provided for the resident. (8) Resident #1's former roommate was interviewed at approximately 5 p.m. on [DATE]. Regarding resident #1, he said, "Truthfully, he didn't get the care he needed. His family came in and found him. He'd been lying in his urine all night and all day. I saw maybe one staff come in here one time all day. I don't recall the previous night." k. Documentation of ADLs According to resident #1's Meal Detail Report, he refused dinner on [DATE], refused breakfast and lunch on [DATE], and no dinner or bedtime snack was documented for him at all on [DATE]. On [DATE], he accepted a bedtime snack, but refused every other bedtime snack from ,[DATE] through [DATE]. - Fluid intake records were requested, but were not provided as of [DATE]. CNA #1 said resident #1 refused fluids on ,[DATE] and was unable to drink. - Bed mobility records revealed resident #1 needed extensive assistance, which was noted to occur two times on [DATE]: at 3:30 a.m. by CNA #3, 10:19 a.m., by CNA #1. All other ADL cares were noted at the same times by the same staff, but appeared to indicate what needs the resident had, not how often the ADL care was provided, as documentation on other days was similar to that noted above. 2. Observations on [DATE] During the onsite investigation initiated at 8:30 a.m. on [DATE], the following observations were made: a. At 8:50 a.m., the hallway outside room [ROOM NUMBER] had a strong odor of stale urine and feces. Neither of the residents were in the room. Upon entering the room, it was observed that the bedside commode (BSC) on the right side of the room had urine and feces inside, and a wad of toilet paper lay on the floor by the BSC. The surveyor went to the sink and observed there was no soap in the dispenser. The activity director and NHA were notified, and said the resident had just left her room and housekeeping had not yet been through that hall. b. At 10 a.m., the hallway outside the room shared by sample residents #2 and #3 smelled of stale urine. Both residents were sleeping in their beds, and no CNA was in sight. Neither of the residents was interviewable. - According to the ADON, one CNA was assigned per hall, and the CNA should be on the hall or could be on break. At 10:05 a.m., the CNA said both residents were toileted a half hour to 45 minutes ago. She checked resident #2, who she said was dry, and she said resident #3 could let them know when she needed to go to the bathroom. - Asked about the urine odor in the room, the CNA checked the wheelchair cushions in both residents' wheelchairs. They both smelled of stale urine, per observation of the CNA and the surveyor. The CNA removed the cushions from the residents' wheelchairs, and said she would ensure they were washed and get replacement cushions for both residents. She acknowledged that odorous wheelchair cushions indicated incontinence that was not adequately managed. c. A CNA who also worked with residents #2 and #3 was interviewed at 2:10 p.m. on [DATE]. She said resident #3 "is a very heavy wetter" and resident #2's urine "has always been very strong." She added the night shift was supposed to clean wheelchairs and cushions. She acknowledged that odorous wheelchair cushions should not be an issue if residents were toileted and changed adequately. d. At 4:45 p.m. on [DATE], resident #2 and #3's room still smelled of stale urine. The BSC on the right side of the room had been emptied but not rinsed. Urine was observed inside the BSC bowl and streaked on the seat. e. Observations during lunch and dinner on [DATE] revealed several residents were brought by staff to the dining room table with their hair uncombed, disheveled and unkempt. 3. Staff Interview The observations above were shared with the NHA and DON at approximately 5:45 p.m. on [DATE]. They said they would follow up with the nursing staff. The DON said CNA #3, who worked the night shift, said she had changed resident #1 at 4:30 to 4:45 a.m. on [DATE]. CNA #1 said he didn't report to the nurse, just "left him (resident #1) alone." Asked how the facility responded to the lack of supervision and care monitoring by the nurses, the DON said they did no formal counseling. The DON said it was her expectation that nurses check their residents to ensure they're receiving necessary incontinence care. 4. Resident Council Meeting Minutes Review of resident council meeting minutes for the last six months revealed residents complained of slow call light response. Specifically: - On [DATE], "Sometimes staff take a little longer answering call lights." - On [DATE], Nursing issues mentioned included "call lights, ice water - not getting enough, inconsistent staffing, bed change - not always been changed." - On [DATE], "Call lights are not within reach." - On [DATE], "Problem: Call lights being answered. (Resident) turns her call light (on, staff) comes in and turns it off, takes forever to come back ... Not enough staff at night." - On [DATE], "(Resident) stated her leg bag wasn't dumped all day, even though she had requested several times ... Call lights, unable to reach them at times ... (Resident) stated she only had 1 bath since she's been here! Also that some of the ,[DATE] staff unable to turn her over on her side, they get short with her, they have no patience." - On [DATE], "(Resident) stated having problems with nurses - sometimes they show up and sometimes they don't ... Ice water not being passed again ... Call lights out of reach." There was insufficient evidence of facility investigation and action on the above concerns voiced by the residents. Responses in concern forms involved talking to CNAs and reminding them to follow up, or instructing residents to inform their ambassadors (facility advocates) of their concerns if they were not resolved. However, several of the same issues continued to resurface during resident council.