Every finding on record at Irondale Post Acute

Based on observations, interviews and record review, the facility failed to ensure one (#25) of two residents reviewed for range of motion received services and assistance to prevent a reduction in range of motion out of 35 sample residents. Resident #25 was admitted to the facility on [DATE]. According to the resident's diagnoses on admission, Resident #25 did not admit to the facility with bilateral hand contractures. On 9/9/25 a joint mobility evaluation was completed which indicated Resident #25's right wrist and right fingers had minimum range of motion limitations and left wrist and fingers had moderate range of motion limitations. He had resting bilateral hand splints and was placed on occupational therapy (OT) services for contracture management.The 11/6/25 OT discharge summary revealed the resident was placed on a restorative splint and brace program with bilateral upper extremity orthotics daily as tolerated. The prognosis to maintain the resident's current level of function was good with consistent staff follow through.However, documentation in Resident #25's electronic medical record (EMR) revealed inconsistent application of the resident's bilateral hand splints.The facility's failure to provide consistent services to maintain the resident's mobility contributed to a decline in the mobility of Resident #25's left and right hand (see below).On 1/8/26 a joint mobility was completed which indicated Resident #25's right wrist had minimum range of motion limitations, his right fingers had moderate range of motion limitation and his left fingers had moderate range of motion limitations. The evaluation indicated the change since the last assessment had worsened. The evaluation revealed the resident was working with skilled physical therapy and occupational therapy to return to the prior range of motion for all joints.The 2/3/26 OT discharge summary revealed the long-term goal was for Resident #25 to safely wear a resting hand splint on the left and right hands for up to six hours with minimal signs and symptoms of redness, swelling, discomfort or pain. The resident was tolerating resting hand splints for six hours per day upon discharge from therapy services.However, observations during the survey (from 2/9/26 to 2/12/26) revealed the resident did not have resting hand splints on and he was unable to extend his fingers independently. The facility failed to consistently provide the resident interventions to prevent a reduction in the resident's range of motion of his hands. Specifically, the facility failed to ensure Resident #25's contracture prevention devices were consistently in place.Findings include: I. Facility policy and procedure The Range of Motion and Contracture Prevention policy and procedure, revised November 2023, was provided by the nursing home administrator (NHA) on 2/12/26 at 2:31 p.m. It revealed in pertinent part, To assist residents in restoring and or maintaining joint function through a comprehensive interdisciplinary approach to joint mobility and proper positions.II. Resident #25 A. Resident statusResident #25, age less than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included frontotemporal neurocognitive disorder (a neurological disease causing dementia early on), multiple myeloma (cancer of blood cells), bilateral osteoarthritis of the knee, type 2 diabetes mellitus, generalized idiopathic epilepsy, stage 2 chronic kidney disease, atherosclerotic heart disease (build up of fat, cholesterol along the artery walls), encephalitis (inflammation of the brain), Pick's disease (form of dementia), stiffness of unspecified joint, other reduced mobility, muscle weakness, and difficulty walking. The 2/1/26 minimum data set (MDS) assessment revealed a brief interview for mental status (BIMS) assessment was not conducted because the resident was rarely or never understood. According to the staff assessment for mental status, the resident had short and long-term memory problems and his cognitive skills for daily decision making were moderately impaired.The MDS assessment revealed there was no indication of a splint or brace assistance. B. Resident representative interview Resident #25's representative was interviewed on 2/9/26 at 1:11 p.m. The representative said Resident #25 developed contractures in both hands and she said Resident #25's contractures had worsened. She said she tried to make suggestions to the nursing staff, such as having the resident hold a small rubber football in his hand. She said the facility told her Resident #25 complained of pain when they tried to use the football. She said Resident #25 wore a brace and went to therapy to help make the contractures not worsen. C. ObservationsOn 2/9/26 at 11:09 a.m. Resident #25 was in the common area of the secure unit in his wheelchair. Both the resident's right and left hands were contracted and his fingers on both hands were touching the palms of his hands. The resident was not wearing hand splints on either hand. During a continuous observation on 2/10/26, beginning at 10:24 a.m. and ending at 12:50 p.m., Resident #25 was observed in the common area of the secure unit in his wheelchair. Resident #25 did not have a brace or a splint on either hand. D. Record review The mobility care plan, initiated 5/22/25 and revised 9/9/25, revealed Resident #25 had limited physical mobility related to contractures on bilateral hands and wrists. Interventions included to monitor, document and report to the physician as needed signs and symptoms of immobility including contractures forming or worsening, thrombus (blood clot) formation, skin-breakdown and fall related injury. Additional interventions included providing gentle range of motion as tolerated with daily care and providing supportive care and assistance with mobility as needed and documenting assistance as needed.-The care plan failed to indicate where the gentle range of motion should be utilized. The musculoskeletal care plan, initiated and revised on 2/6/26, revealed Resident #25 had an alteration in musculoskeletal status related to bilateral hand and wrist contractures. Interventions included anticipating and meeting the resident's needs, encouraging the use of supportive devices, such as bilateral resting hand splints, giving analgesics as ordered by the physician and monitoring for fatigue and needing to change position. A review of Resident #25's February 2026 CPO revealed the following physician's order: Bilateral resting hand splints as tolerated up to eight hours, ordered 2/9/26 (during the survey). -However, observations during the survey revealed the resident did not have the hand splints applied to his bilateral hands (see observations above). The 9/9/25 joint mobility evaluation revealed it was the initial evaluation. Resident #25's right wrist and right fingers had minimum range of motion limitations and his left wrist and fingers had moderate range of motion limitations. The evaluation revealed Resident #25 had bilateral resting hand splints. Resident #25 had hypersensitivity for limited tolerance for splint application and contracture management. The 11/6/25 occupational therapy discharge summary revealed the goal to use upper extremity support and orthotics to be utilized with good tolerance three times a week in order to decrease pain and further contractures and skin breakdown was met on 11/6/25. The discharge summary revealed at time of discharge, Resident #25 had upper extremity support and orthotics utilized five times a week by a certified nurse aide (CNA) and restorative nursing program. The discharge recommendation and status revealed the discharge recommendation was to continue orthotic management with staff. The restorative program was established and staff was trained for a restorative splint and brace program. The splint and brace program was bilateral upper extremity orthotics daily as tolerated. The prognosis to maintain the resident's current level of function was good with consistent staff follow through. The November 2025 restorative care plan documentation revealed the resident received passive range of motion and splint or brace assistance. The goals were splint placement to bilateral hands and wrist three to five times a week and range of motion with placement of splint. The duration was as tolerated with documentation of hours and time of splint tolerance. The December 2025/January 2026 restorative care plan documentation revealed the resident received passive range of motion, active range of motion and splint or brace assistance. The goals were active range of motion reaching table games, range of motion gentle stretching and splint training and placement as tolerated, three to five times per week up to eight hours as tolerated when out of bed. The resident refused the program on 1/2/26, 1/3/26 and 1/4/26. -There was no documentation of splint placement from 12/4/25 to 12/12/25. -There was no documentation to indicate why the resident refused the restorative program on 1/2/26 through 1/4/26. The 1/8/26 joint mobility evaluation revealed Resident #25's right wrist had minimum range of motion limitations, his right fingers had moderate range of motion limitation and his left fingers had moderate range of motion limitations. The evaluation indicated the change since the last assessment (9/9/25) had worsened. The evaluation revealed the resident was working with skilled physical therapy and occupational therapy to return to the prior range of motion for all joints. -The evaluation revealed the resident's contractures had worsened from 9/9/25 to 1/8/26. The 2/3/36 occupational therapy discharge summary revealed occupational therapy treated Resident #25 from 1/8/26 to 2/3/26. It revealed the short term goal met on 2/3/26 was for the resident to tolerate 15 to 30 minutes of passive range of motion on bilateral upper extremities on all appropriate planes with decreased pain as noted by grimacing and behaviors in preparation for resting hand splints to reduce further contractures and promote skin integrity. On 1/8/26 Resident #25 tolerated passive range of motion with moderate and maximum grimacing secondary to pain. On 1/26/26 Resident #25 tolerated passive range of motion stretching while seated in chair with moderate grimacing and verbal behavior secondary to pain. On 2/3/26, the discharge date , Resident #25 tolerated passive range of motion stretching while seated in a chair with moderate grimacing and verbal behaviors secondary to pain. The long-term goal was Resident #25 would safely wear a resting hand splint on his left and right hand for up to six hours per day with minimal signs and symptoms of redness, swelling, discomfort or pain. The 1/8/26 baseline tolerance of the splints was four hours. The 1/26/26 tolerance of the splints was five hours and on 2/3/26, the discharge, the resident's tolerance of the splints was six hours. III. Staff interviews Certified nurse aide (CNA) #6 was interviewed on 2/11/26 at 4:55 p.m. CNA #6 said restorative aides were responsible for carrying out any resident's restorative nursing plan. CNA #6 said she sometimes put a splint or a brace on for residents but she did not do range of motion. She said she knew if a resident was on a restorative program based on a verbal report. She said she only knew of one resident, Resident #25, who was on a restorative program. CNA #6 said she did not know if the restorative program was documented anywhere and she said she did not document if she placed a brace or splint on a resident. She said she was familiar with Resident #25. CNA #6 said Resident #25 was admitted to the facility with no contractures. CNA #6 said she knew some staff had a hard time putting the splint and brace on Resident #25 because if he did not know the person, he refused care. CNA #6 said she sometimes put the brace on and she said she was told to put the brace on for two hours. Registered nurse (RN) #3 was interviewed on 2/12/26 at 10:49 a.m. RN #3 said she had worked at the facility for a month. She said therapy was responsible for restorative nursing. She said she did not know if CNAs were trained on restorative services. RN #3 said there was a schedule for residents who were on a restorative program. RN #3 said she had not seen a resident on a restorative nursing program since she worked here. RN #2 was interviewed on 2/12/26 at 11:02 a.m. RN #2 said therapy was responsible for restorative nursing. She said therapy and restorative nursing kept a paper list of residents who required splints, braces and range of motion. RN #2 said besides the paper list, if a CNA provided restorative nursing, it would be documented in the resident's chart under CNA tasks. RN #2 said there would be a physician's order for a splint or brace after the resident graduated from therapy. RN #2 said therapy provided an inservice on the resident's needs. RN #2 said she was familiar with Resident #25. She said his restorative plan was for his knee and a splint for his hands. RN #2 said he should wear his brace during the day. RN #2 said he received range of motion during his daily cares, such as when CNAs would get him ready in the morning. The assistant director of nursing (ADON) was interviewed on 2/12/26 at 1:59 p.m. The ADON said she was responsible for the restorative nursing program and she had two restorative aides. She said she knew which residents were on a restorative program because therapy entered their orders on the care plan which triggered the CNA tasks. The ADON said the restorative program was documented in the care plan, the CNA's tasks and the orders. The ADON said if a resident required a splint or brace, it would show up on the CNA tasks and care plan. The ADON said therapy monitored if contractures worsened. The ADON said she was familiar with Resident #25. She said his contracture management plan was for him to wear a brace when out of bed and when tolerated. The ADON said Resident #25 received therapy the entire time up until this week (week of 2/9/26) when he transitioned to restorative nursing.-However, the resident's discharge summary from therapy was documented on 2/3/26, one week prior (see above). The director of rehabilitation (DOR) was interviewed on 2/12/26 at 2:43 p.m. The DOR said the ADON was responsible for the restorative nursing program. She said a resident started a restorative nursing program after therapy determined the resident met or exceeded expectations and the resident was ready for restorative nursing. She said the occupational therapy discharge summary talked about the restorative nursing plan. The DOR said CNAs were trained on the restorative nursing program and the training was also documented on the therapy discharge summary. The DOR said she was familiar with Resident #25. The DOR said Resident #25's representative had voiced her concerns about Resident #25's hands and wrists over the last couple of months. The DOR said Resident #25 was specific about the staff who cared for him and every session therapy had with him, there was long passive range of motion, including stretching before putting on the brace. The DOR said she completed the joint mobility evaluation on 1/8/26 at the request of nursing staff because nursing was worried about reduced range of motion in Resident #25's fingers. IV. Facility follow up The facility provided a 2/13/26 joint mobility evaluation (completed after the survey exit) that documented Resident #25's current range of motion limitations were none for the left wrist and minimum for his left fingers. -However, the evaluation did not document evaluation of the resident's right wrist or right fingers to determine if the right wrist or right fingers had worsened.

Based on observations, record review and interviews, the facility failed to ensure one (#25) of three residents out of 35 sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to:-Obtain accurate wound care orders for Resident #25 in a timely manner; and, -Ensure interventions were followed for Resident #25 to prevent an abrasion to the resident's back.Findings include:I. Facility policy and procedure The Wound Care and Treatment Guideline policy and procedure, revised May 2024, was provided by the nursing home administrator (NHA) on 2/12/26 at 4:24 p.m. It read in pertinent part, Treatments will be placed in the electronic medical record (EMR), treatments can be triggered under the EMAR (electronic medication administration record) or TAR (treatment administration record). A licensed nurse will monitor the wounds with treatments and scheduled assessments. Treatments will be placed in the computer upon order from the physician.II. Resident #25A. Resident status Resident #25, age less than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included frontotemporal neurocognitive disorder (a neurological disease causing dementia early on), multiple myeloma (cancer of blood cells), bilateral osteoarthritis of the knee, type 2 diabetes mellitus, generalized idiopathic epilepsy, stage 2 chronic kidney disease, atherosclerotic heart disease (build up of fat, cholesterol along the artery walls), encephalitis (inflammation of the brain), Pick's disease (form of dementia), stiffness of unspecified joint, other reduced mobility, muscle weakness and difficulty walking. The 2/1/26 minimum data set (MDS) assessment revealed a brief interview for mental status (BIMS) assessment was not conducted because the resident was rarely or never understood. According to the staff assessment for mental status, the resident had short and long-term memory problems and his cognitive skills for daily decision making were moderately impaired.B. Resident's representative interview Resident #25's representative was interviewed on 2/9/26 at 1:11 p.m. The representative said Resident #25 had a wound on his back because he was always bending his back to the right side because he could not hold himself upright. She said she asked the facility to put a pillow on the armrest of the wheelchair to help balance him when he sat in his wheelchair. She said he never had wounds. C. Observations During a continuous observation on 2/10/26, beginning at 10:24 a.m. and ending at 12:50 p.m., Resident #25 was observed in the common area of the secure unit in his wheelchair. He did not have a pillow on his arm rest or behind his back. On 2/11/26 at 8:16 a.m. Resident #25's wound care was observed with the wound care physician (WCP) and the wound care nurse. The resident was in bed, lying on his back. The resident's wound had a hardened crust in a lateral pattern on the right flank. The color appeared to be dark brown with a pink dry center. There was no drainage noted. The surface of the resident's skin appeared to be uneven, dry, and rough. No redness or swelling was noted on the surrounding skin. The resident did not appear to have pain while having his wound assessed. The resident's head was elevated on a pillow, and he did not have any offloading measures on his right flank before the WCP began the wound care. On 2/11/26 at 4:55 p.m. Resident #25 was observed in the common area of the secure unit in his wheelchair. He did not have a pillow on his armrest or behind his back. At 5:20 p.m. (following an interview with certified nurse aide (CNA) #6 - see below), CNA #6 placed a pillow behind Resident #25's back. D. Record reviewThe skin integrity care plan, initiated and revised on 2/2/26, revealed Resident #25 had an actual impairment to skin integrity related to an abrasion to the right side of his back. Interventions included administering treatments as ordered, educating the resident, family and caregivers of causative factors and measures to prevent skin injury, encouraging good nutrition and hydration, observation of resident transferring, sling fit, padding the resident's bed rails and wheelchair arms, providing a pillow to the right side of the resident's high back wheelchair for positioning as he would allow, using caution during transfers and bed mobility to prevent striking the resident's arms, legs and hands against sharp or hard surfaces. -However, Resident #25 did not consistently have a pillow to the right side of his wheelchair (see observations above). The 2/10/26 Kardex (an abbreviated care plan utilized to provide consistent resident care by staff) revealed there were no instructions on pillow positioning or wedge use for the resident when he was in his wheelchair. A review of Resident #25's February 2026 CPO revealed the following physician's orders: Skin alteration: wound to right side of back. Monitor for signs and symptoms of infection. Notify the physician of any changes every shift, ordered 1/31/26. -However the WCP's 2/4/26 wound care notes indicated the treatment orders were changed on 2/4/26 (see WCP notes below). Monitor skin: right flank, abrasion. Cleanse site with wound cleanser and normal saline. Pat dry with a clean gauze, apply hydrocolloid (a moisture-retentive wound dressing for superficial wounds)to the affected area, twice a week and as needed for skin alteration prevention. Report to primary care physician if infection or worsening is noted. Offload pressure areas every day shift every Wednesday and Sunday for skin alteration prevention per wound care physician, ordered 2/11/26. Monitor skin: right flank, abrasion. Cleanse site with wound cleanser and normal saline. Pat dry with a clean gauge, apply hydrocolloid to the affected area, twice a week and as needed for skin alteration prevention. Report to primary care physician if infection or worsening is noted. Offload pressure areas as needed, ordered 2/11/26. -However, the above two physician's orders were added on 2/11/26, during the survey after the WCP's interview (see interview below). The 1/29/26 skin evaluation revealed Resident #25 had no new skin issues noted at this time. Turgor (the skin's elasticity and its ability to change shape and return to normal) and temperature were within normal limits. The 1/31/26 skin evaluation revealed Resident #25 had an open area to the right side of his lower back measuring 8 centimeters (cm) in length by 1.5 cm in width. The wound was linear, the wound bed was pink and moist. There was no active bleeding and no signs of infection. There was a periwound (the skin and tissue immediately surrounding a wound) with dark brown discoloration. The 1/31/26 nurse note revealed that at 5:30 a.m. a CNA notified the nurse of Resident #25's open area to the right side of his back. The open area measured 8 centimeters in length by 1.5 cm in width. The wound was linear, the wound bed was pink and moist. There was no active bleeding and no signs of infection. There was a periwound with dark brown discoloration. The wound was cleansed with a wound cleanser and gently patted dry and a dressing was applied. Resident #25 tolerated the treatment well. The physician was notified and staff were unable to reach the resident's representative. The 2/4/26 WCP wound tracker form revealed Resident #25 had a wound on his right flank and the etiology was an abrasion. The dimensions were 0.5 cm in length by 5 cm in width by 0.1 cm in depth. Epithelial tissue (the new, regenerated skin that grows over a wound surface, appearing as a thin, pale pink or pearly white layer) was 100% (percent) and the periwound was discolored. The treatment was hydrocolloid twice a week and as needed. -However the hydrocolloid treatment orders from the wound tracker form were not entered into Resident #25's EMR until 2/11/26 (during the survey- see physician's orders above). The 2/9/26 nurse note revealed Resident #25's representative was updated on the abrasion to the resident's back. A pillow was in place to the right side of the resident's high back wheelchair for positioning.-However, observations on 2/10/26 and 2/11/26 revealed staff were not consistently placing the pillow in the resident's wheelchair (see observations above). The 2/11/26 WCP wound tracker form revealed Resident #25 had a wound on his right flank and the etiology was an abrasion. The dimensions were 0.5 cm in length by 5 cm in width by 0.1 cm in depth. The treatment was hydrocolloid twice a week for prevention. E. 1/3/26 Incident report The 1/31/26 nurse note revealed that at 5:30 a.m. a CNA notified the nurse of Resident #25's open area to the right side of his back. The open area measured 8 centimeters in length by 1.5 cm in width. The wound was linear, the wound bed was pink and moist. There was no active bleeding and no signs of infection. There was a periwound with dark brown discoloration. The wound was cleansed with a wound cleanser and gently patted dry and a dressing was applied. Resident #25 tolerated the treatment well. The physician was notified and staff were unable to reach the resident's representative. The 2/2/26 nurse clinical resource statement documented an observation of a transfer of Resident #25 related to skin alteration. There were no concerns with the fit of the transfer sling, bed mobility or transfer noted. Per staff, Resident #25 leaned to the right side in his wheelchair at times. Currently, there was a pillow on the right side. There were no sharp edges noted to the wheelchair. The resident denied pain, laughing and talking in word salad at the time of review. The 2/2/26 interdisciplinary (IDT) team note revealed they met to review Resident #25's skin alteration. The risk factors were poor motor control, diabetes mellitus type 2, noted to favor leaning to his sides, and the placement of wheelchair padding. Education provided to staff was notifying the resident's representative of the padding placement on the wheelchair due to the resident's skin alteration. -However, there was no documentation in Resident #25's EMR of the IDT note. III. Staff interviewsWound care nurse #1 and the WCP were interviewed together on 2/11/26 at 1:30 p.m. Wound care nurse #1 said he started seeing Resident #25 today (2/11/26) at 8:15 a.m. The WCP said she started seeing Resident #25 last week (on 2/4/26). The WCP said Resident #25 was at risk for skin breakdown. The WCP said some of the interventions to prevent skin breakdown included a hydrocolloid dressing. The WCP said she ordered the hydrocolloid dressing last week (on 2/4/26) and would continue with the same treatment this week. The WCP said she communicated what interventions the facility should use by completing a wound assessment sheet with the recommendation and measurements and returning the sheet to the director of nursing (DON). The WCP said she would want to see the recommendations entered as physician's orders and interventions passed along to the floor staff. The WD said she had not assessed the resident's wound after initial onset (on 1/31/26) because she was not assigned to Resident #25. The WCP said she was told the wound was caused by moisture. The WCP said ordered interventions must be implemented to assess the effectiveness of the treatment. The WCP said if Resident #25 was in his wheelchair for three hours without a pillow on his right side, the facility was not following the physician ordered interventions. The WCP said the wound treatment order was going to continue to be the same from last week and there were no changes. CNA #6 was interviewed on 2/11/26 at 4:55 p.m. CNA #6 said she knew what interventions to use to help a resident who had skin conditions from her CNA training. She said repositioning was one intervention to prevent skin breakdown, as well as not pulling on residents because a lot of residents' skin was thin and was easy to tear. CNA #6 said interventions were documented as a task in the resident's EMR and in the resident's care plan. CNA #6 said another skin breakdown intervention was to keep residents away from walls. CNA #6 said if she noticed a change in a resident's skin, she would notify the nurse in the unit. CNA #6 said she was familiar with Resident #25. She said he had an abrasion on his back. CNA #6 said she did not know how it happened but based on where the abrasion was located, she thought it happened because of a screw located on his wheelchair. She said no one educated her on what interventions were in place for the resident, but she placed a pillow on his back to help him from leaning on one side of his wheelchair. -After the interview, CNA #6 was observed placing a pillow on the back of Resident #25 while he was in his wheelchair in the common area of the secure unit (see observations above). Registered nurse (RN) #3 was interviewed on 2/12/26 at 10:49 a.m. RN #3 said she had worked at the facility for one month. RN #3 said residents' skin was assessed per physician's orders, once a week. RN #3 said she assessed residents if the CNA reported a change to the resident's skin. RN #3 said she notified the physician anytime there was a change in the resident's skin, such as a skin tear. RN #3 was familiar Resident #25. She said he had a skin condition on his back but it was healed. She said she did not know what caused the skin condition. She said an intervention was in place to keep a pillow on his back. RN #2 was interviewed on 2/12/26 at 11:02 a.m. RN #2 said residents' skin was assessed at admission, the following day, weekly and as needed. She said skin assessments were documented in the assessment tab of the resident's chart. She said the physician and the DON or the assistant director of nursing (ADON) were notified when a skin problem was identified. She said when a new skin condition was identified, a risk assessment was initiated which included a skin assessment and pain assessment, treatment orders were obtained if applicable and the physician, family and ADON or DON were notified. RN #2 said skin assessments should be completed every shift if a skin condition was identified to monitor for signs and symptoms of infection. RN #2 said she knew what interventions were in place based on a physician's order. RN #2 was familiar with Resident #25. She said he had a skin condition on his back but it was healed. She said the way Resident #25 sat and the fact that he was restless was what caused his abrasion. She said a pillow placed on his back to prevent him from leaning was one intervention. The ADON and the clinical resource were interviewed together on 2/12/26 at 1:48 pm. The ADON said residents' skin was assessed at admission, the following day, weekly and as needed. She said skin assessments were documented in the assessment tab of the resident's chart. The ADON said the physician should be notified of any skin conditions other than the skin being intact. The ADON said when a new skin condition was identified, a risk assessment was started, treatment done and an intervention was identified. She said after a skin condition was identified, skin should be assessed based on the physician's order, but at least monitoring every shift for signs and symptoms for signs and symptoms for infection. The ADON said the treatment order depended on the physician's order. The ADON said the IDT determined the interventions within 24 hours or the next business day. She said the IDT followed a template that included the dimension, location, measurement and what the care plan should be. She said the ADON, therapy and nutrition were part of the IDT. She said the IDT notes were in risk assessment which was separate from the resident's chart. The ADON said sometimes the IDT note was in the resident's chart. The ADON said interventions could be a physician's order, such as skin treatments. an air mattress or a bed bolster. The ADON said the interventions would be found in the residents' care plans. The ADON was familiar with Resident #25. She said he had an abrasion on his back but it was resolved. She said he moved around in his wheelchair so that was why they padded his wheelchair armrest. She said in addition to the padded armrest, other interventions included a pillow. She said the pillow could be anywhere on the back of the resident. She said if the resident was leaning to one side and the pillow was positioned to help him sit straight, that would be an effective intervention. The clinical resource said hydrocolloid was also an intervention because the WCP said Resident #25 had folds on his sides from leaning and the hydrocolloid helped prevent friction. The clinical resource said during the facility's wound audit this week (week of 2/9/26), the WCP shared the clinical resource the process for how the WCP's treatment orders were communicated from the WCP to the floor nurse. The clinical resource said the process should be the wound care nurse was to transcribe the treatment order from the wound tracker form into the resident's chart the day the WCP visited. The clinical resource said wound care nurse #1 told her he was not given the wound tracker form from 2/4/26 and that was why the physician's order for the hydrocolloid treatment had not been entered into the resident's EMR. The clinical resource said the facility should have followed the WCP orders from 2/4/26. IV. Facility follow-up On 2/13/26 at 5:00 p.m. (after the survey exit), the nursing home administrator (NHA) provided the following information. The NHA indicated education was provided to nurses and CNAs on 2/2/26 instructing if the nurse or CNA observed a new skin integrity, they were to notify the nurse immediately. Staff was reminded to provide individualized care following the care plan: turning and repositioning, offering assistance with fluids, offering assistance with a snack, offloading heels by placing them on a pillow or in heel boots as ordered, applying barrier cream and assisting with toileting. Additionally, a wound program review was completed on 2/2/26. It revealed that the facility's wound program was for complex or nonhealing wounds, including but not limited to, pressure injuries, surgical wounds, stasis ulcers and diabetic ulcers. The wound care nurse and the IDT should confirm the following were in place: wound entered on wound rounds log, enhanced barrier precautions ordered and in place if indicated, nutrition at risk meeting list updated, therapy referral as applicable, appropriate treatment in place and comprehensive care plan in place, including factors leading to development and risk for delayed healing and interventions.-However, the WCP's orders from the wound tracker form were not entered into Resident #25's medical record on 2/4/26 (see above).

Based on interviews and record review, the facility failed to ensure that two (#51 and #12) of four residents reviewed for abuse out of 35 sample residents were kept free from physical abuse.Specifically, the facility failed to protect Resident #51 and #12 from abuse towards each other.Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, revised December 2025, was provided by the nursing home administrator (NHA) on 2/12/26 at 2:08 p.m. It read in pertinent part, It is the policy of this facility that reports of abuse, neglect, misappropriation of property, and exploitation are promptly and thoroughly investigated. When an incident or suspected incident of abuse or neglect is reported, the administrator or designee investigates the incident with the assistance of appropriate personnel. A licensed nurse examines the resident upon receiving reports of alleged physical or sexual abuse and records findings in the resident's medical record. The investigation consists of at least the following: a review of the completed complaint report, an interview with the person(s) reporting the incident, interviews with any witnesses to the incident, an interview with the resident if possible, a review of the resident's medical record, and interviews with staff members having contact with the resident during the period/shift of the alleged incident if applicable, and a review of all circumstances surrounding the incident.II. Physical abuse incident between Resident #51 and Resident #12 on 2/4/26A. Facility investigationThe facility investigation was provided by the NHA on 2/10/26 at 2:15 p.m.The investigation documented that at approximately 3:30 pm on 2/4/26, Resident #51 reported to staff that her roommate, Resident #12, had walked over to her and bopped her on the shoulder. An investigation was immediately started. Residents #12 and #51 were assessed and were found to have no pain, injuries, bruising or signs of distress. Resident #12 was interviewed by the social services director (SSD) on 2/4/26 and the resident denied any physical contact with Resident #51. The investigation documented Resident #51 was interviewed by the SSD on 2/4/26, and stated her roommate walked over to her and bopped her on the shoulder. Resident #51 was offered a room move, which she accepted and was immediately moved to a different unit. Resident #51 denied any fear of Resident #12.The investigation revealed that both residents were placed on 15-minute checks and psychosocial monitoring was ordered for both residents.-The investigation revealed the facility interviewed several staff members during the investigation, however, none of the staff members interviewed typically worked on the unit and were not present during the 2/4/26 altercation between the two residents. Cross reference F610 for failure to investigate an alleged violation.B. Resident #51 (victim)1. Resident statusResident #51, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included schizophrenia, anxiety disorder, repeated falls, cognitive communication deficit, muscle weakness, and drug-induced subacute dyskinesia.The 12/8/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required moderate assistance with toileting, supervision with eating and personal hygiene. The assessment indicated the resident did not exhibit physical or behavioral symptoms towards others.2. Resident interviewResident #51 was interviewed on 2/10/26 at 12:15 p.m. Resident #51 said she remembered the incident of aggression towards her by Resident #12. She said she was sitting in her wheelchair facing her bed, reading her Bible and praying. She said her roommate at that time (Resident #12) approached from behind her and hit her on her right shoulder, causing severe pain in her right shoulder. Resident #51 said she yelled at Resident #12 to leave her alone, but Resident #12 refused to leave and stayed by her side of the room. Resident #51 said she wheeled herself out of the room to report the incident to staff. 3. Record reviewResident #51's dementia care plan, revised 3/1/23, revealed she was at risk for impaired cognitive function or impaired thought processes related to chronic mental illness, schizophrenia, and neurocognitive disorder with behavioral disturbances. Pertinent interventions included engaging the resident in simple, structured activities that avoided overly demanding tasks, identifying oneself at each interaction, facing the resident when speaking, making eye contact, and monitoring, documenting and reporting to the medical director any changes in cognitive function, specifically changes in decision-making ability, memory, recall and general awareness.Resident #51's psychotropic medication care plan, revised 1/20/26, documented that she received psychotropic medication due to schizophrenia. Pertinent interventions included monitoring for episodes of verbal aggression, mood instability and one-on-one removal from the environment. A 2/4/26 social services progress note documented that the social services director (SSD) contacted Resident #51's representative to inform her of a room change for the resident's safety reasons.On 2/4/26 at 4:56 p.m. a psychosocial follow-up note documented that Resident #51's mood and behavior were assessed. She was located in the common area during the observation. Resident #51 stated she was doing well but would like a different roommate.C. Resident #12 (assailant)1. Resident statusResident #12, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included schizoaffective disorder, bipolar type, muscle weakness, and muscle wasting and atrophy.The 1/2/26 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. She was independent with mobility, personal hygiene, toileting, and eating. The MDS assessment indicated the resident did not exhibit physical behaviors directed towards others and did not reject care.2. Resident interviewResident #12 was interviewed via a translator language line in her native Russian language on 2/10/26 at 1:15 p.m. Resident #12 said she was asleep on the afternoon of 2/4/26 and had a dream in which her roommate prayed against her Christian faith. She said she went over to her roommate's side of the room to ask her to stop praying. Resident #12 said her roommate was sitting in her wheelchair, facing her bed. She said she approached her and touched her on her right shoulder, but Resident #51 turned and hit her on her collarbone. She said she had severe pain in the area of her left collarbone where Resident #51 had hit her. She said her roommate, Resident #51, cursed at her earlier that day while entering the bathroom.3. Record reviewResident #12's behavior care plan, revised 3/7/23, documented the resident had a potential for a mood and/or behavior problem related to diagnoses of schizoaffective disorder, bipolar type. Resident #12 maintained a long history of paranoia, delusions, and hallucinations that were religious and persecutory in nature. She exhibited verbal and physical aggression. Pertinent interventions included anticipating and meeting the resident's needs, approaching the resident in a calm manner, assisting the resident to develop more appropriate methods of coping, interacting, and encouraging the resident to express feelings appropriately.Resident #12's antipsychotic medication care plan, revised 2/9/26, documented that she was on prescribed antipsychotic medication for schizoaffective disorder and to monitor her for verbal and physical aggression and hallucinations.-The care plan failed to address appropriate supervision due to hallucinations and mood when Resident #12 was in her room.The care plan acknowledged that Resident #12's hallucinations were religious and persecutory in nature and that she exhibited verbal and physical aggression. -However, the care plan failed to include specialized strategies to de-escalate these specific psychiatric triggers.III. Staff interviewsCertified nurse aide (CNA) #2 was interviewed on 2/10/26 at 2:31 p.m. CNA #2 said she was familiar with the care of Resident #51 and Resident #12. She said Resident #12 had a documented history of aggression toward staff and other residents. CNA #2 said Resident #12 often refused to take her psychotropic medications, which had resulted in hospitalization in the past. CNA #2 said Resident #51 held strong religious beliefs and did not celebrate several holidays that did not align with her faith. She said Resident #51 often prayed openly in her room and liked to talk to others about her Christian faith.Registered nurse (RN) #1 was interviewed on 2/10/26 at 2:45 p.m. RN #1 said she knew of the incident between Resident #12 and Resident #51 and said both residents attacked each other. She said she was off duty the day of the incident. She said Resident #12 had a tendency to refuse medication and could be aggressive towards others. She said Resident #12 kept to herself most of the time due to her language barrier. RN #1 said Resident #51 often read her Bible and prayed in her room. She said that, as a result of the altercation, Resident #51 moved to another unit. RN #1 said Resident #51 told her that her roommate (Resident #12) had hit her on her right shoulder.The assistant director of nursing (ADON) was interviewed on 2/12/26 at 10:05 a.m. The ADON said she was present in the building when the altercation between Resident #51 and Resident #12 occurred on 2/4/26. The ADON said Resident #51 came to her office to report the incident of alleged physical abuse to her, and she completed a skin assessment of the resident; however, she did not document her evaluation in the resident's electronic medical record (EMR). The ADON said that a few moments after she spoke with Resident #51, her roommate, Resident #12, arrived at her office, also alleging that her roommate hit her on her left collarbone. She said both residents were separated and 15-minute checks were initiated.The NHA and the social services director (SSD) were interviewed together on 2/12/26 at 11:45 a.m. The NHA said RNs were required to complete an assessment when allegations of abuse were reported. The NHA said both Resident #51 and Resident #12 were assessed, and an investigation was initiated immediately. He said the allegations of abuse were unsubstantiated because there were no witnesses to the allegation.-However, abuse occurred because both residents said the other resident hit them.The SSD said he interviewed both Resident #51 and Resident #12 and followed up to complete psychosocial assessments. The SSD said he interviewed staff from management to ensure there were no widespread allegations of abuse.

Based on record review and interviews, the facility failed to protect one (#27) of three residents from misappropriation of property out of 35 sample residents. Specifically, the facility failed to prevent Resident #27 from having a significant amount of money stolen from his room.Findings include: I. Facility policy and procedureThe Abuse Investigation and Reporting policy and procedure, revised 12/22/25, was provided by the nursing home administrator (NHA) on 2/12/26 at 2:08 p.m. It read in pertinent part, It is the policy of this facility that reports of abuse, neglect, misappropriation of property, and exploitation are promptly and thoroughly investigated.II. Incident of misappropriation of property for Resident #27 A. Facility investigation The 12/24/25 grievance form revealed the resident reported that he had $700.00 missing from his room. The resolution was the former social services director (SSD) would follow up with Resident #27. Resident #27 said the money had been missing since a week ago (12/17/25) and he did not report it. Resident #27 said he thought the money went to the laundry department. The SSD checked with the laundry department and the laundry department said no money was found. Resident #27's sister confirmed that she brought him $1000.00 on 12/17/25. The SSD saw $389.00 in Resident #27's wallet. She offered to put it into the resident's trust account and he declined. The SSD offered a lock box and he declined. A police report was indicated. The date reviewed with Resident #27 was documented as 12/24/25. The 12/24/25 facility investigation report revealed that at approximately 4:00 p.m. on 12/23/25 Resident #27 informed the SSD that he was unable to locate some money his sister gave him. An investigation started immediately. The SSD interviewed the resident and the resident's sister. The resident's sister said she gave him $1000.00 a week prior (12/17/25). The SSD searched the resident's room with the resident's permission and was able to locate $389.00. Resident #27 was unable to remember where he last saw the funds or where he placed it. The interviews with the resident's roommate, the other residents and staff were ongoing. The police were notified and arrived at the facility to interview the resident. Staff at the facility was not aware the resident's sister brought money to the resident at the facility. The resident was offered a lockbox per facility protocol if a resident had money in their possession. The investigation actions taken revealed the SSD interviewed Resident #27 and the resident's sister. The resident's sister said she gave him $1000.00 a week prior. The SSD searched the resident's room with the resident's permission and was able to locate $389.00. Staff on the unit were interviewed regarding alleged misappropriation and laundry was checked for money potentially left in clothing and none was found. Security camera footage prior to the money allegedly going missing was reviewed and revealed no unauthorized person entering the resident's room. Resident #27 was kept safe by contacting the police to interview the resident. -However, the investigation failed to indicate how the resident and his money were kept safe beyond notifying the police to interview the resident.Resident #27 remembered he had the money one week prior to 12/23/25. -The investigation failed to indicate if the allegation was substantiated or unsubstantiated by the facility. -The investigation failed to reveal if the facility asked Resident #27 who he thought took his money or how he thought the money went missing. However, the 12/23/25 police investigation report and an interview with the resident during the survey on 2/9/26 indicated a female nurse took the money from his wallet (see police report and resident interview below).Cross reference F610 for failure to thoroughly investigate an alleged violation. B. Police investigation report The 12/23/25 police investigation report for the investigation into Resident #27's missing money was provided by the police department on 2/10/26 at 3:50 p.m. It revealed that the case status was pending and active. The incident was reported on 12/23/25 and indicated the theft occurred on 12/17/25 between 12:00 p.m and 1:00 p.m. It revealed $700.00 was stolen. The investigation revealed that on 12/23/25, the police officer was dispatched to a theft. The investigation documented Resident #27 said last Wednesday, 12/17/25, a nurse took $700.00 from his wallet. The officer asked how it happened. Resident #27 said around 12:00 p.m. on 12/17/25, a nurse came into his room and woke him up. The nurse helped him take off his robe for laundry day. The nurse took the robe to the laundry and returned with Resident #27's wallet. Resident #27 said he always kept his wallet in the front pocket of his robe. The nurse put his wallet on his nightstand next to his bed. Resident #27 counted the money inside his wallet and he noticed $500.00 missing. Resident #27 said he needed to go to the bathroom so the nurse assisted him. Resident #27 grabbed his wallet and put it in the front pocket of his pajama bottoms. Resident #27 urinated on his pajama bottoms so the nurse took them off of him and set the pajamas in the room by the sink. When Resident #27 was done using the bathroom, he checked his wallet again. Resident #27 noticed another $200.00 missing. Resident #27 was not sure what to say so he waited to report it. Resident #27 did not know the nurse's name. The officer checked with the nurse on duty and she said the schedule for last week was down so she was not sure who worked. The nurse provided a phone number to the scheduler who was only available during the day. There were no surveillance cameras inside the room. The officer requested the case to be active and assigned back to him for follow-up. III. Resident's representative interviewsThe resident's representative was interviewed on 2/10/26 at 2:03 p.m. The representative said she was aware Resident #27 was missing money. She said another representative called the police to look into it. The resident's representative said Resident #27 told her he was sleeping in bed when a lady woke him up and took his gown that had his wallet in it. She said he told her the lady took the gown to the laundry and took the money out of the wallet. The resident's representative said she gave him $1100.00 and the facility was not doing anything to confirm what happened and what did not happen. She said Resident #27 did not usually have this much money with him. The resident's representative said Resident #27 could be paranoid, but he had the right mind to keep track of his money. A second resident's representative was interviewed on 2/10/26 at 2:47 p.m. The second representative said she called the police department and adult protective services (APS) to look into who stole Resident #27's money. She said no one at the facility cared that Resident #27's money was missing because he was paranoid. She said even though Resident #27 was paranoid, he was very good with his money and was not confrontational about his money. She said she handled Resident #27's money and gave the other representative money because she lived close by to the facility. She said the other representative and Resident #27 got in an argument so the other representative gave Resident #27 all of his money at the same time. She said Resident #27 waited a week to tell her the other representative and he fought and the money went missing afterwards. She said the facility did nothing to resolve the issue. IV. Resident #27A. Resident status Resident #27, age less than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus with hyperglycemia, asthma, delusional disorders, paraplegia, cellulitis of the right lower limb, gout, generalized anxiety disorder, hypertension and depression. The 2/1/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. B. Resident interviewResident #27 was interviewed on 2/9/26 at 3:17 p.m. Resident #27 said on 12/17/25 a female nurse took his wallet and took money out of his wallet. Resident #27 said it happened when the nurse assisted him with toileting care. He said the female nurse took his hospital gown off and he had his wallet in the front pocket. Resident #27 said it happened during a morning shift and police were called. Resident #27 said he did not know what the outcome of the investigation was. Resident #27 said he did not know the name of the nurse but knew it was a female, she worked a day shift and was Hispanic. He said he had a lot of money in his wallet because he had to buy a phone. Resident #27 said on 12/17/25 he had $1300.00. and today, 2/9/25, he had $600.00 in his wallet. He said he would use a lock box if he was given one to keep things like his $100.00 bluetooth speaker he had on his table close to the entrance of his room. C. Record review The behavior care plan, initiated 1/9/26 and revised 2/4/26, revealed Resident #27 had the potential for behavior problems due to a history of false accusations towards staff related to hallucinations and delusions. Interventions included administering medications ordered, anticipating and meeting the resident's needs, approaching the resident in a calm manner, assisting the resident to develop more appropriate methods of coping and interacting, educating family members on successful coping and interaction strategies and ensuring if money was brought in for the resident, to deposit it to his bank to keep money safe and accessible to the resident. -The care plan was not initiated until 1/9/26, 15 days after the allegation of the resident's stolen money. The 2/12/26 social services note, documented during the survey, revealed Resident #27 mentioned missing money that occurred back in December 2025 and understood it was reported to the police and investigated. Resident #27 explained he understood but wanted to express himself.-There was no further documentation in Resident #27's electronic medical record (EMR) related to the resident's allegation of the missing money. V. Staff interviewThe NHA was interviewed on 2/12/26 at 11:44 a.m. He said he was the abuse coordinator. The NHA said if a staff member suspected abuse they contacted the director of nursing (DON) and him. He said the investigation was documented in risk management. He said if an allegation was misappropriation of property, it was usually first documented as a grievance form. The NHA said he interviewed the resident, their roommate, other residents, staff and family members. The NHA said he obtained a statement from the resident who was the victim, the residents who witnessed the alleged abuse or misappropriation and from staff who witnessed the alleged abuse or misappropriation. The NHA said the victim's statement was based on the interview conducted by the staff. He said he did not always have the victim write a statement. The NHA said he reported abuse or misappropriation to the stage agency, the police, the resident's representative and the ombudsman. The NHA said he asked the police if they were involving APS or if the facility should notify APS. The NHA said he determined if he substantiated or unsubstantiated an allegation depending on the situation. The NHA said he took the interviews, security footage if applicable and clear evidence to help determine whether or not to substantiate or unsubstantiated an allegation. The NHA said he selected staff to interview based on if they witnessed the allegation or if they worked in the unit where the allegation took place. The NHA said he interviewed all disciplines, not just nursing staff. The NHA said he selected residents to interview based on if they witnessed the allegation. The NHA said he was familiar with the allegation of stolen money from Resident #27. The NHA said in December 2025 he alerted staff that money went missing. The NHA said Resident #27 was not clear on the details and the facility did not know he kept money on him. The NHA said the former SSD found half of the money in his room. The NHA said the facility tried to find the rest of the money by looking in laundry. The NHA said the facility offered Resident #27 a lock box or to keep his money with the facility and Resident #27 declined. The NHA said no one told the facility they had brought money in for the resident. The NHA said the police came on site and interviewed Resident #27. The NHA said the police said they could not do anything with the allegation since he did not say how much or who he thought took it. The NHA said he unsubstantiated the allegation.-However, according to the 12/23/25 police investigation report and the 2/9/26 resident interview, the resident reported that a female nurse took his money (see above). The NHA and the corporate social services resource were interviewed together on 2/12/26 at approximately 1:15 p.m. The corporate social services resource said the information that Resident #27 said in his interview during the survey about a nurse taking his money was new information and the facility would need to open a new investigation. -However, the 12/23/25 police investigation report indicated the resident thought a female nurse took his money (see above). VI. Facility follow up The assistant director of nursing (ADON) provided the following information on 2/12/26 at 5:00 p.m. The information provided revealed Resident #27 was admitted on [DATE] with diagnoses including delusional disorders and generalized anxiety disorder. Resident #27 was noted to have episodes of delusions and confused thoughts. Resident #27 and the family signed a document acknowledging that any items brought in after admission needed to be added to the inventory list. This ensured that the facility was aware of items that were on site. Resident #27 reported to facility staff that he was allegedly missing money on 12/23/25. The money was allegedly identified as missing by the resident on 12/17/25. Once the facility was notified of the alleged missing money, the facility responded in accordance with established protocol. An investigation was promptly initiated, a search was conducted ($389.00 of an alleged $1000.00 was found), and the incident was reported to the local police department for further investigation. Through the course of the investigation, the resident provided inconsistent information, and the facility was unable to verify that the money had ever been in the resident's possession. The information provided by the ADON indicated the facility was not responsible for items alleged to be in a resident's possession; they must be documented. Therefore, there was insufficient evidence to substantiate the allegation of misappropriation of Resident #27's property as the facility was unable to verify or confirm that these funds were in the resident's possession as alleged.-However, Resident #27 provided a consistent statement with the police officer on 12/23/25 and two resident representatives (see above). -Additionally, according to the facility's own investigation (see above), the facility interviewed one of the resident's representatives who confirmed she had given the resident $1000.00 on 12/17/25 (see investigation above). The resident's belongings inventory list provided by the ADON on 2/12/26 revealed all personal items brought in upon admission and thereafter needed to be properly labeled and added to the inventory list. In order to protect the resident's valuables, all items including money, should be kept in the facility safe or taken home. The facility highly recommended that items that were irreplaceable or of monetary value be left in the care of family or other loved ones, and not stored at the facility. The facility also recommended money be placed in the facility's trust account, if a resident wished to keep it on hand at the facility. Any money placed in the trust account could be requested at the resident's convenience as needed. The signature section on the inventory list documented that by signing below, the resident hereby consented to have all removable appliances clearly identified and marked in a permanent manner with the resident's name. This shall apply, but not necessarily be limited to full dentures, partial dentures, toothbrushes, hearing aids, hearing amplifiers and glasses. -However, the signature section did not confirm if a resident's representative or a resident consented to keep money in the facility's trust account or at home.

Based on observations, interviews and record review, the facility failed to ensure residents were free from chemical restraints for one (#8) of five residents out of 35 sample residents. Specifically, the facility failed to ensure Resident #8's continued use of an antipsychotic medication was appropriately monitored and reviewed by the interdisciplinary team (IDT) for continued medical necessity and gradual dose reduction (GDR).Findings include:I. Facility policy and procedure The Chemical Restraints and Psychotropic Medication Management policy and procedure, revised April 2025, was provided by the nursing home administrator (NHA) on 2/9/26 at 3:59 p.m. It read in pertinent part, Residents who use psychotropic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Quarterly thereafter, or with any significant change in condition, the residents will be calendared by the social services director for interdisciplinary (IDT) review to assess for continued need and justification of the medication and possible Gradual Dose Reduction.II. Resident #8 A. Resident status Resident #8, age greater than 65, was admitted on [DATE], discharged on 4/21/25, and readmitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses include unspecified dementia, hypertension, atrial fibrillation, muscle weakness, lack of coordination, need for assistance with personal care, unsteadiness on feet and cognitive communication deficit. The 12/8/25 minimum data set (MDS) assessment revealed the resident had short and long-term memory problems and his cognitive skills for daily decision making were severely impaired. He had an impairment on one upper extremity and used a wheelchair. He required supervision with eating and oral hygiene. He required maximal assistance with toileting and showering. He was dependent on personal hygiene. The MDS assessment revealed he had little interest or pleasure in doing things for two to six days, felt down, depressed or hopeless for seven to eleven days, had trouble falling asleep or staying asleep for two to six days during the two week assessment look-back period. The resident did not exhibit verbal or physical behavioral symptoms toward others nor reject care during the assessment look-back period. The assessment revealed the resident was prescribed an antipsychotic medication and a gradual dose reduction was not attempted. B. Observations On 2/9/26 at 11:09 a.m. Resident #8 was observed sleeping in his bed in his room. During a continuous observation on 2/10/26, beginning at 10:24 a.m. and ending at 12:50 p.m., Resident #8 was observed sleeping in his bed in his room. During a continuous observation on 2/11/26, beginning at 10:13 a.m. and ending at 12:24 p.m., Resident #8 was observed sleeping in his bed in his room. -During the observations, staff were observed offering activities to other residents in the common area. Staff did not offer activities to Resident #8. There was no music or television in his room. C. Record reviewThe depression care plan, initiated and revised 8/21/25, revealed Resident #8 was at risk for depression related to dementia, his admission to the facility and a current decline in health. Interventions included administering medications as ordered, monitoring and documenting for side effects and effectiveness, encouraging to express feelings and monitoring, documenting and reporting to the nurse and doctor signs and symptoms of depression. The behavior care plan, initiated 8/29/25 and revised 11/14/25, revealed Resident #8 experienced behaviors of anxiety and agitation related to his current health status. Resident #8 was aggressive and agitated with staff during care such as transfers. Interventions were administering medications as ordered, monitoring and documenting for side effects and effectiveness, anticipating and meeting needs, approaching in a calm manner, assisting to develop more appropriate methods of coping and interacting, encouraging to express feelings appropriately. Behaviors included verbal aggression, declining cares, exit seeking, restlessness, and delusions. Triggers included overstimulation, change in health status and change in environment. Interventions included listening to Spanish rock, offering snacks, offering the weather channel on TV, approaching calmly and slowly, sitting outside supervised, visits with family or one-on-one visits from staff. Additional interventions included providing opportunities for positive interactions and attention, documenting behaviors and resident response to interventions, explaining procedures before starting, intervening as necessary, monitoring behavior episodes and attempt to determine underlying cause, praise any indication of progress or improvement of behavior and providing a program of activities that is of interest and accommodates the resident's status. The elopement care plan, initiated 9/19/25 and revised 12/3/25, revealed Resident #8 had wandering and exit-seeking behavior. Resident #8 resided in the secured memory unit. Interventions included distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books, documenting wandering behavior and attempted diversional interventions, identifying the pattern of wandering, monitoring for exit-seeking behaviors, providing structured activities, and monitoring and documenting observed behaviors and episodes every shift of exit-seeking, unplanned exiting and aimless walking and wandering. The antipsychotic medication care plan, initiated 8/21/25 and revised 11/14/25, revealed Resident #8 took antipsychotic medication related to delusions causing agitation, anxiety and exit-seeking. Interventions included documenting episodes of behavior, monitoring episodes of delusions that caused agitation, anxiety and exit-seeking, calling his significant other on the phone, calm environment, laying down, offering coffee and lemonade, pain management and listening to music or watching television, and quarterly AIMS (abnormal involuntary movement scale) assessments.The 1/15/25 patient health questionnaire (PHQ 9, a diagnostic tool to screen, treat and monitor the severity of depression) revealed the resident had little interest or pleasure in doing things for two to six days; and felt down, depressed or hopeless for 12 to 14 days; fell or stayed asleep for two to six days; felt tired or had little energy for 12 to 14 days; and poor appetite seven to 11 days during the assessment look-back period. Resident #8 scored ten out of 27, indicating moderate depression. The 8/19/25 PHQ 9 evaluation revealed an interview was not completed because the resident was rarely or never understood. -There was no documentation in Resident #8's electronic medical record (EMR) to indicate that social services attempted to reach out to family or staff to determine the resident's current mood and if there was a change in the resident's mood until 11/30/25. The 11/30/25 social services assessment revealed Resident #8 was unable to participate in a cognitive assessment due to his cognitive deficits. His PHQ-9 score was a four which indicated the resident had minimal depression. Resident #8 resided in a secured unit due to wandering and exit-seeking. The resident utilized Seroquel (anti-psychotic medication) for dementia with behaviors. The resident enjoyed group activities and visits from his wife. The 12/8/25 PHQ 9 evaluation revealed Resident #8 had little interest or pleasure in doing things for two to six days; felt down, was depressed or hopeless for seven to 11 days; had trouble falling asleep or staying asleep for two to six days; felt tired or had little energy on 12 to 14 days; and had a poor appetite seven to 11 days during the 14-day assessment look-back period. Resident #8 scored four out of 27, indicating minimal depression. -A review of Resident #8's EMR did not reveal any documentation that addressed the resident's PHQ-9 score and what follow up, interventions or services were offered to the resident. The February 2026 CPO revealed the following physician's orders: -Quetiapine fumarate (Seroquel) 50 mg. Take one tablet by mouth twice a day for dementia with behaviors, ordered 9/2/25. Behavior: verbal aggression, declining cares, exit seeking, restlessness and delusions. Triggers: overstimulations, changes in health status, change in environment. Interventions: offer listening to music, offer snacks, offer TV, approach calmly and slowly, sitting outside supervised weather permitting, visits with family or one on ones from staff. Every shift. ordered 2/5/26.Monitor episodes: delusions that cause agitation, anxiety and exit-seeking. Side effects: drowsiness, dry mouth, blurred vision, constipation. Less common side effects: edema, extra pyramidal symptoms, urinary retention, stiff or tight muscles, restlessness. Rare side effect: tardive dyskinesia. Interventions: calling his significant other on the phone, calm environment, lying down, likes coffee and lemonade, pain management, listening to music or watching TV. Every shift. ordered 9/24/25. Monitor for exit-seeking behaviors. If exhibiting active exit-seeking behaviors, provide increased monitoring. Every shift, ordered 10/8/25. Wandering and elopement risk. Monitor and document observed behavior and episodes every shift. Exit-seeking, unplanned exiting, aimless walking and wandering. Interventions: Listening to music, watching television, visiting with family, and snacks. Every shift, ordered 11/11/25. -A review of Resident #8's medication administration records (MAR) and treatment administration records (TAR) from 10/7/25 to 2/12/26 revealed the resident did not exhibit any behaviors. -A review of the resident's EMR revealed there was no documentation to indicate the interdisciplinary team (IDT) reviewed the resident's use of Seroquel (a psychotropic medication), on at least a quarterly basis, to determine if the continued use of the medications was justified or if a GDR of the medications was indicated. III. Staff interviews Certified nurse aide (CNA) #6 was interviewed on 2/11/26 at 4:55 p.m. CNA #6 said she was familiar with Resident #8. CNA #6 said Resident #8 would come to the common area for meals, but primarily stayed in his room. CNA #6 said Resident #8 always slept but she noticed he slept more the past month or two. CNA #6 said she thought he was depressed. CNA #6 said she was not sure why he was depressed. Registered nurse (RN) #2 was interviewed on 2/12/26 at 11:02 a.m. RN #2 said all behaviors were monitored and documented on the MAR and TAR. RN #2 said monitoring was documented as a physician's order that included the behavior, the interventions to use and if the interventions were effective. RN #2 said she was familiar with Resident #8. She said the facility monitored Resident #8's episodes of verbal aggression, refusing care, overstimulation, change in health status, wandering, exit-seeking, delusions, anxiety, restlessness, and aimless walking. RN #2 said calling his spouse was helpful when he exhibited those various behaviors. RN #2 said Resident #8 was first admitted to the facility for skilled care and then discharged home with his spouse. RN #2 said Resident #8 returned to the facility for long-term care when his family was unable to care for him. She said Resident #8 was having a difficult time adjusting to living in the facility. The social services director (SSD) was interviewed on 2/12/26 at 9:02 a.m. The SSD said he had worked at the facility for 10 days. The SSD said social services was responsible for completing the PHQ-9 assessment. He said the purpose of the PHQ-9 assessment was to monitor for mood, behavior and for signs and symptoms of depression. The SSD said if the score increased from one evaluation to another, social services would implement services, offer additional support and review if the resident was on any psychotropic medications or antidepressants. The SSD said he would determine if the change in the resident's PHQ-9 assessment score was related to a specific reason, such as a loss or a specific time of year. The SSD said he relied on the nursing staff to report if the resident was self-isolating. The SSD said he would document a narrative of the conversation when the PHQ-9 assessment was completed and depending on the conversation, the concern for self-harm. The SSD said if counseling was offered, a physician's order was obtained by the nursing staff. The SSD said all behaviors should be monitored, especially self harm and aggression behaviors. The SSD said behaviors were documented by social services at admission, quarterly and as needed in the social services assessment. The SSD said he used the referral information, the family and the resident to develop the care plan and Kardex (summary of the resident's care) to identify triggers and develop effective interventions. The SSD said he relied on nursing staff to tell him anything little or big to help provide proper care and to keep the resident safe. The SSD said if a behavior was monitored due to a resident being prescribed a psychotropic medication, there would be a physician's order to monitor the behaviors. The SSD said residents who were on psychotropic medications were reviewed by IDT quarterly and as needed. The SSD said IDT reviewed medications, behaviors, medication refusals, meal intake and activity participation. The SSD said he was not familiar with Resident #8. The assistant director of nursing (ADON) was interviewed on 2/12/26 at 9:28 a.m. The ADON said social services was responsible for completing the PHQ-9 assessment. The ADON said nursing determined what behaviors to monitor based on progress notes and assessments. The ADON said the IDT reviewed progress notes in the morning clinical meeting to review what behavior was observed and what interventions were implemented. The ADON said the IDT reviewed residents who were administered psychotropic medications quarterly. The ADON said she was familiar with Resident #8. She said the facility was monitoring Resident #8's episodes of verbal aggression, refusing care, overstimulation, change in health status, wandering, exit-seeking, delusions, anxiety, restlessness and aimless walking. The ADON said she did not think Resident #8's behavior had changed over the past two months. The ADON said she would check when Resident #8 was reviewed by the IDT and conduct a new PHQ-9 assessment for Resident #8. The ADON said Resident #8 was on the spreadsheet for a GDR review for September 2025, however she said she was unable to provide documentation of the review.-A review of the EMR did not reveal documentation that the resident's use of Seroquel had been discussed during a GDR review and determined whether it was appropriate to continue the medication or attempt a GDR.IV. Facility follow-up A PHQ-9 assessment was completed on 2/12/26 and the resident did not show any signs or symptoms of depression. The ADON provided documentation on 2/12/26 at 11:15 a.m. which indicated Resident #8 was part of the September 2025 psychotropic pharmacological meeting list. -However, she was unable to provide documentation to indicate what was discussed regarding Resident #8 during the meeting or any recommendations for a potential GDR for the resident's Seroquel.

Based on record review and interviews, the facility failed to thoroughly investigate allegations of abuse for three (#51, #12 and #27) of six residents out of 35 sample residents.Specifically, the facility failed to:-Complete a thorough investigation after an allegation of physical abuse between Resident #51 and Resident #12; and,-Thoroughly investigate an allegation of misappropriation of property involving Resident #27.Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, revised December 2025, was provided by the nursing home administrator (NHA) on 2/12/26 at 2:08 p.m. It read in pertinent part, It is the policy of this facility that reports of abuse, neglect, misappropriation of property, and exploitation are promptly and thoroughly investigated. When an incident or suspected incident of abuse or neglect is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. A licensed nurse will examine the resident upon receiving reports of alleged physical or sexual abuse and will record findings in the resident's medical record. The investigation will consist of at least the following: a review of the completed complaint report, an interview with the person (s) reporting the incident, interviews with any witnesses to the incident, an interview with the resident if possible, a review of the resident's medical record, and interviews with staff members having contact with the resident during the period/shift of the alleged incident if applicable, and a review of all circumstances surrounding the incident. II. Failed to complete a thorough investigation after an allegation of physical abuse between towards Resident #51 and Resident #12 A. Facility investigation The facility investigation was provided by the NHA on 2/10/26 at 2:15 p.m. The investigation documented that at approximately 3:30 pm on 2/4/26, Resident #51 reported to staff that her roommate, Resident #12, had walked over to her and bopped her on the shoulder. An investigation was immediately started. Residents #12 and #51 were assessed and were found to have no pain, injuries, bruising or signs of distress. Cross reference F600 for failure to keep residents free from abuse and neglect. Resident #12 was interviewed by the social services director (SSD) on 2/4/26 and the resident denied any physical contact with Resident #51. The investigation documented Resident #51 was interviewed by the SSD on 2/4/26, and stated her roommate walked over to her and bopped her on the shoulder. Resident #51 was offered a room move, which she accepted and was immediately moved to a different unit. Resident #51 denied any fear of Resident #12. The investigation revealed that both residents were placed on 15-minute checks and psychosocial monitoring was ordered for both residents. -Review of the facility's investigation documented Resident #12 (assaillant) was interviewed on 2/4/26, and she stated she did not make any physical contact with Resident #51. She denied any other incident or altercation. The investigation documented Resident #51 (victim) was interviewed on 2/4/26, and stated her roommate walked over to her and bopped her on the shoulder. The investigation documented Resident #51 did not feel pain and was not afraid of the assailant. The investigation documented seven additional residents on the unit were interviewed by the SSD on 2/5/26, yielding no additional information. The investigation documented that the SSD completed seven additional staff interviews, including the registered dietitian (RD), the activities assistant (AA), the director of rehabilitation (DOR), the activities director (AD), the medical records supervisor, the business office manager, and the maintenance director (MTD), to determine whether they had observed any interactions between Resident #51 and Resident #12 on 2/5/26 and 2/6/26 to determine whether there was widespread abuse going on in the facility. All of the staff members interviewed stated they had not firsthand witnessed anything and had no concerns. -However, none of the staff members interviewed typically worked on the unit and were not present during the 2/4/26 altercation between the two residents. The investigation documented registered nurse (RN) #4 completed the skin assessment of both residents. The assessment concluded that both residents had no pain, injuries, bruising, or signs of distress. -However, the investigation failed to include an interview with RN #4, who completed the skin assessment. B. Resident #51 (victim) 1. Resident status Resident #51, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included schizophrenia, anxiety disorder, repeated falls, cognitive communication deficit, muscle weakness, and drug-induced subacute dyskinesia. The 12/8/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required moderate assistance with toileting, supervision with eating and personal hygiene. The assessment indicated the resident did not exhibit physical or behavioral symptoms towards others. 2. Resident interview Resident #51 was interviewed on 2/10/26 at 12:15 p.m. Resident #51 said she remembered the incident of aggression towards her by Resident #12. She said she was sitting in her wheelchair facing her bed, reading her Bible and praying. She said her roommate at that time (Resident #12) approached from behind her and hit her on her right shoulder, causing severe pain in her right shoulder. Resident #51 said she yelled at Resident #12 to leave her alone, but Resident #12 refused to leave and stayed by her side of the room. Resident #51 said she wheeled herself out of the room to report the incident to staff. C. Resident #12 (assailant) 1. Resident status Resident #12, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included schizoaffective disorder, bipolar type, muscle weakness, and muscle wasting and atrophy. The 1/2/26 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. She was independent with mobility, personal hygiene, toileting, and eating. The MDS assessment indicated the resident did not exhibit physical behaviors directed towards others and did not reject care. 2. Resident interview Resident #12 was interviewed via a translator language line in her native Russian language on 2/10/26 at 1:15 p.m. Resident #12 said she was asleep on the afternoon of 2/4/26 and had a dream in which her roommate prayed against her Christian faith. She said she went over to her roommate's side of the room to ask her to stop praying. Resident #12 said her roommate was sitting in her wheelchair, facing her bed. She said she approached her and touched her on her right shoulder, but Resident #51 turned and hit her on her collarbone. She said she had severe pain in the area of her left collarbone where Resident #51 had hit her. She said her roommate, Resident #51, cursed at her earlier that day while entering the bathroom. D. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 2/10/26 at 2:31 p.m. CNA #2 said she was familiar with the care of Resident #51 and Resident #12. She said Resident #12 had a documented history of aggression toward staff and other residents. CNA #2 said Resident #12 often refused to take her psychotropic medications, which had resulted in hospitalization in the past. CNA #2 said Resident #51 held strong religious beliefs and did not celebrate several holidays that did not align with her faith. She said Resident #51 often prayed openly in her room and liked to talk to others about her Christian faith. CNA #2 said she was not interviewed regarding the incident on 2/4/26 involving Resident #51 and Resident #12. Certified nurse aide with medication authority (CNA-Med) #1 was interviewed on 2/11/26 at 5:15 p.m. CNA-Med #1 said she was familiar with the care of Resident #51 and Resident #12. She said an RN usually completed assessments when there was an allegation of abuse. CNA-Med #1 said Resident #12's primary language was Russian and she spoke very limited English. She said Resident #12 often kept to herself and stayed in her room due to her language barrier. CNA-Med #1 said Resident #51 enjoyed reading her Bible in her room. She said she was not interviewed regarding the incident on 2/4/26 between the two residents. RN #4 was interviewed on 2/12/26 at 9:05 a.m. RN #4 said she was familiar with Resident #51 and Resident #12 and was asked to complete skin assessments for them on 2/4/26, when she arrived for her shift, three hours after the incident. RN #4 said she was not involved in the facility's investigation. RN #4 said an assessment was required immediately after an incident, and she did not know why the facility waited for her to complete the skin assessments for both residents. She said she did not remember the time she completed her assessments, nor whether both residents made any statements during the assessments. RN #4 said she was not interviewed regarding the incident on 2/4/26 involving Resident #51 and Resident #12. The assistant director of nursing (ADON) was interviewed on 2/12/26 at 10:05 a.m. The ADON said she was present in the building when the altercation between Resident #51 and Resident #12 occurred on 2/4/26. The ADON said Resident #51 came to her office to report the incident of alleged physical abuse to her, and she completed a skin assessment of the resident; however, she did not document her evaluation in the resident's electronic medical record (EMR). The ADON said that a few moments after she spoke with Resident #51, her roommate, Resident #12, arrived at her office, also alleging that her roommate hit her on her left collarbone. She said both residents were separated and 15-minute checks were initiated. The NHA and the social services director (SSD) were interviewed together on 2/12/26 at 11:45 a.m. The NHA said RNs were required to complete an assessment when allegations of abuse were reported. The NHA said both Resident #51 and Resident #12 were assessed, and an investigation was initiated immediately. He said the allegations of abuse were unsubstantiated because there were no witnesses to the allegation. -However, abuse occurred because both residents said the other resident hit them. The SSD said he interviewed both Resident #51 and Resident #12 and followed up to complete psychosocial assessments. The SSD said he interviewed staff from management to ensure there were no widespread allegations of abuse. The SSD said he should have interviewed the staff on the floor at the time of the incident. III. Failed to thoroughly investigate an allegation of misappropriation of property involving Resident #27 Cross reference F602 for failure to keep residents free from misappropriation of property. A. Facility investigation The 12/24/25 grievance form revealed the resident reported that he had $700.00 missing from his room. The resolution was the former SSD would follow up with Resident #27. Resident #27 said the money had been missing since a week ago (12/17/25) and he did not report it. Resident #27 said he thought the money went to the laundry department. The SSD checked with the laundry department and the laundry department said no money was found. Resident #27's sister confirmed that she brought him $1000.00 on 12/17/25. The SSD saw $389.00 in Resident #27's wallet. She offered to put it into the resident's trust account and he declined. The SSD offered a lock box and he declined. A police report was indicated. The date reviewed with Resident #27 was documented as 12/24/25. -However, the facility failed to complete a thorough investigation of the alleged grievance (see below). The 12/24/25 facility investigation report revealed that at approximately 4:00 p.m. on 12/23/25 Resident #27 informed the SSD that he was unable to locate some money his sister gave him. An investigation started immediately. The SSD interviewed the resident and the resident's sister. The resident's sister said she gave him $1000.00 a week prior (12/17/25). The SSD searched the resident's room with the resident's permission and was able to locate $389.00. Resident #27 was unable to remember where he last saw the funds or where he placed it. The interviews with the resident's roommate, the other residents and staff were ongoing. The police were notified and arrived at the facility to interview the resident. Staff at the facility was not aware the resident's sister brought money to the resident at the facility. The resident was offered a lockbox per facility protocol if a resident had money in their possession. The investigation actions taken revealed the SSD interviewed Resident #27 and the resident's sister. The resident's sister said she gave him $1000.00 a week prior. The SSD searched the resident's room with the resident's permission and was able to locate $389.00. Staff on the unit were interviewed regarding alleged misappropriation and laundry was checked for money potentially left in clothing and none was found. Security camera footage prior to the money allegedly going missing was reviewed and revealed no unauthorized person entering the resident's room. The resident remembered he had the money one week prior to 12/23/25. -The investigation failed to reveal documentation to indicate the date the interview occurred or what questions were asked of the alleged victim, Resident #27. -The investigation failed to reveal documentation to indicate interviews were conducted with laundry staff. -The investigation failed to indicate if the allegation was substantiated or unsubstantiated by the facility. -The investigation failed to reveal if the facility asked Resident #27 who he thought took his money or how he thought the money went missing. However, the 12/23/25 police investigation report and an interview with the resident during the survey on 2/9/26 indicated a female nurse took the money from his wallet (see police report and resident interview below). Resident #27 was kept safe by contacting the police to interview the resident. -However, the investigation failed to indicate how the resident and his money were kept safe beyond notifying the police to interview the resident. -The investigation failed to reveal documentation to indicate the date the police interview with the resident occurred and what questions were asked of Resident #27. Four staff members were interviewed, including the SSD, a certified nurse with medication authority (CNA-Med), an admissions staff member and another staff member whose title was not documented. The interview questions were as follows: did you suspect any money being taken from other residents, by other residents, if yes, explain; have you witnessed any money being taken from residents by staff, if yes, explain; do you have any concerns of money being taken or stolen from residents by staff or other residents, if yes, explain and who do you report abuse to. -However, the interviews failed to indicate the date the interviews took place and if they had any specific knowledge about Resident #27's missing money. -Additionally, the interviews did not include any nurses, despite Resident #27 indicating in the police report (see below) that a female nurse took his money. B. Police investigation report The 12/23/25 police investigation report for the investigation into Resident #27's missing money was provided by the police department on 2/10/26 at 3:50 p.m. It revealed that the case status was pending and active. The incident was reported on 12/23/25 and indicated the theft occurred on 12/17/25 between 12:00 p.m and 1:00 p.m. It revealed $700.00 was stolen. The investigation revealed that on 12/23/25, the police officer was dispatched to a theft. The investigation documented Resident #27 said last Wednesday, 12/17/25, a nurse took $700.00 from his wallet. The officer asked how it happened. Resident #27 said around 12:00 p.m. on 12/17/25, a nurse came into his room and woke him up. The nurse helped him take off his robe for laundry day. The nurse took the robe to the laundry and returned with Resident #27's wallet. Resident #27 said he always kept his wallet in the front pocket of his robe. The nurse put his wallet on his nightstand next to his bed. Resident #27 counted the money inside his wallet and he noticed $500.00 missing. Resident #27 said he needed to go to the bathroom so the nurse assisted him. Resident #27 grabbed his wallet and put it in the front pocket of his pajama bottoms. Resident #27 urinated on his pajama bottoms so the nurse took them off of him and set the pajamas in the room by the sink. When Resident #27 was done using the bathroom, he checked his wallet again. Resident #27 noticed another $200.00 missing. Resident #27 was not sure what to say so he waited to report it. Resident #27 did not know the nurse's name. The officer checked with the nurse on duty and she said the schedule for last week was down so she was not sure who worked. The nurse provided a phone number to the scheduler who was only available during the day. There were no surveillance cameras inside the room. The officer requested the case to be active and assigned back to him for follow-up. C. Resident's representative interviews The resident's representative was interviewed on 2/10/26 at 2:03 p.m. The representative said she was aware Resident #27 was missing money. She said another representative called the police to look into it. The resident's representative said Resident #27 told her he was sleeping in bed when a lady woke him up and took his gown that had his wallet in it. She said he told her the lady took the gown to the laundry and took the money out of the wallet. The resident's representative said she gave him $1100.00 and the facility was not doing anything to confirm what happened and what did not happen. She said Resident #27 did not usually have this much money with him. The resident's representative said Resident #27 could be paranoid, but he had the right mind to keep track of his money. A second resident's representative was interviewed on 2/10/26 at 2:47 p.m. The second representative said she called the police department and adult protective services (APS) to look into who stole Resident #27's money. She said no one at the facility cared that Resident #27's money was missing because he was paranoid. She said even though Resident #27 was paranoid, he was very good with his money and was not confrontational about his money. She said she handled Resident #27's money and gave the other representative money because she lived close by to the facility. She said the other representative and Resident #27 got in an argument so the other representative gave Resident #27 all of his money at the same time. She said Resident #27 waited a week to tell her the other representative and he fought and the money went missing afterwards. She said the facility did nothing to resolve the issue. D. Resident #27 1. Resident status Resident #27, age less than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus with hyperglycemia, asthma, delusional disorders, paraplegia, cellulitis of the right lower limb, gout, generalized anxiety disorder, hypertension and depression. The 2/1/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. 2. Resident interview Resident #27 was interviewed on 2/9/26 at 3:17 p.m. Resident #27 said on 12/17/25 a female nurse took his wallet and took money out of his wallet. Resident #27 said it happened when the nurse assisted him with toileting care. He said the female nurse took his hospital gown off and he had his wallet in the front pocket. Resident #27 said it happened during a morning shift and police were called. Resident #27 said he did not know what the outcome of the investigation was. Resident #27 said he did not know the name of the nurse but knew it was a female, she worked a day shift and was Hispanic. He said he had a lot of money in his wallet because he had to buy a phone. Resident #27 said on 12/17/25 he had $1300.00. and today, 2/9/25, he had $600.00 in his wallet. He said he would use a lock box if he was given one to keep things like his $100.00 bluetooth speaker he had on his table close to the entrance of his room. E. Staff interview The NHA was interviewed on 2/12/26 at 11:44 a.m. He said he was the abuse coordinator. The NHA said if a staff member suspected abuse they contacted the director of nursing (DON) and him. He said the investigation was documented in risk management. He said if an allegation was misappropriation of property, it was usually first documented as a grievance form. The NHA said he interviewed the resident, their roommate, other residents, staff and family members. The NHA said he obtained a statement from the resident who was the victim, the residents who witnessed the alleged abuse or misappropriation and from staff who witnessed the alleged abuse or misappropriation. The NHA said the victim's statement was based on the interview conducted by the staff. He said he did not always have the victim write a statement. The NHA said he reported abuse or misappropriation to the stage agency, the police, the resident's representative and the ombudsman. The NHA said he asked the police if they were involving APS or if the facility should notify APS. The NHA said he determined if he substantiated or unsubstantiated an allegation depending on the situation. The NHA said he took the interviews, security footage if applicable and clear evidence to help determine whether or not to substantiate or unsubstantiated an allegation. The NHA said he selected staff to interview based on if they witnessed the allegation or if they worked in the unit where the allegation took place. The NHA said he interviewed all disciplines, not just nursing staff. The NHA said he selected residents to interview based on if they witnessed the allegation. The NHA said he was familiar with the allegation of stolen money from Resident #27. The NHA said in December 2025 he alerted staff that money went missing. The NHA said Resident #27 was not clear on the details and the facility did not know he kept money on him. The NHA said the former SSD found half of the money in his room. The NHA said the facility tried to find the rest of the money by looking in laundry. The NHA said the facility offered Resident #27 a lock box or to keep his money with the facility and Resident #27 declined. The NHA said no one told the facility they had brought money in for the resident. The NHA said the police came on site and interviewed Resident #27. The NHA said the police said they could not do anything with the allegation since he did not say how much or who he thought took it. The NHA said he unsubstantiated the allegation. -However, according to the 12/23/25 police investigation report and the 2/9/26 resident interview, the resident reported that a female nurse took his money (see above). The NHA and the corporate social services resource were interviewed together on 2/12/26 at approximately 1:15 p.m. The corporate social services resource said the information that Resident #27 said in his interview during the survey about a nurse taking his money was new information and the facility would need to open a new investigation. -However, the 12/23/25 police investigation report indicated the resident thought a female nurse took his money (see above). F. Facility follow up The assistant director of nursing (ADON) provided the following information on 2/12/26 at 5:00 p.m. The information provided revealed Resident #27 was admitted on [DATE] with diagnoses including delusional disorders and generalized anxiety disorder. Resident #27 was noted to have episodes of delusions and confused thoughts. Resident #27 and the family signed a document acknowledging that any items brought in after admission needed to be added to the inventory list. This ensured that the facility was aware of items that were on site. Resident #27 reported to facility staff that he was allegedly missing money on 12/23/25. The money was allegedly identified as missing by the resident on 12/17/25. Once the facility was notified of the alleged missing money, the facility responded in accordance with established protocol. An investigation was promptly initiated, a search was conducted ($389.00 of an alleged $1000.00 was found), and the incident was reported to the local police department for further investigation. Through the course of the investigation, the resident provided inconsistent information, and the facility was unable to verify that the money had ever been in the resident's possession. The information provided by the ADON indicated the facility was not responsible for items alleged to be in a resident's possession; they must be documented. Therefore, there was insufficient evidence to substantiate the allegation of misappropriation of Resident #27's property as the facility was unable to verify or confirm that these funds were in the resident's possession as alleged. -However, Resident #27 provided a consistent statement with the police officer on 12/23/25 and two resident representatives (see above). -Additionally, according to the facility's own investigation (see above), the facility interviewed one of the resident's representatives who confirmed she had given the resident $1000.00 on 12/17/25 (see investigation above).

Based on observations, record review and interviews, the facility failed to implement activity programs that met the interests and supported the physical, mental, and psychological well-being of one (#12) of 19 residents reviewed for activities out of 35 sample residents. Specifically, the facility failed to offer and provide a personalized activity program for Resident #12.Findings include:I. Facility policy and procedureThe Activity Policy and Procedure Manual, dated December 2024, was provided by the nursing home administrator (NHA) on 2/12/26 at 2:08 p.m. It read in pertinent part, It is the policy of this facility to ensure that residents have the right to choose the types of activities and social events in which they wish to participate.Some activities can be adapted to accommodate the resident's change in functioning due to physical or cognitive limitations: Cognitive impairment (task segmentation, settings that recreate past experiences, smaller groups without interruption, one-to-one); Language barrier (translation tools, audio/video in the resident's language).Daily activities, including those on weekends and holidays, are provided, as well as scheduled religious and social activities. However, residents are free to choose whether or not they wish to attend any activity or other scheduled event(s).II. Resident #12A. Resident statusResident #12, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included schizoaffective disorder, bipolar type, muscle weakness and muscle wasting and atrophy.The 1/2/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. She was independent with mobility, personal hygiene, toileting, and eating.The assessment revealed the resident's preferred language was Russian; however did not require an interpreter to communicate with health care staff.The assessment revealed the resident had been interviewed to determine her activity preferences. The resident indicated it was very important for her to keep up with the news, listen to music she liked, participate in her favorite activities, go outside to get fresh air and participate in religious services or practices.B. Resident interviewResident #12 was interviewed via a translator language line in her native Russian language on 2/10/26 at 1:15 p.m. Resident #12 said she did not participate in most activities because she did not see the importance of them if she could not understand them. She said she did not have any one-on-one activities planned. She said she loved music and enjoyed playing the piano. Resident #12 said the facility had a piano that she enjoyed playing and she believed most of the facility's residents enjoyed listening to and watching her play. Resident #12 said she would love to have piano sessions every week. The resident said she would love to have scheduled piano sessions as part of her activity program. She said the activities department handed out a daily chronicle and an activities schedule each morning, however they were both printed in English.Resident #12 said she had enjoyed the activities at the hospital when she was there because they were in her native Russian language.C. ObservationsDuring a continuous observation on 2/10/26, beginning at 1:00 p.m. and ending at 2:30 p.m., the following was observed.At 1:00 p.m. Resident #12 was lying in her bed, covered with a blanket. She said it was cold and wished the facility could turn the heat up to keep her warm. There was no television or music in the resident's room. Her bed was positioned in the corner, close to the wall and she was facing the wall. Her eyes were open, and she was staring at the wall. There was no activity calendar observed in the resident's room.At 2:00 p.m., a country cart activity was going on in the unit's activity room. However, Resident #12 was not invited to attend the activity.At 2:10 p.m. certified nurse aide (CNA) #2 entered the resident's room and checked on her. She did not invite the resident to the country cart activity.During a continuous observation on 2/11/26, beginning at 10:00 a.m. and ending at 11:00 a.m., the following was observed:At 10:05 a.m. Resident #12 was lying in her bed. There was a daily chronicle, printed in English, in the resident's trash can next to her bed. No activity supplies, individualized activities or an activity calendar were observed in her room.At 10:50 a.m. there was a fitness activity program going on in the activity room. However, Resident #12 was not invited to attend the activity.D. Record reviewThe communication care plan, initiated 7/20/2020, revealed that Resident #12 was at risk for communication problems due to a language barrier and she spoke mostly Russian. Pertinent interventions included anticipating and meeting her needs, providing American mobile nurses (AMN) language service to provide translation services as necessary to communicate with the resident and providing programs of activities that accommodated the resident's communication abilities.The activities care plan, revised 11/12/24, revealed Resident #12 preferred spending time in her room and resting throughout the day, as well as going for walks around the facility and outside when the weather was nice. Pertinent interventions included staff periodically checking in with the resident to ensure her leisure needs were being met and to offer additional activity supplies as necessary. The staff would provide a monthly activity calendar in the resident's room. -However, there was no activity calendar posted in the resident's room (see observations above).The behavior care plan, revised 3/27/23, documented Resident #12 had potential for a mood and or behavior problem related to diagnoses of schizoaffective, bipolar type. Pertinent interventions included offering for the resident to watch television and listen to preferred music.-However, there was no music device or television in the resident's room (see observations above).-The care plan failed to mention the resident's desire to play the facility's piano as part of her preferred activities.III. Staff interviewsCertified nurse aide with medication authority (CNA-Med) #1 was interviewed on 2/11/26 at 4:54 p.m. CNA-Med #1 said Resident #12 stayed in her room most of the time. CNA-Med #1 said the resident isolated herself because of her limited English proficiency. She said the resident's preferred language was Russian. CNA-Med #1 said she had not observed the resident engaging in one-on-one activities.The activity assistant (AA) was interviewed on 2/12/26 at 8:50 a.m. The AA said she was familiar with Resident #12. She said the resident mostly spoke Russian but also spoke some English. She said the resident refused most of the activities the facility offered. The AA said the resident did not currently have any one-on-one activities.-However, per the resident's interview (see above), she enjoyed playing the facility's piano and was interested in playing it weekly for the other residents.The activity director (AD) was interviewed on 2/12/26 at 10:30 a.m. The AD said Resident #12 refuses most of the activities offered to the residents. The AD said she had not identified the reason the resident refused most of the activities offered. She said all activities were offered in English, and there was no one-on-one activity program scheduled with the resident. The AD said the resident enjoyed playing the facility's piano; however, she had not incorporated that into the resident's activities. The AD said the activities calendar was printed in English and posted in the common area of the facility, not in the residents' rooms.-However, according to Resident #12's activities care plan, a monthly activity calendar was to be posted in the resident's room (see record review above).

Based on observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain hearing abilities for one (#13) of two residents reviewed for hearing and vision problems out of 35 sample residents.Specifically, the facility failed to ensure Resident #13 was assisted to receive a replacement hearing aid after her hearing aid was broken.Findings include:I. Facility policy and procedureThe Hearing and Vision Services policy, revised January 2022, was provided by the nursing home administrator (NHA) on 2/12/26 at 2:08 p.m. It read in pertinent part, It is the policy of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. The social worker/social services designee is responsible for assisting residents and their families in locating and utilizing any available resources for the provision of the vision and hearing services the resident needs.II. Resident #13A. Resident statusResident #13, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), unspecified dementia, bipolar disorder, anxiety disorder and cognitive communication deficit.The 11/18/25 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 13 out of 15. The assessment documented the resident had no difficulty hearing and did not require the use of hearing aids.B. Resident observationsOn 2/10/26 at 4:15 p.m. Resident #13 was sitting on her bed. She had a notepad and a pen on her bedside table. She had no hearing aid in either ear.On 2/11/26 at 9:40 a.m. Resident #13 was arranging her room. She had no hearing aid in either ear. She had a notepad and a pen to write.On 2/12/26 at 10:20 a.m. Resident #13 was in her room, sitting on her bed. Certified nurse aide (CNA) #4 entered the resident's room and wrote on the notepad. Resident #13 read the note and responded verbally.C. Resident representative and resident interviewResident #13 was interviewed on 2/10/26 at 4:15 p.m. Resident #13 said her hearing aid was broken and she requested staff to write their questions to her on her notepad. She said her hearing aid had been broken for over a year. Resident #13 said she usually asked staff and visitors to write on her notepad because she could not hear without her hearing aid. She pulled open her bedside drawer and brought out one piece of the broken hearing aid. Resident #13 said she could not find the other piece.The resident representative was interviewed on 2/12/26 at 9:35 a.m. The representative said Resident #13 had been using hearing aids for a very long time. He said that without the hearing aids, it was difficult communicating with the resident, especially on the phone, which sometimes irritated Resident #13. The representative said the resident's current hearing aid had been broken for some time now and the facility had made no effort to repair or replace the hearing aids.D. Record review-There were no documentation in the resident's electronic medical record (EMR) to indicate the facility was attempting to assist Resident #13 with obtaining new hearing aids.III. Staff interviewsCNA #4 was interviewed on 2/11/26 at 2:20 p.m. CNA #4 said Resident #13 had a hearing deficit and often read lips or asked staff to write on her notepads during communication to help her understand. CNA #4 said the resident's hearing aid was broken.Certified nurse aide with medication authority (CNA-Med) #1 was interviewed on 2/11/26 at 3:00 p.m. CNA-Med #1 said Resident #13 had difficulty hearing without her hearing aids. She said Resident #13 would often ask staff to write on her notepad so she could understand. CNA-Med #1 said the resident's hearing aids had been broken for a long time.The social services director (SSD) was interviewed on 2/11/26 at 3:15 p.m. The SSD said he was new to the facility and had not yet met Resident #13. He said residents with hearing impairments should be evaluated for appropriate hearing aids. The SSD said he could not find any recent audiology visit documentation for Resident#13.The SSD was interviewed a second time on 2/12/26 at 11:45 a.m. The SSD said he met with Resident #13 and completed an evaluation. He said he had placed an order (during the survey) to replace the resident's broken hearing aids, which were due to arrive at the facility the next day.-However, the order for the replacement hearing aids was not placed until the concern was brought to the facility's attention during the survey. IV. Facility follow-upOn 2/13/26 at 5:55 p.m. (after the survey exit) the SSD provided an audiologist's note for Resident #13 via email. The note was dated 9/12/22. The audiologist's note indicated the resident's hearing aid was to be returned for a replacement, but the staff were unable to locate the old one.-However, there was no documentation in the resident's electronic medical record (EMR) to indicate Resident #13 had been seen by the audiologist since 9/12/22, over a three-year timespan (see record review above).

Based on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly according to professional standards in two of three medication carts and one of three medication refrigerators.Specifically, the facility failed to: -Ensure expired medications were removed from the medication cart and disposed of; and,-Ensure the medication refrigerator was securely locked on one of three units.Findings include:I. Professional referencesThe United States Food and Drug Administration (USFDA) Don't Be Tempted to Use Expired Medicines (revised 10/31/24), was retrieved on 2/13/26 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It read in pertinent part, Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth, and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed, there is no guarantee that the medicine will be safe and effective. If your medicine has expired, do not use it.II. Facility policy and procedureThe Storage of Medication policy, revised February 2026, was received from the nursing home administrator on 2/9/26 at 12:25 p.m. It revealed in pertinent part, Medication storage refrigerators must be kept locked when medications are currently being stored under refrigeration. Outdated and contaminated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and recorded from the pharmacy if a current order exists. III. ObservationsOn 2/9/26 at 9:16 a.m. the medication cart was observed on the secured unit with certified nurse aide with medication aide authority (CNA-Med) #2. The locked narcotic drawer on the medication cart contained the following: -Morphine 20 milligram per milliliter (mg/ml), expired 1/15/26.On 2/9/26 at 9:28 a.m. the medication room on Castle Rock unit was observed with licensed practical nurse (LPN) #1. -The medication refrigerator was unlocked. The medication refrigerator contained a narcotic box that was locked. The locked narcotic drawer on the medication cart contained the following: -Oxycodone HCI Oral solution 5 mg/5 ml.-However, the Oxycodone was discontinued (see interviews below).IV. Staff interviewsCNA-Med #2 was interviewed on 2/9/26 at 9:17 a.m. CNA-Med #2 said the morphine should have been discarded and should not have been administered to the resident. She said it was the responsibility of the nurses and the CNA-Meds to ensure all expired medications were removed from the medication carts.LPN #1 was interviewed on 2/9/26 at 9:33 a.m. LPN #1 said the oxycodone should have been removed from the medication cart because it was discontinued on 11/18/25. She said the medication refrigerator in the medication room should be locked because it contains narcotic and non-narcotic prescribed medications for facility residents. The clinical resource was interviewed on 2/9/26 at 9:39 a.m. She said the staff should not administer expired or discontinued medication to facility residents. She said the nurses should always review the five rights before administering medication to residents. The clinical resource said the nurses should make sure it was the right resident, medication, dose, route, time, and check the expiration date. The consultant pharmacist was interviewed on 2/9/26 at 11:39 a.m. The consultant pharmacist said each nurses' unit in the facility should have a locked door on the medication refrigerator inside the medication room. She said the medication in the medication refrigerator on the Castle Rock unit was secure because the door to enter the medication room was locked. The consultant pharmacist was interviewed again on 2/10/26 at 3:50 p.m. The consultant pharmacist said there was a sheet at the nurses' station that said the morphine was good for one year. She said the nurses were trained to refer to the medication sheet for directions for expired medications. She said the label on the bottle of morphine on the Castle Rock unit indicated it was expired, which was different from the expiration date on the pharmacy label. She said the nurses and CNA-med should use the expired date on the bottle and not the expired date on the pharmacy label.Registered nurse (RN) #3 was interviewed on 2/11/26 at 1:41 p.m. RN #3 said she would check the pharmacy label for the expiration date and make sure the medication was not expired. She said she was trained by the facility to always check the pharmacy expiration date before administering medications to residents. The assistant director of nursing (ADON) was interviewed on 2/12/26 at 11:29 a.m. The ADON said she would ensure that all nursing staff who administered medications to residents were educated on the facility policy of medication administration. She said she would initiate this re-education training immediately. She said it was the expectation for staff administering medications, to review the expiration date on the medication bottle and discard medication accordingly.

Based on observations and interviews, the facility failed to provide a comfortable and homelike environment in one of four units. Specifically, the facility failed to: -Ensure all residents' rooms in the secured unit were in good repair; -Ensure the small common area of the secured unit was free from unpainted areas on the walls, free of sheet rock damage and missing floor tiles; and, -Ensure the dining room area of the secured area was free from stains in the ceiling and free of sheet rock damage.Findings include: I. Facility policy and procedure The Safe Homelike Environment policy, revised December 2020, was provided by the nursing home administrator (NHA) on 2/12/26 at 4:24 p.m. It revealed in pertinent part, The facility provides a safe, clean, comfortable and homelike environment.II. Observations On 2/12/26 at 9:00 a.m. an environmental tour of the secure unit was conducted. The small common area at the secure unit entrance doors was observed to have multiple black marks on the ceiling. There were unfinished sheet rock patches and multiple areas that needed stippling (texturing). The ceiling around the metal air vent was dirty and was black. There were unpainted areas on the green wall by room [ROOM NUMBER]. There were multiple brown spots on the ceiling and a loose cover base on a small wall near the crash cart. There was sheet rock damage on the corner of the wall at the crash cart. There were multiple floor tiles with missing top laminate. The dining room area had two red marks or drops (the color of blood) on the ceiling at the entrance to room [ROOM NUMBER]. There were brown water-stained areas and black debris (lint) around the ceiling vent as well as sheet rock damage around the ceiling vent. There were multiple areas on the wall under the nurses' station window shelf into dining area that were unpainted and unpainted sheet rock patches on the hallway wall by room [ROOM NUMBER] and room [ROOM NUMBER]. Resident room [ROOM NUMBER] was observed to have chipped paint on the entrance door frame and loose cover bases at the entrance to the bathroom. The bathroom was missing a towel bar and a black plunger was standing upright (not bagged) in one corner of the room. The plastic toilet seat was torn and rough wood was exposed on the bathroom door near the lower door hinge. Resident room [ROOM NUMBER] was observed to have seven unpainted sheet rock patches on two room walls, sheet rock damage on one wall near the bed by the window, and an unpainted section of wall by the window. There was one missing section of cover base at the bathroom entrance and chipped paint on the entrance door frame. The bathroom had one nonfunctional light over the sink, one wooden leg of a table was used to hold the sink up in the corner of the room, and a black plunger (not bagged) was standing upright in one corner.Resident room [ROOM NUMBER] was observed to have a loose cover base at the entrance to the bathroom.Resident room [ROOM NUMBER] was observed to have chipped paint around the sink, chipped paint on two corners at the sink area, and chipped paint on the bathroom entrance door frame. The bathroom had three torn areas of linoleum flooring, one cracked bathroom tile at the cover base, and black marks on one bathroom door.Resident room [ROOM NUMBER] was observed to have sheet rock damage on two room corners at the sink area and black marks on the wall by the sink area.Resident room [ROOM NUMBER] was observed to have scraped paint on the wall behind bed #1, cracked paint on the ceiling, a missing cover for the glove box at the sink area, a missing towel bar at the sink, and multiple grey areas on the room floor tiles.Resident room [ROOM NUMBER] was observed to have mismatched paint in three small areas above the room window. The bathroom had two small holes above the grab bar, a black plunger (not bagged) standing upright in one corner, and a loose cover base by the toilet base.Resident room [ROOM NUMBER] was observed to have one nonfunctional light over the room sink, one missing towel hanger, four small holes in the wall above the street side window, a torn cover base at the entrance door, chipped paint on the entrance door frame, a missing cover for the heater control device and missing horizontal blinds for the window facing the parking lot.Resident room [ROOM NUMBER] was observed to have sheet rock damage on two room corners by the sink, chipped paint around the room sink, two areas of wood damage on the cabinets over the closets, chipped paint on the metal heater cover under the room window and a missing cover base by the bathroom entrance door. The bathroom had a black plunger (not bagged) standing upright in one corner.III. Staff interviews The maintenance director (MTD) and life safety and maintenance resource were interviewed together on 2/12/26 at 12:13 p.m while touring the secured unit. The MTD said he had worked at the facility since June 2025. The MTD said he was responsible for the building's maintenance. He said he had one staff member and was approved for another part-time position. The MTD said he tracked improvements using a spreadsheet. He said he was done patching the walls in the secure unit. The MTD said he prioritized maintenance concerns based on safety tasks first and when there was downtime, he worked on updating the secured unit. The MTD said he knew about the repairs required in the secured unit. The MTD said he was approved to paint the walls in the secured unit and the next step was for the resident council to select the paint color. He said he worked with the NHA to prioritize repairs. The MTD said he knew room [ROOM NUMBER]'s bathroom floor was missing linoleum because the resident who resided in the room pulled up the linoleum constantly and when he repaired the floor, the resident pulled up the floor again. The MTD said the ceiling required a new fire block which arrived on 2/11/26. He said the ceiling would be painted as soon as the resident council approved a color. The MTD estimated the repairs would be done by the end of February 2026. He said in order to update the rooms, including updating the lights, holes,and faucet sinks, he said he tried to have five to six rooms completed by a certain date. The MTD said he did not have a specific end date for when the repairs in the secured unit would be completed.

Based on record review and interviews, the facility failed to ensure residents with a feeding tube received appropriate treatment and services for one (#2) of four residents reviewed out of seven sample residents.Specifically, the facility failed to ensure Resident #2 received his tube feeding administration as ordered by the physician. Findings include:I. Resident #2A. Resident status Resident #2, age [AGE], was admitted on [DATE] and discharged on 11/1/25 to the emergency department via ambulance. According to the November 2025 computerized physician orders (CPO), diagnoses included pneumonia, muscle weakness, acute respiratory failure, dysphagia oropharyngeal phase (difficulty swallowing), protein calorie malnutrition and cerebral infarction (a blood clot in artery in the brain that cuts off oxygen and nutrients to the brain). The 10/29/25 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for a mental status (BIMS) score of 13 out of 15. He required partial to moderate assistance with toileting transfers and chair to bed transfers. The resident required supervision or touching assistance with oral hygiene and personal hygiene. The MDS assessment indicated the resident had a feeding tube upon admission and was receiving 51% or more of his calories through a feeding tube and 501 cubic centimeters (CC) a day of fluid through a feeding tube.B. Record reviewThe enteral feeding care plan, initiated 10/24/25, documented Resident #2 required tube feedings related to difficulty with swallowing. Interventions included elevating the head of the bed at least 30 to 45 degrees at all times during feeding, providing the resident tube feeding and water flushes per physician's orders, obtaining and monitoring lab/diagnostic work as ordered and report results to doctor and follow up as indicated , providing care to feeding tube site as ordered and monitor for signs and symptoms of infection, registered dietitian (RD) to evaluate quarterly and as needed, monitoring caloric intake and estimating needs, making recommendations for changes to tube feeding as needed and use enhanced barrier precautions.The nutrition care plan, initiated on 10/24/25 and revised on 10/29/25, documented Resident #2 had nutritional problem or potential nutritional problem related to his nothing by mouth (NPO) status, currently on tube feedings, pneumonia, aneurysm and acute respiratory failure. Resident #2 had a mini nutritional assessment (MNA) score of five indicating a malnourished status . Pertinent included administering medications as ordered, providing the tube feed as ordered: give 1430 ml enterally every 24 hours for continuous tube feeding.The hospital Discharge summary, dated [DATE], documented the following enteral feed physician's order for Resident #2: Enteral feed via nasogastric (NG) tube. Nutren 1.5 (enteral feed formula) with a continuous rate of 65 milliliters (ml) per hour (1430 ml total per day) with 30 ml free water bolus for tube patency every four hours. -However, review of the November 2025 CPO revealed the enteral feed orders were not entered into Resident #2's CPO until 10/28/25, five days after the resident was admitted to the facility. Review of the November 2025 CPO revealed the following physician's order for Resident #2:Nutren 1.5 oral liquid. Give 1430 ml enterally every 24 hours via feeding tube, ordered on 10/28/25 at 1:00 p.m.-Review of Resident #2's EMR did not reveal documentation indicating Resident #2 receive his enteral feed physician's orders as indicated on the hospital discharge paperwork from 10//23/25 until 10/28/25.C. Staff interviewsThe registered dietitian (RD), the assistant director of nursing (ADON) and the regional clinical resource were interviewed together on 12/8/25 at 1:58 p.m.The RD said when Resident #2 admitted from the hospital, the physician's ordered indicated Resident #2 was NPO with supplemental feeding via tube feed. The RD said the specific diet orders were to give Nutren 1.5 continuous, with a total volume of 1430 ml over 24 hours. The RD said the diet orders should have been transcribed into the medication administration record (MAR). The RD said the admitting nursing staff must have missed these orders upon admission. The regional clinical resource said ideally, the diet ordered was verified with the facility's physician and entered into the resident's CPO. The regional clinical resource said it was the admitting nurses responsibility to verify the hospital discharge orders with the facility physician upon admission. The regional clinical resource said this was important to ensure all of the physician's orders were entered because the facility needed to ensure Resident #2 did not miss any of his nutritional requirements. The regional clinical resource said the potential negative outcomes of a resident not receiving his nutritional requirements could result in a medical decline. The ADON said she provided education to the admitting nurse and all of the nurses in the facility regarding the process of verifying discharge orders and inputting them to the resident's EMR upon admission. The ADON said she provided this training on 10/28/25 after she noticed the missing orders in Resident #2' EMR. The RD said this was important to ensure Resident #2 received an adequate caloric intake required for his recovery during his stay at the facility.Licensed practical nurse (LPN) #1 was interviewed on 12/8/25 at 2:40 p.m. LPN #1 said she did not care for Resident #2 when he was at the facility. LPN #1 said she was familiar with the admissions process and responsibilities for any residents arriving into the facility with who required tube feedings. LPN #1 said upon admission, the admitting nurse should review discharge orders with the facility's physician to ensure the residents had feeding tube orders to initiate. She said the admitting nurse should confirm with the doctor the type of tube feeding, the total amount in a 24 hour period, the rate per hour and any additional water flush needing to be given to the resident.

Based on observations, record review and interviews, the facility failed to ensure one (#4) of three residents reviewed for elopement out of three sample residents and other residents residing in the facility remained as free from accidents/hazards as possible.Specifically, the facility failed to:-Ensure Resident #4 received adequate supervision to prevent the resident from eloping from the facility; and,-Ensure there was an effective evacuation plan in place and that staff were trained on the plan and provided with the necessary equipment to evacuate residents from the facility in the case of an emergency, which had the potential to affect the safety of all 72 residents residing in the facility.ELOPEMENT INCIDENT FAILURE FOR RESIDENT #4Resident #4, who had diagnoses of bipolar disorder, cognitive communication deficit, chronic heart failure, presence of automatic implanted cardiac defibrillator and traumatic subarachnoid hemorrhage (bleeding between the brain and the protective layer of the brain), was admitted to the facility on [DATE].Upon admission, Resident #4 was assessed to be at high risk for elopement due to exit seeking behaviors and verbalizing the desire to leave the facility.The facility implemented a care plan on 6/26/25 of the resident's impulsive behavior problem, which included behaviors such as a history of eloping, threatening to elope, refusing care and throwing his plate of food. However, the facility failed to implement appropriate resident-specific interventions to provide adequate supervision and monitoring to meet the resident's individual needs when Resident #4, who resided on the secured unit, was distressed/upset and voiced desire to leave the facility, refused/threw his plate of food.On 9/20/25 at 4:30 p.m. threw his dinner meal when he was agitated. The resident tried to reach out to his family via phone but they did not answer and his agitation grew.The facility failed to adequately respond to the resident's distress and did not provide increased safety oversight, including frequent checks, monitoring or behavioral support. Staff failed to provide consistent monitoring of the resident for approximately four hours after he was noted to have escalating agitation (see facility investigation below). Resident #4 was officially designated as missing from the facility on 9/20/25 at 8:30 p.m.Per the facility investigation conducted after the resident's elopement, the facility believed that Resident #4 eloped the facility through his window by overriding the safety mechanism and then climbed over a gate in the secured courtyard. The facility was not aware that he was missing for four hours.Resident #4 was not found until two days later at a homeless shelter and was missing for approximately 46 hours (see facility investigation below). Resident #4 did not return to the facility.The facility's failure to provide adequate supervision, implement the elopement care plan, monitoring the resident after a behavioral event created a situation where serious adverse outcome was likely. The resident had acute health concerns that went unaddressed as a result of his elopement.SAFE AND EFFECTIVE EVACUATION ROUTE PLAN FAILUREDuring the investigation of Resident #4's elopement, staff interviews revealed the facility failed to have a plan that ensured the safe evacuation of residents from the facility in the event of an emergency. Observations revealed the facility was on one level and was divided into two unsecured nurse units (Castle Rock and Red Rocks) and one secured unit (Rocky Mountain). Fifty-five residents resided on the two unsecured units and seventeen residents resided on the secured unit. There were no evacuation floor plans or maps posted on any of the walls in the facility. There were no maps or floor plans posted with directional arrows that demonstrated the path staff and residents should follow in the event of an evacuation. Interviews with staff revealed they were not aware of the routes to take to evacuate residents from the building in the event of an emergency.Observations revealed the gate in the secured unit courtyard, which was the primary emergency egress/evacuation route for the Rocky Mountain unit and the Castle Rock unit, was padlocked, preventing staff and residents from exiting the courtyard. Additionally, staff was unaware of where the key for the padlock was located.The facility's failure to have a plan that ensured the safe evacuation of residents and to ensure the primary egress route for emergency exits for the secured unit remained unlocked and accessible created a hazardous environment that made serious harm likely.The facility failed to provide Resident #4 with the supervision necessary to prevent an elopement. Furthermore, there was a padlock placed on the primary evacuation/egress route from the secured unit via the courtyard through the outdoor fenced storage area. The facility's failures created a situation for the likelihood of serious harm to residents' health and safety if the situation was not immediately corrected.Findings include:I. Immediate JeopardyA. Findings of immediate jeopardy ELOPEMENTUpon admission, Resident #4 was assessed to be at high risk for elopement due to exit seeking behaviors and verbalizing the desire to leave the facility.The facility implemented a care plan on 6/26/25 of the resident's impulsive behavior problem, which included behaviors such as a history of eloping, threatening to elope, refusing care and throwing his plate of food. However, the facility failed to implement appropriate resident-specific interventions to provide adequate supervision and monitoring to meet the resident's individual needs when Resident #4, who resided on the secured unit, was distressed/upset and voiced desire to leave the facility, refused/threw his plate of food.On 9/20/25 at 4:30 p.m. threw his dinner meal when he was agitated. The resident tried to reach out to his family via phone but they did not answer and his agitation grew.The facility failed to adequately respond to the resident's distress and did not provide increased safety oversight, including frequent checks, monitoring or behavioral support. Staff failed to provide consistent monitoring of the resident for approximately four hours after he was noted to have escalating agitation (see facility investigation below). Resident #4 was officially designated as missing from the facility on 9/20/25 at 8:30 p.m.Per the facility investigation conducted after the resident's elopement, the facility believed that Resident #4 eloped the facility through his window by overriding the safety mechanism and then climbed over a gate in the secured courtyard. The facility was not aware that he was missing for four hours.Resident #4 was not found until two days later at a homeless shelter and was missing for approximately 46 hours.The facility's failure to provide adequate supervision, implement the elopement care plan and monitoring the resident after a behavioral event created a situation where serious adverse outcome was likely. The resident had acute health concerns that went unaddressed and unmonitored as a result of his elopement.EVACUATION ROUTE PLAN Observations revealed the facility was on one level and was divided into two unsecured nurse units (Castle Rock and Red Rocks) and one secured unit (Rocky Mountain). Fifty-five residents resided on the two unsecured units and seventeen residents resided on the secured unit. There were no evacuation floor plans or maps posted on any of the walls in the facility. There were no maps or floor plans posted with directional arrows that demonstrated the path staff and residents should follow in the event of an evacuation.Upon inquiry during the survey, the maintenance director (MTD) hand-drew the evacuation route/plan on a facility map. Review of the facility evacuation plans/map, observations and interview revealed the secured Rocky Mountain unit had an emergency evacuation route that led to the secured fenced courtyard and then exited out the courtyard gate (secured by a door alarm push bar) to a fenced storage area that had a gate. The fenced storage area had a padlock on the gate, preventing an accessible egress route out and away from the building. The staff interviewed during the survey were unaware of the process to evacuate residents and reported they did not have access to the key to unlock the padlock on the gate. The unsecured Castle Rock unit had an emergency evacuation route that led to the supervised smoking patio, which was fenced and then exited out the gate (secured by a door alarm push bar) to a fenced storage area that had a gate. The fenced storage area had a padlock on the gate and was the same fenced storage area that the secured unit shared and evacuated to, and therefore prevented an accessible egress route out and away from the building. The unsecured Red Rocks unit had an emergency evacuation route that led out the main entrance and was secured by only a door alarm push bar.Staff interviews demonstrated a lack of understanding and training with the plan for evacuation and observations revealed the presence of a physical barrier (padlock) that prevented staff and residents from evacuating the premises. The facility's failure to have a plan that ensured the safe evacuation of residents created a hazardous environment with the potential for serious harm, affecting all 72 facility residents.The facility needed to immediately develop and implement an effective system to proactively identify environmental hazards (windows, gates) and evaluate the resident's need for safety checks, supervision and monitoring during a behavioral episode to prevent further occurrences. The facility needed to immediately ensure all staff were adequately trained and educated on performing adequate supervision, monitoring and meeting the individual needs according to their care plan and include training in emergency preparedness for safe egress.Additionally, the facility needed to take immediate actions to ensure all egress routes in the facility were unlocked and available in case of emergency. The facility needed to implement a systematic approach that enables the facility to evaluate safety throughout its environment and among all staff, and make appropriate adjustments in training and competency testing as required.B. Facility notice of immediate jeopardyOn 10/8/25 at 7:15 p.m. nursing home administrator (NHA) #1 was notified that the facility's failure to provide residents with a safe environment and adequate supervision to avoid preventable accidents created an immediate jeopardy situation for the likelihood of serious harm. C. Facility plan to remove immediate jeopardy On 10/9/25 at 9:40 a.m. NHA #1 provided a plan to remove the immediate jeopardy situation. The removal plan read:The padlock and the latch on the outdoor fenced storage areas were removed by the NHA on 10/7/25 at 4:50 p.m. The facility map of the egress routes were posted by the life safety/maintenance resource on 10/9/25 at 11:00 a.m. for all halls. Resident #4 was no longer a resident at the facility.Identification of others - All residents had the potential to be affected. The facility was toured by the life safety resource on 10/8/25 to identify and ensure all egress exits were unlocked and accessible. All residents were reviewed by the director of nursing (DON) and clinical resource for elopement risk and care plans were updated as needed on 10/8/25. Education with the NHA and the IDT (interdisciplinary team) initiated on 10/7/25 by clinical resource on keeping facility egress routes unlocked and accessible.Immediate interventions for evacuation - All staff education initiated on 10/8/25 by DON/designee on specific evacuation routes, keeping egress exit for emergency exits for the secured unit unlocked and accessible, the codes for the exit doors and the facility evacuation map postings. Education on the emergency operations procedure quick reference guide initiated on 10/9/25 which showed initial employee expectations and responsibilities. Window security devices will continue to be monitored until window alarms are in place. Window alarm installation to be initiated on 10/9/25 for the secured unit. Moving forward, all staff were to be educated on evacuation procedures during orientation.Immediate interventions for precipitating events regarding elopement - Staff education initiated on 10/8/25 by the DON/designee on the need for safety checks and monitoring during a behavioral episode to prevent further occurrences and where to locate resident elopement care plans. Staff were educated that although residents may request to be left alone or to have their door closed, it does not eliminate the facility's obligation to ensure the safety of the resident; staff needs to verify that the resident was safe and present. Increased monitoring will be completed on a case by case basis dependent upon situation and if warranted the resident will be placed on 15-minute checks. Behavioral episodes could include verbal outbursts, physical aggression, increased exit-seeking behaviors, tearfulness, statements about leaving/going home and pacing. Education initiated 10/8/25 and those staff that could not be educated in person will be educated prior to the start of their next scheduled shift. The facility will be completing a headcount on the secured unit every two hours by floor nurse, nursing management, or designee. Headcount to be completed on paper audit form for a minimum of 12 weeks or until substantial compliance has been achieved.The DON, or designee, will complete random audits three times per week for 12 consecutive weeks. The audit will include: Staff interview: Does staff member know evacuation route? Observation: All egress routes are unlocked and available in case of emergency? Staff interview: Does staff know to provide safety checks and increased monitoring during a resident behavioral episode? Increased monitoring will be completed on a case by case basis dependent upon situation and if warranted the resident will be placed on 15-minute checks. Behavioral episodes can include verbal outbursts, physical aggression, increased exit-seeking behaviors, tearfulness, statements about leaving/going home and pacing. Staff interview: Does staff know how to access the resident's elopement care plan? Staff interview: Does staff know the codes to the exit doors? Additional comments and/or interventions if issues noted on audit form. This will be recorded on an audit form. Audit records will be reviewed by the risk management/quality assurance committee monthly until such time consistent substantial compliance has been achieved as determined by the committee.D. Removal of immediate jeopardyNHA #1 was notified the immediate jeopardy was removed on 10/9/25 at 3:10 p.m. based on the facility's removal plan (see above). However, deficient practice remained at a F level, with a potential for more than minimal harm that was widespread.II. Failed to prevent an elopement for Resident #4A. Facility policy and procedureThe Elopement/Unsafe Wandering policy and procedure, revised June 2018, was provided by NHA #1 on 10/8/25 at 3:01 p.m. It read in pertinent part, The facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision and diversional programs to prevent unsafe wandering while maintaining the least restrictive environment for those at risk for elopement. It is the policy of this facility to provide a safe environment for all residents through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement. Wandering is defined as random or repetitive locomotion and can be either goal directed or non-goal directed/aimless. Elopement is when a resident leaves the facility premises or a safe area without authorization (an order for discharge or leave of absence) and/or any necessary supervision to do so. Residents with capabilities of ambulation and/or mobility in wheelchair will have an elopement/wandering evaluation completed to determine risks for elopement and unsafe wandering on admission and with observed behaviors of wandering or attempting to elope. Residents with high risk factors identified on an elopement/wandering evaluation are considered at risk and will have an individualized care plan developed that includes measurable objectives and timeframes. The care plan interventions will consider the particular elements of the evaluation that put the resident at risk and the observations of wandering behavior. These interventions will address the individualized level of supervision needed to prevent elopement/unsafe wandering.B. Resident #41. Resident status Resident #4, age less than 65, was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included traumatic subdural and subarachnoid hemorrhage with loss of consciousness, encephalopathy, chronic systolic (congestive) heart failure, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, cognitive communication deficit, aphasia (A language disorder affecting a person's ability to communicate), presence of automatic implantable cardiac defibrillator (AICD), presence of prosthetic heart valve and bipolar disorder.The 9/18/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. He required substantial/maximal assistance with shower/bathing. He required partial/moderate assistance with personal hygiene and shower transfers. He required supervision/touching assistance with eating, oral hygiene, upper/lower body dressing, walking with a cane, sit to stand transfers and bed to chair transfers. 2. Resident representative interviewResident #4's representative was interviewed on 10/7/25 at 3:54 p.m. The resident's representative said he was sad that Resident #4 had eloped and was now at the homeless shelter and felt Resident #4's health was in jeopardy and that Resident #4 did not make good decisions for himself. The representative said the facility had not done a good job in meeting the resident's mental health needs. The representative said Resident #4 did not want to return to the facility after he eloped, although the family had encouraged him to do so. The resident's representative said he and the family were upset that the facility did not protect Resident #4 from eloping. 3. Facility investigationOn 10/7/25 at 2:48 p.m. NHA #1 provided the facility's investigation of Resident #4's elopement on 9/20/25. The investigation included the following timeline: -On 6/11/25 Resident #4 admitted to the facility from the hospital; -On 6/14/25 Resident #4 had an incident where he exited the facility with supervision (see progress note below);-On 6/30/25 Resident #4 moved to the secured unit after being assessed to be a high risk for elopement due to exit seeking behaviors and verbalizing the desire to leave the facility;-On 9/20/25 Resident #4 eloped from the facility;-On 9/20/25 at 4:42 p.m. staff attempted to give the resident his dinner and he had a behavioral episode by refusing and throwing his meal at the staff; -On 9/20/25 at 5:27 p.m. a nurse attempted to give medication to the resident but Resident #4 not in his room; -On 9/20/25 at 8:08 p.m. a nurse returned to Resident #4's room to give the resident medication but Resident #4 was not in his room; -On 9/20/25 at 8:30 p.m. Resident #4 was designated as officially missing by the facility; -On 9/20/25 at 9:43 p.m. Resident #4 was reported as missing to the police;-On 9/20/25 at 11:35 p.m. the police arrived on scene at the facility to respond to a report of a missing person; and,-On 9/20/25 after 11:35 p.m. police viewed video footage from the facility and discovered the resident left from the facility via the north side of the building on 9/20/25 at 5:27 p.m. According to the police report, the DON said Resident #4 was last seen on 9/20/25 at 4:30 p.m. when staff attempted to give the resident his dinner. -The facility left Resident #4 alone for four hours without appropriately checking on him from approximately 4:30 p.m. to 8:30 p.m.The investigation indicated that on 9/22/25 NHA #1 located Resident #4 at the homeless shelter. NHA #1 asked Resident #4 what happened and the resident said he did not belong there (at the facility) and everyone was just so loud and when he tried to make a joke with someone they did not laugh. The resident said that his sister stole his money with her boyfriend and that he had to get it back but she would not answer him. The resident said he opened the window to his bedroom (at the facility) and closed it back with the screens and used his cane to get over the wall. He said he was not sure how to get down so he just went for it and jumped down and then he stepped on the wood to get through the gate. He said he wanted to go with a friend but he did not have the money to get to where he wanted to go so he ended up at the homeless shelter. -Resident #4 was not found until two days later at a homeless shelter and was missing for approximately 46 hours.4. Record review Review of Resident #4's impulsive behavior care plan, initiated 6/26/25 and revised 10/2/25), revealed the resident had the potential for impulsive behavior problems, including a history of eloping, threatening to elope, refusing care and medication, calling out, barricading himself in his room, verbal aggression towards staff, cursing, aggression towards family, throwing his plate of food and paranoia. Interventions included anticipating and meeting the resident's needs, approaching the resident in a calm manner, assisting the resident to develop more appropriate methods of coping and interacting, encouraging the resident to express feelings appropriately, documenting behaviors and the resident's response to interventions and monitoring behavior episodes and attempting to determine underlying cause, while considering location, time of day, persons involved and situations.-The care plan failed to include specific interventions to address the resident's potential for elopement.Review of Resident #4's elopement risk care plan, initiated 7/1/25, revealed the resident had the potential for elopement related to history of attempts to leave the facility unattended and impaired safety awareness. The resident resided in a secured unit. Interventions included distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books, documenting wandering behavior and attempted diversional interventions, identifying patterns of wandering, including was the wandering purposeful, aimless, or escapist, was the resident looking for something and did the wandering indicate the need for more exercise, intervening as appropriate and providing structured activities, such as toileting, walking inside and outside and reorientation strategies including signs, pictures and memory boxes.-However the facility failed to implement the elopement care plan.Review of Resident #4's electronic medical record (EMR), from 6/11/25 to 9/20/25, revealed the following progress notes:The 6/14/25 at 12:43 p.m. nurse note revealed Resident #4 had come to the nurses' station and stated that he wanted to leave the facility. Resident #4 said he did not like it at the facility and wanted to leave. The nurse called his sister and she said Resident #4 always did that and the sister talked to him on the phone. Resident #4 became calm for a few minutes after talking with his sister but after a few minutes he forcefully unlocked the door and started to walk outside. The nurse followed the resident and called the sister and brother-in-law again. They said they were coming to get him on Monday so he came back to the facility. The DON was notified. The 6/15/25 at 12:46 p.m. nurse note revealed the nurse spoke with Resident #4 regarding his reason for wanting to leave the day before. Resident #4 said that he would rather be at the coalition because he was older than his siblings and they were not his parents. Resident #4 also said he did not like his room. The nurse acknowledged Resident #4's comments and discussed a possible room move and was waiting to discuss leaving the facility with family members and the care team in the morning and Resident #4 agreed. Resident #4 was educated on concerns for safety, medication compliance and medical needs should he abruptly attempt to leave without facility or family coordination. Resident #4 reported understanding. Resident #4 was then assisted to tour an alternate room. Resident #4 agreed to stay overnight and agreed to a new room. The resident was introduced to his new roommate and given a room orientation. Resident #4 and the nurse moved all of his belongings to the new room and Resident #4 was in good spirits. Resident #4 proceeded to follow up with eating his lunch. Resident #4 remained at baseline at the time. Resident #4 was encouraged to talk to family or facility staff regarding any frustrations or issues when they came up and Resident #4 agreed. Staff continued to monitor.The 6/17/25 at 6:55 p.m. nurse note revealed Resident #4 was on 15-minute checks during the shift and Resident #4 stayed in his room the whole time watching television (TV). He exhibited no behaviors of leaving the facility. The 6/25/25 at 12:48 p.m. nurse note revealed Resident #4 refused all morning medications and made statements about calling the police and threats of elopement. Resident #4 was visited by family/friend and his affect improved and Resident #4 took all his afternoon medications.The 6/26/25 at 9:32 a.m. nurse note revealed follow up on the resident's behaviors of refusing medications, threatening to elope and calling the police. The staff utilized the resident's family for support and a behavioral health services referral was sent and in progress. Resident #4 had a history of impulsiveness and making threats of leaving the facility and was to be assessed for secure unit placement.The 7/15/25 at 12:00 p.m. psychological evaluation note documented the behavioral health services nurse practitioner discussed Resident #4's difficulty transitioning into the facility with the resident. The resident expressed difficulty adjusting to the facility and said he was having a hard time overall being in the facility.The 7/28/25 at 9:00 a.m. change of condition note revealed the resident was sent to the hospital per nurse observations, evaluation and recommendations due to seeming agitated, frustrated, and transferred out to ER (emergency room) immediately. The care provider responded with the following feedback to transfer the resident out to ER for further evaluation and care including testing for an EKG (electrocardiogram).The 7/30/25 at 4:50 p.m. nurse note revealed the resident had just returned back from the hospital.The 7/30/25 at 6:29 p.m. admission note revealed that, after dinner, Resident #4 started resisting his roommate from entering the room, he yelled at everyone that tried to calm him down and threatened to call the police three times. The nurse tried to separate the two roommates, and informed the oncoming nurse to monitor and follow up with the new readmit.The 7/31/25 at 5:15 a.m. nurse note revealed Resident #4 had called the police because another resident had picked up his phone. The nurse took the phone back and gave it to the owner. The resident was verbally abusive to the staff and said he wanted to go home.The 8/5/25 at 11:59 a.m. nurse note revealed the resident was repeatedly offered medication but refused them and continued to yell at the staff that he had to leave to go to his family this morning. Education was provided about the importance of his medications and staff continued to redirect him. The 8/6/25 at 11:40 a.m. nurse note revealed that social services informed Resident #4's family about the resident experiencing behaviors and they reported that it helped when they took him out and spent time with him and they would continue to do that with him. The resident also asked them about leaving the facility and they continued to let him know that this was the safest plan for him at this time. Behavioral health services were notified.The 8/12/25 at 10:50 a.m. nurse note revealed that staff notified the physician's assistant of Resident #4's refusal of all his medication as well as his vital signs the morning of 8/12/25. The nurse made a second attempt to administer the medication but the resident repeatedly refused and seemed upset and started to act impulsively. The resident stated he needed to get out of the facility. The nurse left a voice message for the emergency contact. The 8/21/25 at 3:16 p.m. activities note revealed an activities staff member visited Resident #4 and offered art supplies but the resident refused. The resident was very upset and said that he did not want anything from activities because he was not staying there and was going to go home. He also refused any one-on-one activities for conversing or listening to music.The 8/22/25 at 5:46 p.m. nurse note revealed the resident was exhibiting aggressive behavior toward staff. He stated I don't belong here. I want to get out of here. Redirection was attempted but was unsuccessful. The resident refused all of his medications.The 8/25/25 at 10:22 a.m. nurse note revealed the resident had refused all of his medications in the morning and had placed the bed as a barrier behind his room door entrance preventing the staff from getting into his room. Staff had to go through the bathroom from the room next door to offer breakfast to the resident and the resident got up and said expletives aggressively. The resident continued to state I don't belong here. I want to get out of here! Redirection was attempted but was unsuccessful. The 8/26/25 at 12:00 p.m. psychiatric follow-up note, documented by a physician's assistant, revealed that Resident #4 shared that he had had thoughts in the past about trying to leave the unit by breaking a window, but stated he would have turned himself in afterward.The 9/9/25 at 9:52 a.m. nurse note revealed Resident #4 had refused his breakfast and all his medications. Later the resident requested his breakfast be replaced. The nurse staff went to the kitchen to obtain a new plate and upon delivery the resident threw the plate across the dining room and stated that the nursing staff was trying to poison him with his medications and were trying to give him food from another resident. The resident then called 911. Police officers responded and the resident was stating that he wanted to leave and return to the homeless shelter and that he did not belong there. The resident was also displaying paranoia related to his sister. The police officer, the NHA and nursing staff reoriented the resident and explained cares and the process needed to be able to discharge safely. The resident verbalized understanding.The 9/20/25 at 12:09 p.m. nurse note, written by registered nurse (RN) #2, revealed Resident #4 did not want the nurse to touch his AICD monitor. The nurse observed the monitor was unplugged and the resident was agitated.The 9/20/25 at 12:10 p.m. medication administration note revealed the resident refused his skin assessment. RN #2 had attempted the assessment three times.The 9/20/25 at 9:00 p.m. nurse note, written as a late entry by the DON, revealed the executive director (ED), family, ombudsman, police department and medical doctor were all notified. -However, the note did not specify what the notification was regarding. -Review of Resident #4's EMR revealed there were no other progress notes documented on 9/20/25.The 9/21/25 at 3:06 a.m. nurse note, written by licensed practical nurse (LPN) #1 revealed that at 8:30 p.m. on 9/20/25 she entered Resident #4's room to give him his medications and Resident #4 was not sitting on his bed and the door to his bathroom was locked. LPN #1 returned a few minutes later and Resident #4 was still not visible in his room. LPN #1 knocked on the bathroom door with no answer. LPN #1 opened the door and Resident #4 was not there. LPN #1 asked the certified nurse aide (CNA) #2 if he was aware that Resident #4 was not in his room. CNA #2 stated that the last time he saw Resident #4 was at dinner time and Resident #4 had refused hi

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety.Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to: -Accident/hazards in which the facility failed to provide Residents #4 the supervision necessary to prevent elopement that rose to the level of immediate jeopardy and created a situation that a serious adverse outcome was likely; and, -Accident/hazards in which the facility failed to have a system in place to ensure the staff followed the facility emergency plan regarding evacuation procedures and physical barriers (padlock) in place that prevented staff and residents from evacuating the premises which rose to the level of immediate jeopardy and created a situation that a serious adverse outcome was likely.Findings include:I. Facility policy and procedureThe Quality Assurance and Performance Improvement (QAPI) policy and procedure, revised December 2024, was provided by nursing home administrator (NHA) #1 on 10/9/25 at 3:55 p.m. It read in pertinent part, The facility will establish and implement a quality assessment and assurance committee, develop a written QAPI plan, which will be used to continually assess the facility's performance using a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality. The plan will be reviewed and updated annually. QAPI is the coordinated application of two mutually reinforcing aspects of a quality management system. QAPI takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes. Quality Assurance (QA) is the specification of standards for quality of service and outcomes, and systems. QA is on-going, both anticipatory and retrospective in its efforts to identify how the organization is performing, including where and why facility performance is at risk or has failed to meet standards. Performance Improvement (PI) is the continuous study and improvement of processes with the intent to improve services or outcomes, and prevent or decrease the likelihood of problems, by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems or barriers to improvement. PI in nursing homes aims to improve processes involved in health care delivery and resident quality of life. Procedure: Quality Assessment and Assurance Committee (QAA): Members of the committee will include: director of nursing (DON), medical director, administrator, Infection preventionist, at least two other members: Staff with responsibilities for direct resident care and services (CNAs (certified nurse aides), therapists, staff nurses, social workers, activities staff). Staff with responsibilities for the physical plant (maintenance, housekeeping, laundry). The committee will meet at least quarterly or more often as the facility deems necessary. The committee will maintain a record of the dates of all meetings and the names/titles of those attending each meeting. Committee functions include: QAPI plan, identifying and prioritizing Process Improvement Plans (PIPs), implementing actions to correct quality issues, and monitoring to ensure the corrective action implemented is being sustained. QAPI plan components: The plan will include:. Design and scope to include: Address all systems of care and management practices; Include clinical care, quality of life and resident choice; Utilize the best available evidence to assist in defining goals and desired outcomes; and Reflect the care and services provided by the facility. Establishing goals and thresholds for performance measurement. Feedback, data systems, and monitoring demonstrating evidence of identification, reporting, investigating, analysis, and prevention of adverse events. Performance improvement projects (PIPs or QITSs) to demonstrate corrective actions and/or improvement activities. At least one project annually must focus on high-risk or problem-prone areas, identified by the facility through data collection and analysis. Systematic analysis and systemic action of identified quality deficiencies. Identification of, and prioritizing of, PIPs through: Open-door policy for staff reporting of quality problems; Staff meetings; Resident council; Grievances; Systematic review of facility data, data sources, and comparative data, from market, state, and national sources. Prioritizing through identification of high-risk, high volume, or problem-prone issues. Education and information sharing: Staff will be educated on QAPI (Committee, Plan, and PIPs) at the time of hire, as needed, and annually thereafter. QAPI plans and activities will be shared through resident council. QAPI plans and activities may be shared through staff meetings, bulletin boards. Governance and leadership: a. The governing board and administrator will promote and create a fair and open culture where staff are comfortable identifying quality problems and opportunities. The administrator will provide support for staff time, space, and resources to carry out QAPI activities. The administrator will share QAPI plans and activities periodically to the governing board. Governance and leadership that is sustainable through transitions. QAPI tools to support performance improvement activities: The facility may utilize the following established performance improvement tools/processes: Plan-Do-Study-Act (PDSA cycles); The Five Why's to identify the root cause; The Fishbone.II. Review of the facility's regulatory record revealed it failed to operate a QA program in a manner to prevent repeat deficiencies and initiate a plan to correctDuring the recertification survey on 12/14/23, F689 (or free from accident/hazards) was cited at a D scope and severity, a potential for more than minimal harm, isolated, related to falls.During the recertification survey on 1/29/2019, F689 (or free from accident/hazards) was cited at a IJ/J scope and severity, immediate jeopardy to resident health or safety, isolated, related to elopement and smoking.III. Cross-reference citationsCross-reference F689: The facility failed to prevent elopement and failed to have a safe and clear egress route that was free from blockage. The facility's failure to prevent elopement and failure to have a safe and clear egress route that was free from blockage put residents in a situation where a serious outcome was likely to occur and created an immediate jeopardy situation.IV. Staff interviewsThe medical director (MD) was interviewed on 10/9/25 at 11:40 a.m. He said he was in the facility at least once a month. The MD said he provided roles such as attending psychological pharmacy meetings, QAPI meetings, chart reviews and provided education as needed. The MD said he had not provided any education to the staff recently. The MD said he received and reviewed pharmacy and QAPI reports. The MD said he provided oversight and follow up with the NHA when appropriate. The MD said he reviewed resident records when there was an occurrence such as a fall or a hospitalization. The MD said he would review policies and make changes to policies annually, but had not done so yet. The MD said he had been the medical director at the facility for five years since February or March of 2020. The MD said the facility had informed him that morning that the survey team had identified immediate jeopardy for F689 accident/hazards related to elopement and safe egress routes. The MD said his understanding and thoughts about the nature of the immediate jeopardy situation seemed pretty straight forward. The MD said his recommendations for the facility's next steps were to make sure there was a safe egress route and that resident behaviors were attended to and resident supervision. The MD said a lot of education was needed and the facility had started the education but he had not seen the performance improvement plan (PIP) yet. NHA #1 and the director of nursing (DON) were interviewed together on 10/9/25 at 4:00 p.m. NHA #1 said the last QAPI meeting was on 9/16/25 and they met monthly. NHA #1 said the QAPI committee included all of the required members. NHA #1 said the committee discussed all identified issues that the committee was aware of and went over slides for each department. NHA #1 said they had standard issues that they worked on and addressed reportable incidents, falls, infections, hospitalization, weight loss, diet changes, admission, discharges, resident council, grievances and trends.NHA #1 said the QAPI committee identified issues and how they were improving with any corrective actions. NHA #1 said the QAPI committee put forth a good faith attempt to identify and correct its own quality deficiencies and it was a team effort. NHA #1 said the facility had at least one process improvement plan going and most recently it was regarding glucometer calibration. NHA #1 said that elopement and emergency preparedness with safe evacuation/egress had not been identified as a QAPI concern but it would now be added.

Based on observations, record review and interviews, the facility failed to ensure one (#3) of eight residents reviewed for accidents received adequate supervision out of eight sample residents. Specifically, the facility failed to ensure Resident #3 was provided safe transportation. Resident #3 was wheelchair bound and dependent on staff for mobility and positioning. She had functional limitations in range of motion for her lower extremities due to below the knee amputations. Resident #3 was assisted into the van after an appointment on 1/22/25 by van driver #1. Resident #3 was not secured properly in the van. When the van accelerated, Resident #3's wheelchair tipped backward and she fell onto the floor with the wheelchair landing on top of her. When van driver #1 pulled over, she noticed the resident had blood in her mouth. Emergency services were called and the resident was transported to the hospital. The resident was diagnosed with fractures of the sixth and seventh cervical vertebra, first and second thoracic vertebra, epidural hemorrhage (brain bleed), multiple rib fractures and pain. Resident #3 required hospitalization in the intensive care unit (ICU). Findings include: Observations, record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 4/15/25 to 4/30/25, resulting in the deficiency being cited as past noncompliance with a correction date of 1/28/25. I. Situation of serious harm The facility's failure to ensure van driver #1 secured Resident #3's wheelchair in the facility's van when she was being transported to and from her appointment placed the resident at serious risk of harm, serious impairment or death. Resident #3 suffered multiple fractures, brain injury and pain. II. Facility plan of correction The corrective action plan the facility implemented in response to the accident on 1/22/25 involving Resident #3's was provided by the director of nursing (DON) on 4/16/25 at 10:35 a.m. The correction plan revealed the following: A. Immediate action Resident #3 was sent to the hospital immediately following the incident on 1/22/25. Upon return to the facility, van driver #1 performed a demonstration and the facility verified the van driver's knowledge of the proper procedure for securing the wheelchair in the van on 1/22/25 (the date of incident). Van driver #1 was suspended from the facility on 1/22/25, pending an investigation. An inspection of the van and wheelchair restraints was completed on 1/23/25 by the maintenance supervisor (MS). B. Identification of others affected The facility determined the deficient practice had the potential to affect all residents who used wheelchairs in the facility. A review of other residents to determine if anti-tippers (a device used to prevent wheelchairs from tipping backwards) for their wheelchairs was needed was completed on 1/24/25. C. Systematic changes The facility provided documentation that all staff who could transport residents had completed wheelchair securement training by 1/29/25. The training included correct procedures for securing wheelchairs in transportation vehicles, the use of appropriate restraints and securing devices, how to inspect and ensure all safety equipment was functioning properly before transport and procedures to follow in case of an emergency or equipment malfunction. The activities director (AD) was included in the individuals having completed the training. The AD helped transport residents until a new van driver was hired on 3/24/25. III. Facility policy and procedure The Transporting a Resident, Facility Van policy, undated, was provided by the director of nursing (DON) on 4/16/25 at 11:05 a.m. It read in pertinent part, It is the policy of this facility to provide residents safe, non-emergency transportation to doctors appointments, activity outings, and any other trips the facility deems necessary. The van will be well-maintained and equipped with safety features. Each resident will be secured in a seat with a seatbelt or in their wheelchair, secured with wheelchair tie-downs. IV. Resident #3 A. Resident status Resident #3, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included (sustained during the van incident on 1/22/25) fractures of sixth and seventh cervical (neck) vertebrae, fracture of first and second thoracic (chest) vertebrae, multiple fractures of ribs and epidural hemorrhage (bleeding in the brain). Additional diagnoses included chronic obstructive pulmonary (lung) disease, bilateral (both sides) below the knee amputations, kidney disease, epilepsy (seizure disorder) and diabetes. The 2/4/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. Resident #3 utilized a wheelchair and was dependent on staff for repositioning, transferring, showering and toileting. She required substantial assistance for personal hygiene and dressing. B. Resident #3 interviews and observations Resident #3 was interviewed on 4/15/25 at 10:00 a.m. Resident #3 had a neck brace in place. She was sitting in a wheelchair at the entrance to the facility and said she was waiting to go to an appointment and was hoping the neck brace would be removed at the appointment. She said she was required to continuously wear the neck brace for three months since she fell in the van. Resident #3 said she could not turn her head or see anything unless it was directly in front of her. Resident #3 said she was injured in January 2025 because the van driver did not secure her wheelchair in place as she was returning from an appointment. Resident #3 said the driver accelerated the vehicle and Resident #3's wheelchair flipped backward in the van. The resident said she fell onto the floor of the van and the wheelchair landed on top of her. Resident #3 said after the accident, the driver wanted to move her back into her wheelchair and was enlisting the assistance of passersby to assist with moving her. Resident #3 said she instructed the driver not to move her and to call emergency services. On 4/15/25 at 10:08 a.m. van driver #2 assisted Resident #3 into the facility's transportation van. Van driver #2 anchored Resident #3's wheelchair at four points to the floor of the vehicle and then added a lap seat belt and a shoulder strap. Van driver #2 also used his hand to push the wheelchair to ensure it did not move. Resident #3 was interviewed again on 4/16/25 at 3:30 p.m. Resident #3 did not have a neck brace on at that time. Resident #3 said the brace was removed at her appointment. Though the neck brace was not in place, Resident #3 turned her head to the side slowly and cautiously. Resident #3 said she had ridden with van driver #1 previously and van driver #1 had driven fast and erratically. Resident #3 said when she fell in the van, her head hit the door in the back of the van. She said she cried in pain when the accident happened. Resident #3 said she required neck to rib support (the neck brace extended down to the bottom of her chest) after her hospitalization. C. Record review 1. Care plan Resident #3's activities of daily living (ADL) care plan, revised 1/29/25, revealed the following interventions: Resident #3 required a rigid cervical orthosis (collar which supported neck and spine and limited the movement of neck and head), a shower collar when bathing and cervical spine precautions including no bending, twisting or lifting greater than 10 pounds; Resident #3 required one to two staff participation for dressing, to use the toilet and reposition and turn in bed; Resident #3 required two staff to assist with transferring; and, Resident #3 should be encouraged to discuss feelings about self-care deficit. 2. Progress notes A nurse progress note, dated 1/22/25 at 6:00 p.m., documented van driver #1 reported that Resident #3 had a fall in the van and was taken to the hospital for evaluation. The note documented the nurse would assess Resident #3 upon her return to the facility. The physician and the resident's representative were notified. A nurse progress note, dated 1/28/25 at 6:00 p.m., documented Resident #3 was readmitted from the hospital and transferred to bed via a stretcher. The note documented the resident had generalized pain which she rated at a 10 on a pain scale of 0-10 and also documented she was given Tramadol (pain medication) for pain. The note documented the resident required a rigid neck collar and bed wedges while in bed when Resident #3 was on her side. A social services progress note, dated 1/31/25 at 3:24 p.m., documented Resident #3 expressed sadness over her current physical limitations. The note documented the social services director (SSD) would look into pet visits and ordering a stand to enable Resident #3 to use her personal tablet computer in bed. 3. Hospital report The hospital discharge summary record was provided by the nursing home administrator (NHA) on 4/16/25 at 1:40 p.m. The record documented Resident #3 was admitted to the hospital on [DATE] and discharged on 1/28/25. It documented the following diagnoses: fractures of sixth and seventh vertebra, first and second thoracic vertebra, epidural hemorrhage, multiple bilateral rib fractures and pain. The discharge instructions revealed Resident #3 required a rigid cervical collar at all times. Precautions included no bending, no twisting and no lifting greater than 10 pounds. The resident required additional medications at discharge which included a lidocaine patch (pain medication) for rib fracture pain and methocarbamol (pain medication) for muscle spasms. 4. Facility investigation of Resident #3's fall on 1/22/25 Resident #3's fall investigation was provided by the DON on 4/16/25 at 10:35 a.m. and included the following: The 1/22/25 incident report documented Resident #3 was returning to the facility in the transport van, when the resident fell from her wheelchair and landed on the floor in the van. Van driver #1 called 911 and emergency medical services (EMS) came to the van. EMS transported the resident to the hospital for evaluation. The incident report documented Resident #3 had no injuries. -However, Resident #3 sustained fractures of sixth and seventh vertebra, first and second thoracic vertebra, epidural hemorrhage, multiple bilateral (both sides) rib fractures and pain (see above). The investigation included a fall committee interdisciplinary team (IDT) report, dated 1/29/25 at 9:40 a.m. It documented Resident #3 was in transport back to the facility following an appointment. The fall occurred on 1/22/25 at 12:30 p.m. in the transportation van and was partially witnessed by van driver #1. It documented the resident had no injuries, but blood was noted in Resident #3's mouth after the fall. The investigation documented interventions included calling EMS to transport the resident to the hospital. The MS and the director of rehabilitation (DOR) inspected the van upon return to the facility and no issues were noted with the equipment (devices to secure the residents). Van driver #1 was asked to demonstrate how she had Resident #3 secured and was able to secure a wheelchair in place. Van driver #1 was placed on immediate suspension pending investigation. A quality assurance and performance improvement (QAPI) document was provided by the facility which documented the root cause of the incident as Resident #3's wheelchair tipped when the driver accelerated due to altered weight distribution. The facility investigation included 10 interviews of residents (undated) regarding their use of the facility's transportation van. All of the residents said they felt safe and were properly secured when they used the facility's transportation van. -However, during the survey, Resident #5 said she had not been properly secured in the van (see interview below). The facility investigation included an interview with van driver #1 on 1/22/25 (the same date as Resident #3's fall). Van driver #1 said the van was at a stoplight. She said when the van accelerated, Resident #3 tipped back in her wheelchair. Van driver #1 said she saw the resident leaning and then stopped the van. She said the resident was okay. Van driver #1 said she noticed blood in the resident's mouth and then called 911. The facility investigation included an interview with Resident #3 upon her return from the hospital. It documented Resident #3 said she fell back out of the wheelchair and the wheelchair fell on her. Resident #3 said she did not feel like she was buckled in well and could not recall if the wheelchair had been anchored to the floor prior to the van leaving the appointment. The facility investigation included documentation of van driver #1's education, including safe driving large passenger van and wheelchair safety and securement tips, which were completed by van driver #1 on 11/4/24. It included documentation of fall prevention education completed by van driver #1 on 5/8/24. The investigation revealed van driver #1 was terminated from the facility on 1/27/25. D. Resident #5 interview Resident #5 was interviewed on 4/15/25 at 1:15 p.m. Resident #5 said the previous van driver for the facility (van driver #1) did not anchor her wheelchair to the floor or apply seatbelts to her when she used the van for appointments. Resident #5 said van driver #2 anchored the wheelchair and applied seatbelts appropriately all of the time. E. Staff interviews Van driver #2 was interviewed on 4/15/25 at 10:12 a.m. Van driver #2 said when he transported residents, he anchored resident wheelchairs at the base of the four corners of the wheelchair to the floor of the van and then added a seatbelt and shoulder harness. Van driver #2 said he checked all wheelchairs to ensure they did not wiggle when he pushed on the wheelchair. Van driver #2 said residents had not reported any safety concerns with van transportation to him. Registered nurse (RN) #1 was interviewed on 4/15/25 at 1:15 p.m. RN #1 said van driver #1 called her after Resident #3 fell in the van and said she had called EMS. RN #1 said she told the DON about the resident's fall in the van. RN #1 said van driver #1 did not say anything to her about Resident #3's condition or what had happened. The DON and the clinical resource nurse (CRN) were interviewed together on 4/15/25 at 3:25 p.m. The DON said on 1/22/25, van driver #1 took Resident #3 to an appointment and when Resident #3 was returning from the appointment, Resident #3 fell in the van. The DON said van driver #1 called EMS, then notified the facility and waited for the resident to be taken to the hospital. The DON said the previous NHA conducted the investigation and did not find van driver #1 had done anything wrong and there were no mechanical issues with the van's seat belts or anchors. The DON said van driver #1 was initially suspended. She said van driver #1 was later terminated on 1/27/25, as she had not performed well in another role she had at the facility. The DON said she did not know if the NHA asked van driver #1 if she was certain Resident #3 was secured in the van. The DON said it would not be appropriate to move a resident who was involved in a fall until the resident was assessed, as it could harm the resident. The DON and the CRN both said they did not know how the wheelchair could have tipped over if the wheelchair was securely anchored to the floor of the van. The CRN said if the wheelchair was anchored properly, it should not tip backward. The CRN said the facility had not been able to determine how the incident happened. The DON said the facility was unable to interview Resident #3 until she returned from the hospital (on 1/28/25). The DON said there was not additional investigation after Resident #3 returned from the hospital and said van driver #1 did not secure the wheelchair. The DOR was interviewed on 4/15/25 at 4:10 p.m. The DOR said Resident #3 received physical therapy after the fall. The DOR said the resident received a new wheelchair, as she required a wheelchair that could recline after she returned from the hospital. The DOR said the wheelchair was delivered to Resident #3 with an anti-tip device on 2/4/25. The DOR said Resident #3's previous wheelchair did not have an anti-tip device. The AD was interviewed on 4/15/25 at 4:37 p.m. The AD said she was trained on securing wheelchairs and transporting residents in the facility's van. She said a five-point restraint was required (two anchors to the back of the wheelchair, two anchors in front of the wheelchair and a seat belt and shoulder strap. The AD said she would call 911 if a resident was injured and would pull over to be sure they were safe. The AD said she would not move a resident who fell. The MS was interviewed on 4/15/25 at 4:32 p.m. The MS said he did not typically transport residents, however, he said he was trained on securing wheelchairs and transporting residents. The MS said there were four hooks to secure wheelchairs at the bottom corners of the wheelchair. He said if he transported a resident, he would secure the wheelchair and connect the seatbelt across the resident's lap and chest. He said he checked the wheelchair by pushing on it to be sure it did not move.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accidents out of five sample residents remained free from accidents. Resident #1, who was identified as a high fall risk, sustained a fall on 9/6/24 which resulted in a hip fracture that required hospitalization . The hip fracture was not identified until 9/12/24 due to the nurse failing to report the fall. Due to the facility's failure to assess, report and identify the injury, the resident was not treated for her fractured hip for six days. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 11/20/24, resulting in the deficiency being cited as past noncompliance with a correction date of 9/12/24. I. Incident on 9/12/24 The nursing home administrator (NHA) and the director of nursing (DON) started an investigation of Resident #1's change of condition and her bruising on 9/12/24. The NHA and the DON reviewed camera footage for Friday 9/6/24. The video footage revealed Resident #1 was in the doorway to her room when she stood up from her wheelchair and sat back down. Resident #1 backed her wheelchair into her room and then her feet came out into the doorway. The video footage also revealed certified nurse aide (CNA) #3, who was an agency staff member, and facility licensed practical nurse (LPN) #2 were present. The DON interviewed CNA #3 who verified the resident did have a fall. -The fall was not reported until 9/12/24 (see below). II. Facility corrective action A. Immediate action to correct the deficient practice for Resident #1 A thorough investigation of the incident was conducted on 9/12/24. The facility reviewed the camera footage which revealed Resident #1 sustained a fall on 9/6/24, in her doorway. CNA #3 and LPN #2 were identified in the video and interviewed. LPN #2 denied knowing anything about Resident #1's fall and was terminated. CNA #3 verified Resident #1 sustained a fall on 9/6/24. All of the nursing staff were educated by the assistant director of nursing (ADON) on 9/12/24 related to the facility fall policy, reporting a fall and documenting a fall. The facility continued to hold Quality Assurance and Performance Improvement (QAPI) meetings monthly to address concerns. B. Interventions put into place The facility reviewed their current fall policy on 9/12/24 to ensure appropriate procedures were in place to prevent falls/potential harm and reporting a fall. Their policy met all the criteria required and all staff were re-educated on the fall policy and procedure (on 9/12/24). The incident involving Resident #1 on 9/6/24 was in violation of the policy and procedure, so all staff that were present at the time of the investigation were provided further education on the following day (9/13/24). The DON would ensure all newly hired staff would receive education on the fall policy. The education given included the following information: Identifying neglect, reporting a fall, registered nurse (RN) assessment for injuries, neurological checks if there was a head injury or the fall was unwitnessed, and documenting the fall. The facility would review falls and discuss them in the monthly Quality Assurance and Performance Improvement (QAPI) meeting for three months. III. Facility policy and procedure The Fall Monitoring and Management policy, revised October 2021, was provided by the NHA on 11/20/24 at 3:00 p.m. It read in pertinent part, A fall is any unplanned sudden change of position. It is the policy of the facility that residents are assessed and evaluated to identify risks for injuries due to falls, residents receive necessary treatment and monitoring after a fall and interventions are implemented to minimize risks for injury due to falls. For an individual who has fallen, the following interventions should include, but are not limited to: -Obtain vital signs; -Assess for head injury/change in level of consciousness; -Assess for change in normal range of motion/weight bearing; -Initiate neurological assessment on residents who have hit their head or had an unwitnessed fall (even if the resident stated they did not hit their head, because they may have hit their head and may not have recollection that they hit their head); -Assess for pain; -Precipitating factors, details on how fall occurred; -Provide first aid (including intervention for pain if pain was identified); -Notify physician for further orders; -Notify responsible party; -Document details under risk management in the computerized record; -Document neurological assessments on the neurological assessment form.; -Monitor/document daily for 72 hours; and, -Notify the physician if signs/symptoms of complications and update the plan of care. IV. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the November 2024 computerized physicians orders (CPO), diagnoses included displaced intertrochanteric fracture of the left femur (thigh bone), age-related osteoporosis, unspecified osteoarthritis, unspecified protein-calorie malnutrition, vitamin D deficiency, muscle wasting and atrophy (organ and tissue wasting), unspecified abnormalities of gait and mobility, unspecified lack of coordination, muscle weakness, difficulty in walking and unspecified dementia. The 9/6/24 minimum data set (MDS) assessment revealed the resident had severe impairment for daily decision making per the staff assessment for mental status. She had delusions and wandered. She required supervision/oversight for safety with transfers. She used a wheelchair for locomotion. B. Record review A 8/11/24 fall assessment revealed Resident #1 was a high risk for falls. The fall care plan, revised 9/17/24, revealed the resident was at risk for falls related to confusion secondary to dementia, gait/balance problems, osteoarthritis and osteoporosis. Interventions included anticipating and meeting the residents needs, placing the call light within the residents reach, placing the bed in lowest position, educating the resident/family/caregiver about safety reminders and what to do if a fall occurred, following facility protocol, keeping needed items within reach, maintaining a clear pathway and ensuring non-skid strips were placed at the bedside to provide traction during transfers. A change in condition note, dated 9/8/24 at 5:41 p.m., revealed Resident #1 had a functional decline, altered mental status and a decrease in food/liquids intake. The physician and responsible party were notified. A nursing progress note, dated 9/8/24 at 6:04 p.m., revealed the resident continued to have increased lethargy (feeling drowsy or not alert), weakness, low intake, inability to self-transfer and ambulate. Fluids and meal intake were encouraged. A nursing progress note, dated 9/8/24 at 6:48 p.m., revealed a RN assessed the resident and found bruising to the upper part of her spine the size of a nickel. The resident was lethargic and weak during the assessment. The physician and responsible party were notified of the findings. A nursing progress note, dated 9/9/24 at 6:27 p.m., revealed the resident continued to be monitored due to lethargy, poor meal and fluid intake and mobility changes. A nursing progress note, dated 9/9/24 at 6:39 p.m., revealed the resident was noted to have bruising to her back on the right and left side. It was dark purple in color. Due to the resident's current state, she was unable to express pain or discomfort and unable to answer questions appropriately. A nursing progress note, dated 9/11/24 at 4:54 a.m., revealed the resident had dark bruising to her vaginal area. A nursing progress note, dated 9/11/24 at 2:29 p.m., revealed an x-ray for the left hip, leg and knee was ordered due to the identified bruising and swelling. A physician's progress note, dated 9/11/24 at 3:40 p.m., revealed the physician spoke with the DON and the facility staff related to Resident #1's bruising of unknown origin. The skin exam was limited due to the resident's resistance. There were some areas of ecchymosis (bruising) to her mid upper thoracic back. The lower extremity exam was remarkable for the left upper thigh with ecchymosis and bruising to the lower left thigh and in her vaginal area. The exam was concerning for a left hip fracture. A change in condition note, dated 9/11/24 at 8:15 p.m., revealed the resident had a change of condition related to trauma. The physician and family were notified. A nursing progress note, dated 9/11/24 at 10:00 p.m., revealed new orders were received to send the resident to the emergency room secondary to increased swelling and bruising to the left hip and knee. An x-ray of the left hip and knee were pending. The DON was aware of the transfer and the family was notified via a phone message. A nursing progress note, dated 9/12/24 at 1:55 p.m., revealed the resident sustained a fall on 9/6/24 that was not reported until 9/12/24. An x-ray revealed a left hip fracture. The physician and family were notified of the results. A fall committee note, dated 9/19/24 at 9:53 a.m., revealed Resident #1 sustained a fall in her doorway. The resident's injuries included latent bruising and after several assessments by the nursing staff and the medical director, a left hip fracture was suspected and an x-ray was ordered. The x-ray confirmed a left hip fracture and the resident was sent to the emergency room . Prior to the fall, the resident was sitting in her wheelchair in the hallway. She stood up and fell . Therapy evaluated the resident upon her return from the hospital. A daily skilled note, dated 10/16/24 at 3:20 a.m., revealed the resident had limited range of motion (ROM) to her left hip and thigh due to the left hip fracture. V. Staff interviews CNA #1 was interviewed on 11/20/24 at 2:49 p.m. CNA #1 said if a resident had a fall she would immediately get the nurse to assess the resident before moving them. She said the nurse was responsible for reporting a fall to the DON. She said after Resident #1's fall, all nursing staff received education on reporting a fall, documenting a fall and assessing the resident after a fall. CNA #2 was interviewed on 11/20/24 at 2:54 p.m. CNA #2 said if a resident had a fall, a staff member would stay with the resident while another staff member reported it to the nurse. The nurse would assess the resident for any injuries. She said if a nurse was not available, the staff would report the fall to the assistant director of nursing (ADON) or the DON to complete an assessment before moving the resident. She said the nurse was responsible for completing a fall report and notifying the DON. She said after Resident #1's fall all staff was educated on the fall policy procedure. RN #1 was interviewed on 11/20/24 at 3:09 p.m. RN #1 said if a resident had an unwitnessed fall, the CNA would notify the nurse. She said the RN would assess the resident for any injuries. She said neurological checks were started as soon as possible. She said the nurse was responsible for reporting the fall to the DON, the physician and the responsible party. LPN #1 was interviewed on 11/20/24 at 3:11 p.m. LPN #1 said if a resident had a fall she would call an RN to assess the resident for any injuries. She said she would then call the physician and the responsible party. She said if the resident hit their head or had an unwitnessed fall, she would immediately start neurological checks. She said the nurse was responsible for reporting the fall to the ADON, the DON and the NHA. She said she started working at the facility three weeks prior and received the fall policy training, as well as education on reporting, assessing and documenting a fall. The DON was interviewed on 11/20/24 at 3:44 p.m. The DON said on Saturday, 9/7/24, she received a phone call from the RN working who reported Resident #1 was not acting like herself and not eating. She said a change of condition assessment was completed and the physician was notified. She said the following day, Sunday (9/8/24), she received a phone call from the nurse stating Resident #1 had bruises on her back. She told the nurse to document the bruising so the facility could figure out where the bruising came from. She said on Monday, 9/9/24, the staff were still trying to figure out where the resident's bruising came from. She said she interviewed Resident #1, utilizing a translator, and asked the resident if she had a fall. She said the resident said no and wanted to be left alone. She said on Tuesday, 9/10/24, she attempted to assess Resident #1 again and she refused. The DON said on Wednesday, 9/11/24, the medical director was in the facility and she asked him to look at her. She said Resident #1 agreed to the assessment and the medical director found bruising from her hip to her knee. She said the medical director said she needed to order an x-ray because it looked like a fracture. She said the x-ray confirmed a left hip fracture and Resident #1 was transferred to the hospital. She said the following day, Thursday, 9/12/24, she and the NHA reviewed the video footage prior to the resident's change of condition. The DON said the review of the camera footage revealed Resident #1 had a fall in her doorway on 9/6/24. She said CNA #3 and LPN #2 were present when the fall occurred. She said CNA #3 and LPN #2 walked directly into the resident's room and exited approximately three minutes later. She said she interviewed LPN #2 who denied the resident fell . She said LPN #2 was terminated. She said she then interviewed CNA #3 who verified the resident did have a fall. The DON said CNA #3 reported that LPN #2 picked Resident #1 up and placed her in her wheelchair after the fall. She said LPN #2 gave a report to the oncoming nurse and left the facility. She said CNA #3 said the resident should not have been moved until a RN assessed for injuries. The DON said the ADON immediately provided education to the staff on what abuse looked like and the facility policy and procedure for falls.

Based on record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans and resident preferences for one (#40) resident out of 36 sample residents. The facility failed to ensure Resident #40 was administered pain medication as ordered. Resident #40 was prescribed hydrocodone for pain management. The facility ran out of the scheduled prescribed medications and the resident missed seven doses of hydrocodone from 11/11/23 to 11/13/23. The facility failed to implement effective interventions to prevent the resident from running out of his medications (discovered on 11/10/23) from progressing to the resident experiencing pain, suffering withdrawal symptoms, and subsequently being administered Fentanyl by emergency medical services before being transported to the hospital and treated for pain symptoms Furthermore, the facility failed to ensure Resident #40's pain medications were ordered from the pharmacy timely. The facility failed to use the emergency kit to administer Resident #40's pain medication when it was not available. The facility failed to consistently document Resident #40's pain level. Findings include: I. Professional reference According to https://medlineplus.gov/druginfo/meds/a614045.html, it read in pertinent part, Hydrocodone is used to relieve severe pain. Hydrocodone is only used to treat people who are expected to need medication to relieve severe pain around-the-clock for a long time and who cannot be treated with other medications or treatments. Hydrocodone extended-release (long-acting) capsules or extended-release tablets should not be used to treat pain that can be controlled by medication that is taken as needed. Hydrocodone is in a class of medications called opiate (narcotic) analgesics. It works by changing the way the brain and nervous system respond to pain. Do not stop taking hydrocodone without talking to your doctor. If you suddenly stop taking hydrocodone, you may experience withdrawal symptoms such as restlessness, teary eyes, runny nose, yawning, sweating, chills, hair standing on end, muscle pain, widened pupils (black circles in the middle of the eyes), irritability, anxiety, back or joint pain, weakness, stomach cramps, difficulty falling asleep or staying asleep, nausea, loss of appetite, vomiting, diarrhea, fast breathing, or fast heartbeat. Your doctor will probably decrease your dose gradually. II. Facility policy and procedure The Medication Order and Receipt Record policy, revised January 2023, was provided by the director of nursing (DON) on 12/14/23. The policy read in pertinent part, Medications should be ordered in advance, based on the dispensing pharmacy's required lead time. Emergency medications ordered and or received shall also be entered into the medication order and receipt record. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than the days prior to the last dosage being administered to ensure that refills are readily available. III. Resident status Resident #40, age under 65, was admitted on [DATE]. According to the December 2023 computerized physician orders (CPO), diagnoses included other chest pain, generalized anxiety disorder, unspecified asthma, nicotine dependence, spinal stenosis, history of falling, schizoaffective disorder (combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder), depressive type and pain disorder with related psychological factors. The 10/15/23 minimum data set (MDS) assessment revealed the resident had intact cognition with a score of 15 out of 15 for the brief interview of mental status (BIMS) assessment. The resident did not have any rejection of care behaviors and was independent with bed mobility, transfers, locomotion, dressing, toilet use and hygiene. The resident had been on a scheduled pain medication regimen and had pain presence that he experienced frequently. IV. Resident interview Resident #40 was interviewed on 12/11/23 at approximately 10:00 a.m. The resident said the facility thought he had a heart attack but he believed he experienced a panic attack. He said he had gone without his pain medications for three days in November 2023 which led to him having increased pain and anxiety and subsequently a panic attack. The resident said he had an adverse reaction to not having the medications he had been prescribed for a long time for his pain management. V. Record review The November 2023 CPO revealed the resident was ordered hydrocodone-acetaminophen oral tablet 5-325 mg (hydrocodone-acetaminophen). Give one tablet by mouth four times a day for pain. The November 2023 medication administration record (MAR) revealed the resident had missed seven doses of hydrocodone across three days from 11/11/23 to 11/13/23. Missed doses hydrocodone included (see below). -The 11/11/23 6:00 p.m. dose of hydrocodone was not given. The 11/11/23 at 5:20 p.m. nursing progress note revealed, Resident had one tablet left. Wants to save it for later in the evening. Medication has been reordered from the pharmacy. The MAR did not document the resident's pain level. -The 11/12/23 12:00 a.m. dose of hydrocodone was not given. The 11/12/23 at 1:02 a.m. nursing progress note revealed, Med (medication) not available. The resident's pain level was not documented on the MAR. -The 11/12/23 6:00 a.m. dose of hydrocodone was not given. The 11/12/23 at 5:03 a.m. nursing progress note documented , Med not available.The resident's pain level was documented as a 1 out of 10 (with 10 being the worst pain). -The 12:00 p.m. dose of hydrocodone was not given. The 11/12/23 at 2:22 p.m. nursing progress note revealed, Physician is aware (that the hydrocodone medication was not available), sending new script to the pharmacy, pharmacy is then to deliver. The resident's pain level was not documented on the MAR. -The 11/12/23 6:00 p.m. dose of hydrocodone was not given. The 11/12/23 at 6:02 p.m. nursing progress note revealed, Resident has had complaints of pain during the night and during this shift. Pharmacy has been contacting the physician to get a refill. The resident's pain level was documented as an 8 out of 10 (severe) on the MAR. -The 11/13/23 12:00 a.m. dose of hydrocodone was not given. The 11/13/23 at 12:16 a.m. nursing progress note revealed, Medication (hydrocodone) is still not available. The resident's pain level was not documented on the MAR. -The 11/13/23 6:00 a.m. dose of hydrocodone was not given. The 11/13/23 at 5:22 p.m. nursing progress note revealed, Med is still not available. The resident's pain level was not documented on the MAR. -The 11/13/23 12:00 p.m. dose was available and was given; however, the MAR documented the resident's pain was not relieved. The resident's pain level was documented as a 10 out of 10 (severe pain). -The 11/13/23 3:00 p.m. dose was given; however, the resident's pain level was documented as 9 out of 10 (severe pain). The 11/13/23 at 7:30 p.m. nursing progress note revealed, at approx (approximately) 6:30 p.m. the resident complained of chest pain and pain on the left hand with a pain scale of 10. Resident complained of dizziness. Initial vital signs taken blood pressure: 207/135 (elevated), heart rate: 98, respirations rate:19, temperature: 97.3, Oxygen pulse: 95% on room air. Resident stated the pain began when he was outside smoking. 911 called, MD (medical doctor) notified, DON called, family notified. At approximately 6:37 p.m. 911 arrived. At 7:10 p.m. emergency medical services were called and the emergency medical services arrived and administered 200 micrograms of Fentanyl with mild improvement of his pain symptoms before the resident was transferred to the hospital. The resident went to the hospital where they ruled out cardiac concerns and was treated for pain which was relieved and the resident returned to the facility. VI. Staff Interviews Registered nurse (RN) #1 was interviewed on 12/12/23 at 2:17 p.m. She said she would reorder medications once she realized a specific medication was out of stock. Once she identified a medication was out of stock she would notify the provider, her supervisor and the pharmacy. She said she would be able to use the RX Now machine (emergency medication stock) to obtain medications if medications were out of stock by calling the pharmacy and obtaining the verification code. She said a resident who did not receive their pain medications for a few days could potentially develop increased pain, anxiety and an increase in blood pressure. The director of nursing (DON) was interviewed on 12/14/23 at 9:07 a.m. The DON said the hydrocodone was out of stock and the resident missed his doses from 11/11/23 to 11/13/23. The side effects of stopping an opiate could lead someone to become uncomfortable, anxious, sweat, headaches and experience pain. The DON said there were numerous issues with the pharmacy in obtaining medications and therefore the resident missed a few medication doses. The DON said during the time period the medications were out of stock, the facility had access to hydrocodone in the RX Now machine. The RX Now machine had 10 doses of medications available for a resident with hydrocodone ordered. The DON said she would ensure all nurses including agency nurses were trained on MAR documentation, medication re-ordering process, time frame of re-ordering medications and training on STAT (urgent) ordering requests in order to ensure residents were not missing their ordered medications. The DON said the facility would be using a different pharmacy in 2024 and had a new process in place for the physician to fax in scripts and or respond to the pharmacy timely and in urgent situations to involve the medical director to provide verbal orders to the pharmacy to prevent residents from missing medication doses. The DON said if Resident #40 felt anxious and he believed he was in pain; that could have led to his hospitalization since he felt anxious about not receiving medications and he was in pain. The DON said she felt bad he did suffer and he felt that way from experiencing pain which caused him anxiety and a panic attack. The pharmacist was interviewed on 12/14/23 at 2:05 p.m. He said when medications were running low on stock (approximately seven days prior to medications running out) the nurse should place an order through contacting the pharmacy the facility works with. The pharmacist said he has had trouble reaching a physician for a new script and or refill request frequently from the facility and at times the physician would take up to three days to provide correspondence to refill medications and or send a script. The pharmacist said the physician could always call and provide a verbal order to obtain medications as soon as possible from the RX Now machine as a backup until the medications were delivered to the facility to prevent a delay in care.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for two out of three units at the facility. Specifically, the facility failed to: -Ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas (call lights, door handles and handrails); -Ensure housekeeping staff were trained appropriately on housekeeping procedures; and, -Ensure surface disinfectant times were adhered to. Finding include: I Professional reference Assadian O, Harbarth S, Vos M, et al. Practical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative review. The Journal of Hospital Infection. 2021 Jul;113:104-114 was retrieved on 12/22/23 revealed, in pertinent part: High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control (CDC) Environment Cleaning Procedures https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html# retrieved on 12/22/23 read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: -bedrails -IV (intravenous) poles -sink handles -bedside tables -counters -edges of privacy curtains -patient monitoring equipment (keyboards, control panels) -call bells -door knobs Proceed From Cleaner To Dirtier Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: -During terminal cleaning, clean low-touch surfaces before high-touch surfaces. -Clean patient areas (patient zones) before patient toilets. -Within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone. -Clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. II. Facility policy and procedure The Housekeeping Services policy and procedure, revised on January 2009, was provided by the nursing home administrator (NHA) on 12/14/23 at 1:17 p.m. It read in pertinent part, It is the policy of this facility to require effective environmental sanitation to lessen the hazards of exposure to contaminated air, dust, furnishings, equipment and other fomites. Frequent cleaning of the facilities interior will aid in physically removing and reducing microorganisms' potential contribution to the incidence of Health associated infections (HAI). 1. The housekeeping supervisor will Implement effective systems of our environmental sanitation including a regular cleaning schedule for all areas. 2. The housekeeping supervisor will work closely with the infection control team to establish and maintain consistent practices in high standards of cleanliness. 3. Wipe down with disinfectant soaked rag all touched surfaces in the room, allowed to air dry such as doorknobs soap lotion dispenser at light switch towel dispenser. clean heavily soiled restroom fixtures and Porcelain services using the disinfectant and a rug or brush clean mirror with glass cleaner remove trash and realign the receptacle, clean the receptacle using disinfectant as needed. When cleaning all rooms; gloves and rags must be changed out between restroom, side a and side b. at least three pairs of gloves and three rags per room. The disinfectant used in the facility was Bright Solutions HP202 Disinfectant, the guidelines read: A one-step hospital use germicidal cleaner and deodorant designed for general cleaning, disinfecting, and controlling mold and mildew odors on hard, non-porous surfaces: 1. Pre-clean visibly soiled surfaces. 2. Apply Use Solution with a sponge, brush, cloth, mop, low pressure mechanical spray device, or coarse trigger sprayer to hard, non-porous surfaces. 3.Spray 6-8 inches from the surface, making sure to wet surfaces thoroughly. All surfaces must remain visibly wet for 10 minutes. 4. Effective against SARS-Related Coronavirus 2 (SARSCoV-2) (the virus that causes COVID-19) in 1 minute on hard, nonporous surfaces. 5. Apply as a virucide- use Solution until thoroughly wet to hard, non-porous surfaces. All surfaces must remain visibly wet for 5 minutes. A one minute contact time is required for HIV-1 (AIDS virus), Influenza Virus Type A (H1N1), SARS-Related Coronavirus 2 (the virus that causes COVID-19). Wipe surfaces or let air dry. III. Observations On 12/13/23 housekeeper (HSKP) #1 was continuously observed in room [ROOM NUMBER] and #32 from 12:30 p.m. to 12:59 p.m. The observations showed the surface disinfectant was not used in the room (see above). HSKP #1 used a water soaked cloth with a drop of soap from the resident's soap dispenser and wiped all horizontal surfaces in the room (night stand, drawers and tray table). HSKP #1 wiped the surfaces in the room with the water soaked soap cloth for four seconds per surface. The surface was sticky to the touch after the cleaning was completed. No high frequency touch areas (call lights, door knobs, light switches, closet handles, bathroom grab bars and bed remote) were disinfected. The bathroom's safety rail that was shared between four residents was not disinfected and appeared to have white and brown hardened stains on the surface. On 12/14/23 HSKP #2 was continuously observed in room [ROOM NUMBER] and #4 from 9:30 a.m. to 10:00 a.m. The observations showed HSKP #2 used the surface disinfectant diluted with water, four sprays of HP202 and she did not adhere to the surface disinfectant time (see above) and or the manufacturer recommendations for proper application. HSKP #2 used a water soaked cloth with four sprays of HP202 and wiped all horizontal surfaces in the room (night stand, drawers and tray table). HSKP #2 wiped the surfaces in the room with the water and disinfectant soaked cloth for four seconds per surface and the surface was no longer wet within 30 seconds. The outside of the toilet was cleaned with HP202, however after the cleaning the toilet bowl had dried brown stains on the bowl that were not wiped. No high frequency touch areas (call lights, door knobs, light switches, closet handles, bathroom grab bars and bed remote) were disinfected. IV. Staff interviews HSKP #1 was interviewed on 12/13/23 at 1:07 p.m. HSKP #1 acknowledged she did not disinfect the room with the room with the approved cleaning product for the facility. She said she did not know the surface disinfectant time of the housekeeping disinfectant products and she did not clean all high frequency touch areas in the resident's room. HSKP #2 was interviewed on 12/14/23 at 11:31 a.m. HSKP #2 said he was not trained in housekeeping properly and was recently hired. HSKP #2 did not know the surface disinfectant time of the housekeeping disinfectant products and she did not know what high frequency touch areas were. The director of housekeeping (DOH) was interviewed on 12/14/23 at 2:15 p.m. The director of housekeeping acknowledged there are areas of opportunity related to housekeeping and routine room cleaning procedures. The DOH said housekeeping staff did not clean the residents' rooms according to the facility's procedure. The DOH said the approved facility disinfectant should be used when cleaning resident rooms; all high frequency touch areas should be disinfected and rooms should never be cleaned with only soap and water. The DOH said she needed to provide training to all housekeeping staff, she needed to revise the current training and onboarding program to cover surface disinfectant times, room cleaning procedures and high frequency touch areas. The director of nursing (DON) and assistant director of nursing (ADON) were interviewed on 12/14/23 at 2:23 p.m. They said surface disinfectant times should be adhered to ensure surfaces were properly disinfected and all pathogens were destroyed, high frequency touch areas should be disinfected and only approved facility disinfectant products should be used.

Based on observations, record review and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for two (#38 and #20) of six residents out of 36 sample residents reviewed for accident hazards. Specifically, the facility failed to have fall interventions in place for Resident #38 and Resident #20. Findings include: I. Facility policy and procedure The Fall Management System policy and procedure, revised January 2022, was provided by the nursing home administrator (NHA) on 12/13/23 at 1:00 p.m. It revealed in pertinent part, It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. Residents with high risk factors identified on the Fall Risk Evaluation will have an individualized care plan developed that includes measurable objectives and timeframes. The care plan interventions will be developed to prevent falls by addressing the risk factors and will consider the particular elements of the evaluation that put the resident at risk. II. Resident #38 A. Resident status Resident #38, age 68, was admitted on [DATE]. According to the December 2023 computerized physician orders (CPO), diagnoses included encephalopathy (brain disease), atrial fibrillation (abnormal heartbeat), hypertension and degenerative disease of the nervous system. The 9/9/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. The MDS assessment revealed the resident was dependent on assistance for toileting and showering. He needed substantial to maximum assistance with bed mobility, lying to sitting and sitting to stand, and transfers. B. Observations and interview Resident #38 was interviewed on 12/11/23 from 8:33 a.m. to 8:50 a.m. while he was lying in bed. During this time, Resident #38's fall mat was leaning behind the head of his bed. His bed was not in a low position. Resident #38 was observed at 9:19 a.m. He was lying in bed, his bed was not in a low position and his fall bat was leaning behind the head of his bed. Resident #38 was observed on 12/12/23 at 8:30 a.m. lying in bed and the fall mat was leaning behind the head of his bed. There were two wheelchairs next to the side of his bed facing his bed. Resident #38 said one of the two wheelchairs was his roommate's and his roommate's wheelchair was frequently on Resident #38's side of the room. Resident #38 was observed at 9:53 a.m. lying on his bed and the mat was leaning behind the head of his bed. C. Record review Resident #38's fall care plan focus revealed he was at risk for falls due to a personal history of falls, encephalopathy, respiratory failure, atrial fibrillation, polyneuropathy (nerve damage), hydrocephalus ( excess fluid on the brain), AIMS (abnormal involuntary movement), developmental disorder, bilateral ankle contractures, pain, decreased mobility, and medication side effects, revised 8/30/22. Pertinent interventions included the bed in the lowest position, initiated 5/5/22 and to continue with the placement of fall mat and bed in lowest position, initiated, 10/10/23. A review of Resident #38's interdisciplinary team (IDT) 10/10/23 progress note revealed Resident #38 had an unwitnessed fall on 10/9/23 at 9:30 p.m. Predisposing factors included confusion, impaired memory, hydrocephalus (excess fluid on the brain), ankle contractures, diuretics and a recent room move. Resident #38 reported that he slid out of bed. Interventions included to continue with the placement of the fall mat and the bed in the lowest position. Resident #38's fall prevention devices task response history in his electronic medical record was reviewed from 11/14/23 to 12/13/23. The fall mat and low bed that were interventions were not consistently documented in place. -There were no documented refusals of interventions during the review period. Resident #38's kardex (resident care summary) as of 12/12/23 documented under Falls/Safety to continue with placement of a fall mat and the bed in lowest position. III. Resident #20 A. Resident status Resident #20, age 80, was admitted on [DATE]. According to the December 2023 CPO, diagnoses included paranoid schizophrenia, dementia, depression and squamous cell carcinoma (skin cancer). The 10/6/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a BIMS score of nine out of 15. The MDS assessment revealed Resident #20 was dependent on assistance for bathing, needed substantial assistance with lower body dressing, toileting hygiene and transfers, moderate assistance with oral hygiene and needed supervision for eating. The MDS assessment revealed Resident #20 had two falls without injury since admission. B. Observations On 12/12/23 at 8:45 a.m. Resident #20 was observed in his wheelchair wearing regular socks and no shoes ambulating down the hallway in his wheelchair. At 9:06 a.m. Resident #20 was observed wearing regular socks and no shoes ambulating down the hallway in his wheelchair. At 9:34 a.m. Resident #20 was observed wearing regular socks and no shoes and ambulating down the hallway in his wheelchair. At 1:23 p.m. Resident #20 was observed in bed with regular socks on instead of non-skid socks. On 12/13/23 at Resident #20 at 9:43 a.m. was wheeling down the hall and was wearing regular socks, not with non-skid socks or shoes. Resident #20 was observed in bed at 1:25 p.m. wearing regular socks instead of non-skid socks. C. Record review Resident #20's fall care plan focus revealed he was at risk for falls due to diagnoses of mental illness, osteoarthritis, incontinence, difficulty walking, non-compliance with his medication regimen, prescribed psychoactive medications and other medication side effects, initiated 6/30/23 and revised 10/11/23. Pertinent interventions included to ensure the resident was wearing appropriate footwear when ambulating or wheeling in his wheelchair, initiated 7/13/23. Resident #20's fall prevention devices task response history in his electronic medical record was reviewed from 11/14/23 to 12/13/23. The fall prevention tasks included non-skid slippers and shoes. On 12/12/23 the fall prevention task for non-skid slippers and shoes was not marked as in place at 12:39 a.m. and 11:49 a.m. and the task did not indicated Resident #20 refused the intervention. On 12/13/23 the fall prevention task for non-skid slippers and shoes was not marked in place at 12:06 a.m. However, the fall prevention task for non-skid slippers and shoes was marked as in place at 9:28 a.m. -Resident #20 was observed ambulating in the hallway in his wheelchair at 9:43 a.m. and did not have non-skid socks on. V. Staff interviews The director of nursing (DON) was interviewed on 12/14/23 at 12:00 p.m. The DON said there was no reason why Resident #38's fall mat should not be on the floor while he was lying in bed. The DON said Resident #20 should have non skid socks or regular socks with shoes for his fall intervention. Registered nurse (RN) # 1 was interviewed on 12/14/23 at 1:30 p.m. RN #1 said while Resident #38 was in bed, all staff should check to see that his fall mat was in place. RN #1 said the fall mat intervention was on Resident #38's treatment record so it was up to all staff including the certified nurse aides (CNAs) to monitor. RN #1 said Resident #20 should have on non-skid socks or regular socks and shoes, it should be documented if he refused the interventions. RN #1 said the refusals should be recorded on the task history in the resident's electronic medical record. CNA #1 was interviewed on 12/14/23 at 1:45 p.m. CNA #1 said Resident #20 did not refuse his non-skid socks and he used non-skid socks and shoes. CNA #2 was interviewed on 12/14/23 at 1:45 p.m. CNA #2 said Resident #38 should have his bed low to the floor with the fall mat beside his bed when he was in bed and she did not know him to refuse those interventions.

Based on observations, record review and interviews, the facility failed to ensure one (#25) of three residents who required respiratory care received the care consistent with professional standards of practice out of 36 sample residents. Specifically, for Resident #25 the facility failed to: -Ensure the physician's order was followed for oxygen therapy; and, -Accurately complete section O in the comprehensive minimum data set (MDS) assessment under respiratory treatments. Findings include: I. Facility policy and procedures The Oxygen Management policy, revised March 2019, was provided by the director of nursing (DON) on 12/14/23 at 1:31 p.m. The policy revealed in pertinent part: It is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained. The purpose of the oxygen therapy is to provide sufficient oxygen to the bloodstream and tissues. Procedures for oxygen therapy to include: -Obtain appropriate physician's orders. -Identify residents. -Explain procedure. -Gather necessary equipment -Provide privacy for resident. -Wash hands properly. -Assemble the oxygen unit and flowmeter, making sure all connections are secure. -If using a reusable humidifier, fill the bottle to the correct level with distilled water and attach it to the oxygen unit. -Attach the oxygen delivery device to the oxygen unit. -Turn the unit on to the desired flow rate, and assess equipment for proper functioning: Airflow should be felt through the oxygen delivery device. Bubbles should be seen diffusing through the humidifier bottle. -If no evidence of oxygen flow, check connections and tubing for leaks. -Review the resident's care plan to evaluate for any special needs of the resident. II. Resident status Resident #5, age under 65, was admitted on [DATE]. According to the December 2023 computerized physician orders (CPO), other speech and language deficits following cerebral infarction (stroke), depression, insomnia, hypertension, type 2 diabetes mellitus with hyperglycemia, chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, chronic obstructive pulmonary disease (COPD) and shortness of breath. The 8/24/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) of 11 out of 15. She had no behaviors and did not reject care. She required substantial/maximal assistance with personal hygiene, mobility, toileting, transfers, repositioning and dressing. -The use of oxygen therapy was not triggered/coded on the MDS assessment under section O. III. Resident interview and observation Resident #25 was interviewed on 12/11/23 at 11:00 a.m. She said he has been on oxygen since she was admitted and the tubing was changed weekly. The resident said she should be on 2 liters of continuous oxygen but sometimes the certified nurse aides (CNAs) were changing it. Resident #25 was observed on 12/11/23, 12/12/23, and 12/13/23 from 9:00 a.m. to 5:00 p.m. Her oxygen concentrator was set for 3 liters via a nasal cannula. IV. Record review The medical record was reviewed on 12/11/23 and it revealed the resident had an order for oxygen. The order read Oxygen at 2L via nasal cannula-continuous every shift. The care plan was reviewed on 12/11/23 and it revealed the resident has emphysema, COPD and she will display optimal breathing patterns daily through the review date and to give oxygen therapy as ordered by the physician. V. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 12/13/23 at 11:30 a.m. She said she knew residents she cared for very well and they were all on 2 liters of oxygen. She did not ask the nurse to verify if the orders were updated. She said each morning or midday, she checked on the residents ' oxygen and set it to 2 liters even if some were lower or higher. She would not inform the nurse on the unit or document the discrepancy. She said she frequently had to adjust the resident ' s oxygen because it was either set higher or lower than 2 liters. Licensed practical nurse (LPN) #1 was interviewed on 12/13/23 at 11:45 p.m. She said she would look at the resident's order to see how many liters they should be using. She looked at Resident #25's medical record and said the order was for 2 liters of continuous oxygen. She said she typically reviewed if the resident ' s oxygen was set correctly in the evening time. She said it was important to follow the doctor ' s order but she was not certain what could happen if a resident receives more oxygen than what was ordered. The LPN said if she saw the oxygen was under or above 2 liters she would adjust it but would not document it. She said she was not aware of any behaviors the resident had related to adjusting the concentrator. The assistant director of nursing (ADON) was interviewed on 12/13/23 at 2:36 p.m. She said residents using oxygen should have an order including the liters, the route and the frequency. She said nurses should verify the residents ' oxygen level was set correctly at least once per shift when they first arrived. She said a doctor ' s order should be followed because they have assessed the resident and understand their comorbidities. The ADON said too much oxygen especially if someone had COPD could lead to ineffective gas exchange which could cause harm. The oxygen concentrator should be set at the correct liters to ensure it is therapeutic for the resident. The ADON said if a nurse observed the oxygen was incorrectly set the nurse should call the doctor and note the difference and correction in the nurse's progress note. The ADON said if the resident had frequent refusals of oxygen then the care plan should be updated to include the refusals. The ADON said she would provide education on oxygen therapy to the nursing staff. The ADON said she would update the care plan to include the resident ' s refusals of oxygen therapy compliance. -However, the staff did not indicate she refused to comply with the oxygen and rejection of care was not indicated on the MDS assessment.

Based on observation, record reviews and interviews, the facility failed to provide pharmaceutical services, including procedures regarding emergency medications and biologicals. Specifically, the facility failed to communicate and coordinate with the pharmacy to remove an emergency medication kit when an automated dispensing system was implemented. Findings include: I. Facility policy The Medication Access and Storage policy, revised [DATE], was provided by the assistant director of nursing (ADON) on [DATE] at 9:26 a.m. It read in pertinent part: Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy if a current order exists. II. Observations On [DATE] at 3:15 p.m., the memory care unit medication storage room was observed with licensed practical nurse (LPN) #2. A locked cabinet contained a narcotic emergency kit. The contents of the kit included diazepam, hydrocodone, hydromorphone, lorazepam, morphine, oxycodone, and tramadol. A paper note attached to the kit stated narcotic e-kit is used for new orders only, including unexpected change in orders. The kit expired [DATE]. III. Staff Interviews LPN #2 was interviewed on [DATE] at 3:20 p.m. She said she did not know there was an emergency narcotic kit in the locked cabinet until she opened the cabinet. LPN #1 was interviewed on [DATE] at 3:30 p.m. She said she did not know how she would remove narcotics if she needed one that was not in the narcotic drawer of the medication cart. She said she would ask the assistant director of nursing (ADON) for assistance. The clinical resource nurse (CRN) and the director of nursing (DON) were informed of an expired narcotic kit on the memory care unit on [DATE] at 8:35 a.m. The CRN said the kit was no longer used. The CRN and DON were interviewed on [DATE] at 11:39 a.m. The CRN said the facility transitioned from the emergency narcotic kit to an automated narcotic dispensing system in [DATE]. She said the pharmacy should have picked up the kit at that time. She said the pharmacy picked up the expired narcotic kit today ([DATE]). The pharmacy consultant (PC) was interviewed on [DATE] at 12:42 p.m. She said the emergency narcotic kit on the memory care unit had not been accessed since [DATE]. She said the pharmacy should have picked up the kit when the facility switched over to the automated narcotic dispensing system. She said she did not know what the policy said about the process for obtaining narcotics. She said she worked for the facility as their pharmacy consultant and did not work for the pharmacy. The pharmacy director (PD) was interviewed on [DATE] at 2:26 p.m. He said the pharmacy usually removed narcotic emergency kits from the facility if there was a change to an automated dispensing system for narcotics. He said some facilities chose to keep a non-automated kit on site. He said the consultant pharmacist should have checked for expiration dates if the kit remained in the facility. The PD was interviewed again on [DATE] at 3:50 p.m. He said the facility's automated dispensing system began [DATE]. He said the pharmacy did not keep a record of the narcotic kits that remained in facilities and the pharmacy relied upon the consultant pharmacist to check expiration dates for any medications that remain in the facility.

Based on observation, interview, record review, and review of facility policies, the facility failed to ensure one (Resident #40) of three residents reviewed for nutrition maintained his/her body weight and did not sustain severe weight loss. Specifically, on 07/05/2022 the resident weighed 180.4 pounds and on 07/30/2022, Resident #40 weighed 159 pounds, a 21.4 pound or 11.86 percent (%) weight loss in 25 days. The failed to identify and address Resident #40's severe weight loss. Findings included: A review of the facility's Tracking Weight Changes policy/procedure, dated August 2019, revealed A copy of weight records will be forwarded to the appropriate professional each month. The RD or designee will review monthly weights and calculate significant change over one, three, and six months. The RD or designee will review all significant weight losses, and assess for insidious weight loss as well. The RD or designee will make referrals and [MEDICATION(S)] as necessary (including follow up documentation). A review of Resident #40's Admission Record revealed Resident #40 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #40's admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) could not be conducted to assess the resident's cognition. A staff assessment of the resident's cognition indicated the resident had severely impaired cognitive skills for daily decision making. Further review revealed Resident #40 required supervision of one staff for eating and had not sustained weight loss. According to the MDS, Resident #40 weighed 188 pounds. A review of Resident #40's care plan revised on 06/16/2022 revealed the resident had potential for nutritional risk related to a [CONDITION(S)] (TBI), alcohol-induced persisting dementia, liver [CONDITION(S)], [CONDITION(S)], depression, and [CONDITION(S)]. The care plan indicated weight fluctuations were possible for Resident #40 due to [CONDITION(S)], [CONDITION(S)] with diuretic use, sporadic intake, and refusing weights. Interventions included monitoring and reporting to the physician as needed for signs and symptoms of decreased appetite or unexpected/significant weight loss. A review of Resident #40's August 2022 physician Order Summary Report revealed an order was initiated on 03/01/2020 for a regular diet and an order was started on 01/07/2022 for snacks three times a day. A review of nutrition Progress Notes dated 06/16/2022 at 1:51 PM revealed Resident #40 was readmitted after a hospital stay from 06/13/2022 to 06/15/2022. The diet order for a regular diet with thin liquids continued. The note indicated the resident had sporadic intakes; however, was requesting snacks. The note revealed the RD would follow up as needed and continue to monitor intake. A review of Resident #40's nutrition Progress Notes dated 06/20/2022, revealed the resident was consuming zero to 100% of meals, with 100% acceptance of one meal per day and sporadic intake with other meals. The note indicated that Resident #40 was previously accepting 100% of snacks three times per day but had declined several snacks since readmission. According to the note, the RD would start Boost (a supplement) twice daily to increase the resident's intake. Further, the note indicated the RD would continue to monitor the resident's monthly weights and meal/snack intake. Continued review of Resident #40's August 2022 physician Order Summary Report revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #40's readmission Nutrition Evaluation, dated 06/23/2022, revealed Resident #40 required help setting up the meal tray and now required the assistance of one person for meals. Further review revealed Resident #40 consumed 50% to 100% of their meals prior to hospitalization for a left femur fracture in June 2022 but Resident #40 consumed 0 - 25% of their meals since readmission. The resident received Boost twice daily and snacks three times per day. According to the note, per the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed Resident #40's weight on 06/07/2022 was 188 pounds and was stable on diuretic therapy with expected weight fluctuations. Facility staff held a care conference on 06/20/2022 and Resident #40's family member was concerned with Resident #40's reduced meal intake. According to the note, the resident's last weight before hospitalization was stable. The RD then wrote, unknown if resident is currently meeting [his/her] estimated energy needs with intake. The RD recommended continuing the current diet order, obtaining a current weight, and monitoring food intakes. A review of Resident #40's Weight Summary revealed on 06/07/2022, prior to transferring to the hospital, the resident weighed 188.0 pounds. Further review revealed on 07/05/2022 the resident weighed 180.4 pounds (an eight pound or 4.4% weight loss). On 07/30/2022 and 08/03/2022, Resident #40 weighed 159 pounds, an 11.86% weight loss in less than 30 days, and 15.43% in less than 60 days. Continued review of Resident #40's Progress Notes, Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #40's Amount Eaten report, dated 08/01/2022 to 08/30/2022, revealed the resident's meal intakes varied from zero to 100% and the resident refused nine meals during the month of August 2022. An observation of Resident #40 on 08/30/2022 at 11:45 AM revealed the resident was in his/her room. Staff set up the meal tray and the resident was eating. During an interview on 08/30/2022 at 1:22 PM, Certified Nurse Aide (CNA) #1 stated Resident #40 had variable intake at meals, and she offered snacks if Resident #40 refused a meal. According to CNA #1, the resident could verbalize when he/she was hungry. CNA #1 further stated Resident #40 looked as though he/she had lost weight since the resident's femur fracture in June 2022. However, CNA #1 did not notify anyone that Resident #40's clothes looked looser than normal because Registered Nurse (RN) #1 already knew Resident #40 had lost weight. During an interview on 08/30/2022 at 1:35 PM, Registered Nurse (RN) #1 stated she was not aware that Resident #40 had a weight loss. According to RN #1, the RD notified her of any residents with severe weight loss or any new orders; however, the RN had not been notified of weight loss for Resident #40. According to RN #1, Resident #40 ate a regular diet and had good food intake, and the resident's weight did not appear any different. During an interview on 08/30/2022 at 2:00 PM, CNA #2 stated she obtained Resident #40's weight on 08/03/2022 and when she input the weight into the electronic medical record (EMR), she compared the current weight to the previous weight. CNA #2 stated she normally notified RD #2 verbally if there was more than a five-pound difference from the previous weight. CNA #2 further stated when a resident had weight loss, the RD followed up and communicated with nursing regarding any significant weight changes. However, CNA #2 did not remember if she notified RD #2 of Resident #40's weight loss from July 2022 to August 2022. CNA #2 stated if she had notified the RD, it would not have been documented. During an interview on 08/30/2022 at 2:12 PM, RD #2 stated she had been covering the facility since May 2022 and followed residents from week to week. She stated she did not complete a progress note if there were no changes between quarterly nutrition assessments. She stated if a resident had a wound, significant weight loss, or if she was notified a resident was not eating/refusing meals, she would follow up with the resident to see if any supplements were in place or if they just did not like what was being served. If the resident had a higher need, the RD stated she typically would follow the resident weekly to see if there were any changes. RD #2 stated the last time she assessed Resident #40 was on 06/23/2022, when she completed a readmission nutrition assessment. RD #2 stated she reviewed each resident's monthly weight but had overlooked Resident #40's severe weight loss in August 2022. According to RD #2, she was supposed to notify the resident's family and physician and implement new nutrition interventions as needed for weight loss. RD #2 stated it was important to identify significant weight changes and/or the need for nutritional interventions, and to implement them timely to prevent further weight loss, malnourishment, or skin breakdown. During an interview on 08/30/2022 at 2:58 PM, the resident's physician (Physician #1) stated the previous week, the facility notified him that Resident #40 had decreased intake; however, the physician stated he was not aware the resident had weight loss. The physician further stated Resident #40 had psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician #1 further stated the decreased intake could have been a side effect of the recovery process following the femur fracture or from pain medications. The physician stated the resident had [CONDITION(S)] after the hospitalization , and some weight loss could have been expected but the resident had sustained a lot of weight loss quickly. According to the physician, the facility should notify him of any significant changes so he could follow up and implement appropriate interventions to provide proper care. He further stated he expected to be notified because if a resident could not communicate feelings or symptoms, it was a sign of a much bigger problem than not liking the food or needing assistance. Physician #1 stated if the facility had notified him, he would have implemented different interventions such as supplements and an RD consult for an enhanced nutrition plan. During an interview on 08/31/2022 at 1:55 PM, the Director of Nursing (DON) revealed the RD was responsible for reviewing residents' weights, identifying weight loss, and notifying the resident's physician of weight loss. The DON stated significant weight loss should be identified by the RD, then discussed during the facility's weekly standard of care meetings, where the cause of weight loss was assessed. According to the DON, the facility discussed Resident #40's weight loss and the RD determined the loss was due to diuretic use. However, there was no documented evidence the facility assessed/addressed the resident's severe weight loss. The DON further stated they should have discussed Resident #40 more at their weekly meetings to assess for other possible contributing factors such as medication side effects, the femur fracture, or increased nutritional needs. The DON stated it was important to identify a significant weight loss early so interventions could be implemented to prevent further weight loss or decline. During an interview on 08/31/2022 at 3:10 PM, the Administrator stated interventions should have been discussed to prevent further weight loss when Resident #40 had a significant weight loss in August 2022.

Based on observation, interview and record review, the facility failed to ensure 21 residents with symptoms of dementia who resided in the secure unit (#33, #40, #39, #3, #81, #29, #16, #82, #20, #42, #44, #15, #7, #43, #27, #67, #68, #56, #63, #73, #28), received appropriate treatment and services to attain and/or maintain their highest practicable level of physical, mental and psychosocial well-being. Specifically: Repeat incidents of physical aggression, too frequent verbal aggression to document, staff's lack of training in dementia care and their inappropriate and limited response to residents' behaviors, placed the physical, mental, and psychosocial well-being and safety of all 21 residents with symptoms of dementia residing in the unit at risk for immediate and serious harm. (Cross-reference F600, F610, F679, and F947) Findings include: I. Immediate jeopardy for serious harm A. Situation of Immediate Jeopardy Resident #39 was admitted to the facility in early October, (YEAR). Record review revealed the facility was aware as early as the resident's first week of admission and as recently as 1/23/19, that Resident #39 wandered into resident rooms and common areas, taking items from other residents that did not belong to him. As a result, the resident was pushed, punched, hit in the head, arm and stomach, and shoved by other residents at least seven times. Record review revealed the facility failed to engage in a systemic care process to assess, develop and implement a care plan to alter the resident's behavior which made him the subject of resident-to-resident abuse. Review of Resident #15, #33 and #44's records further revealed a lack of a systemic care process to alter behaviors observed and/or documented in their records which risked their well-being and safety. Secure unit staff reported physical aggression among residents on the unit occurred at least once a week and verbal aggression occurred too often to document. Staff disclosed they lacked training in dementia care and observations revealed one staff member's reaction to repetitive behaviors exhibited by Residents #39 and #15 was inappropriate. Moreover, record review revealed staff's response to residents' aggressive behavior, regardless of the individual resident's assessed needs, was the same - redirection, 15 minute checks, and occasionally 1:1 supervision. Repeat incidents of physical aggression, verbal aggression too frequent to document, staff's lack of training and inappropriate and limited response to residents' behaviors, placed the well-being and safety of all 21 residents with symptoms of dementia residing in the unit at risk for immediate and serious harm. The nursing home executive director (ED) was notified of the immediate jeopardy situation on 1/23/19 at 6:13 p.m. B. Facility plan to remove Immediate Jeopardy The facility submitted the following plan on 1/25/19 at 1:07 p.m. to remove the Immediate Jeopardy: We recognize that all residents are in need of continuous supervision and we are implementing the following: -Additional Staff member was placed on unit 1/23/2019 at 10:30pm to perform continuous 15-minute rounding in order to ensure that residents (sic) individualized dementia care needs are met. Staff member was educated on proper rounding for the unit. -Implemented person centered activities on 1/23/2019 as non-pharmacological approaches to care for resident living with dementia. Meaningful and purposeful activities have been scheduled to accommodate interests, preferences and choices to enhance the residents (sic) well-being. In-Service was completed by DON, ADON and/or designee with all staff regarding supervision and importance of observation of resident with [DIAGNOSES REDACTED]. Rounding education included accounting for all residents on the dementia unit, identifying triggers if any and intervening as necessary. -Addressing supervision issues of residents living with dementia on the secure unit with the following: All Management staff will assist during meal services to help to supervise residents. All management team will be responsible for periodic daily rounding to help supervise residents. -Dementia trained staff will be present on unit for entire duration of each shift to ensure safety of resident living with dementia. Also dementia trained staff member will ensure individualized dementia care needs are met. -Dementia education will be provided by social services director to each staff member assigned to the secure unit before start of next shift by 1/28/2019. Social services director will schedule in-service meeting and/or come in at the start of each shift to ensure staff is educated. -Baseline care plan will be completed by 1/26/2019 at 5:00pm and ongoing for each resident living with dementia on the secure unit. Residents will be assessed by Social services and nursing to create a care plan that will include diagnosis, behaviors, triggers, person centered care, and interventions. Baseline care plans will be placed in a binder. Staff will be educated on baseline care plan binder by 1/28/2019 by midnight, -In-Service will be completed by DON, ADON, or designee with staff regarding supervision and importance of observation of resident during rounding to include accounting for every resident of the secure unit, knowing location of every resident, engaging residents in activities, preventing negative interactions or altercations, identifying triggers and intervening when necessary. If there is any type of altercation a verbal report will be made to the administrator and will be documented. Nursing carts will be strategically placed to ensure nurse has an extensive view of the unit. Staff will be educated to stagger lunch times and breaks to ensure maximum number of staff is available to care for residents on secure unit. In-service will be complete by 1/28/2019. -Promoting person centered care activities and programs for residents to help improve self-sufficiency, self-confidence, and cognition. A variety of activities were offered by activities director and social service director to promote person centered activities. Meaningful and purposeful activities will be scheduled by program manager (social services director), reviewed and approved by activities consultant. Activities will be performed by activity personnel as scheduled and as needed and by other staff as needed while working on the secure unit to enhance the residents (sic) well-being. -Snacks and hydration will be offered every 2 hours on the secure and at resident's request unit in attempt to meet the needs of residents with dementia. C. Removal of Immediate Jeopardy situation On 1/25/19 at 2:08 p.m., the NHA was notified the Immediate Jeopardy situation was removed. However, deficient practice in the secure unit remained at an F level, widespread. II. Secure unit environment Twenty-two residents resided in the secure unit, 21 of whom had symptoms of dementia. The unit consisted of ten resident rooms with two to three residents in each room. The secured unit doors had a key pad code that unlocked the door. A second secure door with a key code lock that led to a courtyard that was utilized as a smoking area. When entering the unit, there was a small television area with a small couch and a couple of chairs. It also has a two person table and chair set off to the side. Under the television was a large, locked trunk that contained items utilized in activities. Around the corner was the nurses' station that faced a great room. This room consisted of eight small tables and two recliners. The nurses had a rolling station that was set up in this area which was used for dining, activities and socializing. There was a solid wall between the television room and great room that blocked visualization of the made the door from this area. The maintenance services director had an ofice toward the back corner. III. Facility failure to engage in a systemic care process to assess, develop and implement care plans with person-centered approaches to alter Residents #39, #15, #33, and #44's behaviors which made them subject to resident-to-resident abuse and/or staff-to-resident abuse. A. Resident #39 1. Resident status Resident #39 age 61, was admitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The resident resided in the secure unit except from 10/19 to 10/24/19. According to the minimum data set ((MDS) dated [DATE], the resident had significant cognitive delays; a brief interview for mental status could not be completed. The resident required extensive assistance with activities of daily living but was independently ambulatory. The care plan dated 10/15/18 identified Resident #39 was at potential risk for injury from physical altercations due to the resident taking other residents' belongings. The interventions were to attempt to redirect and use one-to-one (1:1) as needed. The care plan also identified the resident exhibited alterations in mood and behavior; Resident #39 would often take items belonging to other residents and/or staff. Interventions included monitor wondering and redirection as needed, use of 1:1 as needed, and in a handwritten note, an undated care plan revision read, Redirect when agitated and attempt to direct the resident in to a quiet area until calm. The care plan also revealed the resident was alert but very confused and he was not able to make his needs known. His behavior was socially inappropriate and he was not re-directable, although redirection was the primary intervention to address his behaviors (see above). 2. Record review of Resident #39's behaviors, residents' response to these behaviors, facility response to behaviors, and failures in facility response. a. Review of facility departmental notes from 10/4/18 (admission) to 1/23/19 revealed almost daily documentation in (MONTH) through mid-November of the resident wandering into other residents' rooms, and taking items, drinks and food from other residents. Specifically: -In October, the resident was documented with the above behavior on 10/4,10/7, 10/8, 10/10, 10/12, 10/14, 10/17, 10/18, 10/22, 10/24 (x2), 10/25, 10/27, 10/29, 10/31/18. -In November, the resident was documented with the above behavior on 11/1, 11/2, 11/4, 11/5, 11/6, 11/7, 11/8, 11/9, 11/10, 11/11, 11/12, 11/20/18. -In December, the resident was documented with the above behavior on 12/2, 12/3, 12/4, 12/11, 12/13, 12/25/18. -In January, the resident was documented with the above behavior on 1/8/19. b. Review of facility department notes, Resident #39's care plan, and interviews with the social services director (SSD) on 1/9/19 at 10:35 a.m. regarding residents' response to Resident #39 wandering into their rooms and taking items, drinks and food from them, revealed Resident #39 caused other residents to become agitated and caused Resident #39 to be hit, punched and shoved. -On 10/8/18, the note read Resident #39 was agitating other residents. -On 10/10/18, the care plan read Resident #39 was involved in a resident-to-resident altercation with Resident #55. SSD interview revealed Resident #39 was hit when he tried to take a cigarette from Resident #55. -On 10/14/18, the note read Resident #39 had many male residents angry with him. -On 10/15/18, the note read Resident #39 was involved in a resident-to-resident altercation. SSD interview revealed Resident #39 was punched in the head two times, pushed out of his chair to the ground for taking a resident's item in the dining room. -On 10/19/18, the care plan read the resident was hit by Resident #55 after taking Resident #55's chocolate milk. -On 10/24/18, the note read Resident #39 was hit and shoved to the ground by an unidentified resident. SSD interview confirmed this incident. -On 10/29/18, the note read Resident #39 was hit by an unidentified resident after taking that resident's shoes. SSD interview revealed Resident #39 was hit in the stomach after taking the unidentified resident's candy bar. -On 10/30/18, the note read Resident #39 was involved in a resident-to-resident altercation. -On 11/1/18, the note read Resident #39's behavior was agitating other residents. -On 11/4/18, the note read Resident #39's behavior was causing other resident to become agitated. -On 11/8/18, the note read Resident #39 went into another resident's room and came out with two cuts to the ear and a scratch to side of the left eye which was swollen. -On 11/10/18, the note read Resident #39 was causing other residents to become agitated. -On 11/11/18, the note read Resident #39 emerged from his shared room with unexplained bilateral reddened and swollen eyes. He was unable to explain what happened. -On 11/12/18, the care plan read Resident #39 was involved in a resident-to-resident altercation, sustaining an abrasion above the left ear. -On 1/23/19, the note read Resident #39 was involved in a resident-to-resident altercation. c. Record review of staff's response to Resident #39's behavior of wandering into other residents' rooms and taking items, food and drink. Review of Resident #39's record revealed staff response to Resident #39's behavior was documented in either the 15 minute patient observation record (initiated after the resident's behavior had occurred), in departmental notes, or in the Behavioral/Intervention monthly flow record (behavioral record). Review of the departmental notes from 10/4/18 - 1/24/19 revealed staff response to Resident#39's wandering behavior and taking items that did not belong to him included redirection which was sometimes effective but often not, per documentation on 10/8, 10/13, 10/27, 10/31, 11/6, 12/25/18. The notes also indicated two room changes, a short stay on the non-secure unit (10/19 - 10/24/18), and cueing the resident not to enter other residents' rooms. Review of the departmental notes and 15 minute patient observation records revealed 15 minute patient observation of Resident #39 was in place 10/7, 10/8, 10/10 (resident pushed and shoved), 10/12, 10/13, 10/15 (resident punched and pushed), 10/17, 10/19 (resident hit), 10/24 (resident hit and shoved),10/25, 10/26, 10/29 (resident hit),10/30 (resident hit), 10/31,11/2,11/4, 11/8 (resident with cuts),11/11/18 and 1/23 and 1/24/19. Review of all but two of the 15 minute observation records documented either no behaviors or awake, sleeping, cooperative. At least nine 15 minute observation records held no documentation or there was no evidence to show the observation records had been initiated. Review of the behavioral records revealed the directions for filling out the behavioral record was to enter target behavior, record the number of episodes by shift with initials, enter the intervention code (listed below the target behavior), outcome code (listed below the target behavior), and side effects codes with initials beside each shift). Review of behavioral records revealed the record was not filled for intrusive behaviors/taking others' items on the following dates when he was documented with such behavior: 11/4, 11/10, 11/12, 11/20, 12/2 (incomplete), 12/3 (incomplete), and 1/8/19 (incomplete). d. Failures in staff's response While concerns were raised as early as 10/13/18 by nursing and social services about Resident #39's safety in the secure unit, the steps taken by facility (primarily redirection, 15 minute patient observations) were not effective, as evidenced by continued documentation of Resident #39 wandering into resident rooms and taking items, food and drinks and a resident-to-resident altercation as recently as 1/23/19. There was no evidence the facility implemented process to assess, develop and implement a care plan with person-centered approaches to alter Residents #39's behaviors, which subjected him to resident-to-resident abuse. Record review revealed no evidence of interdisciplinary team meetings to discuss Resident #39's needs, the potential causes/or need expressed by his wandering behavior, and how the behavior might be reduced either through meeting a need or through other means. Record review revealed no evidence the facility sought outside consultation on how to understand and address Resident #39's persistent wandering despite experiencing hits, punches and shoves to the ground by other residents in the secure unit. Record review revealed no discussions with Resident #39 physician, although the SSD reminded staff in a note on 10/13/18 to reach out to the resident's physician if necessary. Finally, review revealed the resident's care plan, dated 10/15/18, which instructed staff to monitor wandering, redirect, and use 1:1 as needed, was not revised until 12/18/18, even though staff was aware these interventions were not changing the resident's behavior. Even then, it included no new or revised interventions, but rather documented the resident continued to reside in the secure unit with supervision to keep him from disturbing others and altercations. -There was no evidence the facility attempted to develop person-centered, individualized interventions that were directed toward achievable goals and that maximized the resident's safety. -There was no evidence the facility attempted to identify meaningful activities for Resident #39 that would not only enhance his quality of life but also might reduce his behaviors that place him at risk for harm. 3. Observations of Resident #39's behaviors and failures in staff's response to behaviors Observations on 1/7 and 1/8/19 revealed licensed practical nurse (LPN) #5's interactions with Resident #39 in the dining room were inappropriate. The LPN was observed to pull and peeled items from the Resident #39's hand which he had picked up. She told him in an abrupt, stern and loud voice to go to your own room, to sit, (Resident #39) sit, sit, just sit, and to swallow your pills. When Resident #39 repeatedly asked for two milks, after having received two glasses of milk, the LPN told him he had to wait for lunch. Another request for milk was ignored. And, when the resident knocked his milks off the table, LPN #5 said you will get no more milk, no, you threw your milk, you get none. See F600 for further details. B. Resident #15 1. Resident status Resident #15, age 83, admitted [DATE]. According to the (MONTH) (YEAR), computerized physician orders [REDACTED]. The resident resided in the secure unit. According to the minimum data set ((MDS) dated [DATE] the resident had significant cognitive delays; a brief interview for mental status could not be administered. The resident required extensive assistance with activities of daily living. The care plan dated 5/6/18 identified the resident was to be monitored and documented for paranoid [MEDICAL CONDITION]. The care plan showed the resident would be offered fresh air and sun, 1:1 staffing to express feelings, calm environment, snacks, and music. The care plan interventions for mood and behavior was documentation in the behavior book. The care plan also documented it was important to avoid confrontation when agitated. Document for refusals, when confused or experiencing psychotic disturbances do not attempt to bring to reality, approach in a calm manner, educate resident regarding acceptable alternatives to identified behaviors and document response. Review of physician notes dated 11/8/18 revealed the resident reported being sad about a missing item of clothing. Another visit on 12/11/18 revealed the resident could become repetitive in speech and thinking. The physician documented dementia required guidance and assistance with basic activities of daily lining. The physician's assessment and plan called for monitoring and that the resident should have stable surroundings. 2. Record review of Resident #15's behaviors, residents' response to these behaviors, facility response to behaviors, and failures in facility response a. Review of Resident #15's behavior records and departmental notes revealed she was being monitored for verbal aggression, tearful episodes worsening behaviors and hallucinations. -The behavior record for (MONTH) (YEAR) showed no verbal aggression or tearful episodes on 5, 6, 7, 11, 12, 13, 19, 20, 21, 25, 26, and 27. The following dates in the month of (MONTH) 1, 2, 3, 4, 8, 9, 10, 14, 15, 16, 17, 18, 22, 23, 24, 28, 29, 30 and 31 were not filled out. -The behavior record for (MONTH) (YEAR) showed zero episodes of verbal aggression for the month of December. The record was not filled out for (MONTH) 6, 7, 8, 12, 13, 14, 15, 16, 20, 21, 22, 24, 25, 26, 27, 28, and 31. The date of 12/11/18 was marked for zero episodes of verbal aggression. Episodes of tearfulness were documented on 3, 4, 5, 9, 17, and 30. Tearfulness was not filled out on the following dates: 6, 7, 8, 12, 13, 14, 15, 16, 20, 21, 22, 24, 25, 26, 27, 28, and 31. -The behavior record and departmental noted for (MONTH) 2019 revealed: Notes on 1/5/19 at 1:34 p.m. read the resident had become increasingly agitated during the shift and was having auditory hallucination. The behavior record 1/5/19 showed episodes of tearfulness were documented as a c (continuous); interventions included redirection and food; notes on 1/8/19 at 4:09 p.m. read the resident cried throughout the shift, repeatedly requesting various drinks and food. The interventions used were redirection, activity and offering food and drink (but see observations below on 1/8/19 earlier in the day indicating otherwise). The behavior record was not completed for the afternoon shift; notes on 1/22 documented the resident was having delusions and could not be redirected and a note on 1/23/19 read the resident was lying on the floor and did not want to get up. She was administered prn [MEDICATION NAME] and staff continued to redirect. b. Record review of failures in facility response See above; review of the behaviors records above revealed inconsistent documentation of the resident's behaviors, necessary to determine patterns and interventions. Further review of the resident's record revealed no documented monitoring to support the interventions addressing the resident's paranoid [MEDICAL CONDITION] which (see above), included fresh air, sun 1:1 staffing to express feelings, calm environment, snack and music. Review of the resident's record also revealed no documentation to support the resident's mood and behavior which (see above) included that when the resident was confused or experiencing psychotic disturbance, do not attempt to bring to reality, approach in a calm manner, educate resident regarding acceptable alternatives. There was no evidence the above interventions had been recently reviewed by the interdisciplinary team to ensure they continued to reflect the resident's needs and a current person-centered approach as the (MONTH) behavior record indicated new and increasing symptoms. 3. Observations of Resident #15's behaviors and failures in staff's response Observations on 1/8/19 revealed LPN #5's interactions with Resident #15 in the dining room were inappropriate and contrary to her care plans. Observations revealed when Resident #15 asked the LPN for a Sprite, the LPN responded in a gruff voice, not until (over an hour later); that's when you can go to the country store (to purchase Sprite). Resident #15 began to cry and LPN said, No crying till then, no soda, and the resident began to cry harder. In a loud and irritated voice, the LPN said, Why are you crying? Resident #15 began to cry uncontrollably and asked for coffee. The LPN respond, You already spilled it. She then told the resident she had no reason to cry and to stop crying. The resident was transported to her room at her request by certified nurse aide (CNA) #10. LPN #5 yelled from the dining room, Why are you crying, there is no reason to cry. Once the resident was in her room, the CNA closed the resident's door and returned to the dining room. See F600 for further details. C. Resident #33 and Resident #44 1. Resident #33 Resident #33 age 69, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The resident resided in the secure unit. According to the minimum data set ((MDS) dated [DATE], the resident had significant cognitive delays and was unable to complete the brief interview for mental status exam. The resident required extensive assistance with activities of daily living. The care plan dated 5/11/12 identified resident has episodes depression and manic states. The resident has been identified as wandering into residents rooms, taking other residents items and giving them away. It is also identified the resident has a history of threatening to hurt others, swearing at them, and occasional physical aggression. The intervention for the depression and manic states include attempt to explain the inappropriate behavior, redirection, quarterly monitoring in mood and behaviors, document inappropriate behaviors in the behavioral book and nursing documentation, remove from area, and 15 minute checks. His behavior was at times socially inappropriate and he was not redirect able when depressed or manic. Review of behavior records and departmental notes from 10/30/18 to 1/13/19 confirmed the presence of the behaviors identified in the care plans. However, the record failed to disclose evidence of interdisciplinary team involvement in the development of the resident's care plan. Moreover, the care plan failed to include person-centered interventions for the resident's behaviors - aggression, threatening others, cursing, wandering and taking other residents' belongings - in order to maximize the resident's well-being and safety, as well as the safety of other residents in the secure unit. 2. Resident #44 Resident # 44 age 71, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. He resident resided in the secure unit. According to the minimum data set ((MDS) dated [DATE], the resident had moderate cognitive impairments with a brief interview for mental status exam with a score of 10 out of 15. The resident required extensive assistance with activities of daily living. The care plan identified the resident as having a long history of problematic alcohol use which has impacted his mood and relationships. The resident has had suicide ideation and multiple psychiatric admissions. The resident required a secure unit. Interventions included encourage/ remind residents to use coping mechanisms, positive reinforcement, record and observe medical complications [REDACTED]. It also stated the resident was to be monitored for mood state and to notify the doctor as needed. Review of behavior records and departmental notes from 10/15/18 to 1/23/19 confirmed the presence of the behaviors identified in the care plans. However, the record failed to disclose evidence of interdisciplinary team involvement in the development of the resident's care plan. Moreover, the care plan failed to include person-centered interventions to address the resident's verbal aggression and physical aggression as tracked in the behavior record. IV. Staff interviews Interviews with staff on the secure unit disclosed they lacked training in dementia care. Staff interviews further revealed staff's response to residents' aggressive behaviors, regardless of the individual resident's assessed needs, was the same - redirection, 15 minute checks, and occasionally 1:1 supervision, confirmed the facility's failure to engage in a systemic care process to assess, develop and implement care plans with person-centered approaches to alter behaviors of residents with dementia symptoms on the secure unit, including Residents #39, #15, #33, and #44's behaviors which made them subject to resident-to-resident abuse and/or staff-to-resident abuse. A. Interviews conducted 1/8 - 1/10/19 1. The executive director (ED) was interviewed on 1/8/19 5:50 p.m. The ED said Resident #39 was the perpetrator as well as the victim and that they had put out a referral to find a new placement for him. The ED said he would assign a 1:1 staff for that night (1/8/19) to keep Resident #39 and the other residents safe. The ED said he could not think of another way to keep residents safe. The ED said he was aware there was a lot of resident-to-resident altercations due to the Resident #39 taking other residents items. The ED said a lot of the residents in the secured unit have behaviors and that it was the reason they were on the secured unit and he has found that it keeps the other residents in the non-secure area happier. The ED said the extra person would provide help and that dementia and Alzheimer's training were needed. 2. CNA #1, who worked in the secure unit, was interviewed on 1/8/19 10:21 a.m. She said there was at least one resident-to-resident altercation(s) a week. She said the 15 minute patient observation or check was standard intervention for physical altercations. She said the secure unit was small and having an extra staff was the only intervention that was effective. She said the staffing in the secure unit was routinely one licensed nurse and two CNAs. She said when interventions call for 1:1 staffing, they do not bring in additional help; rather, they use the staff already in the unit. She said there is protocol addressing how long staff are to spend with a resident on 1:1 but usually, it is no more than 15 minutes. She said Resident #39 was always wandering into other resident rooms and searching for clothing, food, and drinks. The CNA said the resident was not always redirect able and she would offer snacks to get him to leave residents' rooms. The CNA said there was no specific training regarding how to assist Resident #39; she said she redirects him based upon personal experience. She said the facility had offered a generalized training but nothing specific to the resident in regards to mental illness, memory care or dementia training. 3. CNA #9, who worked in the secure unit, was interviewed on 1/8/19 10:43 a.m. 3CNA #9 said there was no individualized training for the staff in the unit, no preventive trainings in place and no training on interventions, beyond the 15 minute patient observation/check. The CNA said the residents would fight over food and drinks and stated she knew an altercation was happening when she heard the residents yelling and stated physical altercations happen weekly, verbal altercations happen too many times to document. CNA #9 said they document resident to resident altercations with 15 minute checks; however, staff do not put the 15 minute checks in place unless the residents physically hit each other. The CNA confirmed Resident #39 was frequently in other residents' rooms, taking their clothing, food, and drinks and as a result, he was often hit or pushed. The CNA said the last altercation during her shift took place on 1/5/19 when Resident #39 and an unidentified resident got into a tug a war with the other resident's shirt. She said she was able to redirect the residents but she felt like the residents were about to hit each other as she saw closed fists. She said there were quite a few times she was unable to redirect the residents. The CNA said typically there were two CNAs and one licensed nurse on each shift in the secure unit. Communication was usually passed from CNA to CNA at shift change.

Based on observation, record review and interview, the facility failed to ensure the resident environment remained as free of accident hazards are possible, and that each resident received adequate supervision and assistive devices to prevent accidents. This failure affected 13 (#55, #39, #67, #43, #15, #64, #38, 81, #60, #66, #18, #34 and #25) of 61 sample residents. Specifically: ELOPEMENT AND SMOKING Resident #55, severely cognitively impaired and independently ambulatory, was transferred from the secure to the non-secure unit on 10/21/18. This transfer took place without an evaluation of the resident's safety in a non-secure environment. Record review and interview revealed Resident #55 exhibited behaviors likely to cause serious harm, eloping from the unit over a dozen times at all times of the day, collecting cigarette butts and smoking them in his room. Resident #55's behaviors and failures in the facility's response to the behaviors created a situation of immediate jeopardy for serious harm. Resident #39, cognitively impaired and independently ambulatory, resided in the secure unit. Interview revealed the resident tried to walk out of the unit with staff six times a day. On 1/10/19, Resident #39 was observed to exit the secure unit as the door slowly closed behind staff and walked down the hallway of the non-secure unit until staff was alerted to the resident's exit from the unit. Record review revealed no care plan identifying the resident's risk to wander from the secure unit and there was no documentation in Resident #39's record that his exiting behavior was being monitored. TRANSFERS Facility failed to ensure safe transfers conditions to effectively prevent falls for Residents # 67, #43, and #15. FALLS The facility failed to ensure a fall investigation was completed for Resident #64. The facility failed to ensure the fall interventions were in place for Resident #38. WANDER GUARDS The facility failed to have recognizable photos in the facilities elopement book or monitor daily operational functionality of wander guards placed on resident ' s at risk for elopement, on a daily basis for Residents # 81, #60, #66, #18, #34, and #25. Findings include: I. ELOPEMENT AND SMOKING A.Immediate jeopardy 1. Situation of Immediate Jeopardy Resident #55, severely cognitively impaired and independently ambulatory, was transferred from the secure to the non-secure unit on 10/21/18. This transfer took place without an evaluation of the resident's safety in a non-secure environment. Record review and interview revealed Resident #55 exhibited behaviors likely to cause serious harm, eloping from the unit over a dozen times at all times of the day, collecting cigarette butts and smoking them in his room. Resident #55's behaviors and failures in the facility's response to the behaviors created a situation of immediate jeopardy for serious harm. On 1/28/19 at 7:21 p.m., the nursing home administrator (NHA) was notified Resident #55's behaviors and failures in the facility's response created a situation of immediate jeopardy. 2. Plan to remove Immediate Jeopardy On 1/28/19 at 7:21 p.m., the facility submitted the following plan to remove the Immediate Jeopardy situation: We recognize that resident 6983 (Resident #55) has had a history of [REDACTED]. · [MEDICATION NAME] 2.5 mg QD ordered 1/15/2019 with no further behaviors documented since medication ordered and started. [MEDICATION NAME] documented on care plan as intervention. · 15 minute checks care planned and implemented on 1/15/2019 for 72 hours with no further behaviors documented. 15 minute checks x72 hours documented on care plan as intervention. We will continue to monitor for behaviors. · Room change done to place resident furthest away from front entrance as possible with no further behaviors documented. Wander guard was not an affective (sic) intervention for this resident. Therefore, room change has been an effective intervention and we will continue to validate and monitor. We will implement additional interventions as needed. · One on One supervision as of 1/28/2019 at 7:30pm for monitoring of any further behaviors through the night. One on One supervision will continue for 72 hours in order to document any behaviors and monitor effectiveness of [MEDICATION NAME]. Once 72 hours is completed, we will validate if the one on one is needed. If needed, we will continue one on one and reevaluate every 72 hours. · Social Service Director confiscated all smoking material on 1/15/2019 and on 1/17/2019. Care plan intervention noted to be monitoring resident for any smoking in room or possession of smoking material. Nursing staff will monitor Q-shift for safety of resident, compliance with smoking policy, and behaviors. At 5:15pm on 1/29/2018 Social Services director along with one on one staff member assessed for any smoking materials. No materials were found on resident. Residents stated Smoking materials are kept in the box. Social services director will perform random checks to assess for smoking materials. · Interventions to get resident back into the building: offer additional smoking time and activities that resident may enjoy i.e. books, bingo etc. Staff will be educated on interventions to redirect resident by midnight 1/30/2019 · All residents are assessed upon admission for elopement risk and quarterly thereafter. · Elopement drill and training is due every quarter. The facilities (sic) next scheduled drill and training is for 1/30/2019. · IDT (interdisciplinary team) reviews all new admissions for elopement risk and updates elopement book as needed. Social services department is responsible to ensure elopement book is current. Resident has been added to facility elopement book. · Note: If any further behaviors occur and resident is unable to managed one and one resident will be sent for a psych evaluation and medication review. 3. Based on review of the facility's plan, observations and record review, the NHA was informed the Immediate Jeopardy situation was removed on 1/29/19 at 5:59 p.m. However, deficient practice remained at an E level. II. Resident #55 - Multiple elopements and unsafe smoking A. Resident status Resident #55, age [AGE] years old, was admitted [DATE]. According to the (MONTH) 2019 computerized physician's order [REDACTED]. The 12/2/18 minimum data set (MDS) assessment documented the resident was severely cognitively impaired and was unable to complete the brief interview for mental status exam (BIMS). The staff assessment indicated the resident had little interest or pleasure in doing things, had difficulty concentrating on things and was short tempered. He had delusions, had verbal behaviors directed toward others and rejected care. He ambulated independently. Resident #55 had care plans for verbal and physically aggressive behaviors (12/3/12), for non-compliance with smoking (9/12/12), and walking the halls with focus on smoking (4/6/17). Smoking assessments (4/4/18, 12/27/18 and 1/15/19) read Resident #55 required supervision while smoking. Assessments documented the resident sometimes kept cigarettes/partial cigarettes although not allowed to do so. Record review and interview with the social service director (SSD) on 1/29/18 at 10:06 a.m. revealed Resident #55 resided in the non-secure unit until (MONTH) (YEAR), when he was transferred to the secure unit. He resided in the secure unit until 10/21/18 when he was transferred back to the non-secure unit. Observations during survey (1/7/19 - 1/29/19) revealed the resident continued to reside in the non-secure unit. B. Unsafe behaviors - Smoking and elopement pre-12/13/17 through 10/21/18 Interview revealed the resident was known to be non-compliant with smoking and to leave the building to go outside, find cigarettes and smoke them. The facility's response was to transfer the resident to the secure unit where he remained until 10/21/18. In an interview with the SSD on 1/29/19 at 10:06 p.m., the SSD said Resident #55 used to reside on the non-secure unit, but was moved to the secure unit in December, (YEAR) because he was going outside in the front of the building to smoke. Review of the resident's Secure Neighborhood Placement Evaluation dated 12/13/17, read Dementia increasing, refuses to follow smoking policy, smoking near oxygen. The 90 day re-evaluation for continued stay in the secure unit dated 10/20/18 read the resident had moved to the open (non-secure) unit. C. Unsafe behaviors in the non-secured unit - Smoking and elopement from the facility 10/21/18 to current 1. Record review Review of progress notes and interviews revealed Resident #55 repeatedly left the facility at various hours day and night to find and smoke cigarettes. Progress notes also revealed documentation of Resident #55 smoking in his room. -A progress note dated 11/13/18 documented the resident was on continued monitoring for smoking in his room. -A progress note dated 12/21/18, written at 4:15 a.m., documented the resident appeared to have smoked in his room. The resident ' s room was searched and a cigarette was found in the bedside drawer. -A progress note dated 12/22/18, written at 5:47 p.m., documented the resident was caught smoking in his room around 6:30 a.m. -A progress note dated 12/25/18 written at 7:18 p.m. documented the resident was reminded multiple times to not go outside and look for cigarettes. -A progress note dated 12/26/18, written at 4:26 a.m. documented the resident was observed going outside several times during the day. -A progress note dated 12/30/18, written at 12:39 p.m., documented the resident continued to go out the front door for cigarettes to smoke between normal smoke breaks and resident was successful at finding cigarettes. -Another progress note dated 12/30/18, written at 12:39 p.m., documented the resident continued to walk out the front door. -Another progress note dated 12/30/18, written at 1:31 p.m. documented the resident kept leaving the facility to find cigarettes outside. The resident had been educated multiple times but continued to leave the facility successfully and find cigarettes. The resident would return but continued to go outside. -A progress note dated 12/31/18 written at 3:17 a.m. documented the resident was observed outside in the parking lot looking for cigarettes. -A progress note dated 1/2/19 written at 4:03 a.m. documented the resident continued to go outside and was redirected. -A progress note dated 1/5/19, written at 3:45 a.m., documented the resident went outside twice during the shift and was redirected. -A progress note dated 1/5/19, written at 6:50 p.m., documented the resident continued to go outside to find cigarettes despite being advised not to and being redirected. -A progress note dated 1/6/19 written at 12:56 p.m. documented the resident continued to walk out the front door to cull cigarette butts from the parking lot. The note documented the resident was redirected each time to come back to the building but appeared anxious and would pace the hallway. -A progress note dated 1/7/19 written at 4:02 a.m. documented the resident was found in the facility parking lot on two occasions during the shift. The resident was redirected. -A progress note dated 1/10/19, written at 6:34 p.m. documented the resident was placed on 15 minute checks for smoking in his room. Resident ' s room was full of smoke and resident ran to bathroom and flushed the cigarette, resident was (educated) about smoking in his room and the dangers of smoking around oxygen machines. The resident continued to go outside to smoke unsupervised. -A progress note dated 1/12/19 written at 2:50 p.m. documented the resident was found outside in the parking lot, picking up cigarette butts. -A progress note dated 1/14/19 written at 12:42 p.m. documented the resident continued to walk out the front door and would become verbally aggressive when redirected. Another progress note on 1/14/19 written at 3:40 a.m. documented the resident refused to give cigarette butt to staff after his smoke break. -A progress note dated 1/15/19 written at 5:27 p.m. documented the resident continued to be monitored for leaving the facility and walked out of the facility 18 times on this date. During one attempt to be redirected the resident yelled I will snap your neck to staff. Resident was also caught in his room smoking and was educated on the hazards and safety. -A progress note dated 1/17/19 written at 8:58 a.m. documented the resident had increased behavior and was going outside to smoke and smoking in his room. The resident refused to give up his lighter. The resident remained on 15 minute checks due to going outside and smoking in his room. 2. Observations On 1/7/19, at 8:40 a.m., Resident #55 was sitting on his bed in a room he shared with Resident #385. Resident #385, was receiving oxygen therapy by nasal cannula. The privacy curtain was drawn between the two men and they were not interacting. Resident #55 was not interested in answering any questions and Resident #385 was not able to answer more than a few basic questions. 3. Interviews Staff interviews confirmed Resident #55's elopements, looking for cigarette butts, and unsafe smoking behavior. In an interview with the social services director (SSD) on 1/28/19 at 5:53 p.m., she said everyone worries when Resident #55 goes outside alone, but said they have not had to contact the police because they have been able to find the resident. She said the resident will manage to have a lighter from time to time and when his room was searched (with his guardian's permission) on 1/15/19, staff found a lighter. The receptionist was interviewed on 1/29/19 at 10:41 a.m. She said the resident would stand by the receptionist door and wait for her to go to the bathroom and then he will go outside. She said the resident never had any money and always looked for cigarette butts. She said when he left the building, he would go to the corner of the building or to the parking lot. LPN #3 interviewed on 1/29/19 at 2:35 p.m. He said he had been Resident #55 ' s nurse for approximately six weeks, until they moved him to another hall. He said the resident was very mobile, mainly wanted to smoke and drink coffee, and would usually make his way outside. He said and getting the resident back to the unit interrupted his ability to do his job. LPN #3 said he had walked past Resident #55's room and could smell smoke coming from the bathroom and saw the resident come out of the bathroom. (See interview below) D. Facility response to Resident #55's elopements and unsafe smoking Review of progress notes above revealed documentation in various notes that Resident #55 was placed on 15 minute checks, he was redirected from outside back into the facility, he was advised to not leave the facility to pick up and smoke cigarettes, and his whereabouts and his smoking were monitored. Record review revealed an Elopement/Wandering Risk Assessment was completed 12/3/18 which documented the resident had a wanderguard and was at risk for elopement, was oriented to person and place, had poor safety/environmental awareness and had gone greater than 120 days without an elopement incident. Record review of documentation provided by the SSD revealed the facility had made a number of attempts to find alternate placement for the resident prior to and after his transfer to the non-secure unit. The documentaiton read, 10/17/18 resident denied, 10/18/18 no openings, 10/22/18 resident denied, 1/14/19 resident denied, and undated information at four other facilities documented no availability, resident denied due to TBI ([MEDICAL CONDITION]) and no return call. Interview with the SSD on 1/28/19 at 5:53 p.m. revealed they attempted to have the resident wear a wanderguard; however, the resident only wore it for five minutes. She said the only intervention that was in place since the resident returned to the non-secure unit to ensure his safety was 15 minute checks. Interview with the SSD on 1/28/19 at 5:53 p.m. also revealed the resident's Risperidal (antipsychotic) had been increased and [MEDICATION NAME] (antipsychotic) had been started for anxiety, smoking, drinking and exit seeking. The DON and LPN #6, present during the interview, agreed and review of the Medication Administration Record [REDACTED]. Interview with the SSD on 1/28/19 at 5:53 p.m. further revealed the resident had been moved to four different rooms. She said he had first resided in a semi-private room with another resident but had been moved to a private room because of an altercation with his roommate (Cross-reference F600). Thereafter, he had moved to two other semi-private rooms because of smoking in his room and because the location of his room was near the front door. E. Failures in facility response to Resident #55's elopement and obtaining and smoking cigarettes in his room, thereby placing Resident #55, as well as other residents on the non-secure unit at continuing risk for harm. 1. Resident #55's move to non-secure unit without an assessment, orders, or safety plan. According to the facility's Elopement Protocol (August (YEAR)), Elopement is the ability of a resident who is not capable of protecting himself or herself from harm to successfully leave the facility unsupervised and unnoticed and who may enter into harm's way.' The protocol read any resident who elopes will be assessed for risk factors that place the resident at risk for elopement, will be reassessed for need of further intervention to reduce the risk, and immediate interventions for resident safety will include behavior monitoring for elopement, one to one monitoring if necessary, and a clinical assessment. Record review revealed no evidence the safety of the resident on the non-secure unit was assessed prior to his transfer on 10/21/18. There was no documentation regarding what in the resident's status had changed to make him appropriate to reside in a non-secure environment and what interventions would be put in place to prevent the resident repeating his unsafe behaviors that had triggered his placement in the secure unit (MONTH) (YEAR) (see above). In an interview on 1/29/19 beginning at 10:00 a.m. the SSD said the former assistant nursing home administrator (NHA) had made the decision to transfer Resident #55 to the non-secure unit over the weekend of 10/20 - 10/21/18, following an altercation with a secure unit resident. (Cross-reference F610). She said she was informed of the decision to move the resident but was not involved in the decision. She said they had not completed an assessment of the resident at the time of transfer, but said, I think we had a conversation about 15 minute checks. Review of the 15 minute check documentation provided by the facility revealed that 15 minute checks were completed for an entire 24 hour period follow Resident #55's transfer to the non-secure unit one time, on 1/2/19. The facility provided incomplete documentation for x days in (MONTH) (YEAR), eight days in (MONTH) 2019 and four days in (MONTH) (YEAR). There was no other documentation provided by the facility and the facility confirmed all documentation was provided. The social services director was interviewed again on 1/29/19 at 1:45 p.m. She said that no order was obtained to move Resident #55 off of the secure unit prior to moving him. See above; an Elopement/Wandering Risk Assessment was completed 12/3/18, over a month after the resident's transfer to the non-secure unit. Even then, based on the progress notes in (MONTH) (YEAR) (see above), the assessment was not correct. Review of the resident's care plans revealed no evidence of a comprehensive, person-centered care plan to address the resident's known history of leaving the building. The resident had no care plan for elopement, and his behavior monitoring did not include elopement. Review of smoking care plan revealed no updates upon his return to the non-secure unit, despite documentation of the resident smoking in his room. 2. Room choices that failed to reduce the risks posed by Resident #55's unsafe behaviors A progress note dated 12/30/18 at 12:39 p.m. read, New room assignment is not a good location for resident either because location makes it harder to notice when resident headed towards front door. See observations above on 1/7/19. Resident #55 currently resided in room with another resident who was receiving oxygen therapy. 3. Lack of reassessment for need of further intervention to reduce the risk. Progress notes 11/13/18 to 1/17/19 (see above) revealed Resident #55's cycle of unsafe behavior - eloping from the facility to find cigarettes, then smoking the cigarettes outside and on five occasions inside the facility his room - continued, with documentation 11/13, 12/21, 12/22, 12/25, 12/26, 12/30 (x3), 12/31/18,1/2, 1/5(x2), 1/6, 1/7, 1/12, 1/14, 1/15, and 1/17/19. Despite the ineffectiveness of the facility's response to Resident #55's behaviors as evidenced by the progress notes, two progress notes (12/30 at 12:39 p.m. and 1:31 p.m.) requesting changes in the resident's plan of care, and an Elopement Protocol directing a reassessment, there was insufficient evidence such an assessment was completed by the interdisciplinary team (IDT) in order to consider further interventions to keep both Resident #55 and other residents on the non-secure unit safe. While another antipsychotic medication was added 1/15/19, there was no evidence it was added as part of a comprehensive reassessment by the IDT of the resident's plan of care. Moreover, review of the behavior/intervention monthly flow record revealed seven occasions of verbal aggression from 1/15 to 1/28/19 after the [MEDICATION NAME] was started. Moreover, interviews revealed other than medication changes, there were no changes in the resident's plan of care, even though the facility was aware that interventions, such as the wanderguard and 15 minute checks, were known to be ineffective. Finally, there was no evidence a change in the environment, in particular, the environment outside the front of the building where unsupervised smokers smoked and where Resident #55 was known to look and find cigarette butts, was considered as a means to interrupt the cycle of the resident obtaining cigarettes which he brought into the facility to smoke. LPN #3 was interviewed on 1/29/19 at 2:35 p.m. LPN #3 said he had expressed concerns about Resident #55 through the nursing notes, when leaving his shift to the oncoming nurses and to the NHA. He said he had discussed Resident #55's smoking habits and the resident's refusal to wear the wanderguard with the NHA. He said he told the NHA that Resident #55 always talked about smoking. -LPN #3 said he had walked past Resident #55's room on 1/10/19 (according to progress note above) and could smell smoke coming from the bathroom and saw the resident come out of the bathroom. He asked the resident if he had a lighter and the resident said he did not. He said after this incident, they did not do any type of extra intervention, just 15 minute checks and keeping an eye on the resident. He said staff knew the resident had a lighter but when asked, he denied it and got agitated so staff don't push it. He said he assumed the resident got cigarette butts from the front of the building where unsupervised smokers frequently smoked. In summary, the facility failed to take effective steps to break a cycle that put Resident #55 and other residents in the non-secure unit at risk for serious harm. Specifically, the facility's failure to prevent Resident #55 from eloping from the facility at all times of the day placed the resident at risk for serious harm. His seeking and finding cigarettes during his elopements which he then smoked in his room unsupervised, placed both Resident #55 and other residents in the non-secure unit at risk for serious harm. III. Resident #39 - Exit seeking A. Resident status Resident #39 age 61, was admitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The resident resided in the secure unit. According to the minimum data set ((MDS) dated [DATE] the resident had significant cognitive delays; a brief interview for mental status could not be completed. The resident required extensive assistance with activities of daily living but was independently ambulatory. B.Record review The care plan dated 10/15/18 identified Resident #39 was at potential risk for injury from physical altercations due to the resident taking other resident ' s belongings. The interventions were to attempt to redirect and use one-to-one (1:1) as needed. The care plan also identified the resident exhibited alterations in mood and behavior: Resident #39 would often take items belonging to other residents and/or staff. Interventions included monitor wondering and redirection as needed, use of 1:1 as needed, and in a handwritten note, an undated care plan revision read to redirect when agitated and to attempt to direct the resident in to a quiet area till calm. The care plan also revealed the resident was alert but very confused and he was not able to make his needs known. His behavior was socially inappropriate and he was not re-directable, although this was the primary intervention to address his behaviors (see above). Observations on 1/7/19 at 9:15 a.m. and 11:43 a.m. and 3:12 p.m. and 1/8/19 at 10:35 a.m. revealed the resident wandered into resident rooms unattended. C. Failure to keep Resident #39 safe from exiting the secure unit. 1. Record review Review of Resident #39's care plan revealed the resident was to be monitored for wandering (see above), further care review revealed no specific care plan regarding the resident's risk to wander from the secure unit although interviews (see below) revealed at least one member of the facility's staff was aware the resident often sought to exit the unit. There was no documentation in Resident #39's record that his exiting behavior was being monitored. 2. Observations On 1/10/19 at 10:45 a.m. the maintenance services director (MSD) was observed walking from his office located in the secure unit to the front of the facility. The MSD said hello to Resident #39, entered the code to unlock the secure unit door and walked through the door with another staff member. As the door was slowly closing, Resident #39 walked through the door and left the secure unit. None of the staff on the secure unit were aware the resident had left the unit. Resident #39 walked past eight resident rooms and six other rooms in the non-secure unit, about 100 feet. At that point, the surveyor alerted the executive director (ED) and Resident #39 was escorted back to the secure unit. 3. Staff interviews The MSD was interviewed on 1/10/19 at 10:45 a.m. The MSD said his office was recently moved to the secure unit. He said he walks through the unit at least six to ten times a day. He said he was preoccupied and not paying attention when the resident walked out the door with him. He said he knew Resident #39 would try to leave and that was a concern. The MSD said he also watched the housekeepers as the Resident #39 attempts to leave the unit as the doors open. The MSD said Resident #39 would attempt to walk out the secure unit door with him about six times a day; the resident goes to the door when the MSD is exiting the unit and pulls the door open from the inside. The MSD said he tries to redirect the resident. The MSD said he tells the resident he has to stay in the secure unit and pulls the door shut while the resident pulls on the other side. LPN #2 was interviewed on 1/10/19 11:07 a.m. LPN #2 said that unless the resident left the building, the facility would not track the incident and there was no interventions put into place after an incident of the resident leaving the secure unit. The ED was interviewed on 1/10/19 at 10:59 a.m. and again at 12:32 p.m. The ED said it was concerning that Resident #39 made it out of the secure unit and down the hall. The ED said that if a resident were to leave the facility, there is a book at the receptionist's desk with resident information and a photo. The book was viewed with the receptionist and the ED; neither could not recognize the photocopied photo of the resident. The ED said they would correct that. FALLS Resident #64 and #38 Facility policies and procedures 1. The Quality Assurance Program Standard of Practice policy, revised 11/17, was provided by the director of nursing (DON) on 1/8/19 at 6:00 p.m. It read in pertinent part, All falls will have an investigation completed to determine appropriate interventions. The clinical management team will complete a CAA (care area assessment) fall worksheet if needed when compared to the last comprehensive CAA and update the resident's plan of care as appropriate. Falls will be screened by therapy for balance, apparatus changes/recommendation, strengthening, and/or safety when indicated. 2. The Fall Assessment/Intervention Process policy, revised 11/17, was provided by the assistant director of nursing (ADON) on 1/10/19 at 4:20 p.m. It read in pertinent part, Fall/Incident Investigation tool must accompany any fall. The IDT (interdisciplinary team)/designee will review and ensure implementation of any recommendations offered by utilization of this investigation tool. 3. The Incident & Accident Process policy, revised 11/17, was provided by the nursing home administrator (NHA) on 1/10/19 at 6:20 p.m. It read in pertinent part, Incident and accidents, including incidents of unknown origin are investigated by the IDT and reported according to regulatory guidelines. Assessments and investigations are done in a systematic manner: Identifying hazards and risks; Evaluating and analyzing hazards and risks; Implementing interventions to reduce hazards and risks; and Monitoring for effectiveness and modifying interventions when necessary. The IDT will review risks, appropriate interventions and trends at least weekly for those residents with falls and other accident related injuries. I. Resident #64 A. Resident status Resident #64, age 76, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 12/6/18 minimum data set (MDS) assessment revealed the resident had short- and long-term memory loss. He did exhibit behaviors or resist care. He required extensive one-person assistance with bed mobility, transfers, and toileting. He was always incontinent of bowel and bladder. The 9/7/18 MDS assessment revealed the resident required extensive two-person assistance with bed mobility, transfers, and toileting. (See section below under therapy screen). B. Record review The fall care plan, initiated 9/19/16 and revised on 12/28/18 revealed the resident was at risk for injury related to poor safety awareness and [MEDICAL CONDITION] disorder. Interventions included, attempt to identify the root cause for falls and physical therapy to evaluate and treat as indicated. The self care deficit care plan, initiated 9/21/16 and revised on 12/28/18 revealed the resident needed extensive assist with activities of daily living (ADLs) interventions included to encourage the resident to participate to

Based on observations, interviews and record review, the facility failed to ensure four (#55, #34, #39 and #15) out of 61 total sample residents were free from abuse. (Cross-reference F609 and F610). Specifically: I. Resident-to-resident abuse Interviews revealed that following an argument in the facility smoking area on 11/18/18 Resident #55, with a known history of physically aggressive behaviors, hit Resident #34 in the face. Resident #34 fell to the floor, where Resident #55 kicked the resident in the stomach numerous times. Resident #34 sustained a laceration that required sutures. II. Staff-to-resident abuse Observations of Licensed Practical Nurse (LPN) #5's on 1/7 and 1/8/19 revealed her interactions with Residents #39 and #15 were deliberate, intimidating, and punitive. Findings include: I. Resident-to-resident abuse A. Resident #55 1. Resident status Resident #55, age [AGE] years old, was admitted [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. Resident #55 resided in the secure unit until 10/21/18 when he was transferred to the non-secure unit. The 12/2/18 minimum data set (MDS) assessment documented the resident was severely cognitively impaired and was unable to complete the brief interview for mental status exam (BIMS). The staff assessment indicated the resident had little interest or pleasure in doing things, had difficulty concentrating on things and was short tempered.He had delusions, had verbal behaviors directed toward others and rejected care. He ambulated independently. The behavior care plan, initiated on 12/3/12, documented the resident could be verbally aggressive (cursing, threatening, making racist comments) to both staff and residents and had a history of [REDACTED]. The goal was for the resident's behaviors to not interfere with daily living or care of self or others. The interventions included all behaviors should be documented, if having disruptive behaviors remove the resident from the common area, review [MEDICAL CONDITION] medications quarterly, request the resident to return to his room if the behaviors are in the dining room, encourage activities of interest, remind the resident of facility policies and redirect residents in other behaviors. 2. Resident #55's history in the secure unit shortly before transfer to the non-secure unit. Record review and interviews revealed the facility was aware of Resident #55's physically aggressive behaviors toward other residents. Interviews with the social services director (SSD) on 1/9/19 at 4:15 and the activities assistant (AA) #2 on 1/10/19 at 10:35 a.m. revealed the Resident #55 and #34 often fought over items; Resident #39 would take things, and Resident #55 would hit him. The AA said Resident #39 was hit many times by Resident #55. Review of Resident #39's record revealed at least four incidents of Resident #39 being hit, punched or pushed off his chair by Resident #55 (10/10/18, 10/10/18, 10/15/18 and 10/19/18). Cross-reference F610 for further details. Review of Resident #55's record revealed the following incidents involving Resident #39, as well as another, unidentified resident: -A nursing note, dated 10/10/18, documented the resident was in his room and a certified nurse aide (CNA) witnessed Resident #55 and another resident in a resident to resident altercation. Resident #55's right 1st knuckle was injured. -A nursing note, dated 10/10/18, documented Resident #55 was going out to smoke and another resident (Resident #39) reached to take a cigarette and Resident #55 pushed him into the door. The residents were separated; however, while in the dining room an hour later, the resident who reached to take a cigarette went to take Resident #55's milk and Resident #55 punched the resident in the cheek. -A nursing note, dated 10/17/18, documented Resident #55 had shown an increase in aggression with other residents on the secure unit and will become agitated when other residents come near him while sitting in the dining room. Resident had also threatened to beat the (expletive) out of other residents. -A nursing note, dated 10/19/18, documented Resident #55 was sitting at the table eating dinner when a resident (Resident #39) came and took his chocolate milk; Resident #55 grabbed the resident by the arm and began punching him in the back of the head. 3. Resident #55's transfer to the non-secure unit Interviews revealed Resident #55 was transferred to the non-secure unit on 10/21/18 without an assessment of his ability to reside there safely and without a comprehensive plan to address his known physically aggressive behaviors. The SSD, director of nursing (DON) and licensed practical nurse (LPN) #6 were interviewed on 1/28/19 at 5:53 p.m. The SSD said after an altercation with Resident #39, they moved Resident #55 out of the secure unit into a room with Resident #34 on the non-secure unit. The SSD said they had to move Resident #55 out of the secure unit quickly because of the altercation between the resident and Resident #39. She said they did not complete an assessment but did attempt to use a wander guard; however, Resident #55 only wore if for five minutes. She said the only intervention that was in place to ensure his and other residents' safety after Resident #55 came off the secure unit was 15 minute checks. The SSD was interviewed again on 1/29/18 at 10:00 a.m. She said the former administrator had made the decision to move Resident #55 out of the secure unit over the weekend (10/20 - 10/21/18) because of a resident-to-resident altercation with Resident #39. She said this was communicated to her over the weekend. She confirmed the facility had not completed an assessment of the resident prior to the transfer but said,I think we had a conversation about 15 minute checks. Review of Resident #55's care plan (see above), revealed no reference to Resident #55's increased aggression with other residents or of 15 minute checks. Likewise, there was no revision to his care plan to ensure his safety, as well as the safety of other residents on the non-secure unit. B. Resident-to-resident abuse 11/18/18 contributing to actual harm. Interview with the SSD on 1/23/19 at 10:15 a.m. revealed that following an argument in the facility smoking area on 11/18/18, Resident #55 hit Resident #34 in the face. Resident #34 fell to the floor, where Resident #55 kicked the resident in the stomach numerous times. Resident #34 sustained a laceration that required sutures. In another interview with the SSD and director of nursing (DON) on 1/28/19 at 5:53 p.m., the SSD stated Resident #34 called Resident #55 a derogatory name and then Resident #55 punched Resident #34 several times in the face, knocking him out of his wheelchair. Resident #55 then kicked Resident #34 in the stomach. She said Resident #34 went to the hospital after the altercation. The DON said there were lacerations in Resident #34's mouth that required stitches. The SSD said she believed the resident also had a loose tooth. Resident #55 had bruises on his knuckles. C. Failure to thoroughly investigate the incident involving Residents #55 and #34 in order to develop a comprehensive plan with effective interventions to keep Resident #55 and other residents on the non-secure unit safe. 1. Interview with the SSD and DON on 1/28/19 at 5:53 p.m. revealed that following the 11/18/18 incident, Resident #55 was moved to a private room. The SSD said the resident's antipsychotic (Risperidal) had been increased and he had started on the antidepressant [MEDICATION NAME], but these medication changes were to address his anxiety, smoking, drinking and exit seeking, not his physically aggressive behaviors toward other residents. The SSD also stated the facility has tried to find alternative placement for the resident but this has been unsuccessful. 2. Record review revealed no evidence of an interdisciplinary team meeting to discuss Resident #55's physically aggressive behaviors, no revisions to his behavior care plan, and no plan, other than 15 minute checks, to supervise the resident when he was around others in the building or outside in the smoking area. 3. Interview with the DON on 1/28/19 at 3:34 p.m. confirmed the facility had not completed an investigation of the resident-to-resident abuse involving Resident #55 and #34 which contributed to Resident #34 sustaining actual harm. (Cross reference F610) II. Staff-to-resident abuse A. Resident #39 1. Resident status Resident #39 age 61, was admitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The resident resided on the secure unit. According to the minimum data set ((MDS) dated [DATE] the resident had significant cognitive delays. A brief interview for mental status could not be completed. The resident required extensive assistance with activities of daily living, but was independently ambulatory. The care plan dated 10/15/18 identified Resident #39 was at potential risk for injury from physical altercations due to the resident taking other residents' belongings. The interventions were to attempt to redirect and use 1:1 as needed. The care plan also identified the resident exhibited alterations in mood and behavior; Resident #39 would often take items belonging to other residents and/or staff. Interventions included to monitor wondering and redirection as needed, use of 1:1 as needed, and, in a handwritten note, an undated revision read, redirect when agitated and attempt to direct the resident into a quiet area until calm. The care plan revealed the resident was alert but very confused and he was not able to make his needs known. His behavior was socially inappropriate and he was not redirectable, although redirection was primary intervention in other sections of his care plan (see above). 2. Observations of interaction between LPN #5 and Resident #39 Observations on 1/7 and 1/8/19 revealed LPN #5's interactions with Resident #39 were deliberate, intimidating and punitive. 1/7/19 -At 10:44 a.m., residents in the secure unit were observed to return from country store with snacks; Resident #39 had not been invited to attend this activity. While the other residents sat at the dining room tables and ate their snacks, Resident #39 had nothing to eat. He took a wrapped set of silverware and walked by the tables. LPN #5 followed behind the resident and pulled the silverware from the resident's hands. The resident said two milks. LPN #5 told him in a brusque and commanding tone to Sit. The resident sat and LPN #5 gave the resident two glasses of milk. The resident drank both cups of milk and asked for two (more) milks. LPN #5 responded, You have to wait for lunch, and turned and walked away from the resident. -At 12:22 p.m., after Resident #39 had wandered into two resident rooms, LPN #5 told him in a loud, curt voice to Go to your own room. -At 1:44 p.m., Resident #39 sat in the dining room area. LPN #5 said in an abrupt and loud voice, Sit, (Resident #39) sit. While handing the resident his pills she said, Swallow your pills. Then, speaking sharply, LPN #5 asked the resident if he had swallowed his pills. LPN #5, in the same abrupt tone, repeated, Swallow your pills. The resident then requested two milks. LPN #5 did not acknowledge the request. The resident made a scowl and became frustrated and repeated two milks numerous times. -At 1:48 p.m. LPN #5 in a sharp and startling voice told the resident to swallow. When the resident again requested two milks, LPN #5 did not acknowledge his request. -At 2:58 p.m., Resident #39 picked up a package of Styrofoam cups and said, two milks. LPN #5 abruptly and roughly pulled the package of cups out of the resident's hands and said, no, no, no. The resident looked startled and continued repeatedly to ask for two milks. -At 3:12 p.m., residents in the unit again were observed to return from country store with snacks; Resident #39 had not been invited to attend the activity. Resident #39 was observed to take a cookie-type bar from another resident. LPN #5 was observed to peel Resident #39's fingers from around the snack and jerked it away from the resident. LPN #5 then offered the resident crackers. From across the room another unidentified resident was observed to call Resident #39 a piece of (derogatory term). LPN #5 chuckled and did not intervene. -At 3:37 p.m., LPN #5 told Resident #39 in a [MEDICATION NAME] and curt manner to sit, just sit. as Resident #39 wandered around the dining room as residents ate their snacks. 1/8/19 -At 8:46 a.m., Resident #39 wandered around the dining room. The resident picked up two cups left behind by other residents which contained small amounts of liquid. LPN #5 said in an abrupt and commanding manner, Those are dirty, we don't drink from those. Resident #39 was then offered milk. LPN #5 in a gruff, pointed manner said to Resident #39, This time, throw away your own cups. The resident with furrowed eyebrows looked at LPN #5 and with one quick swoop, knocked his milks off the table. LPN #5 speaking loudly and angrily said, You will get no more milk. -At 9:00 a.m. Resident #39 approached LPN #5 and asked for two milks. LPN #5 responded in a loud, terse manner, No. You threw your milk, you get none. B. Resident #15 1. Resident status Resident #15, age 83 admitted [DATE]. According to the (MONTH) (YEAR), computerized physician orders [REDACTED]. The resident resided in the secure unit. According to the minimum data set ((MDS) dated [DATE] the resident had significant cognitive delays; a brief interview for mental status could not be administered. The resident required extensive assistance with activities of daily living. The care plan dated 5/6/18 identified the resident was to be monitored and documented for paranoid [MEDICAL CONDITION]. The care plan showed the resident would be offered fresh air and sun, 1:1 staffing to express feelings, calm environment, snacks, and music. The care plan also documented it was important to avoid confrontation when agitated. Document for refusals, when confused or experiencing psychotic disturbances do not attempt to bring to reality, approach in a calm manner, educate resident regarding acceptable alternatives to identified behaviors and document response. 2. Observations on 1/8/19 of interactions between Resident #15 and LPN #5. -At 8:15 a.m., Resident #15 sat at a table in the dining room of the secure unit. She asked LPN #5 for a Sprite. Thirty-five minutes later, LPN #5 responded to Resident #15, stating in a gruff voice, That's when you can go to the country store. Resident #15 started crying. In an authoritative voice, LPN #5 said No crying till then, no soda. Resident #15 started to cry harder. LPN #5 said in a loud, accusatory voice, Why are you crying? Resident #15 responded she wanted some chocolate milk. LPN #5 said in a loud and exasperated voice, You have some in front of you! Resident #15 put her head down and started to cry loudly and hiccup. LPN #5 again asked the resident, Why are you crying? Resident #15 continued to cry and said she wanted Sprite. LPN #5 said in a gruff, loud voice, The store does not open till 9:45 a.m. (Resident #15). you need to calm down. There was no reason to cry. Resident #15 cried louder. In a loud and irritated voice, LPN #5 again said to Resident #15 that the store did not open until 9:45 a.m., and asking the resident again, Why are you crying? Resident #15 began to cry uncontrollably and said to LPN #5, I want coffee. LPN #5 said in a loud, gruff voice, You already spilled it. You can have your chocolate milk in front of you. You need to stop crying. LPN #5 then said, No reason to cry, you have coffee and milk. Taste it before you start crying. Resident #15 said, It's not coffee. I want coffee. -At 8:46 a.m., Resident #15 continued to cry. LPN #5 said in a brusque voice, (Resident #15) why are you crying? Resident #15 said I want to go to my room. Taking the resident to her room, certified nurse aide (CNA) #10 was overheard to say to Resident #15 in a sharp voice, There is no need to cry - I hope you wake up in a better mood. Resident #15 continued to cry uncontrollably. From the dining room, LPN #5 yelled, Why are you crying, there is no reason to cry. Once Resident #15 was in her room, CNA #10 closed her door and returned to the dining room. C. Facility failure to protect Resident #39 and Resident #15 from abuse. 1. On 1/7/19 at 5:50 p.m., LPN #5's observed interactions with Resident #39 and Resident #15 were reported to the executive director (ED). The ED said Resident #39 was the perpetrator as well as the victim and that they had put out a referral to find a new placement for him. The ED said a lot of the residents in the secure unit have behaviors and that was the reason they were on the secure unit. He said that he has found that it keeps the other residents in the non-secure area happier. The ED said they were going to re-train staff (LPN #5 and CNA #10) and review the cameras that record staff and resident behavior in the common areas and hallways. He also said at this time that the entire unit was in need of retraining. 2. On 1/8/19 at 10:21 a.m., the ED and the director of nursing (DON) were interviewed. The DON acknowledged the LPN #5's behavior sounded like abuse; Resident #15 should have been given a soda and Resident #39 should have received two milks. The ED and DON said they would conduct an investigation. They said they do not condone yelling at residents and residents should of been given requested items. The DON said staff do not pry fingers from items unless there is danger. She confirmed Resident #39 was not in danger of eating the wrapping, as this was a behavior they had not seen before. Following this interview, LPN #5 and CNA #10 were removed from the floor and sent home at 10:15 a.m. 3. On 1/10/19 at 11:07 a.m., the ED said there was no time to do an investigation of this incident; instead, he said he would train the staff. He felt training would be more effective then dismissal. 4. Observations on 1/28/18 at 11:30 a.m. revealed LPN #5 was working in the secure unit on the day shift. The ED confirmed at 1:00 p.m. that both LPN #5 and CNA #10 had returned to work.

Based on observations, record review and interview, the facility failed to have evidence that allegations and/or incidents of abuse and an allegation of misappropriation of personal property had been thoroughly investigated, that steps were taken to prevent further abuse and misappropriation, and that corrective actions had been taken to keep residents and their property safe. This affected seven (#55, #34, #39, #15, #73, #82, #16) of 61 residents, with one resident, Resident #34, sustaining actual harm. (Cross-reference F600) Specifically: I. Resident-to-resident abuse Record review and interview revealed that in (MONTH) (YEAR), Residents #39 and #55 were involved in at least four abusive incidents in the secure unit which involved pushing, punching and name calling. There was insufficient evidence these incidents were thoroughly investigated and corrective actions were taken to prevent additional abusive incidents and to keep the residents safe from injury. Resident #55 was transferred out of the secure unit on 10/21/18 to prevent further abusive incidents with Resident #39. However, the resident's transfer was not accompanied by information gained from a thorough investigation of Resident #55's incidents in the secure unit; no person-centered care plan or behavior plan was developed that identified triggers to Resident #55's aggressive behaviors and instructed staff how to effectively minimize and respond to these behaviors. Less than one month after his transfer to the non-secure unit, Resident #55 punched Resident #34 in the mouth. Resident #34 sustained a laceration which required sutures. There was no evidence the incident was thoroughly investigated and corrective measures taken to prevent a recurrence. II. Staff-to-resident abuse A. Observations of licensed practical nurse (LPN) #5 on 1/7 and 1/8/19 revealed the LPN interacted with Residents #39 and #15 in a deliberate, intimidating and punitive manner. The facility failed to have evidence the LPN's interactions with the two residents were thoroughly investigated and sufficient corrective actions were taken. B. Interview revealed revealed the facility received a report that Residents #73 and #82 had been abused by a certified nurse aide (CNA) in (MONTH) (YEAR). Although the CNA resigned, the facility failed to investigate the allegation to ensure the residents' safety and to develop corrective measures to prevent a recurrence. II. Misappropriation of property Interviews revealed Resident #16 reported she was missing a ring, valued at more than $500. Review of facility documentation revealed, and interview with staff confirmed, the facility had not conducted an investigation of the resident's missing ring. Findings include: I. Allegations and/or incidents of resident-to-resident abuse A. Resident #39 and #55 1. Residents' status a. Resident #39 age 61, was admitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The resident resided in the secure unit. According to the minimum data set ((MDS) dated [DATE] the resident had significant cognitive delays; a brief interview for mental status could not be completed. The resident required extensive assistance with activities of daily living but was independently ambulatory. The care plan dated 10/15/18 identified Resident #39 was at potential risk for injury from physical altercations due to the resident taking other residents ' belongings. The interventions were to attempt to redirect and use one-to-one (1:1) as needed. The care plan also identified the resident exhibited alterations in mood and behavior; Resident #39 would often take items belonging to other residents and/or staff. Interventions included monitor wondering and redirection as needed, use of 1:1 as needed, and in a handwritten note, an undated care plan revision read, redirect when agitated and to attempt to direct the resident in to a quiet area until calm. The care plan also revealed the resident was alert but very confused and he was not able to make his needs known. His behavior was socially inappropriate and he was not re-directable, although redirection was the primary intervention to address his behaviors (see above). Social service notes revealed concerns about the resident's safety in the secure unit. -A progress note from the social service director (SSD) dated 10/13/18 read the SSD reported the nursing staff is concerned for the safety (of) Resident #39 due to behaviors of taking others food. Staff reported Resident #39 continued to cycle through repetitive behavior and unable to sit still for any period of time. SSD brought suckers to the unit in hopes of temporary relief for other residents. SSD encouraged staff to chart on behaviors and to reach out to the physician if necessary. -A progress note from the SSD dated 10/19/18 left a message for the decision makers regarding the need for (Resident #39) to be removed from the secure unit for behaviors and safety. Observations on 1/7/19 at 9:15 a.m. and 11:43 a.m. and 3:12 p.m. and 1/8/19 at 10:35 a.m. revealed the resident wandered into resident rooms unattended and took food from other residents, placing himself at risk for abuse from other residents continued to occur. b. Resident #55, age [AGE] years old, was admitted [DATE]. According to the (MONTH) 2019 computerized physician's order [REDACTED]. Resident #55 resided in the secure unit until 10/21/18 when he was transferred to the non-secure unit. The 12/2/18 minimum data set (MDS) assessment documented the resident was severely cognitively impaired and was unable to complete the brief interview for mental status exam (BIMS). The staff assessment indicated the resident had little interest or pleasure in doing things, had difficulty concentrating on things and was short tempered. He had delusions, had verbal behaviors directed toward others and rejected care. He ambulated independently. The behavior care plan, initiated on 12/3/12, documented the resident could be verbally aggressive (cursing, threatening, making racist comments) to both staff and residents and had a history of [REDACTED]. The goal was for the resident's behaviors to not interfere with daily living or care of self or others. The interventions included all behaviors should be documented, if having disruptive behaviors remove the resident from the common area, review [MEDICAL CONDITION] medications quarterly, request the resident to return to his room if the behaviors are in the dining room, encourage activities of interest, remind the resident of facility policies and redirect residents in other behaviors. B. Allegations and/or incidents of resident-to-resident abuse, including repeat incidents involving Resident #55 in October, (YEAR). Interviews with the SSD on 1/9/19 at 4:15 p.m., and the activities assistant (AA) #2 on 1/10/19 at 10:35 a.m., revealed Resident #39 and #55 often fought over items; Resident #39 would take things, and Resident #55 would hit him. The AA said Resident #39 was hit many times by Resident #55. Review of Resident #39's record revealed at least four incidents of Resident #39 being hit, punched or pushed off his chair by Resident #55 (10/10/18, 10/10/18, 10/15/18 and 10/19/18) 1. 10/10/18 Resident #39's care plan, dated 10/10/18, read the resident was involved in a resident-to-resident altercation involving Resident #55. In an interview 1/10/19 10:35 a.m. with AA #2, the AA said the residents will at times get into physical altercations over items and said Resident #39 got punched and called names for taking a cigarette from another resident (Resident #55). She said Resident #39 does not smoke but he wanted the cigarette because he probably thought it was snack. She said Resident #39 was hit many times by Resident #55. 2. Review of Resident #39's care plan and interview with the SSD on 1/9/19 at 10:35 a.m., revealed the following resident-to-resident physical altercations: -On the care plan dated 10/19/18, Resident #39 was hit by Resident #55 after taking his chocolate milk. This incident was verified by SSD on 1/9/10 10:35 a.m. -On the care plan dated 10/24/18, Resident #39 was hit and shoved to the ground by an unknown resident. This incident was verified by the SSD on 1/9/19 10:35 a.m. -On the care plan dated 10/29/18, Resident #39 was hit by an unidentified resident when Resident #39 took the other resident's shoes. 15-minute checks were put in place and a room move was list. This incident was verified by the SSD on 1/9/19 10:35 a.m. -On 10/30/18, it was verified by the SSD on 1/9/19 at 10:35 a.m., that on 10/30/18, Resident #39 was hit in the stomach by an unidentified resident because resident #39 took the unidentified resident ' s candy bar. -In a facility departmental note dated 11/8/18 at 10:50 a.m., Resident #39 went into another resident's room and came out with two cuts to the ear and a scratch to side of the left eye which was reported as swollen. C. Failure to thoroughly investigate the above incidents, take steps to prevent re-occurrence, and take appropriate corrective action 1. Investigations of the above incidents were requested from the executive director (ED) on 1/7/19 at 5:50 p.m. However, there was no evidence provided of a thorough investigation of the allegations and/or incidents, such as what triggered the repeated altercations, what residents were involved, what interviews with residents and staff who witnessed the incidents were obtained, or what was the facility's conclusion regarding the incidents. 2. In addition, while review of Resident #39's and Resident #55's secure unit care plans (see above) revealed, while the plans identified behaviors that placed the residents at risk for abuse and to abuse, there were no individualized person-centered interventions to prevent additional incidents and to keep Resident #39 and #55, as well as other facility residents, safe. 3. The executive director (ED) was interviewed on 1/7/19 5:50 p.m. The ED confirmed no investigation of the above incidents was conducted, no steps had been taken to prevent further abuse, and no corrective measures beyond 15 minute checks had been implemented. He said the only documentation regarding the incidents was found on the reports submitted to the state as required under state law and in the documentation referenced above from Resident #39's care plan. The ED said Resident #39 was the perpetrator as well as the victim. The ED said a lot of the residents in the secure unit have behaviors and that it was the reason they were on the secure unit. He said that he has found that it keeps the other residents in the non-secure area happier. D. Resident-to-resident abuse involving Resident #55 on the non-secure unit, resulting in actual harm. (Cross-reference F600) 1. Interview with the SSD on 1/23/19 at 10:15 a.m. revealed that following an argument in the facility smoking area on 11/18/18, Resident #55, hit his roommate, Resident #34, in the face. Resident #34 fell to the floor, where Resident #55 kicked the resident in the stomach numerous times. Resident #34 sustained a laceration that required sutures. 2. In another interview with the SSD and director of nursing (DON) on 1/28/19 at 5:53 p.m., the SSD stated Resident #34 called Resident #55 a derogatory name and then Resident #55 punched Resident #34 several times in the face, knocking him out of his wheelchair. Resident #55 then kicked Resident #34 in the stomach. She said Resident #34 went to the hospital after the altercation. The DON said there were lacerations in Resident #34's mouth that required stitches. The SSD said she believed the resident also had a loose tooth. Resident #55 had bruises on his knuckles. E. Failure to thoroughly investigate the incident involving Residents #55 and #34 in order to develop a comprehensive plan with effective interventions to keep Resident ##55 and other residents on the non-secure unit safe. 1. Interview with the SSD and DON on 1/28/19 at 5:53 p.m. revealed that following the 11/11/18 incident, Resident #55 was moved to a private room. The SSD said his antipsychotic (Risperidal) had been increased and he had started on the antipsychotic [MEDICATION NAME], but these medication changes were to address his anxiety, smoking, drinking and exit seeking, not his physically aggressive behaviors toward other residents. The SSD also stated the facility has tried to find alternative placement but this has been unsuccessful. 2. Record review revealed no evidence of an interdisciplinary team meeting to discuss Resident #55's physically aggressive behaviors, no revisions to his behavior care plan, and no plan, other than 15 minute checks, to supervise the resident when he was around others in the building or outside in the smoking area. 3. Interview with the DON on 1/28/19 at 3:34 p.m. confirmed the facility had not completed an investigation of the resident-to-resident abuse involving Resident #55 and #34 which contributed to Resident #34 sustaining actual harm. II. Allegations of staff to resident abuse A. Residents #39 and #15 and LPN #5 (Cross-reference F600) 1. Observations and record review revealed LPN #5's interactions with Residents #39 and #15 were deliberate, intimidating, and punitive when observed on 1/7 and 1/8/19. In a brusque voice, LPN #5 told Resident #39, among other commands, to sit, to swallow (his pills), and to go to his own room, as well as jerking/pulling/peeling items from his hands. LPN #5 commanded Resident #15 repeatedly to stop crying. 2. The executive director (ED) was interviewed on 1/7/19 at 5:50 p.m. See above; the ED said Resident #39 was the perpetrator as well as the victim and that they had put out a referral to find a new placement for him. The ED said a lot of the residents in the secure unit have behaviors and that was the reason they were on the secure unit. He said that he has found that it keeps the other residents in the non-secure area happier. The ED said they were going to re-train LPN #5 and review the cameras that record staff and resident behavior in the common areas and hallways. He also said at this time that the entire unit was in need of retraining. 2. On 1/8/19 at 10:21 a.m., the ED and the director of nursing (DON) were interviewed again about the observations on 1/7 and 1/8/19 involving LPN #5. The DON said it sounded like abuse and the facility would begin an investigation. Following this interview, LPN #5 and CNA #10 were removed from the floor and sent home at 10:15 a.m. 3. However, on 1/10/19 at 11:07 a.m., the ED said there was no time to do an investigation of this incident; instead, he said he would train the staff. He felt training would be more effective then dismissal. 4. Observations on 1/28/18 at 11:30 a.m. revealed LPN #5 was working in the secure unit on the day shift. The ED confirmed at 1:00 p.m., that both LPN #5 and CNA #10 had returned to work. B. Resident #73 and #82 1. Residents' status a. Resident # 73, age 56, was admitted on [DATE]. According to the (MONTH) (YEAR) CPO, [DIAGNOSES REDACTED]. The resident resided on the secure unit. According to the 12/15/18 minimum data set (MDS) assessment, the resident could not complete the brief interview for mental status exam. The resident required extensive assistance with activities of daily living. b. Resident # 82, age 83, was admitted [DATE]. According to the (MONTH) (YEAR) CPO, [DIAGNOSES REDACTED]. The resident resided on the secure unit. According to the 12/22/18 MDS assessment, the resident could not complete the brief interview for mental status exam. The resident required extensive assistance with activities of daily living. 2. Staff interviews On 1/10/19 7:20 p.m. Registered Nurse (RN) #3 was interviewed. RN #3 stated that it had been reported to her that the two residents above had been sexually abused by a CNA. The RN said there was no investigation as the staff had been told by the former executive director and the current assistant director of nursing (ADON) that the matter had been resolved as the CNA no longer worked at the facility which resolved the matter. RN #3 said she feared for her job and did not report this matter to anyone else after being told the matter had been resolved and they should not be talking about it. The ADON was interviewed on 1/10/19 at 8:13 p.m. regarding an employee formerly employed as a CNA about the date of 9/5/18. The ADON said she worked the night shift on that date and was concerned about the former CNA as she appeared to be on inebriated. The ADON said around midnight it was reported to her that the former CNA needed to be watched as she was acting like she was on drugs. The ADON said she was aware of the situation and was watching her. The ADON reported she was doing her rounds and found the CNA in Resident #73's room sitting on his bed and touching him inappropriately. The ADON asked the CNA what she was doing, she said she was putting the resident to bed. The ADON asked her to stop all cares for the residents and then asked her to take a drug test as per company policy. The former CNA left the facility and did not submit to a test. The facility said she resigned as she left. The ADON said she called the director of nursing (DON) and left copies of the employee disciplinary record with Human Resources and the former executive director. The ADON said there was no investigation done. 3. Interview with the current ED confirmed the facility had not evidence an investigation of the allegation had been completed. III. Allegation of misappropriation of personal property A. Resident #16 Resident #16, age 74, was admitted on [DATE]. According to the (MONTH) (YEAR) CPO, [DIAGNOSES REDACTED]. According to the 10/22/18 minimum data set (MDS) assessment revealed the resident had severe/moderate cognitive impairment; the resident could not complete the brief interview for mental status exam. The resident required extensive assistance with activities of daily living. B. Family interview Resident #16 ' s family member was interviewed on 1/8/19 at 12:09 p.m. The family member stated the resident had reported a lost a ring. She said in (MONTH) (YEAR) the ring had been valued at more than $500.00. The family member said photos of her mother wearing the ring were sent to the social service director (SSD). She said that no police report had been filed and that she had never heard back about the ring from the SSD or any representative from the facility. C. Record review The facility was asked for investigation dated (MONTH) (YEAR) through (MONTH) (YEAR). The investigations failed to show an investigation of the resident's missing ring. D. Staff Interview The SSD and the social services assistant (SSA) were interviewed on 1/9/19 at 12:48 p.m. The SSD and SSA reported Resident #16 ' s family member had provided the facility with a list of missing items which included a ring valued at more than $500.00. The SSD said the resident ' s family member had sent a photograph and a sketched picture of the missing ring. The SSA confirmed she had also seen the picture(s) which were sent and heard about the complaint. The SSD confirmed the records provided by the family were lost. The SSD said that since she did not hear from the resident ' s family again she assumed it had been resolved. Therefore, the facility had not conducted an investigation. E. Facility follow up during survey The SSD was interviewed on 1/9/19 2:48 p.m. The SSD said the facility would follow up with the family member and the executive director on the resident's ring. The SSD said an investigation would be started as an investigation had not been completed.

Based on record review and staff interviews, the facility failed to ensure one (#4) of three residents identified with skin impairment of 12 sample residents, received the necessary treatment and services to prevent pressure ulcers from developing, to promote healing and to prevent new pressure ulcers from developing. Specifically: Resident #4 was admitted on [DATE] with intact skin but was identified at risk for pressure ulcers. Record review and interviews revealed the facility failed to meet regulatory and facility expectations to prevent the resident from developing three pressure ulcers after admission, first on his coccyx/sacrum (2/3/17) and then his right and left heel (2/14/17). The facility failed to create a care plan to address the resident's known pressure ulcer risks, failed to timely assess his coccyx ulcer and monitor all three pressure ulcers and failed to implement interventions from 2/3/17 to 2/16/17 to promote healing. The facility did not provide evidence the above failures had been identified and addressed to prevent reoccurrence. The findings included: I. Professional reference The National Pressure Ulcer Advisory Panel, NPUAP Pressure Ulcer Stages/Categories 2014, http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stages-categories (February 2017), reveals the following pertinent information: - .International NPUAP-EPUAP Pressure Ulcer Definition-A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear . -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. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). -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. - Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. II. Facility policy and procedure The 3/16 Skin System Policy & Procedure was provided by the director of nursing (DON) on 4/10/17 at 12:58 p.m. The document revealed the following pertinent information: -All residents will be assessed on admission, readmission, and quarterly and with each change in condition assessment for their individual risk for skin compromise . -Care Planning starts with admission and the Comprehensive Care Plan is to be fully developed within 21 days of admission . -Upon identification of skin/wound impairment the nurse will: Complete the SBAR (situation background assessment recommendation) and obtain orders from the physician for care in accordance with the formulary guidelines for the identification wound as approved by the physician . Staff interviews (see below) revealed inconsistent understanding by staff whether a SBAR and/or incident report was to be completed upon identification of skin/wound impairment. III. Resident #4 Resident #4, age under 60, was admitted on [DATE] and discharged on [DATE] (death in facility). According to the face sheet, [DIAGNOSES REDACTED]. According to the 1/30/17 minimum data set (MDS) assessment, the resident had long-term and short-term memory concerns. He required extensive assistance of one staff member with bed mobility, transfers, locomotion on and off unit, dressing, toilet use, and personal hygiene. He was at risk for the development of pressure ulcers, but did not have an unhealed pressure ulcer. There was no care plan related to skin integrity or to address his risk for the development of pressure ulcers. A Record review 1. Resident status 1/26/17 to 2/14/17 Record review revealed the resident entered the facility without a pressure ulcer and with conflicting information regarding his risk for pressure ulcers. However, as of 2/3/17, a pressure ulcer was identified and the resident was assessed with [REDACTED]. Interventions to address the pressure ulcer (pressure relief, treatments, orders), and to minimize known risks were delayed and/or omitted. Specifically: Two Braden Risk Assessments (Braden) were completed within two days with conflicting results. -The 1/26/17 Braden risk assessment report revealed the resident was at high risk for developing pressure ulcers. -The 1/27/17 Braden risk assessment report revealed the resident was a mild risk for developing pressure ulcers. -Both assessments were completed by licensed practical nurses (LPNs) and did not have a registered nurse (RN) signature. Differences between the two assessments revealed the 1/27/17 assessment documented improved mobility, less shearing issues, improved sensory perception, and improved nutrition. According to the (company name) Internal Medicine documents, the resident was last seen by the physician on 2/1/17. On 2/1/17, the resident had no suspicious [MEDICAL CONDITION], and his skin was warm and dry. The Skin Inspection Report (Skin Inspection) revealed the resident's skin was intact on 2/2/17. The 2/3/17 Braden report completed by a LPN revealed the resident was at moderate risk for developing pressure ulcers. The resident's skin was rarely moist (was dry), and linens only required changing at routine intervals. His ability to walk was severely limited or non-existent. He could not bear weight and/or had to be assisted into a chair or a wheelchair. His mobility was very limited, and he made occasional slight changes in body extremity position, but was unable to make frequent or significant changes independently. The 2/3/17 Departmental Notes (departmental notes) for nursing revealed at 10:37 a.m., the nurse noted an open area on the coccyx. The measurements were 2.0 cm x 0.2 cm. The resident was given pain medication for discomfort and hospice was contacted for an air mattress and pain medication. At 1:48 p.m. hospice returned the phone call and discontinued [MEDICATION NAME] (a diuretic), [MEDICATION NAME] (a pain medication), [MEDICATION NAME] (for constipation/liver disease), and [MEDICATION NAME] (a pain medication). [MEDICATION NAME] was added for pain. Record review revealed there was not a 2/3/17 SBAR form, as expected per policy (see above), describing the resident's new pressure ulcer and no care plan to address the resident's new pressure ulcer. The 2/3/17 Wound Healing Progress Report revealed the resident had a sacrum wound, and an open area on the coccyx. The measurement was 2.0 cm x 0.1 cm. The 2/3/17 Wound Assessment Report (wound assessment report) revealed the resident had a sacrum open area on coccyx. The measurements were length 2.0 cm, width 0.1 cm, and depth 0.2 cm. (From record review and interview it appeared the facility used coccyx and sacrum in regards to the same area and wound.) The telephone orders (TOs) revealed the following pertinent information: - Order date: 2/3/17, zinc oxide (skin care and preventative) to coccyx daily; and - Order date: 2/14/17, reposition every two hours to prevent skin breakdown and dressing change to sacrum ([MEDICATION NAME] Border), changing every seven days (Tuesday) or as needed. -Order date: 2/15/17, reposition resident every two hours. - Order date: 2/15/17, apply [MEDICATION NAME] Boarder dressing on sacrum every Tuesday. A 2/6/17 Routine Visit by hospice documented the resident had a stage II pressure ulcer to the coccyx. The wound was not measured and the note did not reveal treatment was provided to the wound. A 2/7/17 Routine Visit, likewise, did not reveal treatment was provided to the wound. Despite evidence of a pressure ulcer, the 2/9/17 Braden Risk Assessment Report revealed the resident again was assessed at moderate risk for developing pressure ulcers. The skin inspection report on 2/9/17, documented the resident's skin was not intact. The report, however, did not describe the wound size, depth, edges, undermining, necrotic tissue type and amount, exudate type and amount, skin coloring around the wound, [MEDICAL CONDITION]/induration, tissue, location, and shape of the wound. The 2/17 treatment administration record (TAR) confirmed the decline in the resident's skin condition and delays or omissions indicated in the above record review. Specifically: -Order date: 1/26/17, skin assessment every Thursday. The resident's skin was intact on 2/2/17, and not intact on 2/9/17 (indicated by a + or - sign on the TAR). - Order date: 2/3/17, zinc oxide to coccyx daily was not transcribed from the TOs to the TAR. The treatment was not documented in the TOs, departmental notes, or hospice documentation as administered. The treatment was discontinued and new orders revealed a new treatment on 2/14/17. The new treatment was scheduled for Tuesdays and was not documented as administered. -Order date: 2/15/17, reposition resident every two hours. The resident was repositioned every two hours starting 2/16/17, 13 days after the identification of the pressure ulcer. - Order date: 2/15/17, apply [MEDICATION NAME] border dressing on sacrum every Tuesday. Review of the departmental notes from nursing did not reveal wound care, including ointment and dressing changes, or a resident refusal of wound assessments and/or wound treatments between 2/4/17 and 2/13/16. The charts/clinical notes, effective 2/10/17 by hospice revealed the resident and the social services director (SSD) contacted hospice and requested a registered nurse (RN) visit because the resident was uncomfortable and his coccyx wound was open with, some blood noted, although review of the departmental notes by nursing did not reveal concerns related to pressure ulcers. The resident was not seen by hospice until 2/14/17 (see below). 2. Resident status 2/14/17 to 2/17/17 Record review revealed the resident's coccyx ulcer deteriorated and he was identified with additional pressure ulcers on 2/14/17 and additional risks for pressure ulcers. However, interventions to address the pressure ulcers (pressure relief, treatments and monitoring), and to minimize known risks were delayed and/or omitted. The 2/14/17 Routine Visit and Charts/Clinical Notes, effective 2/14/17 by hospice revealed the resident had a wound to sacrum that had increased from 2.0 cm x 2.0 cm on 2/11/17 to 5.0 cm x 7.0 cm on 2/14/17 and revealed hospice identified two additional pressure ulcers, one on each heel. -Hospice documented the resident's coccyx ulcer, a stage II pressure ulcer, was observed to be 5.0 cm in length and 7.0 cm in width, beefy red, slough 20 percent, and eschar 90 percent. The dressing was changed per the new order (see above) and a cushion for the wheelchair and multiply mattress was ordered. The right heel wound was a blister, 4.5 cm in length and 3.5 cm in width, pink, and the comments revealed the blister popped. The left heel wound was a blister, 4.0 cm in length and 3.0 cm in width, pink, and the blister remains intact. - Hospice further documented the resident was non-ambulatory and able to reposition himself by rolling but encouraged the facility to try and reposition the resident knowing he may not stay off the area. The resident's appetite was poor and he was only eating a few bites when offered food, which added to poor wound healing. He had difficulty making his needs known, did not use the call light and was often hard to understand when trying to speak. The 2/14/17 departmental notes from nursing revealed hospice changed the wound dressing to the coccyx and right foot. However, record review revealed no treatment orders were obtained for the left and right heel pressure ulcers, no SBARs or incident reports documenting the new pressure ulcers for the resident was completed and no care plan to address the resident coccyx ulcer or new heel ulcers was developed. Review of the Wound Assessment Report, Wound Healing Progress Report, and Skin Inspection Report did not reveal a left and right heel wounds. The facility did not identify, describe the wound size, depth, edges, undermining, necrotic tissue type and amount, exudate type and amount, skin coloring around the wound, [MEDICAL CONDITION]/induration, tissue, location, and shape of the wound for the left and right heel wounds. Review of the TAR revealed the dressing changes and [MEDICATION NAME] Border treatment was for the sacrum, not the left and right heel. The 2/16/17 Braden risk assessment report revealed the resident was a high risk for developing pressure ulcers. The skin inspection report on 2/16/17, documented the resident's skin was not intact. The report, however, did not describe the wound size, depth, edges, undermining, necrotic tissue type and amount, exudate type and amount, skin coloring around the wound, [MEDICAL CONDITION]/induration, tissue, location, and shape of the wound. The 2/16/17 departmental notes for nursing revealed the interdisciplinary team (IDT) met. The resident had an open area on the coccyx measuring 5.0 cm x 7.0 cm. The heel wounds were not noted on the IDT note. The Charts/Clinical Notes, effective 2/17/17, by hospice revealed the resident passed away at 2:00 p.m. 3. Review of facility quality assurance documents revealed the regulatory and facility failures in managing resident #4's pressure ulcer risk and pressure ulcer development were not identified by the facility prior to survey. B. Staff interviews Staff interviews revealed conflicting understanding of facility expectations upon the identification of a new pressure ulcer. Administrative interviews confirmed the delays and omissions in care and treatment revealed in the record review, LPN #3 was interviewed on 4/9/17 at 8:29 p.m. She said an incident report or SBAR was created upon the identification of a pressure ulcer, indicating the location, appearance, and size of the wound. Medication and treatment orders were obtained immediately from the physician, and interventions put into place. Skin and wound checks were completed weekly and documented on the TAR. She said oxygen administration and oxygen saturations values were monitored and documented on the TAR. Certified Nurse Aide (CNA) #6 was interviewed on 4/9/17 at 8:33 p.m. She said when a wound was identified they would be reported to the nurse immediately. Interventions CNAs completed for residents identified as being at risk for pressure ulcers included frequent repositioning and offloading of pressure. RN #1 was interviewed on 4/9/17 at 8:41 p.m. regarding procedures for skin assessments and pressure ulcers. He said skin assessments were completed when the online charting system notified completion was required. He said at times, he was the only RN in building during the night shift. He was not asked to stage wounds for the LPNs on duty. He revealed he assessed, staged, and documented the location of the wounds onto the assessments and progress notes. An incident report and SBAR were completed after the identification of a new pressure wound and the physician and responsible party notified. Interventions were put into place immediately, and treatments documented on the TAR. Interventions for wounds included offloading the pressure, podus boots, pillows, and medications such as ointment. Medication and treatment orders were required to be followed at all times and documented on the MAR or TAR. Treatment was not allowed to be provided without an order. CNA #8 was interviewed on 4/9/17 at 8:48 p.m. She said the identification of new pressure ulcers were documented on a Stop and Watch Early Warning Tool and submitted to administration. RN #3 was interviewed on 4/9/17 at 8:52 p.m. She said changes of condition, including newly identified pressure ulcers, were documented on the 24 hour report and an incident report. A full head to toe assessment was completed weekly. There were two types of weekly assessments: skin and wound. The skin assessment determined if the skin was intact or not intact. The wound assessment determined the location, size, and description of the wound. The Director of Nurses (DON) was interviewed on 4/10/17 at 10:38 a.m. She said treatment orders were put into place immediately after the identification of a pressure ulcer and an incident report should be completed. The physician should be notified and treatment orders obtained. Skin checks, pressure and non-pressure were required to be completed weekly. The checks consisted of observations from head to toe, and noted if the skin had an existing or new conditions. The nursing home administrator (NHA) and DON were interviewed on 4/10/17 at 2:15 p.m. Both revealed the wound physician did not work with resident #4. The resident received hospice services, and treatment was provided by both the facility and hospice. The NHA reviewed and confirmed the resident's treatment for [REDACTED]. She said the resident did not have facility bathing records due to hospice completing this task. RN #2 was interviewed on 4/10/17 at 2:54 p.m. She said verbal orders were received and written onto a TO slip. The order was then transcribed into the physician orders [REDACTED]. Orders and care plans were required to be followed. It was the responsibility of the wound team coordinator to coordinate pressure ulcer interventions and treatments with hospice. The assistant director of nursing (ADON) was interviewed on 4/10/17 at 5:13 p.m. She said she was responsible for completing wound rounds with the physician. The resident was not on the caseload of the physician due to his admission to hospice. She revealed she was unsure how residents were assessed upon admission, quarterly, and annually for skin integrity. She said the assessments should have noted if the skin was intact or not intact, and included a picture of a person which allowed for the nurses to identify the location of the wound. Wound measurements and descriptions were completed weekly, and identified on the assessment tool and/or the progress notes. A SBAR form and incident report were completed after every incident (such as identification of a pressure ulcer), and placed in the resident's clinical record. The DON was interviewed on 4/10/17 at 3:53 p.m. She said resident care plans were created upon admission, and updated quarterly, annually and after a change in condition. -She reviewed the resident's chart and said there was not an acute care plan for skin integrity and/or pressure ulcers. She confirmed the resident did not have a care plan related to skin integrity and/or pressure ulcers, but should have had a care plan. Within a week of an incident, including the identification of pressure ulcers, the wound team was supposed to meet and create a resident plan of care. -The MDS assessment was reviewed and the DON stated a care plan was required upon admission due to the assessment identifying the resident was at risk for pressure ulcer development. -She said an incident report should be completed after the identification of a wound. She was not sure if an SBAR report was required to be completed. She reviewed the chart and confirmed the resident did not have any SBAR forms, there was no initial order for the dressing change and the dressing change and new treatment order were not written until 2/14/17 for the resident's sacral/coccyx ulcer. She also confirmed the resident's orders did not identify treatment for [REDACTED]. Finally, she confirmed TOs were required to be transcribed correctly to the TAR for treatment and weekly skin and wound assessments were required to be completed per physician orders. She agreed weekly wound assessments were not completed for the resident; only one wound assessment (2/3/17) was completed by the facility.

Based on observation, record review and interviews, the facility failed to ensure the resident environment remained free from hazards as possible, and that three (#15, #28, #30) of the 38 sample residents received adequate supervision and assistive devices to prevent accidents. Specifically: -Resident #30 - The facility failed to complete a comprehensive post-fall investigation after each of resident #30's ten falls, contributing to failure to identify the resident's safety needs, and failure to implement strategies to minimize the risk of future falls. The resident's final fall resulted in a fracture and pain (cross-reference F309) -Resident #28 -The facility failed to complete a comprehensive post-fall investigation after resident #28's fall with fracture and failed to timely address environmental hazards, including wet floors, which may have contributed to resident #28's fall. -Resident #15 - The facility failed to ensure an anti-tipping device was placed on the resident's wheelchair as 'immediately' recommended post-fall. -Environment - In addition to unaddressed wet areas on the floor, chemical and electrical hazards were observed. Findings include: A. Facility Expectations In pertinent part, the 2001 (revised in 2007) "Falls and Fall Risk Management" policy provided by the facility on [DATE] at 11:30 a.m., stated, "Based on previous evaluations and current data, the staff will identify interventions related to resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling." B. Resident Failures 1. Resident #30 Resident #30, age 88, was admitted to the facility on [DATE] to a room on the secure unit. The [DATE] Computerized physician's orders [REDACTED].#30 had [DIAGNOSES REDACTED]. A telephone order dated [DATE] revealed resident #30 was admitted to hospice. a. Resident status The [DATE] quarterly Minimum Data Set (MDS) revealed: -Resident #30 usually understood and was usually understood by others. Resident #30 had short-term and long-term memory problems with severely impaired decision making skills. -Resident #30 required limited assistance with walking in her room and the corridor, locomotion on and off the unit, Resident #30 required extensive assistance with bed mobility, transfers, dressing, toileting, eating and personal hygiene. -Resident #30 was documented to have had one fall with no injury since her previous MDS assessment on [DATE]. Resident #30 was noted to be at risk for falls as evidenced by fall risk evaluations on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] that yielded scores showing resident #30 was at risk or at high risk for falls. A review of a care plan dated [DATE] and reviewed [DATE] and [DATE], showed resident #30 was at risk for falls. The stated goal was for resident #30 to have no significant injury related to falls for the next 90 days. Approaches were: -Rule out medical complication with increased falls -Notify physician and family of falls or injuries as needed -Periodic medication review -Ensure safe environment, free of clutter, adequate lighting, clean spills promptly -Fall assessment on admission, quarterly and with changes or falls -Ensure appropriate footwear when out of bed -Provide adequate lighting -Physical Therapy evaluation/treatment as indicated -Undated, hand written approaches of occupational therapy evaluation and treatment as needed and restorative nursing as indicated were included. An undated "ADL Plan of Care" in the "Accunurse," the electronic record system used to cue nurse aide staff on providing and documenting cares, stated that resident #30 had "fall potential." No approaches to prevent falls were listed. b. Record Review Record review revealed the facility failed to complete a comprehensive post-fall investigation after each of resident #30's falls to identify and implement, per care plan, effective strategies to minimize the risk of future falls. (1) Fall on [DATE] A nurse's note dated [DATE] at 6:16 p.m. stated that resident #30 experienced a fall to the floor. Prior to the fall, resident #30 was heard to be having a verbal altercation with another resident in the TV room. A review of the clinical record revealed no investigation was completed for the fall on [DATE]. A review of the care plan revealed no review or update of interventions to prevent the resident from falling listed on the care plan after the fall. A written request to the facility for any and all fall investigations for resident #30 was made on [DATE] at 4:30 p.m. The facility supplied all available fall investigations on [DATE] at 11:30 a.m. No investigation for the fall on [DATE] was furnished. A second request was made for any and all fall investigations on [DATE] at 10:47 a.m. The Director of Nursing (DON) stated that all fall investigations had been provided. No therapy screening form for this fall was located in the clinical record. (2) Fall on [DATE] A nurse's note dated [DATE] at 10:42 p.m., stated that resident #30 was found on the floor of another resident's room. A hematoma was noted on the top of resident #30's head. No RN assessment was documented in the nurse's notes for this fall. A review of the clinical record revealed no investigation into the fall on [DATE]. Written requests for all any and all fall investigations on [DATE] and [DATE] did not result in an investigation for the fall on [DATE] being furnished. A review of the care plan revealed no review or update of interventions to prevent the resident from falling listed on the care plan after the [DATE] fall. No therapy screening form for this fall was located in the clinical record. (3) Fall on [DATE] or [DATE] A nurse's note [DATE] at 2:21 a.m., stated that resident #30 was on incident follow-up for an unwitnessed fall. There was no further reference or description of this fall in the nursing notes. A review of the clinical record revealed no investigation into the fall on [DATE] or [DATE]. Written requests for all any and all fall investigations on [DATE] and [DATE] did not result in an investigation for the fall on [DATE] or [DATE] being furnished. A review of the care plan revealed no review or update of interventions to prevent the resident from falling listed on the care plan after the [DATE] or [DATE] fall. No therapy screening form for this fall was located in the clinical record. (4) Fall on [DATE] A nurse's note dated [DATE] at 12:46 a.m., stated that resident #30 was walking in the hall hand in hand with another resident. As the residents tried to turn, resident #30 was pulled to the ground by the other resident as the other resident lost his balance and fell . The [DATE] fall investigation concluded that this fall was an isolated incident. The investigation stated the immediate intervention to prevent further falls was "will continue to monitor resident." The investigation recommendation did not define monitoring by describing who would monitor or how frequently the monitoring would occur. The "fall committee review" portion of the investigation stated, "see note from ,[DATE] worksheet addressed on wrong incident." A review of the care plan revealed that there was no review of update of interventions, including "monitoring resident" added to the care plan. No therapy screening form for this fall was located in the clinical record. (5) Fall on [DATE] A nurse's note dated [DATE] at 4:39 p.m., stated that resident #30 was found on the floor by a Certified Nurse Aide (CNA). The fall was witnessed by the CNA and the resident did not hit her head. Time and circumstances of the fall were not documented in the nurse's note. A telephone order dated [DATE] at 2:00 p.m., stated monitor orthostatic blood pressure each shift for three days. No fall investigation dated [DATE] was identified; however, there was a fall investigation dated [DATE] that was entered into the electronic record on [DATE]. This investigation form indicated resident #30 awoke and began walking in the common area. Resident #30, at some point, went to her knees. Orthostatic blood pressure was started for three days. The "Fall Committee Review" of the incident stated that resident #30 was walking with another resident and fell on her bottom. The intervention was to monitor closely. An incident report, which is not part of the clinical record, was furnished for review by the DON on [DATE]. According to the incident report, resident #30 was found on the floor by a CNA. The CNA witnessed the fall and stated the resident did not hit her head. A review of the nurse's notes revealed no documentation on the outcome or findings of the orthostatic blood pressures. A nurse's note on [DATE] at 4:34 p.m., stated the resident continued on monitoring for orthostatic hypotension and that none was detected; however, this was the only reference to orthostatic hypotension monitoring in the clinical record. There were no nurse's notes at all on [DATE]. A review of the care plan revealed that there was no review of update of interventions, including "monitoring resident" added to the care plan. No therapy screening form for this fall was located in the clinical record. (6) Fall on or around [DATE] Nurse's notes on [DATE] at 5:15 a.m., and on [DATE] at 11:54 a.m. and 9:30 p.m., indicated that resident #30 was on neuro checks for an unwitnessed fall. The nurse's notes did not include a note documenting the date, time, description or circumstances of the fall that necessitated the neuro checks. A review of the clinical record revealed no investigation into the fall on [DATE]. Written requests for all any and all fall investigations on [DATE] and [DATE] did not result in an investigation for the fall on or about [DATE] being furnished. An incident report, which is not part of the clinical record, furnished on [DATE] by the DON, showed that resident #30 had a fall with head injury on [DATE]. The report stated that resident #30 was walking in the hall when another resident with unsteady gait fell toward causing resident #30 to fall backwards hitting her head on the ground. This was now the third incident (see previous falls on [DATE] and [DATE]) where resident #30 experienced a fall related to the actions of another resident. A review of the care plan revealed no facility review or update of interventions to prevent the resident from falling listed on the care plan after the [DATE] fall. No therapy screening form for this fall was located in the clinical record. (7) Fall on [DATE] A nurse's note dated [DATE] at 8:11 p.m., written by LPN #1, stated that resident #30 experienced a fall while standing in the hall near her room at 5:00 p.m. The note stated, "Resident said she was coming out of her room, lost balance in the doorway hitting her head on the wall before landing on her back on the floor." Resident #30 "was unconscious for about a minute." The RN supervisor was called to assess resident #30 and resident #30 was assisted to a wheelchair. Ice was applied to the bump on resident #30's head. The physician and family were notified and neuro checks were started. The RN supervisor, who was reported to have assessed resident #30, did not document findings from this fall in the clinical record. The fall investigation report entered on [DATE], which was not marked as being completed, stated that resident #30 would be referred to therapy and would have medications reviewed and adjusted. The "Fall Committee Review" section of the form was blank. A handwritten note in the discharge care plan dated [DATE] noted resident #30 experienced a fall on [DATE]. The note stated that therapy screened resident #30 and her medications were reviewed and adjusted. The "Fall Screening Form" dated [DATE] stated the date resident #30 fell was [DATE]. The form did not note the time or location of the fall or the reason for the fall, although spaces for this information were provided. The form noted that resident #30 received occupational and physical therapy from [DATE] to [DATE]. There were no new approaches or recommendations on how to prevent further falls. The fall risk evaluation dated [DATE] at 4:25 p.m., completed by Assistant Director of Nursing (ADON) #2 showed resident #30 had a fall risk of "6" which was not considered to be a value showing the resident to be at risk for falls. (8) Fall on [DATE] A nurse's note dated [DATE] at 9:31 p.m., stated that resident #30 was found on the floor by a CNA. The CNA witnessed the fall and resident #30 did not hit her head. The location, time, and circumstances of the fall were not recorded in the note. An undated, incomplete fall investigation entered into the electronic record on [DATE] stated in the "intervention to prevent further falls" section that resident #30 was found on the floor. Resident #30 was experiencing a change of condition. Labs were ordered on [DATE]. Staff will continue to monitor resident #30. The [DATE] investigation was not complete and the "Fall Committee Review" section was blank. An undated, handwritten note in the "discharge" care plan noted resident #30 experienced a fall on [DATE]. The care plan note stated that resident #30 had a change of condition (undefined), labs were ordered on [DATE], and that the facility would "continue to monitor" resident #30. A telephone order dated [DATE] at 2:00 p.m., directed that comprehensive metabolic panel, complete blood count, urinalysis and thyroid stimulating hormone be completed for resident #30. No labs collected on [DATE] were identified in the clinical record. Labs were present for specimens collected on [DATE]. Thyroid levels were within normal limits and resident #30 had labs that were consistent with [DIAGNOSES REDACTED]. The lab results from [DATE] were similar to previous results from labs on [DATE]. A significant change Minimum Data Set was completed [DATE]. It revealed that during the MDS observation period, resident #30 experienced delirium characterized by an acute mental status change that presented as continuous inattention, disorganized thinking, an altered level of consciousness and psychomotor retardation. She was noted to require extensive assistance of two staff for bed mobility, dressing, personal hygiene and toilet use and limited assistance to walk in the corridor and for locomotion on and off the unit. Contrary to other documentation in the record (see above), the MDS documented resident #30 had no falls since the [DATE] quarterly assessment. In pertinent part, a "Monthly Note" by the nurse practitioner dated [DATE] stated, "Resident with several falls in the past month including one with head injury. Staff members have noticed a general functional decline since then characterized by declining verbalization, bradykinesia, lack of initiative, holding food in mouth and inability to complete basic tasks and activities she previously enjoyed." No care plan updates or revisions were made to increase resident supervision given the changes in the resident's status as documented in the significant change MDS and nurse practitioner note (see above). (9) Fall on [DATE] A nurse's note dated [DATE] at 9:37 p.m., stated that resident #30 was found on floor in hallway while walking. The fall was witnessed by a CNA who stated the resident did not hit her head. Family and physician were notified of the fall. An undated, incomplete, fall investigation with an entry date of "[DATE]" stated that "intervention to prevent further falls" section resident #30 had a fall while walking in the hallway. Resident #30 was noted to be declining and on hospice. The stated plan was that resident #30 would be monitored by staff and continue on comfort care. The "fall committee review" section of the form was blank. An undated, handwritten note in the "discharge" care plan noted resident #30 experienced a fall on [DATE]. The care plan note stated that staff wound monitor resident #30 (frequency undefined) due to change of condition (undefined), and resident #30 would continue on hospice. No new interventions to prevent future falls were identified. (10) Fall on [DATE] A nurse's note dated [DATE] at 3:47 p.m., written by LPN #1 stated that a CNA was getting resident #30's roommate for lunch when the CNA heard a loud thud, pulled curtain and saw resident #30 on the floor on her right side in front of her bed. Resident #30 experienced a hip fracture from the fall on [DATE] and expired on [DATE] at 10:20 a.m. On [DATE] x-ray results showing a right femoral neck fracture and [DATE] at 10:25 a.m., interview with hospice Registered Nurse case manager stating resident #30 passed away. Cross reference to F309 for further details. The undated, incomplete, fall investigation with an entry date of [DATE] into the electronic record stated in the "immediate intervention to prevent further falls" section that resident #30 fell from bed and had a hip fracture. Resident #30 was noted to be declining, on hospice and "requires comfort care only." A landing mat, bed alarm and new mattress were placed on the resident's bed in response to the fall. The "Fall Committee Review" section of the form was blank. The care plan was not updated to reflect addition of land mat, bed alarm or a new mattress to resident #30's fall prevention approaches. An incident investigation and incident report, which are not part of the clinical record, were provided by the DON on [DATE] at 7:30 a.m. for review. The incident investigation stated that resident #30 was agitated most of the morning on [DATE]. Resident #30 was toileted by a CNA and placed in bed. The bed contained a "scoop" mattress that hospice had changed from a regular mattress. The report further stated resident #30, " ...probably had difficulty getting out of bed with the scoop mattress and fell out of the bed trying to get out ..." A review of the clinical record, including hospice records, showed no evidence of a physician's orders [REDACTED]. c. Family Interview On [DATE] at 3:10 p.m., a family member who regularly visited resident #30 was interviewed. According to the family member, resident #30 had numerous falls at the facility and seemed to "fall all the time." The family member denied being aware of interventions the facility had implemented to prevent or reduce resident #30's risk of injury from falling. d. Staff Interviews On [DATE] at 12:31 p.m., CNAs #34 and #28 who stated they regularly worked on the secure unit were interviewed. The following was revealed: -CNA #34 stated she was not aware of any fall prevention strategies or fall prevention precautions in place for resident #30 prior to her fall on [DATE]. -CNA #28 agreed with CNA #34 stating she did not know of fall prevention strategies or fall prevention precautions in place for resident #30 before her fall on [DATE]. -Both CNAs #34 and #28 stated that resident #30 did not usually fall on the day shift. -CNA #28 stated that resident #30 was ambulatory and used a cane when she first arrived on the unit. -Both CNAs stated that resident #30 was incontinent of bowel and bladder and was on the check and change program. On [DATE] at 12:54 p.m., Activity Assistant (AA) #3, who reported working five days each week on the secure unit, was interviewed about resident #30. The interview revealed: -Resident #30 had experienced a decline in the past three weeks. -Resident #30 usually attended activities most days prior to the fall on [DATE]. -Prior to the fall on [DATE], resident #30 ambulated independently. -AA #3 stated she was not informed about any fall prevention strategies to reduce resident #30's falls. On [DATE] at 2:04 p.m., CNA #31, who reported usually working evenings on the secure unit, was interviewed. CNA #28 and #31 were in the general area conducting shift change. The interview revealed: -CNA #31 stated resident #30 did have falls on the evening shift. -CNA #31 denied awareness of fall prevention strategies for resident #30. On [DATE] at 2:40 p.m., the DON was interviewed about resident #30's falls. The interview revealed the following: -The DON stated that it was her expectation that new fall interventions be in place after each fall. -The DON stated that it was her expectation that care plans be updated after each fall to reflect new strategies being implemented. -The DON acknowledged that fall investigations were not in place for each fall experienced by resident #30. -The DON stated that recently (no specific date was offered), the facility has tried to improve fall response. -The DON stated that falls had been reduced by half in the past month, from February 2014 to [DATE]. -The DON stated the source of the decrease was placing a particularly fall prone resident on the unit (resident #74) into a merry walker, which decreased that resident's falls to zero in recent weeks. -The DON stated that resident #30 had falls that were caused by resident #74 pulling her down. -The DON stated that the focus on addressing resident #74's falls resulted in a lack of attention to resident #30's falls. -The DON stated that she wanted to implement root cause analysis to help identify causes for resident falls. -The DON acknowledged that current fall investigation procedures did not include basic information gathering such as witness statements from the person finding a resident on the floor. -The DON further stated that a comprehensive fall investigation was difficult to attain when she was unable to get staff to document basic information in the nurse's notes. On [DATE] at 7:10 a.m., the DON was re-interviewed. The re-interview revealed the following information about resident #30's fall on [DATE]: -The DON had spent the previous evening investigating resident #30's fall on [DATE]. -According to her investigation, LPN #1 reported that resident #30 was agitated on the morning of [DATE]. -LPN #1 reported that resident #30 was toileted by two CNAs and put in bed in an agitated state. -The mattress on resident #30's bed was changed on Wednesday or Thursday (,[DATE] or [DATE]) by hospice from a regular mattress to a "scoop" mattress. -The facility was not made aware of the change in mattress. -The DON stated she felt the fall on [DATE] was the result of the new mattress, which would have been difficult for resident #30 to negotiate in a weakened state with impaired cognition. On [DATE] at 7:15 a.m., LPN #1, who was the unit nurse on duty when resident #30 fell on [DATE] was interviewed. The interview revealed: -LPN #1 stated he believed resident #30 went to bed a 9:30 or 10:00 a.m., on [DATE] because she was tired from "walking around a lot." -LPN #1 stated he was not sure if resident #30 had a "scoop" mattress on her bed. -LPN #1 suggested speaking with a CNA because they changed bed linens. On [DATE] at 9:20 a.m., Activity Assistant #4, who reported discovering resident #30 on the floor on [DATE], was interviewed. According to AA #4, resident #30 had not been at activities on the morning of [DATE] because resident #30 was in bed. On [DATE] at 10:45 a.m., the hospice RN case manager was interviewed. The interview revealed: -The RN case manager did not recall ordering a "scoop" mattress for resident #30. -The RN case manager did not check the mattress in place on resident #30's bed before ordering a low loss air mattress for resident #30's bed after resident #30's fall on [DATE]. -The RN case manager did not see documentation about a "scoop" mattress on the hospice care plan. On [DATE] at 8:52 a.m., the acting therapy manager, a Physical Therapist (PT) was interviewed about resident #30's therapy services. The interview revealed: -Resident #30 received occupational therapy services from [DATE] to [DATE]. -Resident #30 was being seen for improvements to balance, safety and functional activity improvement. -Resident #30 was receiving physical therapy service from [DATE] to [DATE]. -Resident #30 was being seen for enhanced safety and functional mobility. -Resident #30 had a therapy screen on [DATE] but was not picked up on case load. On [DATE] at 10:37 a.m., CNA #28 was re-interviewed about resident #30's fall on [DATE]. The following was stated: -Resident #30 was tired on [DATE] and had spent the morning in bed. -CNA #28 stated she did not recall seeing a "scoop" mattress on resident #30's bed. 2. Resident #28 Resident #28, age 63, was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. According to the [DATE] Computerized physician's orders [REDACTED].#28 had [DIAGNOSES REDACTED]. a. Resident status The [DATE] significant change Minimum Data Set (MDS) showed resident #28 was cognitively intact with a Brief Interview Mental Status score of ,[DATE]. The [DATE] fall risk evaluation for resident #28 showed a value of "6." According to the risk evaluation form, scores of "10" or more represent "high risk" for falls. Record review (see nurses' note below) further revealed the resident experienced a fall with fracture [DATE]. b. Resident Interview On [DATE] at 8:07 a.m., resident #28 was interviewed about his fall with right leg fracture on [DATE]. -Resident #28 said he experienced a fall with fractures to his right leg when he slipped and fell on a wet spot on his floor. Resident #28 stated a previous spill was not completely wiped up, causing him to slip and fall when he inadvertently stepped on the wet spot. -Resident #28 reported he was on the way to the bathroom at the time of his fall. Resident #28 expressed a concern that falls went unaddressed in the facility. On [DATE] at 10:30 a.m., the room where resident #28 had resided at the time of the fall was observed. The flooring material was shiny linoleum tile. c. Record Review In pertinent part, a nurse's note dated [DATE] at 12:40 p.m., written by LPN #8 stated, "Resident was heard in his room calling for help. When the nurse went in, the resident was on the floor with hand holding fast to the night stand draws (sic) holders. Water over the floor. Resident stated "I bend over to open my night stand draws (sic) then I slip and fell ." Resident stated "No, I fell before the water spill on the floor."" The nurse's note did not document if resident #28 what substance, if any, resident #28 slipped on. An undated, incomplete fall investigation form in the electronic record dated [DATE] at 12:28 p.m., was reviewed. The "obstacles to safety" and "assistive devices" section of the form were not completed. The form did not document what resident #28, an alert and oriented resident, felt was the reason for his fall. No witness statements from staff or others in the area at the time of the fall were identified and interviewed in the fall investigation. d. Staff Interviews On [DATE] at 1:30 p.m., Licensed Practical Nurse (LPN) #8 was interviewed about resident #28's fall on [DATE]. The interview revealed: -LPN #8 stated resident #28 experienced a fall with fracture on the morning of [DATE]. -LPN #8 stated the floor was wet when he found resident #28 on the floor. -LPN #8 stated that the water on the floor was from resident #28's drinking cup falling when the resident tried to halt his fall by grabbing the nightstand. -LPN #8 acknowledged he asked resident #28 about the presence of the water from the drinking cup and not about other fluids that may have been on the floor at the time of the fall. On [DATE] at 7:20 a.m., CNA #9 was interviewed about resident #28's fall on [DATE]. The interview revealed: -CNA #9 reported being on duty on resident #28's unit at the time of his fall on [DATE]. -CNA #9 stated that resident #28 told her he slipped and slid on water before falling. -CNA #9 stated that resident #28 reported he was on his way to the bathroom to shave at the time of his fall. -CNA #9 stated that resident #28 often wore regular socks to walk around in his room, but that he usually had on tennis shoes when walking around the facility. e. Facility Observations See environmental failures below; Observations of numerous wet areas not timely addressed throughout the facility on [DATE] at 9:58 a.m., 10:05 a.m., 10:40 a.m., 12:44 p.m.; [DATE] at 1:29 p.m., 1:31 p.m., 1:56 p.m., 2:04 p.m.; [DATE] at 9:15 a.m., 9:24 a.m., 9:45 a.m., 1:08 p.m.; and [DATE] at 11:16 a.m.). 3. Resident #15 Resident 15, age 66, was admitted into the facility on [DATE]. The resident's face sheet indicated resident #15 was admitted into the facility with [DIAGNOSES REDACTED]. a. Resident status The resident's [DATE] minimum data set (MDS) revealed a score of 7 out of 15 on the brief interview for mental status (BIMS), indicating severe cognitive impairment. Section G of the MDS showed resident #15 with range of motion impairment on one side of lower extremity with use of a wheelchair mobility device. b. Fall [DATE] and safety recommendation for anti-tipping device A review of the resident's revised [DATE] care plan indicated the facility identified on [DATE] the resident's potential for injuries related to falls. There were additional risks related to visual deficit, poor safety awareness, memory impairment, psychiatric medications, lower extremity amputation, and bladder and bowel incontinence. The care plan also revealed the resident fell on [DATE] while the resident was rolling backwards in his wheelchair. -The goal was to minimize the risk for falls related to injuries daily. -The approaches included: to assist resident with transfers, blood sugar test after falls and as needed, educate staff to anticipate and assist the resident with his mobility in and out of the court yard as he allows, bed alarm put in place to alert staff when resident tries to self transfer, and a referral for anti-tipping device. A fall investigation dated [DATE] was completed at 3:34 p.m., by the assistant director of nursing (ADON). The report completed by ADON #2 showed the resident was rolling his wheelchair backward when the chair tipped over. A referral to the therapy department for an anti-tipping device was listed as an immediate intervention. The review of the nursing notes from [DATE] to [DATE] revealed the last note entered on resident was from [DATE]. The nursing notes failed to show a note describing the fall on [DATE] or evidence of the referral for an anti-tipping device. However, record review did reveal a nursing screen request was submitted to physical therapy; this request was dated [DATE] prior to the [DATE] fall although it referenced the [DATE] fall. The request showed the resident had a change identified in areas of falls and gait/wheelchair mobility. The handwritten comment stated the resident had a fall on [DATE] while rolling his wheelchair backwards and needed an anti-tipping device. -Review of the therapy screening form dated [DATE] revealed the resident was referred to the restorative nursing program to place anti-tippers on the resident's wheelchair. -Review of the ,[DATE] computerized physician orders [REDACTED]. c. Observations On [DATE] at 9:07 a.m., the resident was observed sleeping in his bed, positioned low to the ground with his wheelchair parked on top of a soiled cream colored floor mat. The resident's wheelchair was not observed with an anti-tipping device. On [DATE] at 2:16 p.m., the resident's wheelchair was observed parked on top of his soiled cream colored floor mat without application of an anti-tipping device. On [DATE] at approximately 11:00 a.m., resident was observed in the milieu of the secure unit seated in his wheelchair. The resident's wheelchair was observed without the use of an anti-tipping device. d. Interviews On [DATE] at 9:05 a.m., CNA #34 who worked on the secure unit and who was familiar with resident #15 was interviewed. CNA #34 recalled resident #15 suffering a fall from tipping backwards in his wheelchair. CNA #34 reported she was

Based on interview and record review, the facility failed to ensure that based on a resident's comprehensive assessment, two (residents #30 and #8) of 38 sample residents maintained acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible. Specifically, the facility failed to: -Timely identify, assess and implement strategies to reverse resident #30's initial and subsequent significant unplanned weight loss. -Identify and implement effective, resident-centered approaches for resident #30 in order for her to meet her nutritional needs. - Assess and re-assess resident #8 in a timely manner, implement interventions to the documented weight loss, evaluate the effectiveness of the interventions, and modify approaches when interventions were unsuccessful. The findings include: Professional Standards According to Geriatric Nutrition: The Professionals Handbook, Third Edition, by Chernoff on pages 427-458 in pertinent parts; "Many health care professionals are not attuned to the important role that nutrition plays in the maintenance of health throughout life; therefore, subclinical or marginal nutritional deficits may go unnoticed and undocumented. Malnutrition is the consequence of chronically inadequate intake of essential nutrients. [MEDICATION NAME] of normal tissue requires protein, energy, vitamins in amounts adequate to replace old cells with new ones. These elements are needed to repair damaged cells and tissues and to make substrate for protein compounds such as [MEDICATION NAME], hormones and enzymes ... Body weight is one of the simplest and most routinely collected anthropometric indices used to monitor individuals and is used as a rough estimate of body energy stores ... To increase the reliability and reproducibility of repeated measures, standardized procedures should be followed ... Each scale should be calibrated periodically against a set of standard weights ... A more clinically useful and predictive factor than relative body weight is the evaluation of changes in weight over given period of time, therefore, a careful history of previous weight gain or loss should be obtained. [MEDICATION NAME] is the major visceral protein produced by the liver, and its synthesis is dependent on an adequate supply of protein and, to a lesser degree, total energy intake ... In the past, [MEDICATION NAME] has been shown to be a reliable predictor of protein malnutrition in elderly people ... a serum [MEDICATION NAME] level of less than 3 g/dl (gram/deciliter) was found to be the best single predictor of mortality." According to Fundamentals Of Nursing: The Art And Science Of Nursing Care by Taylor, Lillis, LeMone and Lynne, Sixth Edition, on page 360, "Patient records serve many purposes, such as communication with other healthcare professionals, recording of diagnostic and therapeutic orders, care planning, quality of care reviewing, research, decision analysis, education, legal documentation, reimbursement, and historical documentation. The primary purpose of the patient record is to help healthcare professionals from different disciplines (who interact with the patient at different times) communicate with one another. Communication fosters continuity of care." 1. Resident #30 Resident #30, age [AGE] years, was admitted to the facility on [DATE] to a room on the secure unit. The April 2014 Computerized physician's orders [REDACTED].#30 had [DIAGNOSES REDACTED]. A telephone order dated 3/8/14 demonstrated that resident #30 was admitted to hospice. The 3/24/14 significant change Minimum Data Set (MDS) revealed: -Resident #30 usually understood and was usually understood by others. -Resident #30 had short-term and long-term memory problems with severely impaired decision making skills. -Resident #30 experienced delusions, verbal behaviors with no significant impact to the resident or others, wandering without impact to the resident or others, and daily rejection of care. -Resident #30 required extensive assistance for eating. -Resident #30 was 127 pounds. a. Weight History A review of previous MDS assessments showed: -On the 2/10/14 quarterly MDS, resident #30 weighed 136 pounds. -On the 11/18/13 quarterly MDS, resident #30 weighed 140 pounds. -On the 9/9/13 admission MDS, resident #30 weighed 153 pounds. -On the 8/31/13 previous facility discharge MDS, resident #30's weighed 164 pounds. -For each of the MDS on 2/10/14, 11/18/13, 9/9/13 and 8/31/13, the MDS showed resident #30 did not have a chronic disease or condition that the resulted in a life expectancy of less than six months. A review of all weights in the electronic health record revealed the weights measured in pounds: -9/2/13 =153 -10/3/13 =145 This weight represented an unplanned loss of eight pounds and a 5.22% weight loss in one month. -10/11/13 = 145 -11/1/13 = 139 This weight represented an unplanned loss of 14 pounds and a 9.1% weight loss in two months. -11/15/13 = 140 -12/27/13 = 131 This weight represented an unplanned weight loss of nine pounds and a 6.4% weight loss in just over one month. This weight also represented an unplanned weight loss of 22 pounds and a 14.3% weight loss in just under four months. -1/14/14 = 133 -2/2/14 = 136 This weight represented an unplanned weight loss of 17 pounds and an 11% weight loss since admission. -3/3/14 =124 This weight represented an unplanned weight loss of 29 pounds and an 18.95% weight loss in six months. -3/11/14 = 123 -3/21/14 = 127 Although resident #30 was experiencing a severe, unplanned weight loss, the clinical record bore no evidence that at any point during her stay, the facility increased the monitoring of resident #30's weights to weekly weights. No re-weighs of any weight were identified in the clinical record. A review of provider progress notes showed monthly notes dated 10/30/13 and 11/20/13 that stated resident #30's weight was stable with no weight loss or gain. No plan for physician guided weight loss was mentioned. On 4/1/14 at 3:10 p.m., resident #30's daughter was interviewed. According to resident #30's daughter, the resident had lost "between 30 to 40 pounds" since being admitted to the facility. The daughter stated resident #30's weight loss was not planned or expected. On 4/4/13 at approximately 12:45 p.m., the Certified Dietary Manager (CDM) was interviewed. The CDM interview revealed: -The CDM was new to the building, having been there less than a month. -The CDM had been certified since 1992 and had helped manage resident care in conjunction with a registered dietician for more than [AGE] years. -The CDM stated that resident #30 experienced significant weight loss in the first month she arrived at the facility and should have been referred to the registered dietician right away for review. -The CDM stated that resident #30's weight history showed the resident had severe weight loss between admission and the end of December 2013. -The CDM acknowledged that resident #30 was not on a planned weight loss program. -The CDM stated that the weight history showed a failure to place resident #30 on weekly weights, a practice that the CDM explained was necessary to monitor and assess efficacy of interventions put in place to stabilize a resident experiencing unplanned weight loss. -The CDM explained that unplanned weight loss needed to be avoided because it depleted reserves. -The CDM stated that when weight loss is desired, it needed to be planned and completed under a supervision of a physician to ensure that electrolytes and other lab values are maintained within a normal range, particularly in the presence of kidney disease. On 4/4/14 at approximately 4:00 p.m., the Director of Nursing (DON) was interviewed about resident #30's unplanned weight loss. The interview revealed: -The DON acknowledged that resident #30 was not placed on weekly weights, even though the resident experienced unplanned weight loss. -The DON confirmed the weights in the electronic record system (listed above) were all of the weights measured for resident #30. -The DON stated that the registered dietician did not participate in the facility weight committee, but provided written recommendations for inclusion in the weight meeting. On 4/7/14 at 8:28 a.m., the Registered Dietician (RD) was interviewed in the presence of the Corporate Dietary Consultant (CDC) and the CDM. The interview revealed: -The RD stated that resident #30 experienced a significant unplanned weight loss between 9/2/13 and 10/3/13. -The RD stated that resident #30 continued to experience weight loss in October 2013 and November 2013. -The RD stated that she was not notified of the weight loss concern for resident #30 until 11/20/13, when she completed a reassessment of the resident. -The RD stated she depended on the dietary manager to provide weight list and alert her to weight loss concerns. -The RD stated that she had been consulting in the building twice monthly and recently requested an increase in monthly visits to three times monthly because of nutrition concerns. b. Resident Nutritional Assessment The "Data Collection/Evaluation Nutritional" form completed 9/6/14 showed: -Resident #30 was at nutritional risk due to [DIAGNOSES REDACTED]. -Resident #30 had a current weight of 153 and a usual body weight in the 150s. -The ideal body weight was not completed. -Resident #30 consumed 50% at breakfast, lunch and dinner and was not marked as receiving a bed time snack or nutritional supplement. -Resident #30 was not marked as being on a physician prescribed weight loss program. -Resident #30 was not assessed for favorite foods or food dislikes. -Resident #30 did not have [MEDICAL CONDITION]. -Resident #30 had calculated daily nutrition needs of 1738 calories; 55 grams of protein; and 2000 ml of fluid. The 11/20/13 "Dietary Progress Notes" written by the RD revealed: -Resident #30 experienced a significant weight loss with a 10% decline in weight since admission. -Resident #30 looked thinner since last observation on 9/6/13. -Resident #30 had a diet down grade from regular texture to puree with nectar thick fluids on 10/15/13. -Resident #30's weight loss was attributed to inadequate oral intake and advancing dementia. -Resident nutrition needs were re-calculated as 1579 calories; 63 grams of protein; and 1900 mL of fluid daily. -A goal of maintain weight at 135 pounds was established. The 11/25/13 "Dietary Data Set and Progress Note" completed by a previous dietary manager read: -Resident #30 was 61 inches tall, 140 pounds. -The "weight trend" section of the assessment stated, "No significant change (less than 5% in 30 days, 7.5% in 90 days, 10% in 180 days.)" -Meal intake was listed as "50%" -Supplement intake was listed as "75%." Resident weight history (see above) revealed that at this time resident #30 had experienced significant weight loss. Resident meal intakes (see below) showed that during November 2013 resident #30's meal intakes averaged 31% over all. The 2/21/14 "Dietary Data Set and Progress Note" completed by a previous dietary manager read: -Resident #30 was 61 inches tall, 135.9 pounds. -The "weight trend" section of the assessment stated, "No significant change (less than 5% in 30 days, 7.5% in 90 days, 10% in 180 days.)" -Meal intake was listed as "55%" -Supplement intake was listed as "100%." Resident weight history (see above) revealed that at this time resident #30 had experienced significant weight loss. Resident meal intakes (see below) showed that during January and February 2013 resident #30's meal intakes averaged 37% and 36% respectively, over all. Labs drawn on 3/2/14, 12/12/13, and 9/4/13 revealed values consistent with an individual diagnosed with [REDACTED]. On 4/4/14 at approximately 12:45 p.m., the CDM was interviewed. The CDM interview revealed: -The CDM stated she began preparing for a dietary assessment by reviewing labs. The CDM then reviewed resident #30's labs. -The CDM stated that the 11/25/13 and the 2/21/14 dietary assessments were inaccurate because resident #30 had experienced significant weight loss. -The CDM stated the meal assessment information was inaccurate because the resident was eating far less than the stated amount according to the meal intake documentation. -The CDM stated the assessment of supplement intake was not accurate because nursing staff were not recording the amount of supplement consumed according to the Medication Administration Records. On 4/7/14 at 8:28 a.m., the RD was interviewed. The interview revealed: -The RD was not asked to re-assess resident #30 for nutrition concerns related to unplanned weight loss until 11/20/13. -The RD was not asked to provide additional nutrition assessment to resident #30 beyond 11/20/13, even though the resident continued to lose weight. -The RD depended on the dietary manager to alert her to concerns about resident weight. c. Care Plan Cross reference to F279 for record review and 4/4/14 interview with the CDM stating resident #30's first nutrition care plan was developed and implemented on 3/28/14; 4/4/14 interview with the Director of Nursing confirming resident #30 did not have a nutrition care plan in place until 3/28/14; and 4/7/14 interview with the RD and CDM confirming the importance of nutrition care planning. d. Meal Intakes A review of resident #30's meal intakes recorded in the electronic record from 9/5/13 through 3/30/14 revealed: -For September 2013 resident #30 had five breakfast refusals and seven total meal refusals. There were 12 blank meal intakes recorded for the evening meal with 15 blanks total for the month. The meal consumption's calculations on the intake report showed intake averages of 49% breakfast, 59% lunch, 32% dinner and 22% over all. -For October 2013 resident #30 had 17 breakfast refusals with 19 total meal refusals. There were 22 blank meal intakes for the evening meal and 27 total blank meal intakes for the month. The meal consumption calculations on the intake report showed intake averages 17% breakfast, 37% lunch, 12% dinner and 46% over all. -For November 2013 resident #30 had 11 breakfast refusals with 13 total meal refusals. There were 23 blank intakes for the evening meal and 24 total blank meal consumptions for the month. There were 12 meals where the amount of food consumed was listed as "bites." The meal consumption calculations on the intake report showed intake averages 14% breakfast, 31% lunch, 13% dinner and 31% over all. -For December 2013 resident #30 had 14 breakfast refusals with 20 total meal refusals. There were seven blank intakes for the evening meal and eight total blank meal consumptions for the month. There were six meals where the amount of food consumed was listed as "bites." The meal consumption calculations on the intake report showed intake averages 27% breakfast, 44% lunch, 31% dinner and 34% over all. -For January 2014 resident #30 had 17 meal refusals all of which were breakfast. There were nine blank intakes for the evening meal and 12 total blank meal consumptions for the month. There were two meals where the amount of food consumed was listed as "bites." The meal consumption calculations on the intake report showed intake averages 22% breakfast, 54% lunch, 31% dinner and 36% over all. -For February 2014 resident #30 had 14 breakfast refusals with 20 total meal refusals. There were seven blank intakes for the evening meal and eight total blank meal consumptions for the month. There were six meals where the amount of food consumed was listed as "bites." The meal consumption calculations on the intake report showed intake averages 22% breakfast, 54% lunch, 31% dinner and 37% over all. -For March 2014 resident #30 had eight total meal refusals. There were seven blank intakes for the evening meal and 15 total blank meal consumptions for the month. There were 17 meals where the amount of food consumed was listed as "bites." The meal consumption calculations on the intake report showed intake averages 21% breakfast, 23% lunch, 20% dinner and 21% over all. A provider progress note dated 12/10/13 stated that resident #30 experienced a weight loss. The contributing factors of the weight loss included daytime somnolence, loss of upper partial, dislike of puree diet, and dementia. The provider noted that supplements were added to resident #30's diet. On 4/2/14 at 4:30 p.m., CNA #31, who worked the evening shift on the secure unit, stated that resident #30 exhibited "sundowners" behaviors of being up and wandering around throughout the evening and at night. On 4/4/14 at 12:45 p.m., the CDM was interviewed about resident #30. The interview revealed: -The DM reviewed the meal intakes noting the persistent blanks for the evening meals and the frequent refusals for the breakfast meal. -The DM stated that she felt meal intake documentation was so important that she had, in previous buildings, training and oversight of CNAs in meal intake documentation in order to ensure that she and the RD had correct information on resident meal oral/calorie intake and meal habits. -The DM explained that a resident's meal intake was used to determine if the resident was meeting his or her calorie needs. -The DM acknowledged that resident #30 did not have nutritional interventions developed to address enhanced intake opportunities- resident #30's late sleeping and nighttime wakefulness. On 4/7/14 at 8:28 a.m., the interview with the RD in the presence of the CDM and the CDC revealed: -The RD stated she did not have access to the electronic records system where meal intakes were maintained. -The RD stated she needed the dietary manager to print out and provide meal intake information on residents with weight change in order to have an understanding of factors contributing to resident weight change. -The RD stated that the new CDM was now providing her with meal intake information; however this was not done previously. -The RD stated that resident #30's continued weight loss suggested that she was not meeting her calorie needs. -The RD stated that the persistent refusals of morning meals suggested that resident #30 could benefit from additional intake opportunities when she was more awake, in the evening and at night. e. Interventions The 10/15/13 Speech Therapy Evaluation and Plan of Treatment stated in pertinent part that: -Resident #30, "presented with delayed cough and wet vocal sounds following swallowing of thin liquids." -Resident #30 "presented with decreased ability to effectively and efficiently masticate mechanical soft textures." -The recommendation was made to downgrade resident #30's diet to puree texture with nectar thickened fluids. -"No further skilled ST (speech therapy) tx (treatments) is recommended at this time secondary to pt. (patient) safely tolerating current diet; puree textures and nectar thick liquids with no refusal of P. O. (by mouth) intake on this diet." On 4/21/14 at 4:30 p.m., an interview with Certified Nurse Aide (CNA) #31 revealed: -CNA #31 reported she had worked on the secure unit for six months. -CNA #31 stated resident #30 started coughing at meal time months ago and was switched to puree diet. -CNA #31 reported that resident #30 did not care for the puree food. -CNA #31 stated that resident #30 did tolerate puree sweet foods like fruit. -CNA #31 stated pudding and applesauce were the snacks available for residents on puree diet. -CNA #31 stated that she was not aware of any care approaches directing evening snacks be provided to resident #30. -CNA #31 stated that she noticed as resident #30 lost weight, she got weaker and had diminished balance. On 4/8/14 at 8:52 a.m., the acting therapy supervisor, a Physical Therapist (PT) stated that resident #30 received a speech screening on 10/15/13. At that time resident #30's diet was downgraded to puree with thickened fluids and no further treatment was recommended. Resident #30 was added to speech case load beginning 11/15/13 in order to try and return resident to an upgraded diet. The 11/20/13 "Dietary Progress Notes" written by the RD revealed: -Resident #30 had insufficient intake to maintain weight. -The RD recommended resident #30 receive Magic Cup (a high calorie frozen supplement) with lunch and dinner each day. -The RD recommended resident #30 receive one can of Ensure three times daily with meals. -The RD recommended resident #30 receive "mouth care." A telephone order dated 11/21/13 directed resident #30 to receive Magic Cup with lunch and dinner and one can of Ensure with each meal daily. The amount of Ensure consumed was to be recorded. The November 2014 Medication Administration Record (MAR) was reviewed. Records for Administration of Ensure and Magic Cup were not present in the November 2013 MAR. The December 2013 MAR showed documentation for: -Magic Cup by mouth offered at lunch and dinner for weight loss/supplement. -Ensure one can by mouth at meal time three times daily as supplement for weight loss. -Neither the amount of Magic Cup nor Ensure consumed by the resident was documented on the MAR. The January 2014 and February 2014 MARs showed continued administration of Magic Cup and Ensure with meals without the percentage consumed for either supplement being documented. A telephone order dated 3/6/14 directed that the Magic Cup and the Ensure be discontinued. A new order for Ensure Plus 240 ml three times daily with meals was started. The order directed staff to record the percentage of supplement consumed. The March 2014 MAR showed that the Magic Cup and Ensure were discontinued on 3/6/14. Ensure Plus was started on 3/7/14; however the amount consumed was not being documented. On 4/3/14 at 12:31 p.m., CNA #28 was interviewed about resident #30's meal intake habits. CNA #28 stated that resident #30 liked to sleep late because she wandered the unit at night. On 4/4/14 at 12:45 p.m., an interview with the CDM about resident #30 revealed: -The CDM stated that resident #30 received one to two nutritional supplements with each meal. -The CDM stated that her certification training taught her that providing nutritional supplements with meals was not an advisable practice because the supplements are filling and can "bulk up" in the stomach causing the resident to feel full. -The CDM stated the end result of providing nutritional supplements with meals was that the resident would not consume the meal resulting in continued poor meal consumption. -The CDM stated supplements should be provided between meals to increase over-all calorie intake. On 4/7/14 at 8:28 a.m., the interview with the RD in the presence of the CDM and the CDC revealed: -The RD stated she generally preferred a "food first" approach for increasing calorie intake. -The RD explained that the facility did not have a fortified food program for adding additional calories with meals, but that the new CDM was working to get one off ground. -The RD explained she also would try to ensure that favorite foods were provided more frequently; however the facility did not conduct a favorite food assessment so she was unable to implement this approach. -The RD stated that on 11/20/13, she recommended adding Ensure at meal time because resident #30 was observed to accept the Ensure when it was offered. -The RD acknowledged that providing supplements at meal time was known to decrease meal intake. -The RD reviewed the MARs and stated that the amount of supplement being consumed by resident #30 was not being documented. -The RD stated it was important to document supplement consumption in order to determine the amount of supplement calories being accepted by the resident. -The RD stated she did review resident #30 on 3/6/14, but did not document any new findings in the clinical record other than the recommendation to change supplements in the telephone orders. -The RD acknowledged that the facility did not develop any approaches for meal intake or supplement intake that capitalized on resident #30's evening and nighttime wakefulness. f. Conclusion The facility failed to thoroughly assess resident #30's nutritional needs due to facility communication barriers where the RD relied on the dietary manager to provide information; failure to monitor intake; and failure to implement standard care interventions. The facility failed to identify and implement resident-centered nutritional approaches to increase meal intake to meet her calorie needs. 2. Resident #8 The [AGE] year old resident was admitted to the facility 1/5/10 and re-admitted [DATE] with [DIAGNOSES REDACTED]. The minimum data set (MDS) significant change assessment dated [DATE], revealed the resident had clear speech, made self understood and was able to understand others. His cognitive skills were moderately impaired for daily decision making. Delusions were documented. He required supervision with bed mobility, transfers, and eating, and total assistance with dressing, toilet use and personal hygiene. The resident was on mechanically altered diet. The most recent MDS quarterly assessment dated [DATE], documented the resident had no hallucinations or delusions, required supervision with bed mobility, eating, and walking with a walker, limited assist with transfers, extensive assist with dressing and personal hygiene, and total assist with toilet use. The resident was on mechanically altered diet. The resident's weights were documented in his medical record as follows: 11/1/13 - 167 lbs 11/15/13 -170 lbs 12/27/13 -170 lbs 1/14/14 - 175 lbs 2/2/14 - 176 lbs 2/26/14 - 160 lbs (9% weight loss in three weeks) 3/3/14 - 167 lbs (5% weight loss in four weeks) The most recent resident's [MEDICATION NAME] level was documented on 1/20/14 - 3.7 (range 3.5 - 5.0). The resident's care plan (CP) dated 4/7/11, addressed risk for alteration in nutrition, and documented approaches including (in pertinent part): regular diet/ mechanical soft texture, monthly weights, and encourage >/= (more or equal) 75% meals intake. The resident's care plan (CP) dated 3/13/12, documented the resident had history of [MEDICAL CONDITION] and approaches included "serve diet as ordered, encourage/monitor intake." The CP did not address resident's weight loss related to frequent urinary tract infections. Review of the computerized nursing notes between 1/22/14 and 2/22/14 revealed the resident was treated for [REDACTED]. The resident's food intake was documented 80%-100% in the dietary assessment dated [DATE]. Review of the resident's meal intake in February (2014) revealed the resident's average food intake was 85%. On 4/4/14 at 9:25 a.m., the Director of Nursing (DON) stated the residents' weights were very often inaccurate due to the facility scale malfunction, and lack of calibration. She added the scale will be calibrated today and new scale will arrive within next two days. The DON stated that each time resident #8 had urinary tract infection he was refusing to eat. On 4/4/14 at 10:20 a.m., the Dietary Manager stated she did not have any documentation regarding the resident's weight loss in February 2014, as she started her employment with the facility in March (2014). On 4/7/14 at 8:15 a.m., the DON stated the resident #8 cannot be weighed because the facility scale was malfunctioning and the new scale had not arrived yet. On 4/7/14 at 8:20 a.m., the facility RD, Corporate Regional Dietary Specialist and the facility Dietary Manager stated that resident #8 should be re-weighed within 24 hours and assessed if there was a significant weight loss. The resident's weight on 4/8/14 was documented 168.9 lbs. On 4/8/14 the facility received a new weight scale for the residents. The facility failed to timely assess resident's weight loss and implement appropriate approaches.

Based on observations, interviews and record review, the facility failed to ensure that three (residents #30, #28 and #15) of 38 residents received the care and services necessary to promote their highest practicable level of well being. Specifically, the facility failed to: -Ensure resident #30 received a comprehensive post-fall assessment by Registered Nurse (RN) prior to movement to another surface after a fall with fracture. -Ensure resident #30 was monitored and treated for [REDACTED]. -Ensure skin injuries to resident #30's right elbow were identified and monitored. -Ensure resident #28 was assessed by a RN prior to relocation to another surface after a fall with fracture. -Ensure resident #28 was monitored for efficacy of pain medication that was administered post-fall with fracture. -Ensure resident #28 was timely sent to the hospital in accordance with the resident's preference. -Ensure resident #15's skin injuries were identified, monitored and treated as necessary. The findings include: 1. Resident #30 Resident #30, age [AGE] years, was admitted to the facility on [DATE] to a room on the secure unit. The [DATE] Computerized physician's orders [REDACTED].#30 had [DIAGNOSES REDACTED]. A telephone order dated [DATE] demonstrated that resident #30 was admitted to hospice. The [DATE] significant change Minimum Data Set (MDS) revealed: -Resident #30 usually understood and was usually understood by others. -Resident #30 had short-term and long-term memory problems with severely impaired decision making skills. -During the MDS observation period, resident #30 experienced [MEDICAL CONDITION] characterized by an acute mental status change that presented as continuous inattention, disorganized thinking, altered level of consciousness and psychomotor [MEDICAL CONDITION]. -Resident #30 experienced delusions, verbal behaviors with no significant impact to the resident or others, wandering without impact to the resident or others, and daily rejection of care. -Resident #30 required extensive assistance of two staff for bed mobility, dressing, personal hygiene and toilet use. -Resident #30 required limited assistance to walk in the corridor and for locomotion on and off the unit. A. Background A review of resident #30's clinical record was conducted on [DATE], [DATE], [DATE], [DATE] and [DATE]. On [DATE] at 9:29 a.m., Licensed Practical Nurse (LPN) #1 stated that resident #30 had a fall with [MEDICAL CONDITION] hip on [DATE]. LPN #1 stated resident #30 had a fall from bed that was unwitnessed. The fall occurred before lunch at approximately 11:15 a.m. The [DATE] x-ray report, faxed to the facility at 6:36 p.m. on [DATE], showed that resident #30 had an acute right femoral neck fracture with modest displacement. On [DATE] at approximately 1:30 p.m., the RN case manager from hospice was interviewed. The hospice RN case manager stated that prior to the fall on [DATE] resident #30 was not "actively" dying so she visited the resident weekly and as needed. The hospice RN case manager stated that resident #30 was now actively dying and would be visited daily. On [DATE] at 10:25 a.m., the hospice RN case manager stated that resident #30 had expired at 10:20 a.m. B. Failure to Conduct Complete Post-Fall Assessment A nurse's note dated [DATE] and timed at 3:47 p.m., was written by LPN #1. The nurse's note indicated: -Resident #30 had a fall from bed before lunch. -Resident #30 was able to "move all extremities" after the fall; had pupils that were equal and reactive to light; had equal hand grasp strength. -The note did not mention any RN assistance in completing the post-fall assessment for resident #30. -The note did not mention review of resident #30 for difference of length in her legs. -The note did not mention observation for external rotation of the legs post-fall. The clinical record did not include a post-fall assessment form or similar document for the fall on [DATE]. The undated, incomplete, fall investigation with an entry date of [DATE] into the electronic record stated in the "immediate intervention to prevent further falls" section that resident #30 fell from bed and had a [MEDICAL CONDITION]. No mention of a RN assessment was made prior to movement to a wheelchair was present in the investigation. A review of electronic record and the paper chart failed to yield evidence of an RN assessing resident #30 prior to removal from the floor and placement in a wheelchair. A request was made on [DATE] at 4:30 p.m., for any and all post fall assessments for resident #30 throughout the course of her stay. On [DATE] at 11:30 a.m., the facility provided the fall assessment information (see above) that was previously reviewed in the clinical record. On [DATE] at 12:31 p.m., the two Certified Nurse Aides (CNAs) who were on duty for the secure unit on the day shift on [DATE], when resident #30 fell , were interviewed. The interview revealed: -CNA #28 stated she was on break at the time of the fall that resulted in the fracture to resident #30's femoral neck. -CNA #28 stated she did not see resident #30 until she returned from break, at which time resident #30 was up in the wheelchair in the secure unit dining room. -CNA #34 stated she was called to resident #30's room by Activity Assistant (AA) #4. -CNA #34 stated she was "across the hall" helping another resident when resident #30 fell . -CNA #34 stated she saw resident #30 on her back on the floor by her bed and called for LPN #1 to come to the room. -CNA #34 stated that she and LPN #1 placed resident #30 in her wheelchair and then took resident #30 to lunch. -CNA #34 stated that she and LPN #1 were the only nursing staff in the room with resident #30 after the fall. -CNA #34 stated the only nurse that assessed resident #30 in her room after the fall was LPN #1. -CNA #34 stated LPN #1 had resident #30 move her legs to check for injury before resident #30 was moved to the wheel chair. On [DATE] at 1:54 p.m., LPN #1 was interviewed about the [DATE] post fall assessment for resident #30. The interview revealed the following: -LPN #1 confirmed that he was summoned to resident #30's room by CNA #34 because resident #30 was found on the floor. - LPN #1 reported another male nurse assisted him with the post fall-assessment; however LPN #1 was unable to recall the name of the nurse. -LPN #1 stated he had felt resident #30 was safe to move because resident #30 could move both her legs and wiggle her toes. -LPN #1 stated he performed a neuro check of resident #30 after the fall. -When asked to explain how resident #30 was assessed post-fall, LPN #1 did not state he checked resident #30's legs for external rotation or difference of length. -When asked to explain how resident #30 was assessed post-fall, LPN #1 did not state that he checked resident #30 for deformity by observing for visual signs of injury or by manual examination of the resident for areas of pain. On [DATE] at 2:04 p.m., CNA #34 was re-approached for an interview. CNA #34 restated that only LPN #1 was present when resident #30 was examined after the fall on [DATE]. On [DATE] at 2:13 p.m., the Director of Nursing (DON) was interviewed about resident assessment post-fall. The interview revealed the following: -The DON stated that it was her expectation that an RN on duty assess residents for injury post-fall. -The DON stated there is an RN on duty in the building at all times for the purpose of patient assessment. -The DON stated that it was her expectation that the RN document his/her finding in the nurse's notes in the electronic medical record. -The DON acknowledged that she was unable to locate a nurse's note from an RN stating that he/she assessed resident #30 after the fall on [DATE]. -The DON acknowledged that the nurse's note composed by LPN #1 made no mention of RN assessment of resident #30 immediately post-fall. -The DON stated that RN #3 was the RN on duty who should have assessed resident #30 after her fall. -The DON was heard to call and request that RN #3 come to her office for interview. On [DATE] at 2:28 p.m., RN #3 was interviewed in the presence of the DON. The interview revealed the following: -RN #3 acknowledged that he was the nurse on duty at the time of the fall. -RN #3 stated he was aware that resident #30 had a fall on [DATE] and that he was asked to assess the resident. -RN #3 stated that he got busy and was unable to see resident #30 promptly. -RN #3 denied seeing the resident while she was on the floor and prior to placement in a wheelchair. -RN #3 stated that he first observed resident #30 in a wheelchair at the nurse's station. -RN #3 stated his first observation of resident #30 occurred around the middle of shift change, which begins at 2:00 p.m. On [DATE] at 9:20 a.m., Activity Assistant (AA) #4 was interviewed. The interview revealed: -AA #4 stated on Fridays and Saturdays she worked providing activities on the secure unit. -AA #4 stated she was in the common area before lunch on [DATE] when she heard loud "ghostly" moaning of "OOOOOOOO! OOOOOOOOOO!" coming from an unknown location. -AA #4 stated she left the common area to identify the source of the loud moaning. -AA #4 stated that the CNAs and the LPN were not readily visible to her when she left the common area. -AA #4 stated that she found resident #30 on her back, on the floor by her bed. The resident's head was near the night stand and her feet were pointed toward the foot of the bed. -AA #4 stated that resident #30 reported that her leg hurt. -AA #4 stated she went to the hall and summoned CNA #34 for assistance. -AA #4 stated CNA #34 then obtained assistance from LPN #1. -AA #4 stated she watched as CNA #34 and LPN #1 assisted resident #30. -AA #4 stated that she only saw CNA #34 and LPN #1 assist resident #30. -AA #4 stated that CNA #34 and LPN #1 moved resident #30 from the floor to the wheelchair. C. Pain Assessment and Pain Intervention a. Facility Policy The facility "Pain Management Process" document, last revised on [DATE], provided by the Director of Nursing (DON) on [DATE] at 11:41 a.m., stated in pertinent part, "Documentation of pain intensity will be recorded along with intervention for pain reduction using appropriate facility forms ...Post intensity evaluation will be assessed and documented in a timely manner. Upon follow-up, if the intervention is ineffective, process should be repeated until the resident indicated adequate relieve (sic) and/or functional goals are met." b. Facility Pain Assessment Tool The facility's "Comprehensive Pain Assessment Scales" tool, provided by the DON on [DATE], included the Numerical, Wong-Baker Faces and the Pain AD pain scales. The Wong-Baker Faces pain scale depicted a frowning face with tears above the numeric value "10" and the words "Hurts Worst." c. Pain Assessment post-fall A nurse's note dated [DATE] and timed at 3:47 p.m., (four hours after the fall occurred), written by LPN #1 stated: - Resident #30 denied pain or discomfort after the fall. (See AA #4 interview above and below) -At 1:15 p.m., LPN #1 observed resident #30 was crying and complaining of right hip pain. -The nurse's note did not demonstrate that resident #30 was assessed for her level of pain at 1:15 p.m., when LPN #1 noticed resident #30 was crying. -The nurse's note did not demonstrate what, if anything, LPN #1 did to relieve resident #30's pain at 1:15 p.m. -The nurse's note stated hospice and resident #30's responsible party were notified of the fall at 11:30 a.m. -The nurse's note indicated that LPN #1 had left a message about resident #30's fall with the physician's answering service at 12:00 p.m. -No documentation what the facility did to obtain timely relief for resident #30's pain was present in the note. -Per the nurse's note, a nurse from hospice arrived to assess resident #30 at 3:30 p.m.; an hour and fifteen minutes after resident #30 was noticed by LPN #1 to be crying from pain. A nurse's note dated [DATE] and timed at 8:31 p.m., written by LPN #14 stated: -Resident #30 began complaining of pain upon moving her right leg and hip area. -Resident #30 was sitting in her wheel chair crying and wincing when LPN #14 arrived for shift change. -Resident #30 was given [MEDICATION NAME] by LPN #14, although the time was not noted. -Resident #30's level of pain was not documented prior to or after the administration of the routine [MEDICATION NAME]. -An x-ray of the hip was ordered at 3:45 p.m. -The family elected not to send resident #30 to the hospital. -The hospice nurse ordered 0.25 ml of [MEDICATION NAME] sublingually every four hours as needed for pain. -Delivery time for the [MEDICATION NAME] was not identified in the nurse's note. -LPN #14 stated she administered [MEDICATION NAME] to resident #30 and that this provided pain relief. The Medication Administration Record (MAR) for [DATE] included pain charting for each shift. On [DATE] resident #30 was documented to have pain levels of ,[DATE] on each shift. On [DATE] at 12:31 p.m., CNAs #34 and #28 were interviewed about resident #30's fall on [DATE]. The interview revealed: -CNA #28 stated resident #30 did not eat her lunch on [DATE], even though resident #30 was up in her wheelchair in the dining room for the lunch meal. -CNA #28 stated that once lunch concluded, resident #30 was crying and complaining of pain. -After conferring, CNA #34 and #28 believed resident #30's crying began around 1:00 p.m. On [DATE] at 1:54 p.m., LPN #1 was interviewed. The interview revealed: -Resident #30 fell at around 11:15 a.m. on [DATE]. -Resident #30 did not appear to LPN #1 to be in any distress immediately after the fall. -LPN #1 stated he did not think resident #30 was in pain immediately after her fall because "she was not crying or anything."-LPN #1 stated resident #30 began crying at 1:15 p.m. on [DATE]. -LPN #1 stated he determined from speaking with resident #30 that she was in pain. -LPN #1 stated that he called the DON to have her contact the hospice agency because he was unable to obtain a timely response from the hospice agency. -LPN #1 stated that he did not think resident #30 was in severe pain, even though the resident was crying. On [DATE] at approximately 1:30 p.m., the RN case manager from hospice was interviewed. The hospice RN stated she had ordered resident #30 to be placed on bed rest because being placed in a sitting position with a femoral neck fracture causes "excruciating pain." On [DATE] at 2:04 p.m., CNA #31, who was reported being on duty on the secure unit for the evening shift on [DATE], was interviewed in the presence of CNA #28 and #34 about post-fall pain for resident #30. The interview revealed: -CNA #31 arrived on the unit at about 2:00 p.m. on [DATE]. -Resident #30 was up in her wheelchair at 2:00 p.m. -CNA #31 stated that resident #30 was "definetly in pain" when she arrived on the unit and remained in pain for hours causing CNA #31 to wonder "what was taking so long?" -CNA #31 stated she could tell resident #30 was in pain because resident #30 was "wincing a lot" and "not moving that leg." -CNA #31 stated that resident remained in the wheelchair until after the nurse arrived from hospice to look at her. On [DATE] at 2:13 p.m., the Director of Nursing (DON) was interviewed about resident pain assessment. The interview revealed the following: -The DON stated that she expected her staff to document pain levels in the nursing notes when a resident experienced a fall, especially with major injury. -The DON reviewed the electronic record, where nursing notes were maintained, and stated that she did not see evidence that resident #30 had her pain levels documented post fall. -The DON acknowledged that the post-fall nursing notes on [DATE] for resident #30 did indicate the resident was experiencing pain. -The DON acknowledged that the frequency of pain assessment, pain treatments, and resident response to pain treatments were not recorded. -The DON acknowledged that when nursing services are not documented, they are not considered to have been done. -The DON stated that for the secure unit, she likes to use the Pain AD scale, which looks at more than just facial expression for persons with cognitive impairment. On [DATE] at 2:28 p.m., RN #3 was interviewed in the presence of the DON. The interview revealed: -RN #3 acknowledged that he was the shift supervisor on [DATE] and that he was responsible for completing nursing assessments as needed for residents in the building during that shift. -RN #3 stated that when he saw resident #30 at approximately 2:00 p.m., she was sitting in her wheelchair at the nurse's station. -RN #3 stated that resident #30 was grimacing and crying. -RN #3 stated that resident #30 was in pain, but was unable to assign a pain level. -RN #3 denied assessing resident #30 for a level of pain. -RN #3 stated that he believed resident #30 received some kind of pain medication after the fall, but that he was not aware of what was provided. -RN #3 acknowledged he should have completed a Pain AD scale assessment for resident #30 to determine her pain level when he observed her post fall. On [DATE] at 9:20 a.m., AA #4 was interviewed. The interview revealed: -AA #4 stated resident #30's post-fall moaning caused her to leave an activity to identify the source of the noise. -AA #4 stated upon discovering resident #30 on the ground, she knew the resident was in pain because the resident reported leg pain by saying "My leg," and resident #30 was moaning. -AA #4 stated that resident #30 looked pained throughout lunch because of her facial tensed expression and crying. -AA #4 stated that resident #30 did not eat her lunch on [DATE]. b. Pain Medications The [DATE] CPO showed: -An order effective [DATE] for one tablet [MEDICATION NAME] (also known as [MEDICATION NAME]) ,[DATE] mg by mouth twice daily for pain. According to Mosby's 2012 Nursing Drug Reference 25th edition, [MEDICATION NAME] is a medication for the treatment of [REDACTED]. -An order effective [DATE] for [MEDICATION NAME] 5% patch apply one to the right hip daily on at HS and off in the morning for pain. -An order effective [DATE] for one tablet of Tylenol ([MEDICATION NAME]) 325 mg by mouth daily for pain. According to Mosby's 2012 Nursing Drug Reference 25th edition, [MEDICATION NAME] is a medication given for the treatment of [REDACTED]. -No "As Needed" (PRN) pain medications were identified on the [DATE] MAR. A telephone order dated [DATE] and timed at 4:00 p.m., showed an order for [REDACTED]. According to Mosby's 2012 Nursing Drug Reference 25th edition, OxyFAST is medication given to treat moderate to severe pain. The [DATE] Medication Administration Record (MAR) showed: -On [DATE] resident #30 received scheduled [MEDICATION NAME], which consisted of one tablet of ,[DATE] [MEDICATION NAME] by mouth between 7:00 a.m., and 10:00 a.m., and second tablet of [MEDICATION NAME] ,[DATE] between 4:00 p.m., and 7:00 p.m. -On [DATE] resident #30 received the scheduled [MEDICATION NAME], which consisted of one 325 mg tablet of [MEDICATION NAME] by mouth at 7:00 a.m., to 10:00 a.m., a second 11:00 a.m., to 2:00 p.m., and a third at 4:00 p.m., to 7:00 p.m. -On [DATE] resident #30 received the 8:00 p.m., dose of 0.25 ml sublingual OxyFAST for pain. On [DATE] at approximately 1:30 p.m., the RN case manager from hospice was interviewed. The interview revealed: -A different case manager covered resident #30's needs over the weekend. -Resident #30's fall with fracture created increased pain for resident #30 that necessitated the use of more potent pain medications. -Resident #30 would have had to wait for the new medication (OxyFAST) from the pharmacy to be delivered so that it could be administered. On [DATE] at 1:54 p.m., LPN #1 was interviewed. The interview revealed: -LPN #1 stated he did not have an order for [REDACTED].#30 to relieve her pain at 1:15 p.m. -LPN #1 stated that resident #30 received one tablet of 325 mg routine scheduled Tylenol on the remainder of his shift. -LPN #1 acknowledged that on [DATE] that resident #30 went from 11:15 a.m., until 4:00 p.m., with only routine Tylenol to relieve the pain from a fracture. -LPN #1 acknowledged that one tablet of Tylenol would not be effective in relieving pain from a displaced fracture. -LPN #1 stated that he called the DON to have her contact the hospice agency because he was unable to obtain a timely response for assistance in relieving resident #30's pain. On [DATE] at 2:13 p.m., the Director of Nursing (DON) was interviewed about resident pain assessment. The interview revealed the following: -The DON acknowledged that pain treatments and resident response to pain treatments were not recorded in the nurse's notes for resident #30's fall with fracture on [DATE]. -The DON reviewed resident #30's orders in the electronic record, and acknowledged the only pain medications available to resident #30 after her fall and before the OxyFAST arrived was her routine [MEDICATION NAME] and routine [MEDICATION NAME]. -The DON stated the facility only had [MEDICATION NAME] on hand in the emergency kit to treat severe emergency pain. -The DON stated that resident #30 was allergic to [MEDICATION NAME]. -The DON stated that she was contacted about resident #30's fall, in part, because the hospice agency was not timely returning calls of assistance in addressing resident #30's acute pain after the fall. -The DON stated she was able to reach the hospice agency, which resulted in the agency dispatching an RN to assess resident #30 for pain management needs. -The DON acknowledged that [MEDICATION NAME] and [MEDICATION NAME] were for the treatment of [REDACTED]. -The DON stated that after assessment, hospice ordered OxyFAST to treat resident #30's pain. -The DON stated that the OxyFAST was administered to resident #30 as soon as it was received from the pharmacy. On [DATE] at 2:28 p.m., RN #3 was interviewed in the presence of the DON. RN #3 stated that he believed resident #30 received some kind of pain medication after the fall, but that he was not aware of what was provided. D. Identify and Monitor Skin Injury a. Observations On [DATE] at 9:10 a.m., resident #30 was observed in bed in her room. Her right arm at the lateral elbow had a silver dollar sized scabbed area with steri-strips in place. The medial side of the arm had a silver dollar sized dark purple bruise. The bruise and the scabbed areas were also observed on [DATE] at 1:55 p.m. and [DATE] at 11:41 a.m. b. Record Review A [DATE] skin assessment for resident #30 made no mention of the bruise and of the scabbed area to the right arm. The [DATE] and [DATE] TAR did not have tracking in place for the injury to the right arm. The [DATE] TAR did not include monitoring and follow-up of the skin injuries to the right arm at the elbow. Review of the Nurse's Notes on [DATE] and [DATE] revealed that there were no documented injuries to resident #30's skin from falls on those days. c. Staff Interviews On [DATE] at 2:58 p.m., the DON was asked to observe resident #30's right arm. The observations and interview revealed: -The DON stated that there was bruising and a skin tear to resident #30's right arm. -The DON acknowledged that the nurse's notes did not show the presence of a skin injury for falls that resident #30 sustained on [DATE] and [DATE]. -The DON stated she did not know how the skin injuries to resident #30's right elbow occurred. -The DON reviewed the [DATE] and [DATE] MARs. -The DON approached LPN #14 to speak with her. -LPN #14 stated that resident #30 was not on monitoring for any skin injuries. -LPN #14 stated she did not know where the skin injury to resident #30's arm came from. On [DATE] at 7:10 a.m., an interview with the DON revealed: -The DON stated that she found mention of the injury to resident #30's right arm on an incident report from [DATE] which showed steri-strips were applied to the right elbow. -The DON acknowleged that the absence of documentation on the skin injury that was sustained on [DATE] resulted in a lack of monitoring and possible treatment of [REDACTED]. -The DON acknowledged that the injury was not recorded in the resident's clinical record and monitoring and care for the injuries were not established in accordance with her expectations. 2. Resident #28 Resident #28, age [AGE] years, was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. According to the [DATE] Computerized physician's orders [REDACTED].#28 had [DIAGNOSES REDACTED]. The [DATE] significant change Minimum Data Set (MDS) showed: -Resident #28 was cognitively intact with a Brief Interview Mental Status score of ,[DATE]. -Resident #28 experienced delusions during the MDS observation period. -Resident #28 demonstrated verbal behaviors that did not significantly impact the resident or others. -Resident #28 rejected care on one to three days of the MDS observation period. -Resident #28 experienced a decline of ability to perform activities of daily living (ADLs) from requiring supervision only for all ADLs on [DATE] MDS to requiring extensive assistance from staff with bed mobility, transfers, locomotion on and off the unit, dressing, and toileting. A. Background A review of resident #28's clinical record was conducted on [DATE], [DATE], [DATE], [DATE] and [DATE]. On [DATE] at 1:30 p.m., Licensed Practical Nurse (LPN) #8 revealed that resident #28 experienced a fall with fracture on the morning of [DATE]. The [DATE] emergency room assessment from hospital records showed that resident #28 experienced a comminuted (bone fragments into several pieces) spiral (caused by rotating force) fracture distal tibia fracture and a [MEDICATION NAME] (break occurring at a 90 degree angle to the bone's axis) fracture with small fracture fragments of the distal fibula on the right leg. B. Failure to Conduct Complete Post-Fall Assessment a. Record Review A review of nurse's notes for [DATE] revealed there was one note for the day, which was written by LPN #8 at 12:40 p.m. The note stated: -Assistant Director of Nursing (ADON) #1 assisted with resident #28's post fall assessment. The note did not summarize, refer to or capture ADON #1's findings. -A description of resident #28's right leg/ankle after the fall was not included in the nurse's note. -A description of resident #28's pain (e.g., sharp, dull) was not included in the nurse's note. The clinical record did not include a post-fall assessment form or similar document for the fall on [DATE]. A review of electronic record and the paper chart failed to yield evidence of a registered nurse assessing resident #28 prior to removal from the floor and placement in a wheelchair. A request was made on [DATE] at 4:30 p.m., for any and all post fall assessments for resident #28 throughout the course of his stay. On [DATE] at 8:45 a.m., the medical records director provided the fall assessment information (see above) that was previously reviewed in the clinical record. b. Resident Interview On [DATE] at 8:07 a.m., resident #28 was interviewed about his fall with right leg fracture on [DATE]. According to resident #28, LPN #8 looked at him and then helped him up. c. Staff Interviews On [DATE] at 9:19 a.m., ADON #1 was interviewed about resident #28's fall with fracture on [DATE]. The interview revealed: -ADON #1 stated he did not assess resident #28 when he was on the ground. -ADON #1 stated he first observed resident #28 about ten minutes after the fall occurred. -ADON #1 stated that resident #28 was sitting in a wheelchair at the time of his fall. -ADON #1 stated he did not document his assessment of resident #28's right leg after the fall. -ADON #1 stated he recalled that after the fall occurred, resident #28's right ankle had swelling and pain. On [DATE] at 10:00 a.m., the Director of Nursing (DON) was interviewed about resident #28's fall on [DATE]. The interview revealed: -The DON was not at the facility on that date. ADON #1 was in charge on that day. -The DON stated it was her expectation that residents be fully assessed by an RN before they are moved from the floor. -The DON stated that resident #28 may have refused such an assessment because the nurses on staff that day were persons of color, and resident #28 had prejudice against such persons. -The DON acknowledged there were no documented refusals of assessment on [DATE]. -The DON stated that she expected RNs to document their post-fall assessment of residents in nurse's notes. -The DON acknowledged that there was no documented RN assessment for resident #28 after the fall on [DATE]. -The DON stated that the facility was probably busy on [DATE] and staff may not have had time to document what occurred. C. Failure to Conduct Pain Assessment Post Fall with Fracture a. Record Review The [DATE] Pain Data Set for resident #28 revealed a "pain goal intensity" of ,[DATE] for resident #28. The [DATE] Medication Administration Record (MAR) showed that resident #28 received two tablets of [MEDICATION NAME] ,[DATE] on [DATE] at 10:45 a.m., for pain of ,[DATE]. The efficacy of the pain medication was not documented on the back of the MAR. The [DATE] Nurse's Note written by LPN #8 at 12:40 p.m., stated that resident #28 had "severe" right ankle pain after a fall. The note stated that pain medication was administered. Other than the [DATE] note at 12:40 p.m., mentioned above, there was no nursing note demonstrating assessment of resident #28's pain post-fall. The [DATE] "SBAR" form completed by LPN #8 at 11:00 a.m., which was approximately 15 to 30 minutes after the fall, was reviewed. The form showed: -Resident #28 had "severe pain to right ankle r/t (related to) fall," and the pain level of ,[DATE] the same since it started. -The pain was made worse by touching the affected area and that the pain was made better by elevating the affected area. -The affected area was swollen. Review of the paper and electronic clinical record for resident #28 revealed no additional documentation of resident #28's post-fall pain levels on [DATE]. A telephone order dated [DATE] at 11:00 a.m., showed an order for [REDACTED]. A telephone order dated [DATE] at 1:20 p.m., showed an order to send resident #28 to the hospital for severe pain related to fall. The earlier x-ray order was discontinued. Review of the telephone orders revealed no request for additional pain relief for resident #28 between 11:00 a.m. and 1:20 p.m. on [DATE]. The [DATE] emergency department report from the hospital stated in pertinent part, "The patient complains of severe pain" to the lower right extremity upon arrival emergency department. The [DATE] history and physical report from the emergency department at the hospital stated, in pertinent part, that resident #28, " ...was examined on his hospital bed where he again is not able to provide much history as he is perseverating on the pain to his lower right extremity." b. Resident Interview On [DATE] at 8:07 a.m., resident #28 was interviewed. Resident #28 stated after he fell , "I was in lots of pain, bad pain, more than 10." c. Staff Interviews On [DATE] at 1:30 p.m., LPN #8 was interviewed about resident #28's fall with fracture. The interview revealed: -LPN #8 stated resident #28 fell sometime around 10:00 a.m., on [DATE]. -According to LPN #8, resident #28 was "not really in pain" immediately after the fall. -LPN #8 stated that resident #28 experienced an increase in pain as time passed after the fall. -LPN #8 stated that pain level should be documented in the MAR and the nurse's notes. Due to an inability to access the electronic record, LPN #8 was unable to verify the absence of pain level in the nurse's note for resident #28. -LPN #8 stated he administered [MEDICATION NAME] to resident #28 approximately 30 minutes after the fall, when the resident complained of increased pain. -LPN #8 acknowledged the [DATE] MAR did not demonstrate that resident #28 was re-assessed for pain level after the [MEDICATION NAME] was administered on [DATE] at 10:45 a.m. -LPN #8 stated that resident #

Based on observation, interview and record review, the facility failed to keep one of seven sample residents free from injury. Specifically, the facility failed to keep one sample resident (#4) out of seven sample residents free from exposure to sub zero temperatures resulting in frostbite to the resident's hand and knuckles requiring medical treatment for [REDACTED]. Sample resident #4, age 71, was admitted to the facility on [DATE] from the hospital. The face sheet of the same date indicated the admitting [DIAGNOSES REDACTED]. The computerized physician orders [REDACTED]. The minimum daily set (MDS), dated [DATE], indicated the following: -The resident was severely cognitively impaired as indicated by scoring a 3/15 on the brief mental status exam (BIMS). -The resident was inattentive and had difficulty focusing and was easily distracted. -The resident had exhibited the behavior of wandering on a daily basis in the seven day reporting period. The resident's care plan, dated 10/8/13, was reviewed by facility nursing and social work. The care plan documented the following areas of care for the resident: -Elopement risk related to confusion and [DIAGNOSES REDACTED]." The interventions included placement on the secure unit and quarterly assessment of secure unit placement. -Behaviors related to a history of continuously wandering in the unit, courtyard and into other resident rooms, which puts him at risk for injury. The approaches included providing a secure living environment and holding his hand and leading him where you wanted him to go if he was wandering. -Cognitive problems related to [DIAGNOSES REDACTED]. The interventions included providing a secure living environment to provide consistency and structure and to prevent elopement attempts. -Potential for falls related to poor safety awareness and impulsive behaviors. The interventions documented included keeping the resident's area free from clutter, staff education to provide safe environment when walking with resident and encouraging the resident to ask for assistance. There had been no updates to the resident's care plan after the 12/5/13 incident of the resident eloping and then falling in the court yard in sub zero temperatures, sustaining frostbite, while unattended by staff. Observations: On 12/23/13 at approximately 9:00 a.m. until 11:00 a.m., the resident was observed on the secure unit during the morning and the morning activities. The observations revealed the resident was in constant motion. The resident continually walked around the secure unit. He was observed going to all three doors on the unit and attempting to exit the secure unit. He was verbally able to express the desire to go outside. He was re-directed by the activity staff to a common area. The resident was not observed sitting down during the two hour observation and staff was seldom observed visualizing the resident when he was pacing the halls near two of three exit doors. The resident was on 12/26/13 observed at approximately 11:45 a.m., during the lunchtime meal. The resident was seated by staff at a dining table. The resident remained seated for approximately six minutes and then got up and left the area. The resident was re-directed towards the dining area a total of six times during the meal. The observation revealed that the resident was very easily distracted by staff and resident conversations and actions. The resident was observed on 12/26/13 at approximately 3:00 p.m., ambulating around the secure unit and drinking a beverage. The resident was observed walking to the unit doors and looking outside the doors through the small window in the door. The resident was observed walking from one end of the unit to the other end and then back. The resident repeated this pattern for approximately two hours. The resident was observed on 12/30/13 at approximately 1:00 p.m. while the wound physician assessed the resident's wounds to the right hand and all digits including knuckles. The wounds on the knuckles were observed to have hardened, dry and adherent black necrotic tissue. The second digit knuckle was observed to have light yellow exudates and drainage. The resident was observed on 12/31/13 at approximately 8:00 a.m. in the secure unit. The resident was observed in another resident's room and needed staff re-direction to come out of the room. A memo posted on the wall above the secure unit nursing station and dated 12/2/13 was observed. The memo read: "We are getting ready to head into really cold weather. Please make sure we are doing a head count on a regular basis, especially those residents that can go outside on their own. We need to make sure our residents are not outside too long and that they are appropriately clothed to go outside and avoid prolonged skin exposure." The document was signed by the facility director of nursing (DON). Interviews: On 12/30/13, an interview was held with the wound care specialist assigned to the resident's case. The interview revealed the following: -The wound physician was assigned the case on 12/13/13; one week after the resident was evaluated and diagnosed at the emergency room with frostbite/exposure to all digits of the right hand. The request for consult was from the resident's medical provider at the facility. -The resident's wounds were healing and had decreased in size since the original consultation on 12/12/13. -If left unsupervised in sub freezing temperatures the resident was at high risk related to age and poor safety awareness of being exposed to the elements. On 12/30/13 at approximately 11:00 a.m., an interview was conducted with the facility certified nursing assistant (CNA) who was present the morning (12/5/13) when the resident eloped and was found outside in sub zero temperatures. The interview revealed the following: -The CNA knew the resident well and was very familiar with his daily routines. -The resident was in constant motion and always ambulating all over the unit. The resident had recently fallen and received an eyebrow laceration in 10/2013. -The resident was last seen on 12/5/13 at approximately 6:00 a.m. (when she and another CNA were getting up residents for the day). -When the CNA finished getting another resident up for the day and went to assist sample resident #4, she and the other CNA realized that the resident was not on the unit. She stated in the mornings when the residents are waking up and everything is happening at once it can be hard to keep track of all the commotion and people on the unit. -She and other staff began searching the unit and all the resident rooms looking for the resident. He was found outside in the courtyard area where he had fallen. The door from the secure unit to the courtyard did not have any alarms or locking mechanisms' on it to alert staff of resident's exiting the unit into the court yard. -When the resident was found it was approximately 6:30 a.m., the resident was very cold and his body temperature measure 96.9 temporally. This measures the temperature from the forehead. The resident was given extra blankets and warmed up. The resident's hands were assessed to have possible frostbite from exposure and abrasions from an unwitnessed fall while outside. -The director of nursing, the family and the administrator were notified. The resident was sent to the hospital later on in the day and returned the same day. On 12/31/13 at approximately 9:45 a.m., an interview was conducted with the charge nurse for the day shift of the secure unit. The interview revealed: -The resident had fallen on 10/2013 and had an eyebrow laceration. He was a high fall risk and should be monitored by staff. -The resident never sat down for longer than five minutes. He was easily re-directed by staff when he began exit seeking. -When the resident got outside on 12/5/13 during the morning the exit door did not have any alarms on it to warn staff that the door had been opened either by staff or a resident. -The exit door was less than 10 feet from the nursing station where the nurses and staff sit. -She had been doing daily dressing and treatments to the resident's right hand and knuckle area beginning on 12/6/13, after the resident received frostbite while being outside unattended. The wounds were improving as far as she could tell. On 12/31/13 at approximately 10:30 a.m., an interview was held with the director of Nursing (DON). The interview revealed the following: -The DON had concerns about residents getting out when there were severe weather extremes. -She had in-serviced the staff and put out a memo regarding residents getting outside in the cold weather on 12/2/13. -After posting the memo to the staff of the secure unit no other measures were taken by the facility to ensure that this resident or other residents did not get out unsupervised while there were weather extremes. -The exit door did not have any alarms on it to warn staff that a resident had gotten outside. -The resident had a history and was well known by staff to exit seek, constantly wander and be capable of self ambulation within the unit. -The facility did not utilize a check and change policy on residents in the secure unit. This policy had staff visualize residents every two hours and offer incontinent cares if needed. The facility used a system that alerted staff members via headsets when it was time to check on a resident. On 12/ 31/13 at approximately 10:00 a.m., an interview was held with the assistant director of Nursing (ADON). The interview revealed the following: -He had assessed the resident's wounds since the incident had happened during the wound rounds held weekly. -He thought the wounds were getting better. The resident did require an increase in his pain medication for the discomfort to the frost bitten areas of the right hand beginning on 12/12/13. -He was not sure what the facility could have done to keep the resident from going out the door when it was -9F outside and falling, while unsupervised. The resident had fallen previously and needed supervision related to poor safety awareness. The resident was a high fall risk. Record Review A review of the resident's assessment of fall risk revealed that the resident was last assessed on 11/30/13, five days prior to falling outside in the sub-zero temperatures and had scored a 21. The document indicated that a score of 10 or above represented a high risk for falls. According to the National Weather Service, the average temperature at the facility on 12/5/13 between the hours of 6:00 a.m. and 6:30 a.m. was negative - 9 degrees Fahrenheit. A review of the physician telephone orders, dated 12/5/13 at 2:00 p.m. read in part: transfer the resident to the emergency room for the [DIAGNOSES REDACTED]. A review of the physician telephone orders, dated 12/5/13 at 7:30 p.m., after the resident returned to the facility from the emergency room , with a [DIAGNOSES REDACTED]. The second part of the order read: monitor swelling and abrasion to the right hand every shift for signs and symptoms of infection until resolved. A review of the physician telephone order, dated 12/9/13 at 2:20 p.m., indicated an order for [REDACTED]. The order read, Tramadol 50 mg three times daily for pain. This was four days after the resident received frostbite to all five digits of the right hand. A review of the telephone orders written on 12/17/13 at 2:00 p.m., indicated that the wound physician had ordered skin prep to the frostbit areas on the right first finger, right third finger, right fourth finger and right fifth finger daily. The order further read to allow the right second finger frostbit area to dry. A review of the social service quarterly assessment, dated 10/21/13 and authored by the facility social service worker indicated in the section behaviors; the resident knocks on the unit door and attempts to exit daily. The notation further read that the resident wanders daily. A review of the emergency room physician notes, dated 12/5/13, indicated that the resident had been assessed at 3:15 p.m. This was nine hours after the resident was found outside in -9 F temperatures and post fall. The progress notes indicated that the resident had been in the facility courtyard unattended and fell and was exposed to the elements for approximately 15 minutes. The report received from the nursing home to the hospital read "hypothermia and right hand." The final [DIAGNOSES REDACTED]. A progress note, dated 12/12/13, one week after the resident received frostbite to the right hand the attending physician made the following documentation in the resident medical record in the section progress notes. The note read "the resident was reported to have sustained frostbite after wandering in the backyard where he was found having fallen down. Under the section assessments the physician had documented frostbite as the primary reason for the visit on the date. The physician also documented that the resident had frostbite to both hands on the fingertips. The resident should be monitored for skin breakdown and apply local dressing till healed, The resident required an increase in pain control medications and the addition of Tramadol a pain reliever was added to the resident's medication regime on 12/12/13.

Based on observations, interviews and record reviews, the facility failed to accurately assess a pressure ulcer upon admission and provide necessary treatment and services to promote healing, prevent infection and prevent new sores from developing in a timely manner for two of seven sample residents (#2, #1). Specifically: Sample resident #2, who was admitted with a Stage I pressure area on the sacrum, developed additional pressure areas, including advancement of the sacral pressure area to a Stage IV which required surgical debridement after admission. Sample resident #1 had a foot abrasion that progressed to a stage III pressure sore. The findings include: Sample Resident #2 A. Resident Status Non-interviewable sample resident #2, age 62, was admitted to the facility on [DATE] under full Cor status from an acute care setting with the following [DIAGNOSES REDACTED]. Resident #2 was readmitted on the following dates after hospitalization to treat acute medical conditions: 10/26/13, 11/25/13, and 12/10/13. According to admission Minimum Data Set (MDS), completed on 9/26/13, the resident's cognitive score was 0/15 on the brief interview mental status (BIMS), indicating severe cognitive impairment. Review of the MDS revealed resident #2 had short and long-term memory problems and was moderately impaired for daily decision making. There was no indication for rejection of care or behavioral symptoms interfering with the resident's care. Further review of the MDS revealed resident #2 was totally dependent on staff for bed mobility, transfers, locomotion on/off the unit, dressing, eating, toilet use, personal hygiene and bathing; all of which required two person physical assist to complete the tasks. The resident had limitation in bilateral lower extremities and required a wheelchair for mobility. The resident was admitted with an indwelling catheter and was always incontinent of bowel. The resident's admission wt (weight) was documented to be 124# (pounds) and was on a mechanically altered, therapeutic diet. The admission MDS assessed the resident to be at risk of developing a pressure ulcer and revealed the resident had an unhealed, Stage 1 pressure ulcer upon admission. B. Reference According to Daniel Silverman, M.D., "Prevention of Pressure Sores," Coping with [MEDICAL CONDITION], July 2009, www.msfocus.org <http://www.msfocus.org> (1/3/14). Contrary to popular belief, it is not MS, but immobility, that creates an increased risk for pressure sores. Pressure sores are usually seen over bony prominences, including the coccyx, buttocks, heels, elbows, and other areas. In such areas, the skin is pressed and rubbed between the bone underneath and the clothes or bed sheets above. The clothes or sheets act like sandpaper, rubbing away the layers of the skin. If this goes undetected, which may happen in an area of numbness, the skin can erode all the way down to the muscle, or even the bone. The exposed tissues may become infected and begin to decay from lack of circulation. In some cases, this can be life-threatening. Fortunately, pressure sores are preventable. C. Record Review: a. Resident Data Resident-data collection sheet and nurse's note for admission completed on 9/20/13 at 12:00 p.m., identified resident #2 to be total assist for all ADLs and transfers, and oriented to person only upon admission related to [MEDICAL CONDITION] and dementia. According to documentation on the body diagram, the resident had redness on the sacrum (no measurement), dryness to the bilateral feet, with no other skin issues identified. The admission weight was recorded as 124.3 lbs. The BRADEN scale for predicting pressure sore risk, completed 9/20/13, indicated the resident was moderate risk with a score of 13/23; a total score of 12 or less represents high risk. The resident also had a Foley catheter and was incontinent of bowel. On 9/20/13, the facility initiated a resident care plan in which the following problem was identified: Resident has bowel incont (incontinence) and [DIAGNOSES REDACTED]. The documented goal was the skin will remain intact (target date of 12/20/13), and free from additional skin breakdown/irritation x 90 days - also with an original target date of 12/20/13. Approaches included: Pressure redistributing mattress and/or wheelchair cushioning, appropriate footwear, weekly skin checks, promote adequate nutrition and hygiene, report symptoms of infection (odor, increased drainage, pain or redness), RD consult as needed, incontinent care as needed, adult briefs and barrier cream as indicated, notify MD, family, and responsible party of changes, turn and reposition as needed, treatment as ordered, and weekly wound monitoring. b. physician progress notes [REDACTED]. Review of the physician nursing home admission visit and note, dated 9/23/13, indicated the resident had no rashes or [MEDICAL CONDITION] present on the skin. The assessment summary indicated the resident was incontinent of urine and had no reported skin breakdown. On 10/1/13, Prostat 30 ml PO BID, sugar free (a protein supplement providing 128 kcal, 30 gram of protein) for wound healing was ordered. 10/10/13 A physician nursing home regulatory visit (NHRV) note read in part: Foley was d/c 9/30/13 without sequelae, patient on Prostat sugar free for sacrum/coccyx wound, nurse reports it is getting smaller. Wound not visualized today as patient declined, wanted to sleep. On back in bed, cooperative, short answers, 124#. 10/17/13 The resident was admitted to the hospital for treatment of [REDACTED]. There was a notation by the facility that the resident had a sacral wound when she was sent to the hospital. The resident #2 returned to the facility on [DATE]. A computerized wound assessment report for the resident's wounds for 10/28/13 revealed in pertinent part the pressure ulcer to sacrum was first identified on 9/30/13 and not present on admission. According to the documentation, the wound status deteriorated. It was currently a Stage III, measuring 3.5 cm x 1.0 cm x 0.10 cm. (See Skin Review Committee & Skin Assessments below.) 10/26/13 The hospital discharge summary noted the following new Diagnoses: [REDACTED]. There was also notation that the resident had some skin break on her ankle however, it did not indicate which ankle, stage or size of the wound. 10/26/13 Pertinent physician orders [REDACTED]. [MEDICATION NAME] with daily dressing changes. 10/28/13 Wound care order revealed: Right great toe - Clean with NS, apply skin prep to blister and surrounding area, leave open to air every shift. A 10/30/13 order note from resident #2's primary care provider (PCP) was reviewed and read in part: patient with wounds: left medial heel, coccyx and right great toe. Orders: wound care consultation URGENT for wound left medial heel, coccyx and right great toe, consult, tests, procedures, treatments, visits. The resident had lab tests and an x-ray of the left heel completed on 10/31/13 to rule out osteo[DIAGNOSES REDACTED]. The resident had a high white blood count (WBC) at 15.8. The x-ray was negative for osteo[DIAGNOSES REDACTED]. On 11/01/13 at 1:25 p.m., the facility received a telephone order from the resident's PCP to initiate Palliative Care services provided through the resident's PCP. Change in wound care orders received 11/04/13 read in part: D/c previous wound care orders. Clean sacral wound with saline wound cleanser, cut [MEDICATION NAME]/Duoderm to border wound, apply mixture of zinc oxide 20% and [MEDICATION NAME] powder to wound, apply Dakin's solution 0.25% moistened gauze to wound bed, cover with [MEDICATION NAME] over [MEDICATION NAME]/Duoderm. Change daily and prn. Notify Palliative nurse of any changes to wounds or refusal of care. Left heel cleanse with Saline wound cleanser, apply zinc oxide 20% to peri-wound, apply Dakins solution 0.25% moistened gauze to left heel and wrap with kerlix, secure with Tubi-grip. Change daily. Measure wounds weekly and fax measurements to the PCP. Off load heels with pillows and boots at all times. The physician progress notes [REDACTED]. An 11/20/13 physician progress notes [REDACTED]. Wound #1 coccyx, wound #2 left heel, and wound #3 right great toe. Palliative care nurse doing wound care and nurse at facility. Patient on [MEDICATION NAME], second round 11/7/13 for elevated, although improving, WBC 13.0 on 11/7. No fevers. Upon physical examination the patient was lying supine in bed. Wounds were assessed and documented as: 1) Coccyx, Stage III, 4 cm x 4 cm, x less than 0.25 cm deep, with pink and yellow wound bed; no eschar. 2) Left heel, unstageable, 3 cm x 3 cm, wound bed pink with central red area no slough, peri-wound pink, no maceration; no eschar. 3) Right great toe, no wound, skin pink and intact. Record review revealed that resident #2 was hospitalized from 11/22-11/25/13, with a discharge [DIAGNOSES REDACTED]. On 12/04/13, an order note from the resident's PCP read in part: Coccyx- d/c Dakins and gauze. New treatment order for Zinc oxide to periwound, apply [MEDICATION NAME] to wound bed, cover with non-adhesive pad, cover with [MEDICATION NAME] placed on Duoderm borders. Continue turn schedule every two hours, d/c (discontinue) wound treatment to left heel, resolved. Continue heel protector boot and off loading. On 12/05/13, the physician progress notes [REDACTED]. Upon examination, the patient was lying on back in bed. Change in wound care orders received 12/02/13 read in part: -D/c current coccyx wound treatment -Cleanse coccyx wound with wound cleanser, apply skin prep to peri-wound, cut [MEDICATION NAME]/Duoderm to border wound, apply mixture of zinc oxide and [MEDICATION NAME] powder to periwound. Apply [MEDICATION NAME] to wound, cover with non-adherent pad and cover with transparent dressing over Duoderm daily and as needed. On 12/05/13, nutritional med pass supplement 120 cc was initiated and given orally twice daily between meals and documented on the resident's medication administration sheet. Record review revealed resident #2 was hospitalized from 12/08-12/10/13, with hospital discharge [DIAGNOSES REDACTED]. Review of the PCP orders, dated 12/13/13, documented the following: nurse practitioner had decided to consult their wound care MD for heel ulcer but referral never issued. Plan/orders: wound care consultation, Physician at facility for sacral decubitus 12/13/13. See amendment-wound care for sacral decubitus. Continue physician at facility for wound care. On 12/16/13, a physician progress notes [REDACTED]. No notes or orders in chart. Per DON wound was debrided. Patient on back in bed most of day; up in wheelchair twice daily for one hour. Legs flaccid, some contractures at the knee, ankle, is unable to move arms voluntarily. Sacral wound Stage IV 15% yellow slough, 40% black eschar, 5.5 x 6.0 x 1.0 cm with undermining from 11 to 1 o'clock at 1.5 cm deep. Peri-wound is red and excoriated 2 cm surrounding the entire wound. Continue to see wound care doctor at facility. Change in wound care orders received on 12/16/13 per physician progress notes [REDACTED]. Clean daily with wound cleanser, Dakins packing, cover with 4x4, [MEDICATION NAME] or Duoderm borders, cover with transparent film dressing. Periwound apply zinc oxide mixed with contents of [MEDICATION NAME] capsule daily. Position patient on side, turn every 2 hours. May be up in wheelchair one hour daily. Change in wound care orders received on 12/23/13 read in part: D/C previous orders for sacral wound care Clean wound with wound cleanser, apply skin prep to periwound, and cut Duoderm to border wound. Apply mixture of zinc oxide with contents of [MEDICATION NAME] capsule to periwound. Apply Santyl ointment to wound bed, cut Calcium Alginate to wound size and apply to wound bed then cover with a foam dressing and secure with transparent film dressing. Change daily and as needed for drainage. Apply skin prep every shift to left heel blisters. Change in wound care orders received 12/30/13 for bilateral heels documented:. Apply skin prep daily to soft area of right heel Left heel, clean with wound cleanser, apply skin prep and hydrofoam dressing covered with kerlix. c. Care Plan: 9/30/13- Bowel and Bladder Incontinence 9/21/13 Self care deficit related to [DIAGNOSES REDACTED]. Approaches: PT/OT as ordered, provide assistance with all ADLs. On 9/30/13, the facility updated the care plan to include the identified Stage II Sacral Pressure Area. The documented goal read: will be healed without complications (no target date was identified). The following approaches were added: administer treatment as ordered by MD, weekly and as needed skin assessment, notify MD of changes, air mattress. The care plan was updated on 10/26/13, after the resident returned from the hospital and revealed: re-admit from hospital with Stage III sacral decubitus, blister on right great toe and left heel, and excoriated perineal area. Goal - will heal without complications. Approaches: Administer treatment as ordered by MD, weekly and prn skin assessment, notify MD of increased changes, air mattress, and relieve pressure off bilateral feet, nutritional supplement per order. A review of the care conference notes, dated 11/12/13 in summary revealed the resident was incontinent of bowel and bladder and had one Stage II pressure ulcer; as well as one Stage III pressure ulcer (no indication as to location or wound status/progress). The document recorded the resident's weight at 97 pounds, with unstable checked next to the weight. It was also noted that the resident was on Prostat and Juven supplements; however, there was no documentation addressing a plan for the resident's unplanned weight loss. The resident care plan was updated on 11/25/13: re-admit from hospital with stage III sacral decubitus. There were no new or additional interventions documented. d. Nurse's Notes: A review of the nurse's notes from 9/20-9/30/13 read in pertinent part: Staff must anticipate resident needs, requires assist with ADL's and transfers. According to the notes, the resident was up in the wheelchair most of morning and evening shifts without mention of repositioning or off-loading of pressure to resident's coccyx or sacrum. On 9/30/13, a nurse's note entry identified the resident was developing a pressure ulcer to the coccyx measuring 4.1 x 2 cm. Barrier cream and a dressing were applied. The note indicated the resident is repositioned every two hrs when in bed to alleviate pressure. The Foley catheter was discontinued on 9/30/13. The first order for wound treatment was obtained on 9/30/13 and read: clean wound with wound cleanser, apply barrier cream and sacrum dressing daily and prn for draining, monitor for signs and symptoms of infection. On 10/26/13, the nursing re-admission note read in pertinent part: Resident has a blister to left heel measuring 10 x 6 cm, blister to right great toe measuring 3.0 x 2.5 cm. The resident had pressure sore to right buttock next to sacral wound of 3.5 x 1 cm, and a pressure sore to right buttock measuring 1.0 x 1.0 cm. There was excoriation to groin area, and a Foley catheter. The resident [MEDICAL CONDITION] in the wound, and was placed on contact precautions. The resident's physician was notified that the director of nursing wanted a wound nurse STAT (immediately). The physician said they would send a wound nurse by Monday. e. Skin Review Committee & Skin Assessments On 10/14/13, a Skin Review Committee report was provided by the assistant director of nursing (ADON) (who was also the facility skin management nurse) on 12/30/13 at 12:45 p.m. It documented the resident as having a Stage III pressure ulcer to the coccyx measuring 3.5 cm x 1.5 cm x 0.1 cm; prior to her hospitalization ,[DATE]-[DATE]. The document described the treatment as cleanse, apply Santyl to wound bed and cover with a [MEDICATION NAME] border dressing, change daily and as needed. On 10/15/13, the treatment order was changed to every other day and as needed dressing changes. The facility completed a computerized wound assessment report for the resident's wounds for 10/28/13. The report was completed by the ADON, and read in pertinent part: 1) Pressure ulcer to sacrum with excoriation was first identified on 9/30/13; not present on admission. Wound status is deteriorated. Currently Stage III, measuring 3.5 cm x 1.0 cm x 0.10 cm with scant amount of serosanguinous drainage. The resident has symptoms of infection and currently being treated for [REDACTED]. The surrounding skin is red and indurated. There is a notation that the resident returned from the hospital with the pressure ulcer having increased redness around the peri-wound area and that the resident is on antibiotics [MEDICAL CONDITION]. 2) Wound type is categorized as other: Blister to left heel. The documentation revealed the wound was identified on 10/28/13 as being a new wound and present upon re-admission. The cause is listed as unknown. The wound measured 1 cm x 6 cm x 0.00 cm. The wound had moderate amount of serosanguinous drainage. The affected extremity had more than three second capillary refill, was of normal color, warmth and elasticity. The note indicated the wound resolved on 12/4/13. 3) Wound type was categorized as other: Blister to right great toe. According to the assessment, the wound was identified on 10/28/13, a new wound, present upon admission. The cause was unknown. There was no evidence of drainage. The skin on the affected extremity was described as of normal color, temperature, with the skin being shiny and taut. There were no measurements recorded. 4) The assessment documentation indicated the wound resolved on 11/18/13. The facility completed a computerized wound assessment report for the resident's wounds for 12/4/13. The report was completed by the ADON, and read in pertinent part: 1) Pressure ulcer to sacrum has deteriorated. Assessed as a Stage III, measuring 5.0 cm x 4.0 cm x 0.9 cm deep. No drainage or evidence of infection is documented. The wound consists of 80% slough and 20% granulation tissue and is described as normal healthy tissue. The resident's current weight on the assessment is 124.30, same as the original admission weight. There was a notation dated 11/26/13 to monitor coccyx wound every shift for signs and symptoms of infection. A computerized Braden risk assessment report was completed on 12/6/13 by a facility staff nurse as a quarterly assessment. The resident's risk level was determined to be very high with a total risk score of 9 (a score of 12 or less is high risk). The assessment indicated the resident was completely immobile and did not make even slight changes in body or extremity position without assistance. The facility completed a computerized wound assessment report for the resident's wounds for 12/12/13. The report was completed by the ADON, and read in pertinent part: 1) Sacral pressure ulcer, Stage III is deteriorated. The wound now measured 5.5 x 4.5 x 0.9 cm with scant amount of serosanguinous drainage. The wound bed was comprised of 90% slough and 10% granulation tissue. The wound edges were described as well defined with normal healthy skin, although macerated. The peri-wound was pink with slight [MEDICAL CONDITION]. The resident's weight was documented as 120.4 pounds. On 12/16/13, the facility completed a computerized wound assessment report for the resident's wounds. The report was completed by the ADON, and read in pertinent part: 1) Sacral pressure ulcer, Stage IV is deteriorated. The wound now measured 5.6 x 6.0 x 1.0 cm with a small amount of serosanguinous drainage. The wound bed was comprised of 50% slough, 40% eschar, and 10% granulation tissue. There was undermining present from 11 to 1 o'clock. The wound edges are macerated. The resident's weight remained documented at 120.4 pounds. f. Dietary Notes: The dietary nutritional evaluation, completed on 9/26/13 by the consultant dietitian, indicated the resident's skin was intact and there was care in place for redness. The dietitian determined the resident may need additional protein added for skin care. Resident #2 was assessed to require 67 grams of protein per day based on 1.2 gm/kilogram of wt. 10/8/13 Dietary progress notes completed by the consultant dietitian read in part: follow-up from phone call on 10/1/13 regarding pressure ulcer. Recommended Prostat. Last recorded wt 124#. Provided diet education for wound care. Current wt 131#, weight up 7# since admission, 5% wt gain, acceptable wt. On 11/8/13, a significant change in status MDS assessment was completed by the facility. Under section K, for swallowing/nutritional status, the resident's weight was recorded at 97 pounds; documentation indicated the resident had significant weight loss. The documentation also revealed the resident was assessed to have one Stage III pressure ulcer present upon readmission, and two unstageable pressure ulcers also present upon readmission. 11/20/13 Dietary progress notes completed by the consultant dietitian read in part: Reviewed related to weight and skin. Current weight 120 pounds, return to usual body weight. Possible weight change related to [MEDICAL CONDITION]. Review of labs and recent orders including Palliative care. Diet order consistent carbohydrates, pureed texture with thin liquids. Per DON, wound area improving. Continue nutritional intervention at this time of Prostat 30 ml twice daily and Juven twice daily. A review of the care plan on 12/30/13 revealed an initial nutrition care plan dated 9/20/13 with no specific problem, goal or target date identified. The care plan interventions were not resident specific; consisting of a check list as follows: intake/appetite, diet, weigh, supplements. Facility Action Plan: On 12/31/13 at approximately 11:00 a.m., the DON provided a form titled "Plan for Resolution," to address the issue with the facility identified inaccurate weights. According to the document, inaccurate weights were identified on 11/10/13. The document revealed the following pertinent issue/concerns - 1) weights not accurate, 2) increased weight loss over several months, 3) errors in previously reported weights. The documented interventions to address the above concerns read in pertinent part: dietitian consultant to be in the building 2 x a month to review all residents with weight loss (target date 11/10/13). Wound Care Specialist (WCS) Evaluations: On 12/13/13, the resident was evaluated by the facility contracted wound care specialist. A review of the initial evaluation revealed the following in part: Stage IV pressure ulcer of midline sacrum at least 86 days duration. There is no indication of pain associated with the wound. The resident is contracted and immobile. The wound is assessed to measure 4.5 x 6.0 x 1.7 cm, with 80% eschar and 20% devitalized necrotic tissue. The periwound had deep tissue injury (purple/maroon). There was light serous drainage present. The wound was debrided via surgical excision and muscle removal along with necrotic tissue. The following recommendations were made: Dressing - Calcium alginate, foam, and [MEDICATION NAME] once daily, and a group- two mattresses, gel cushion in wheelchair, limit sitting to 60 minutes, off-load wound, reposition per facility protocol. The need for Santyl as opposed to [MEDICATION NAME] given the degree of necrosis, techniques for offloading, debridement, long-term time frame to complete wound healing, and strict need for off loading was discussed with the wound care team, resident and family. On 12/20/13, the resident's sacral wound was assessed at a Stage IV and measured 6.0 x 5.5 x 2.2 cm. The periwound was excoriated and macerated. The wound had light serous drainage. The wound consisted of 5% black necrotic eschar, 90% devitalized necrotic tissue, and 5% granulation tissue. Documentation revealed the wound was not improved and that the wound edges had been desiccated by application of Dakins. Notes indicate there was further necrosis of the wound by application of Dakins. According to the wound care specialist's documentation, the resident's palliative care nurse changed his orders and told staff that her company would not provide Santyl and calcium alginate for the wound. The DON is to discuss with the facility medical director. The wound was debrided via surgical excision and muscle removed along with necrotic tissue. Recommendations were unchanged from prior assessment. 12/26/13 Stage IV pressure ulcer at least 97 days duration, measuring 5.8 x 6.4 x 1.4 cm. The periwound has [DIAGNOSES REDACTED]. There was moderate serous drainage. The wound consisted of 5% black necrotic eschar, 90% devitalized necrotic tissue, and 5% granulation tissue. The left heel has unstageable (due to necrosis) pressure ulcer measuring 2.5 x 5.7 x not measurable cm. There is no drainage associated with the wound. The wound is comprised of 25% black necrotic tissue and 75% devitalized necrotic tissue. The black eschar measures 2.5 x 1.5 cm, and now connects to previous blister. Recommendations: Dressing- Skin Prep, every shift. EZ boot (Prevalon) to be worn in bed and chair to off-load wound, float heels in bed, off-load wound. Observations: On 12/23/13 at 10 a.m., the resident was observed lying on her back and was repositioned onto her right side facing the wall by the certified nurse aide (CNA). During repositioning, the resident's sacral area was covered by a dressing that was grossly soiled with dark brown drainage. The primary dressing was secured with a transparent film that had rolled up on the edges allowing drainage to seep out and onto the bed linens. She was wearing Prevalon boots to bilateral feet. The resident had a Foley catheter with a bedside drainage bag stored in a wash basin that rested on top of the impact mat in front of the bed. The resident was resting on a group-two alternating air pressure mattresses. The recover air 3500 mattress had a tag attached to the pump indicating it was delivered to the facility on [DATE]. On 12/23/13 at 10:30 a.m., the sacral dressing change and wound care were provided by the PCP's palliative care nurse (PCN), and the ADON. Observations include: the soiled dressing had been removed prior to the observer's arrival. The ADON cleaned the wound bed using 4x4's and a premixed wound cleansing spray. The sacral wound was measured to be 7.5 x 5.0 x 1.5 cm with undermining from 11 to 2 o'clock measuring 0.5 cm deep. The measurements were performed by the ADON. Wearing the same gloves the ADON applied skin prep to the periwound area, then applied the precut Duoderm strips around the wound to create a border. A mixture of zinc oxide and [MEDICATION NAME] powder was painted around the periwound to the edge of the inner border of Duoderm. The ADON removed the soiled gloves but did not wash his hands prior to donning new gloves. 4x4's were soaked with a 25% Dakins solution, then folded and placed in the wound bed and covered with a transparent film secured to the Duoderm border. The resident was nonverbal throughout the dressing change even when staff attempted to engage in conversation. The resident did not appear to be in pain, although facial expression could not be observed due to her positioning. The PCN assisted by opening the dressing packaging, cutting the Duoderm for the border and holding the resident on her side. Cross reference 441- Infection Control On 12/23/13 at 10:45 a.m., the resident's feet were observed. The PCN and ADON reported that the resident's left heel resolved approximately two weeks prior and that there was no scab as of last Monday. The left medial heel was observed to have an unstageable black eschar measuring 2.0 x 1.5 cm. When asked about the findings, the PCN and ADON stated that the resident's heel was resolved as of two weeks prior. The PCN then said it must be new because it was not there last week. There was a new Stage II clear fluid filled blister to the bottom of the left heel measuring 2.0 x 1.3 cm measured by the ADON. The ADON applied new gloves prior to measuring the left heel but did not perform handwashing or hand hygiene. The PCN and ADON confirmed that the blister had not previously been identified. The PCN applied skin prep to both areas prior to the Prevalon boots. Further observations revealed the resident's wheelchair cushion was a honeycomb patterned cushion with no cover, measuring approximately 2 inches; and, when pressure/weight was applied to the cushion while it was on the wheelchair, the seat it bottomed out, providing ineffective pressure relief. The ADON took a thicker foam cushion that was on the floor resting and placed it on the wheelchair and placed the gel cushion on top of it. The ADON said he would check with therapy to see what they had available. On 12/26/13 at 9:04 a.m., the resident returned from the shower room. At 9:10 a.m., the resident was observed sitting on the shower chair in her room covered by the sheet, her sacral area was visible from the opening between the chair back and seat. There was no dressing covering her wound. The wound was completely exposed; the mesh chair back was within a few inches of the wound. At 9:30 a.m., the resident was resting in bed on her right side, facing the wall. The Prevalon boots were in place with the feet resting directly on the mattress and not floated. The resident's side lying pressure points were not off loaded with pillows; her knees resting on one another. At 10:15 a.m., the unit nurse prepared supplies for the facility contracted wound specialist to provide treatment to the resident's sacral wound. At 10:30 a.m., the wound care specialist arrived at the resident's room. The physician measured the sacral wound to be 5.8 x 6.4 x 1.4 cm deep; a stage IV pressure sore. It had dark adherent eschar around the wound edges from approximately 7-10 o'clock and again at 2 o'clock. Thick yellow slough filled the wound bed from 7 to 12 o'clock. At 10:45 a.m., the physician performed sharp surgical debridement. The ADON stated the wound was being treated with Santyl ointment; however, the Santyl ointment tube was new, still in the box with an order date of 12/23/13. The WCS gave verbal recommendations until the written report was sent to the ADON and unit nurse to use Santyl and calcium alginate to the wound daily and as needed. The unit nurse was observed to clean the wound then change her gloves, but did not wash her hands. She then applied zinc and [MEDICATION NAME] mixture to the periwound and Santyl to the wound bed using a sterile cotton applicator. While the ADON assisted the WCS and ADON he was observed touching the privacy curtain and table top surfaces with gloved hands. The ADON did not remove his original gloves until 11:05 a.m., then did not wa

Based on record review and interviews, the facility failed to ensure incidents of abuse/involuntary seclusion and altercations among residents of verbal, physical, and sexual aggression on the open unit, as well as the facility's two secure units, involving eight of 18 sample residents (#3, #6, #4, #8, #12, #16, #14, and #7), were thoroughly investigated and that measures were taken to protect residents from further incidents of abuse. Cross-reference F223D (abuse); F226D (abuse policies) and F323K (accidents). The incidents of abuse, seclusion, verbal, physical and sexual aggression set forth in these deficiencies created a situation of immediate jeopardy for serious harm. The findings include: I. IMMEDIATE JEOPARDY A. IMPOSITION OF IMMEDIATE JEOPARDY On 6/6/11, a complaint was called in to the Health Facilities and Emergency Medical Services Division (HFEMSD) that alleged sexual abuse had occurred between residents on 5/13/11. Upon arrival at the facility and review of the facility documentation, it was determined the alleged sexual abuse, by male resident #4 toward female residents #3 and #6, had occurred. Record review revealed numerous episodes of abusive and/or threatening behaviors by residents #16 and #4, inadequate supervision of the residents, and lack of effective safety precautions and interventions to prevent further incidents of resident to resident abuse. Further record review also revealed episodes of aggressive behavior by residents #7, and #8 toward other facility residents. The facility failed to timely, adequately and effectively intervene to minimize the risk of repeat episodes of such aggression and to protect residents' safety. On 6/6/11, at 7:15 p.m., the nursing home administrator (NHA) and the Director of Nursing (DON) were informed by HFEMSD of the State Health Department that the facility's failure to adequately supervise residents who physically, verbally and/or sexually abused other residents created situation of immediate jeopardy for serious harm. B. FACILITY ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY The facility's proposed plan to remove immediate jeopardy, submitted 6/8/11 at 11:30 a.m. and again at 3:40 p.m., were rejected by HFEMSD as incomplete. The facility submitted another plan on 6/9/11 at 11:25 a.m. This plan included a timeline of actions taken after the incidents involving resident #4 on 5/13/11 and residents #3 and #6. Section 1: "Allegation of Removal of IJ In regards to (resident #4) on 6/7/2011 the following actions were taken upon receiving the IJ: -A sitter was placed outside of his room -15 minute checks were immediately implemented -Sitters were scheduled for around the clock -The sitters were instructed to document on the fifteen minute check form the resident's behaviors every fifteen minutes -The sitters' schedules and fifteen minute check forms were given to the Survey Team -A meeting was held with the unit Charge Nurse and the IDT (Interdisciplinary Team) @ approximately 1900 (7:00 p.m.) to discuss a plan of action if the Resident's behaviors/aggression increased/escalated. -The plan of action was to call the (name of city) Police Department immediately -Shortly after the IDT meeting, the sitter reported she was with the resident explaining her responsibilities/duties, he became threatening and used profanity. He told her to get out of the room and that is when she left and reported the situation to the Administrator. -The family was notified and informed of the current situation -The resident was also notified the Police were being called due to his behaviors -A conference call with the NP (Nurse Practitioner) occurred concerning the incident and discharge orders -Police arrived and took over the situation -Family arrived and removed all personal belongings -Resident arrested -Charge Nurse gave the Police the resident's medications with instructions -Charge Nurse gave scheduled medications to resident prior to him leaving with the Police -The family informed the Administrator and the Police that the resident would be released to their custody and not return Section 2: Abuse Reporting and Investigation -All active staff will be in-serviced on Abuse Reporting -Staff will be in-serviced prior to reporting to work for their shift and/or shortly after taking assignment -The facility conducts an investigation of alleged or suspected abuse -The facility designates a qualified staff member as oversight for abuse prohibition -Employees are educated that they must report any suspicious event that may constitute abuse -All incidents are tracked to identify possible trends that could constitute abuse -Any events of unknown origin are investigated -The facility's administrator/designee conducts an internal investigation and reports the results of the investigation to enforcement agency in accordance with state law including the state survey and certification agency within 24 hours -Investigations are prompt, comprehensive and responsive to the situation -All staff are in-serviced on reporting alleged, suspected or known abuse to the charge nurse -Immediate action will be taken to ensure the safety of all residents; suspension of the employee, removal of the assailant, 1:1 supervision, 15 minute checks of the assailant until appropriate action can be taken -Charge Nurse reports the incident to the Director of Nursing immediately -The Director of Nursing immediately notifies the Administrator at this time -The Director of Nursing and/or designee will notify the State Agency of the occurrence, Police, Family, Physician and Ombudsman -All active staff will be in-serviced on the above by 6/9/2011 -Staff will be in-serviced on a continued basis for the next 3 months on the abuse policy. Then policy will be incorporated in more detail during Orientation by the Administrator/designee -Chain of Command is as follows: Person observing will tell Charge Nurse and/or Supervisor>Director of Nursing>Administrator>Regional Director>Nurse Consultant (The reporting to whom depends upon the department that the observer is working) -A random audit will be done on abuse reporting to ensure staff are well versed in the process daily times 5 days, weekly times 4, then monthly thereafter for 3 months. Results will be taken to QA (Quality Assurance) monthly -Results of audits will be monitored through QA on a monthly basis." The interim NHA signed and dated the allegation to remove immediate jeopardy as of 6/9/11. The interim NHA signed and dated the allegation to remove IJ as of 6/9/11. The allegation to remove IJ was submitted by the facility to HFEMSD on 6/9/11, at 11:25 a.m. IJ was not removed at this time, however, because review of all "Abuse Training In-service Records" submitted on 6/9/11 at 11:25 a.m. C. REMOVAL OF IMMEDIATE JEOPARDY On 6/10/11 at 2:00 p.m., review of staff training records revealed the facility had substantially complied with staff training; all but three staff had received training on abuse. The allegation to remove immediate jeopardy was signed by the NHA. On 6/10/11, at 2:00 p.m., the NHA, DON and Regional Director were notified that the immediate jeopardy in F225 had been removed; however, deficient practice remained at a scope and severity of a G (actual harm). II. FACILITY POLICIES, PROCEDURES AND TOOLS IN EFFECT 2/27/11 Abuse, Neglect, and Misappropriation of Property (This undated and unsigned policy/procedure was supplied to the surveyors upon request). It read, in pertinent part: 1. Standard 1) The facility prohibits resident neglect and mental or physical abuse, including but not limited to, involuntary seclusion and the misappropriation of property of residents. 2) The facility conducts an investigation of alleged or suspected abuse, neglect, or misappropriation of property and provides notification or information to the proper authorities according to state and federal regulations. 3) The facility designates a qualified staff member as oversight for the abuse prohibition standard. 2. Employee Screening The facility does not retain and (sic) employee with a history of abuse or neglect if that information is known to the facility. 3. Training All new and current employees receive training and education on abuse, neglect and misappropriation of property at the time of their initial employment, annually and through ongoing in-service. Employer training includes, but is not limited to, the following topics: (a) identification of potential victims of abuse or neglect, (b) interventions to be taken by employee and employer if abuse of (SIC) is suspected, (c) reporting incidents of abuse and neglect to your supervisor, (d) reporting to the state and (e) identification of employees at risk for engaging in abuse/neglect. 4. Prevention Staffing levels are assessed on a continuing basis. Adjustments to staffing levels are based on census and the individual needs of the residents. Each facility administrator completes an analysis to determine any special needs or risks associated with their facility. 5. Identification Employees are educated that they must report any suspicious event that may constitute abuse or neglect. Each facility tracks all incidents and accidents to identify possible trends that could constitute abuse or neglect. 6. Investigation 1) The facility's administrator or designee conducts an internal and reports the results of the investigation of (sic) the enforcement agency in accordance with state law including the state survey and certification agency within five (5) working days of the incident, or according to state specific law. 2) The facility investigates all alleged violations and, when indicated, takes appropriate actions. 3) Investigations are prompt, comprehensive and responsive to the situation. The facility strives to ensure the investigation will include, but is not limited to, the following: -Identification of the person abused -Notification of physician and family -Identification and the removal of the alleged person or persons responsible for the incident -Type of alleged abuse -Where and when the incident occurred -Interviews and/or written statements from individuals with first hand knowledge of the incident -Follow up resolution -Measures to prevent repeat incidents -All material/documentation of pertinent data to the investigation is collected, maintained and safeguarded by the facility -Notification of information relating to alleged or actual violation and its release to the proper authorities will be done as legally required. -Referrals may be made to private or public community agencies that provide or arrange for the evaluation of abuse victims. -The facility takes measures to ensure confidentiality to the extend (sic) possible. 4) Actions taken during the investigation are based on the outcomes of the investigation. 5) The alleged perpetrator of abuse is removed from the patient care setting or suspended during the investigation process. 6) If the allegations are founded, the suspension is without pay and appropriate disciplinary action is taken against the perpetrator up to and including possible termination. 7) If the allegations are unfounded or cannot be substantiated, the employee receives pay for the days of suspension. 8) In the event there is evidence of suspected or reported abuse by another resident, a family member or visitor, the facility will intervene and follow these practice guidelines. 9) During the investigation, the facility protects the resident, as appropriate, included but limited to the following: -Removal of the alleged abuser from the patient care setting -Enforcing a zero tolerance standard for retaliation against the alleged victim 10) The facility collects, retains and safeguards all information and evidentiary material pertinent to the investigation of alleged abuse or neglect. 11) If the alleged violation is verified, the administrator/designee notifies corporate legal counsel, regional vice-president and the regional nurse consultant and follows reporting and investigation measures under state and federal laws. 12) If a family member or other is suspected of violation of these policies, they may not be allowed to visit the resident or in any other way have access to the facility pending investigation. 6. Protection 1) The facility strives to keep all residents protected from harm. 2) All allegations involving staff necessitates either movement of the staff member to another area of the facility or suspension pending investigation. 7. Reporting/Response 1) The facility is aware it must report all alleged violations and substantiated incidents to the state agency promptly per state regulation and to all other agencies as required by state and federal law and that it must take all necessary corrective actions depending on the results of the investigation. 2) The facility must report to the nurse aide registry or licensing authority any knowledge it has of any actions taken by a court of law which would indicate any individual is unfit for service. 3) The facility analyzes all occurrences to determine what change or changes are needed, if any, to the facility's policies and procedures to prevent further occurrences. 4) The facility conducts self-audits of its own processes to ensure all requirements of policies and procedures are followed. III. FACILITY FAILURE TO KEEP RESIDENTS SAFE FROM ABUSE BY OTHER RESIDENTS AND STAFF A. Cross-reference F223; Abuse - involving residents #14 and #7. 1. Record review and interviews revealed resident #14, [AGE] years old, had a known tendency to reach out toward others (residents and staff) when they walk by him. Facility failure: On 6/12/11 (or 6/13/11), resident #14 was slapped in the face by a certified nurse aide. The aide had previously been reported for locking a resident in the shower room. 2. Record review and interviews revealed that after a resident to resident altercation in which resident #7 was an aggressor (in concert with another resident), resident #7 was confined to his room, after being told the alternative to confinement was placement on the men's secured unit. Facility failure: The facility plan to confine the resident to his room was broad and ill-defined. Specifically, the length of time the resident was to be confined to his room was uncertain, limited solely by evidence that the resident's "behaviors have changed." Moreover, there was no therapeutic plan of care to assist the resident in changing his behaviors and thereby, in limiting the length of his confinement to his room. Finally, there was no documentation that showed confinement of the resident at all times to his room, including for meals, was necessary and was the least restrictive approach for the minimum amount of time. On 3/4/11, the resident was transferred to the men's secure unit with police assistance. Record review revealed no documentation of the reason the resident was transferred to the secure unit on 3/4/11, or the reason the police were called to facilitate the transfer. See findings under F223 for further details. B. Cross-reference F323; Accidents - involving residents #16, #12, #3, #4, #6, #7, and #8 The facility failed to develop and implement interventions to ensure the safety of residents in the facility on the open and secure units from residents #16, #12, #4, #7 and #8, who had known aggressive, impulsive, and violent behaviors. 1. Resident #16 Record review and interviews revealed resident #12 ([AGE] years old) was choked in the common area by her roommate, resident #16 ([AGE] years old) on 4/24/11. On admission to the facility, resident #16 was known to be a danger to herself and others, with a history of suicidal and homicidal tendencies. Resident #16 also had a history of [REDACTED]. a. Residents #16 and #12 )1) Resident #16, [AGE] years old, was admitted on [DATE] to the facility's open unit. The resident was transferred to the mixed gender secure unit in 4/11. According to the face sheet, the medical [DIAGNOSES REDACTED]. According to the 3/24/11 Minimum Data Set (MDS), the resident scored nine, indicating moderate cognitive impairment. There were no [MEDICAL CONDITION] present, no physical or verbal abusive behaviors present and the resident required set up only for activities of daily living (ADL). The resident was independent with ambulation and transfers. (2) Resident #12, per closed record review, [AGE] years old, was admitted to the facility on [DATE]. According to the face sheet, the medical [DIAGNOSES REDACTED]. According to the 4/29/11 MDS, the resident was rarely to never understood, was delusional with moderately impaired cognition. The resident had short/long term memory problems and required extensive assist of one person assist for Activities of Daily Living (ADL). Review of the face sheet listed the primary language as "other" and birthplace as Romania. Resident #12 had a guardian. Review of the care problem/needs for this resident included at risk for falls secondary to confusion and decreased cognition, compromised skin integrity, potential for developing skin issues related to [DIAGNOSES REDACTED]. At the time of survey (6/6/11 - 6/16/11), the resident no longer resided in the facility. b. Resident #16's history showed problems with roommates and aggression prior to admission: -Review of the February 2011 hospital paperwork revealed resident #16 resided on the inpatient psychiatric unit awaiting placement for a locked nursing home and remained potentially dangerous to herself and others when angry or upset with a significant history of impulsivity (in the hospital since 12/25/10). The resident suffered from a mental illness that caused her to be a danger to self and others. The resident threatened to kill someone. During her hospital stay, she got into an altercation with her roommate (2/21/11). Again in March, 3/10/11, the discharge criteria was secured placement. On 3/14/11, the resident threatened to kill her roommate (while still in the hospital). (See above; the resident was admitted to the facility's open unit on 3/17/11 due to lack of a bed in the secure unit. She was transferred to the secure unit 4/11) -According to the 3/17/11 PASRR (pre-admission screening and resident review) recommendations (reviewed in pertinent part), -"...3. At the hospital, if (resident #16) becomes agitated or cannot sleep due to her roommate, she has been allowed to change rooms and this has been effective. It would be helpful to have her own room or be paired with a roommate who does not have a breathing apparatus and does not snore. (resident #16) can become very agitated and aggressive towards others when her sleep is disturbed in this manner... -Care plan to address 1. (resident #16) becomes a risk to self and others when she becomes agitated with others around sleep issues and issues with roommates. How will NF emphasize with staff that they should regularly check in with (resident #16) on how she and her roommate are doing? How will the NF approach conflict management with (resident #16)? 2. What will the behavior management plan be for issues of verbal threats, physical aggression, and [MEDICAL CONDITION]? How will the NF ensure the safety of other residents in lieu of a history of physical aggression when agitated?..." Attached with the PASRR information, from one of the mental health providers, the evaluator documented, "At this time a secure and locked facility is also recommended to enhance safety for the client and others. She also notes she feels at risk of relapse on an unsecured unit which has resulted in increased risk to others and self in the past...made multiple threats to kill other residents and herself, while residing at (a previous nursing home)...would like to be placed on a secured unit. She notes her fears of relapsing if she is not on a locked unit. She identifies that her most recent issues while at (hospital) have been with roommates." c. Review of facility care plans failed to clearly identify safety interventions related to roommate issues and conflicts: -A 3/28/11 care plan identified the resident was at risk for self-directed or violence directed at others due to history of physical and verbal aggression, poor impulse control, suicidal ideation, self mutilation and homicidal threats. The approaches included physician notification of mood/behavior changes, setting limits with resident, approach the resident in a calm manner, listen attentively and attempt resolution of problems, attempt to refocus behaviors to something positive with anger outbursts and encourage activities of the resident's choice and preference. Handwritten entries were made on this document, "resident will cut self superficial cut to get attention on her way, follow physician orders, mental health to treat, mental sees times per care plan and as needed, mental health to work with facility on treatment plan for times to prevent behaviors, provide 1:1s due to assaulting another resident. There was no indication when these interventions were added (dates on this document showed 4/11, 4/14, 4/15 and 4/25). -A 3/30/11 care plan revealed a history of suicidal and homicidal ideations with a history of threatening others, roommates who make her angry. The interventions included social services to meet one on one as needed, mental health services to follow her, staff to help her with preferred coping skills, offer rewards, encourage to take medications, encourage to verbalize feelings, attempt to keep room free of items she could use to harm herself and others and pour pop into a cup. There were no interventions directing staff to check in on the resident frequently to see how she and her roommate were doing and no plans related to escalating roommate concerns (see social service notes below). -The day of the choking incident (4/24/11) a 4/24/11 self harm and harm to other care plan was developed (additional dates were written on this care plan 5/30/11 and 5/8/11). Interventions included keep the resident in sight (or line of vision), escort the resident to the bathroom, and sent out to hospital for a mental health evaluation. One to one monitoring was implemented upon her return to the facility. d. Review of social service notes and nurse's notes revealed resident #16 expressed roommate concerns to staff and threats were made towards the roommate (notes reviewed in pertinent part): (1) Notes while residing on open unit: -On 3/18/11 social service note, "..does not have roommate right now that does not have a breathing problem and does not snore as she has had a history of [REDACTED]. -On 3/25/11, the social service note, "MH (mental health) is being looked into for her it is unclear if she is eligible for MH services...SW (social worker) meets with her almost daily to see how she is doing and remind her of coping skills..." -On 3/29/11, a care conference occurred and the following comments were documented: "...history of suicidal and homicidal ideations, has assaulted staff at previous facility, can be verbally abusive as well...history of stealing when opportunity presents itself, will lie and manipulate...is notorious for having difficulty with roommates, usually related to noise. SW to look into AA..." (2) Notes after transfer to secure unit. -On 4/12/11 at 5:40 a.m., the nurse documented, "...resident was having behavior during the early part of the shift. Verbalized 'I cannot stay in the same room with this my roommate, all she does is to talk in an unknown language'...resident was moved to room [ROOM NUMBER]B tentatively." -On 4/12/11 (no time), the nurse documented, "...Res. not adjusting to new roommate, Resident came out of room "I have to get out of here" Res. went to telephone, called 911, nurse stopped call. This nurse asked resident what's wrong? Resident says, 'I can't stay in the room with that woman, she never stops talking'. Redirected resident, talked to her and efforts calmed down resident. No further attempts to call 911 or to leave facility." -On 4/13/11, social services documented, "(name) is not happy with her placement on the secured unit. Explained to (name) why she was on the secured unit...did say she was not happy with the person she is sharing a room with and that all that person does is talk all night...was asked what she thought could help her she said a set of head phones might help her..." Headphones were obtained for the resident but there was no addition to the care plan with this intervention or to continue monitoring the roommate situation for these residents. -On 4/13/11 at 6:00 a.m., the nurse documented, "resident could not sleep all night related to roommate." --At 7:15 a.m., the nurse documented, "Resident tried to escape from the front door when the other residents were in line getting ready to go to the dining room for breakfast. She was in tears, she was mad and when this writer of night shift, nurse tried to talk to her; she was verbally aggressive later she told she could not sleep all night because of her roommate talking all nite. The resident was in tears and the staff reminded/re-directed her that we understand her situation and we'll talk with SW and DON (director of nursing) about this..." --At 1:35 p.m., the nurse documented, "tried to elope x3 during the shift..." -On 4/14/11 at 10:00 p.m. (after self cutting and sent to hospital), the nurse documented, "...Resident does not want to be in same room with (name of roommate)." -On 4/14/11, the resident called 911 again as she had cut herself. Social services documented, "the resident was standing next to the fridge by the window, with her left arm up in the air and was holding something sharp...She stated that she did not want to go back to her room because she stated her roommate was too loud..." The resident was transported to the hospital and returned the next day. One-to-one monitoring was implemented and 15-minute checks per the social service notes. -On 4/15/11 at 12:16 p.m., the nurse documented the resident was readmitted into room [ROOM NUMBER]A (same room and same roommate as before hospitalization ). About 30 minutes later, the resident cut herself with a toothpaste tube and was sent back to the hospital. The nurse documented, 'when you bring me back I'm going to hurt myself again.' The resident returned that evening on one-to-one monitoring. Even though nurses documented one-to-one observation was occurring after 4/15/11, on 4/17/11 on the 2-10 shift, the nurse documented, "Nurse spent one to one time with resident, resident stated, 'If I had someone to talk to all the time. I wouldn't try to hurt myself' Nurse advised resident that s/he can talk to staff at any time and when she feels like hurting herself to let nurse or staff know ASAP (as soon as possible)...Resident monitored on 15-minute checks." -On 4/18/11, social services documented, "...I don't care I want to kill my roommate." SW explained what a serious threat that was. (Resident #16) stated, 'I don't care, I will strangle her.' (Resident #16) was very upset. (Resident #16) said her roommate is too loud. SW explained there were no other beds available to move her to and also reminded her she has had three other roommates since her admission. (Resident #16) would not calm down, but stated she doesn't care. SW left her 1:1's and consulted with SW director. SW's spoke to (mental health name) and advised to call crisis team. Crisis team member came out to meet with (name. CNA from (name) unit ran up to SW and screamed we need help. SW along with other staff ran to unit when (Resident #16) had taken the fire extinguisher and set it off in hall, filling unit with smoke cloud. SW and other staff got resident out of unit. SW spoke with (Resident #16) about her actions and how they could have harmed someone else, she stated, 'I don't care.' Fire department and cops came, unit was cleaned. Dr. started resident on [MEDICATION NAME] IM every six hours until Dr. D/C...Psychiatrist to see resident on 4/19/11. On this date, resident #16 cut herself again with a hair clip. Mental health saw her and discussions took place for behaviors and reward strategies (if she was good for three-four hours, she received a pop when she did not self harm and within 24 hours, she would get her cards back). There was no revision to the care plan to reflect the threatening remarks of wanting to kill her roommate. Even when the remarks were made that she wanted to kill her roommate, social services stated there were no other beds available. -On 4/22/11 from 10-6, the nurse documented, "Resident was already in room [ROOM NUMBER]B (indicating a room move) before the report. Refused to go to room [ROOM NUMBER]A. Efforts made were not successful at this period..." Staff was attempting to have resident return to room [ROOM NUMBER] (with the resident she was threatening to kill). e. Incident 4/24/11 On 4/24/11, six days after resident #16 verbally threatened harm to her roommate (resident #12), resident #16 choked resident #12 in a common area: On 4/24/11 at 1:30 p.m., the nurse documented, "near 1230 resident out of chair with hands on neck, base of neck, 2 staff to pry her hands off the resident. She returns to her chair without event, now calm, she wants to go to jail. Calm and to room for short rest, comes out and after 10 minutes. Out of chair attempt with same resident again. Intercepted by 2 staff persons. Returned to chair..." Resident #16 was discharged to the hospital 4/24/11 for a mental health evaluation. According to social service notes dated 4/25/11, "..(Resident #16) will return today from hospital and she will be placed with a 1:1 at all times on the open unit and with a wanderguard...found a room with 2 quiet roommates." On 4/29/11 five days after the above incident involving resident #12, social services documented: "SW on locked unit and nurse told SW that (resident #16) had cut herself with a pop can tab, went after the nurse with cane and choked roommate in common area in front of staff. Residents separated. SW called 911 and (resident #16) is still on 1:1. (Resident #16) stated she wanted to kill her roommate. Cops took over an hour to respond r/t residents being separated - not an emergency according to dispatch...she was under arrest and placed her in handcuffs...SW explained that (resident #16) had threatened to kill her roommate last week by strangling her, she had set off fire extinguisher week before and (resident #16) admitted in front of officers that she had hurt roommate the week before, her roommate had been sent out the previous week with unknown bump on head, bruising, and swelling hand. (Resident #16) had previously denied having anything to do with this until today with the officers..." Review of resident #12's record revealed resident #12 was identified with bruising of unknown origin and was sent to the hospital for an evaluation on 4/21/11; nurses' notes 4/21/11 indicated resident #12 was observed to have a right lateral skin tear (location not specified), left hand [MEDICAL CONDITION] of +1, right arm bruise, right forehead bruise (above eye). An investigation was initiated. Resident #16 was discharged from the facility in June 2011. f. Staff Interviews A discussion occurred with the facility on the events of resident #16's room moves. The question was asked how the facility chose an appropriate roommate for resident #16 based on her history and resident safety: On 6/13/11 at 2:30 p.m., the Admissions Director (AD) revealed, "we felt she wasn't doing well in the open unit" and she was moved to the secured unit after a month, in a room with resident #12. When asked about resident #16's behaviors, the AD stated, "you can't take your eyes off of her (resident #16)." The admissions director revealed resident #12 could be vocal in expressing if something was going on that she didn't like. On 6/14/11 at 1:36 p.m. the Director of Nursing (DON) stated resident #16 was placed with resident #12 based on room ava

Based on observation, record review and interviews, the facility failed to ensure the resident environment remained as free from accident hazards as possible, and residents, including eight of 18 sample residents (#1, #3, #4, #6, #8, #7, #16 and #12), received adequate supervision and assistive devices to prevent accidents. Specifically: I. The facility failed to develop and implement interventions to ensure the safety of residents in the facility on the two secured units (an all male unit and a mixed gender unit) from residents #4, #7 and #8, #16, who had known aggressive, impulsive, and violent behaviors. The facility failures contributed to repeat incidents of verbal and physical abuse of residents and created a situation of immediate jeopardy for serious harm. II. The facility also failed to ensure the Wander Guard system (which was intended to prevent elopements from the facility) was working adequately for residents #1 and #7. The findings include: I. RESIDENT TO RESIDENT ABUSE A. IMPOSITION OF IMMEDIATE JEOPARDY On 6/6/11, a complaint was called in to the Health Facilities and Emergency Medical Services Division (HFEMSD) that alleged sexual abuse had occurred between residents on 5/13/11. Upon arrival at the facility and review of the facility documentation, it was determined the alleged sexual abuse, by male resident #4 toward female residents #3 and #6 had occurred. Record review revealed numerous episodes of abusive and/or threatening behaviors by resident #4, inadequate supervision of the resident, and lack of effective safety precautions and interventions to prevent further incidents of resident to resident abuse. Further record review also revealed episodes of aggressive behavior by residents #7 and #8 toward other facility residents. The facility failed to timely, adequately and effectively intervene to minimize the risk of repeat episodes of such aggression and to protect residents' safety. On 6/6/11, at 7:15 p.m., the nursing home administrator (NHA) and the Director of Nursing (DON) were informed by HFEMSD of the State Health Department that the facility's failure to adequately supervise residents who physically, verbally and/or sexually abused other residents created situation of immediate jeopardy for serious harm. B. FACILITY ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY The facility's proposed plan to remove immediate jeopardy, submitted 6/8/11 at 11:30 a.m. and again at 3:40 p.m., were rejected by HFEMSD as incomplete. The facility submitted another plan on 6/9/11 at 11:25 a.m. This plan included a timeline of actions taken after the incidents involving resident #4 on 5/13/11 and residents #3 and #6. Section 1: "Allegation of Removal of IJ In regards to (resident #4) on 6/7/2011 the following actions were taken upon receiving the IJ: -A sitter was placed outside of his room -15 minute checks were immediately implemented -Sitters were scheduled for around the clock -The sitters were instructed to document on the fifteen minute check form the resident's behaviors every fifteen minutes -The sitters' schedules and fifteen minute check form were given to the Survey Team -A meeting was held with the unit Charge Nurse and the IDT (Interdisciplinary Team) @ approximately 1900 (7:00 p.m.) to discuss a plan of action if the Resident's behaviors/aggression increased/escalated -The plan of action was to call the (name of city) Police Department immediately -Shortly after the IDT meeting, the sitter reported that she was with the resident explaining her responsibilities/duties, he became threatening and using profanity. He told her to get out of the room and that is when she left and reported the situation to the Administrator. -The family was notified and informed of the current situation -The resident was also notified that the Police were being called due to his behaviors -A conference call with the NP (Nurse Practitioner) occurred concerning the incident and discharge orders -Police arrived and took over the situation -Family arrived and removed all personal belongings -Resident arrested -Charge Nurse gave the Police the resident's medications with instructions -Charge Nurse gave scheduled medications to resident prior to him leaving with the Police -The family informed the Administrator and the Police that the resident would be released to their custody and not return Section 2: Abuse Reporting and Investigation -All active staff will be in-serviced on Abuse Reporting -Staff will be in-serviced prior to reporting to work for their shift and/or shortly after taking assignment -The facility conducts an investigation of alleged or suspected abuse -The facility designates a qualified staff member as oversight for abuse prohibition -Employees are educated that they must report any suspicious event that may constitute abuse -All incidents are tracked to identify possible trends that could constitute abuse -Any events of unknown origin are investigated -The facility's administrator/designee conducts an internal investigation and reports the results of the investigation to enforcement agency in accordance with state law including the state survey and certification agency within 24 hours -Investigations are prompt, comprehensive and responsive to the situation -All staff are in-serviced on reporting alleged, suspected or known abuse to the charge nurse -Immediate action will be taken to ensure the safety of all residents; suspension of the employee, removal of the assailant, 1:1 supervision, 15 minute checks of the assailant until appropriate action can be taken -Charge Nurse reports the incident to the Director of Nursing immediately -The Director of Nursing immediately notifies the Administrator at this time -The Director of Nursing and/or designee will notify the State Agency of the occurrence, Police, Family, Physician and Ombudsman -All active staff will be in-serviced on the above by 6/9/2011 -Staff will be in-serviced on a continued basis for the next 3 months on the abuse policy. Then policy will be incorporated in more detail during Orientation by the Administrator/designee -Chain of Command is a s follows: Person observing will tell Charge Nurse and/or Supervisor>Director of Nursing>Administrator>Regional Director>Nurse Consultant (The reporting to whom depends upon the department that the observer is working) -A random audit will be done on abuse reporting to ensure staff are well versed in the process daily times 5 days, weekly times 4, then monthly thereafter for 3 months. Results will be taken to QA (Quality Assurance) monthly -Results of audits will be monitored through QA on a monthly basis." The interim NHA signed and dated the allegation to remove immediate jeopardy as of 6/9/11. The interim NHA signed and dated the allegation to remove IJ as of 6/9/11. The allegation to remove IJ was submitted by the facility to HFEMSD on 6/9/11, at 11:25 a.m. IJ was not removed at this time, however, because review of all "Abuse Training In-service Records" submitted on 6/9/11 at 11:25 a.m. C. REMOVAL OF IMMEDIATE JEOPARDY On 6/10/11 at 2:00 p.m., review of staff training records revealed the facility had substantially complied with staff training; all but three staff had received training on abuse. The allegation to remove immediate jeopardy was signed by the NHA. On 6/10/11, at 2:00 p.m., the NHA, DON and Regional Director were notified that the IJ had been removed; however, deficient practice remained at a scope and severity of a G (actual harm). D. RESIDENT FAILURES 1. Resident #16 On 4/24/11, resident #16 choked her roommate, resident #12, in a common area. Two weeks prior to the incident, the resident expressed escalating remarks about killing her roommate and being angry towards her roommate. The resident had a history of [REDACTED]. The facility failed to ensure the residents on the secure unit were kept safe when resident #16's mood escalated. a. Residents #16 and #12 (1) Resident #16, [AGE] years old, was admitted on [DATE] to the facility's open unit. The resident was transferred to the mixed gender secure unit in 4/11. According to the face sheet, the medical [DIAGNOSES REDACTED]. According to the 3/24/11 Minimum Data Set (MDS), the resident scored nine, indicating moderate cognitive impairment. There were no delusions present, no physical or verbal abusive behaviors present and the resident required set up only for activities of daily living (ADL). The resident was independent with ambulation and transfers. (2) Resident #12, per closed record review, [AGE] years old, was admitted to the facility on [DATE]. According to the face sheet, the medical [DIAGNOSES REDACTED]. According to the 4/29/11 MDS, the resident was rarely to never understood, was delusional with moderately impaired cognition. The resident had short/long term memory problems and required extensive assist of one person assist for Activities of Daily Living (ADL). Review of the face sheet listed the primary language as "other" and birthplace as Romania. Resident #12 had a guardian. Review of the care problem/needs for this resident included at risk for falls secondary to confusion and decreased cognition, compromised skin integrity, potential for developing skin issues related to [DIAGNOSES REDACTED]. At the time of survey (6/6/11 - 6/16/11), the resident no longer resided in the facility. b. Resident #16's history showed problems with roommates and aggression prior to admission: -Review of the February 2011 hospital paperwork revealed resident #16 resided on the inpatient psychiatric unit awaiting placement for a locked nursing home and remained potentially dangerous to herself and others when angry or upset with a significant history of impulsivity (in the hospital since 12/25/10). The resident suffered from a mental illness that caused her to be a danger to self and others. The resident threatened to kill someone. During her hospital stay, she got into an altercation with her roommate (2/21/11). Again in March, 3/10/11, the discharge criteria was secured placement. On 3/14/11, the resident threatened to kill her roommate (while still in the hospital). (See above; the resident was admitted to the facility's open unit on 3/17/11 due to lack of a bed in the secure unit. She was transferred to the secure unit 4/11) -According to the 3/17/11 PASRR (pre-admission screening and resident review) recommendations (reviewed in pertinent part), -"...3. At the hospital, if (resident #16) becomes agitated or cannot sleep due to her roommate, she has been allowed to change rooms and this has been effective. It would be helpful to have her own room or be paired with a roommate who does not have a breathing apparatus and does not snore. (resident #16) can become very agitated and aggressive towards others when her sleep is disturbed in this manner... -Care plan to address 1. (resident #16) becomes a risk to self and others when she becomes agitated with others around sleep issues and issues with roommates. How will NF emphasize with staff that they should regularly check in with (resident #16) on how she and her roommate are doing? How will the NF approach conflict management with (resident #16)? 2. What will the behavior management plan be for issues of verbal threats, physical aggression, and suicidal ideations? How will the NF ensure the safety of other residents in lieu of a history of physical aggression when agitated?..." Attached with the PASRR information, from one of the mental health providers, the evaluator documented, "At this time a secure and locked facility is also recommended to enhance safety for the client and others. She also notes she feels at risk of relapse on an unsecured unit which has resulted in increased risk to others and self in the past...made multiple threats to kill other residents and herself, while residing at (a previous nursing home)...would like to be placed on a secured unit. She notes her fears of relapsing if she is not on a locked unit. She identifies that her most recent issues while at (hospital) have been with roommates." c. Review of facility care plans failed to clearly identify safety interventions related to roommate issues and conflicts: -A 3/28/11 care plan identified the resident was at risk for self-directed or violence directed at others due to history of physical and verbal aggression, poor impulse control, suicidal ideation, self mutilation and homicidal threats. The approaches included physician notification of mood/behavior changes, setting limits with resident, approach the resident in a calm manner, listen attentively and attempt resolution of problems, attempt to refocus behaviors to something positive with anger outbursts and encourage activities of the resident's choice and preference. Handwritten entries were made on this document, "resident will cut self superficial cut to get attention on her way, follow physician orders, mental health to treat, mental sees times per care plan and as needed, mental health to work with facility on treatment plan for times to prevent behaviors, provide 1:1s due to assaulting another resident. There was no indication when these interventions were added (dates on this document showed 4/11, 4/14, 4/15 and 4/25). -A 3/30/11 care plan revealed a history of suicidal and homicidal ideations with a history of threatening others, roommates who make her angry. The interventions included social services to meet one on one as needed, mental health services to follow her, staff to help her with preferred coping skills, offer rewards, encourage to take medications, encourage to verbalize feelings, attempt to keep room free of items she could use to harm herself and others and pour pop into a cup. There were no interventions directing staff to check in on the resident frequently to see how she and her roommate were doing and no plans related to escalating roommate concerns (see social service notes below). -The day of the choking incident (4/24/11) a 4/24/11 self harm and harm to other care plan was developed (additional dates were written on this care plan 5/30/11 and 5/8/11). Interventions included keep the resident in sight (or line of vision), escort the resident to the bathroom, and sent out to hospital for a mental health evaluation. One to one monitoring was implemented upon her return to the facility. d. Review of social service notes and nurse's notes revealed resident #16 expressed roommate concerns to staff and threats were made towards the roommate (notes reviewed in pertinent part): (1) Notes while residing on open unit: -On 3/18/11 social service note, "..does not have roommate right now that does not have a breathing problem and does not snore as she has had a history of [REDACTED]. -On 3/25/11, the social service note, "MH (mental health) is being looked into for her it is unclear if she is eligible for MH services...SW (social worker) meets with her almost daily to see how she is doing and remind her of coping skills..." -On 3/29/11, a care conference occurred and the following comments were documented: "...history of suicidal and homicidal ideations, has assaulted staff at previous facility, can be verbally abusive as well...history of stealing when opportunity presents itself, will lie and manipulate...is notorious for having difficulty with roommates, usually related to noise. SW to look into AA..." (2) Notes after transfer to secure unit. -On 4/12/11 at 5:40 a.m., the nurse documented, "...resident was having behavior during the early part of the shift. Verbalized 'I cannot stay in the same room with this my roommate, all she does is to talk in an unknown language'...resident was moved to room 47B tentatively." -On 4/12/11 (no time), the nurse documented, "...Res. not adjusting to new roommate, Resident came out of room "I have to get out of here" Res. went to telephone, called 911, nurse stopped call. This nurse asked resident what's wrong? Resident says, 'I can't stay in the room with that woman, she never stops talking'. Redirected resident, talked to her and efforts calmed down resident. No further attempts to call 911 or to leave facility." -On 4/13/11, social services documented, "(name) is not happy with her placement on the secured unit. Explained to (name) why she was on the secured unit...did say she was not happy with the person she is sharing a room with and that all that person does is talk all night...was asked what she thought could help her she said a set of head phones might help her..." Headphones were obtained for the resident but there was no addition to the care plan with this intervention or to continue monitoring the roommate situation for these residents. -On 4/13/11 at 6:00 a.m., the nurse documented, "resident could not sleep all night related to roommate." --At 7:15 a.m., the nurse documented, "Resident tried to escape from the front door when the other residents were in line getting ready to go to the dining room for breakfast. She was in tears, she was mad and when this writer of night shift, nurse tried to talk to her; she was verbally aggressive later she told she could not sleep all night because of her roommate talking all nite. The resident was in tears and the staff reminded/re-directed her that we understand her situation and we'll talk with SW and DON (director of nursing) about this..." --At 1:35 p.m., the nurse documented, "tried to elope x3 during the shift..." -On 4/14/11 at 10:00 p.m. (after self cutting and sent to hospital), the nurse documented, "...Resident does not want to be in same room with (name of roommate)." -On 4/14/11, the resident called 911 again as she had cut herself. Social services documented, "the resident was standing next to the fridge by the window, with her left arm up in the air and was holding something sharp...She stated that she did not want to go back to her room because she stated her roommate was too loud..." The resident was transported to the hospital and returned the next day. One-to-one monitoring was implemented and 15-minute checks per the social service notes. -On 4/15/11 at 12:16 p.m., the nurse documented the resident was readmitted into room 43A (same room and same roommate as before hospitalization ). About 30 minutes later, the resident cut herself with a toothpaste tube and was sent back to the hospital. The nurse documented, 'when you bring me back I'm going to hurt myself again.' The resident returned that evening on one-to-one monitoring. Even though nurses documented one-to-one observation was occurring after 4/15/11, on 4/17/11 on the 2-10 shift, the nurse documented, "Nurse spent one to one time with resident, resident stated, 'If I had someone to talk to all the time. I wouldn't try to hurt myself' Nurse advised resident that s/he can talk to staff at any time and when she feels like hurting herself to let nurse or staff know ASAP (as soon as possible)...Resident monitored on 15-minute checks." -On 4/18/11, social services documented, "...I don't care I want to kill my roommate." SW explained what a serious threat that was. (Resident #16) stated, 'I don't care, I will strangle her.' (Resident #16) was very upset. (Resident #16) said her roommate is too loud. SW explained there were no other beds available to move her to and also reminded her she has had three other roommates since her admission. (Resident #16) would not calm down, but stated she doesn't care. SW left her 1:1's and consulted with SW director. SW's spoke to (mental health name) and advised to call crisis team. Crisis team member came out to meet with (name. CNA from (name) unit ran up to SW and screamed we need help. SW along with other staff ran to unit when (Resident #16) had taken the fire extinguisher and set it off in hall, filling unit with smoke cloud. SW and other staff got resident out of unit. SW spoke with (Resident #16) about her actions and how they could have harmed someone else, she stated, 'I don't care.' Fire department and cops came, unit was cleaned. Dr. started resident on haldol IM every six hours until Dr. D/C...Psychiatrist to see resident on 4/19/11. On this date, resident #16 cut herself again with a hair clip. Mental health saw her and discussions took place for behaviors and reward strategies (if she was good for three-four hours, she received a pop when she did not self harm and within 24 hours, she would get her cards back). There was no revision to the care plan to reflect the threatening remarks of wanting to kill her roommate. Even when the remarks were made that she wanted to kill her roommate, social services stated there were no other beds available. -On 4/22/11 from 10-6, the nurse documented, "Resident was already in room 47B (indicating a room move) before the report. Refused to go to room 43A. Efforts made were not successful at this period..." Staff was attempting to have resident return to room 43 (with the resident she was threatening to kill). e. Incident 4/24/11 On 4/24/11, six days after resident #16 verbally threatened harm to her roommate (resident #12), resident #16 choked resident #12 in a common area: On 4/24/11 at 1:30 p.m., the nurse documented, "near 1230 resident out of chair with hands on neck, base of neck, 2 staff to pry her hands off the resident. She returns to her chair without event, now calm, she wants to go to jail. Calm and to room for short rest, comes out and after 10 minutes. Out of chair attempt with same resident again. Intercepted by 2 staff persons. Returned to chair..." Resident #16 was discharged to the hospital 4/24/11 for a mental health evaluation. According to social service notes dated 4/25/11, "..(Resident #16) will return today from hospital and she will be placed with a 1:1 at all times on the open unit and with a wanderguard...found a room with 2 quiet roommates." On 4/29/11 five days after the above incident involving resident #12, social services documented: "SW on locked unit and nurse told SW that (resident #16) had cut herself with a pop can tab, went after the nurse with cane and choked roommate in common area in front of staff. Residents separated. SW called 911 and (resident #16) is still on 1:1. (Resident #16) stated she wanted to kill her roommate. Cops took over an hour to respond r/t residents being separated - not an emergency according to dispatch...she was under arrest and placed her in handcuffs...SW explained that (resident #16) had threatened to kill her roommate last week by strangling her, she had set off fire extinguisher week before and (resident #16) admitted in front of officers that she had hurt roommate the week before, her roommate had been sent out the previous week with unknown bump on head, bruising, and swelling hand. (Resident #16) had previously denied having anything to do with this until today with the officers..." Review of resident #12's record revealed resident #12 was identified with bruising of unknown origin and was sent to the hospital for an evaluation on 4/21/11; nurses' notes 4/21/11 indicated resident #12 was observed to have a right lateral skin tear (location not specified), left hand edema of +1, right arm bruise, right forehead bruise (above eye). An investigation was initiated. Resident #16 was discharged from the facility in June 2011. f. Staff Interviews A discussion occurred with the facility on the events of resident #16's room moves. The question was asked how the facility chose an appropriate roommate for resident #16 based on her history and resident safety: On 6/13/11 at 2:30 p.m., the Admissions Director (AD) revealed, "we felt she wasn't doing well in the open unit" and she was moved to the secured unit after a month, in a room with resident #12. When asked about resident #16's behaviors, the AD stated, "you can't take your eyes off of her (resident #16)." The admissions director revealed resident #12 could be vocal in expressing if something was going on that she didn't like. On 6/14/11 at 1:36 p.m. the Director of Nursing (DON) stated resident #16 was placed with resident #12 based on room availability (room open at the time of need for a transfer). On 6/14/11 at 3:45 p.m., an interview was conducted with a counselor from (a mental health provider), familiar with resident #16. The counselor did not feel that resident #16 was an appropriate admission to the facility and described her as 'a sociopath who tries to hurt other people.' Before attempting to strangle resident #12, the resident indicated she was planning on harming her. The counselor stated she always did what she said would do. The counselor stated a concern was addressed to the former nursing home administrator about supervision, usually two aides and one nurse on the (secure) unit. One aide out of the two was supposed to provide the 1:1 visits. 2. Resident #4 Resident #4, a [AGE] year-old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to his most recent Minimum Data Set (MDS), a quarterly dated 3/14/11, the resident had a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment, no verbal or physically abusive behaviors present, required one person assist for dressing and using a walker for stabilization with ambulation. Review of the Pre-Admission PASSR review, 12/3/2009 read, in pertinent part: "...Comments and Recommendations:...This client has been at (name of hospital) since 10/26/09 due to a CVA (stroke)...He has cognitive impairment from the CVA. He can only follow simple directions and is not able to understand complex tasks. He is reported to be withdrawn and frustrated due to difficulty with speech..." A UR (utilization review) Determination, dated 12/21/10 read, in pertinent part: "...A request was made for quarterly follow-up assessment for depression and mental status functioning for this resident who experienced a CVA at age 26. He has significant cognitive impairment...He appears to have a serious speech impairment as a result of the CVA which further limits his ability to respond & communicate..." a. History of socially inappropriate and aggressive behaviors - facility response - facility failures (1) Review of the resident's comprehensive care plan revealed the resident was care planned, beginning 12/10/10, for (1) socially inappropriate behavior and verbal abuse, (2) resident to resident altercation 2/21/11, (3) resident to resident altercation 3/1/11 and 3/2/11, (4) stealing 3/2/11, (5) R/T behaviors, (6) thought to have kicked other resident 3/27/11, borrowing money 3/28/11, (7) resident to resident altercation 4/5/11. Interventions to address the resident to resident altercation 2/21/11 (altercation with resident #32) included to (1) monitor and track kicking behavior, (2) separate residents (3) 15 minute checks x 72 hours, and (4) redirect physical aggression. Interventions to address the resident to resident altercation 3/1/11 (along with roommate, kicked resident #15) included (1) monitor behavior, (2) notify MD as needed. Interventions to address the resident to resident altercation 3/2/11 (other resident not identified) included (1) mental health to follow, (2) SS (social services) 1:1 as needed, (3) 15 minute checks til further notice, (4) moved to men's secure unit on 3/4/11 for structured environment. Interventions to address the resident to resident altercation on 3/27/11 (kicked resident #29) included (1) continue mental health, (2) SS 1:1 as needed Interventions to address the resident to resident altercation 4/5/11 included (1) 15 minute checks, (2) medication review, (3) redirect when agitated, (4) mental health, (5) increase involvement in games/activities (6) police called. (2) Social Service notes In January, 2011, SS notes started showing behaviors (arguing with van driver as to music played, wearing a seatbelt, etc.) Physical altercations were noted to have started 2/27/11 when he and his roommate kicked another resident (see care plan above). Resident #4 also admitted to taking $4.00 off a staff member's desk and other residents complained that resident #4 stole money and other items from them as well. According to the SS notes, the resident was moved to the men's secure unit on 3/7/11, for a "more structured environment." Despite several resident to resident altercations on the men's secure unit, the resident, per SS notes, was moved off the secure unit and onto the open unit on 5/9/11. (4) Facility Failures There was no documentation explaining the resident's transfer off the secure unit and cross-refer F309, there was no assessment of the resident's status at the time he was transferred and no assessment of his appropriateness for the open unit. b. Behaviors on the open unit, beginning 5/12/11 - resident to resident altercations - facility response - facility failures. (1) 5/12/11 a) Incident SS notes dated 5/12/11, documented a resident to resident altercation. The note read, in pertinent part: "It was reported to SW (social worker) that (resident #4) had an altercation with another resident." b) Facility response Per SS notes, "Residents separated...15 min checks started...SW met with (resident #4) who stated "Nothing happened." SW reminded (resident #4) he is not to touch others..." c) Failure in facility response Review of the resident's care plan revealed no care plan for the resident's return to the open unit on 5/9/11, and no revision of existing care plans relating to the 5/12/11 incident which, by SS notes above, involved touching others. (2) 5/13/11 On 5/13/11 while on 15 minute checks, the following allegations of sexual abuse were reported by staff and residents #3 and #6. a) Incident -Resident #3, [AGE] years old, was admitted to the facility 4/20/11 with [DIAGNOSES REDACTED]. Her MDS, dated [DATE], indicated her cognitive status was severely impaired. -Resident #6, [AGE] years old, was also admitted to the facility 4/20/11. Her [DIAGNOSES REDACTED]. Her MDS, dated [DATE], indicated her cognitive status was intact. Review of facility incident reports dated 5/13/11, revealed resident #3 alleged resident #4 touched her over her clothing in an inappropriate manner. She stated resident #4 touched her breasts and her private areas over her clothing. She stated she asked him to stop but that he continued to touch her. Another resident witnessed the assault and reported it to a staff member. Resident #4 was interviewed and did not deny the incident. Resident #3's roommate, resident #6, was present during questioning of resident #3. Resident #6 stated that resident #4 had inappropriately touched her - came behind her in the common area and touched her breasts and legs. b) Facility response to incident Resident #3: According to nurse's notes on 5/13/11 at 4:40 p.m., resident #3 was assessed from head to toe and no bruising, scratches or injury of any kind were noted. The resident denied pain or discomfort. A T.O. (telephone order) dated 5/13/11 at 4:50 p.m. read, "Sent to (name of hospital ER) for eval and Tx (evaluation and treatment)." It was written for a [DIAGNOSES REDACTED]. Another nurse's note at 9:00 p.m. documented the resident had returned from the hospital. Because the resident denied penetration, the resident was sent back to the facility without an exam. The case was reported to the police, and the NHA and resident's sister were notified of the incident. The resident's care plan was upd

Based on closed record review, family and staff interviews, the facility failed to provide the proper treatment and care for one (#12) of 14 sample residents, receiving oxygen therapy as indicated for treatment. Specifically, the facility failed to: -ensure the oxygen tank was filled and was in good working condition; -respond timely to oxygen equipment alarms (which alert staff of malfunction of equipment); -investigate the cause of the change in condition (unresponsiveness) or why the oxygen tank equipment alarms were sounding and failed to respond immediately and provide oxygen; -accurately document the resident's acute change of condition/unresponsiveness. The above failures resulted in the resident experiencing acute respiratory distress requiring hospitalization . Findings include: Sample resident #12's closed medical record was reviewed on 5/2/11 through 5/4/11. 1. Resident Data Fifty-two-year-old sample resident #12 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged to a local hospital emergency room (ER) on 4/29/11 for an episode of unresponsiveness and was re-admitted to the facility on [DATE]. The most current Minimum Data Set (MDS), dated [DATE], indicated that the resident was without short-term memory problems or long-term memory problems. The resident was modified independent with cognitive skills for daily decision-making. The resident sometimes understood others and was sometimes understood by others. The resident had mood indicators of little interest in doing things, trouble falling asleep, had little energy, a poor appetite or overeating, trouble concentrating on things. The resident had no behavioral symptoms. The MDS indicated that the resident had no behavioral problems. The MDS indicated that the resident required extensive assistance of one staff for bed mobility, eating, toilet use and personal hygiene and bathing. The resident needed extensive assistance of two staff for transfer and dressing. The resident was non-ambulatory in his room or off of the unit. The resident had an indwelling Foley catheter. The resident experienced pain and received scheduled pain medication. The MDS indicated that the resident received O2 therapy prior to admission to the facility, and received O2 therapy while in the facility. 2. Record Review -Review of the resident's current care plan revealed no care plan for oxygen use. -Review of physician telephone orders (PTO), computerized physician orders [REDACTED]. The resident had multiple admissions and discharges from the facility to the hospital. Specifically, -Review of a form entitled, "ADMISSION DATA SET (ADS)," dated 4/28/11 at 3:00 p.m., documented the resident was readmitted from the hospital to the facility on [DATE]. The resident was alert and oriented. His breathing was labored, with crackles in his lung sounds. The resident was on O2 per nasal cannula (NC) administered at 4 liters per minute (4 L/min). -Review of nursing comprehensive notes, dated 4/29/11 at 7:00 p.m., revealed the resident was discharged from the facility when he experienced a period of unresponsiveness. The resident had a brief stay at the hospital; and returned to the facility on [DATE]. -Review of hospital ER physician notes, dated 4/29/11 at 10:11 p.m., read in pertinent parts, "CLINICAL IMPRESSION: Medium sized right and medium sized left plural effusion ...Probable [MEDICAL CONDITION]. Probable [MEDICAL CONDITIONS]. Doubt overdose." The resident was discharged back to facility early on 4/30/11, with no changes in his medication regimen. -Review of re-admission nurses' notes, dated 4/30/11, revealed the resident was readmitted from the hospital to the facility via ambulance at 12:40 a.m. The notes indicated the resident had stable vital signs (VS) and his O2 sat (saturation) was at 92%; the notes did not reveal if the resident was utilizing oxygen or not, when the saturation measurement was done. The nurses' notes revealed the physician was notified of the resident's return, and ordered to continue medications per the hospital discharging physician. The nurses' notes documented the resident was medicated for pain at 1:50 a.m. Nurses' notes, dated 4/30/11 at 1:00 p.m., read in pertinent parts, VS 128/82 (blood pressure) 98.1 (temperature degrees in Fahrenheit) 18 (respirations per minute) 95% (O2 saturation, however, it was unclear if the resident was on O2 or room air). The nurses' notes further read in pertinent parts, the resident appeared to be in a very unstable and distressed condition and was medicated for pain per orders and complained of nausea. According to the notes, the resident was medicated for nausea, his appetite was fair and he was encouraged with fluid intake. The notes further indicated no respiratory distress. The notes continued, and read in pertinent parts, "Resident continues to state I don't feel good, but I don't want to go to the hospital ...Resident was assisted with ADLs (activities of daily living) and was made comfortable. At this time resident is visit with PT (physical therapist). Will continue to monitor." 3. Failure to maintain oxygen equipment in working condition and respond timely to oxygen equipment alarm On 5/4/11 at 1:30 p.m., a friend/family member was interviewed via telephone. In the interview, the friend/family stated in pertinent part "(Resident's name) was oxygen dependent. He was on oxygen when he was in the hospital (prior to discharge to the facility)." The friend/family stated on 4/30/11, she came in to visit the resident. The friend/family stated, "on 4/30/11, I walked into his (resident #12) room, his face was gray, his extremities were blue and he was unconscious, his eyes were rolled back into his head, I shook him; he had an O2 tube in his nose ...The O2 alarms were sounding loudly when I came in ...it was not working (O2) ...I went to the desk (nurses' station) just outside his room ...there were a bunch of nurses just talking- and the alarms were sounding ...no one went in . . . then they all came running in. The nurse traced the O2 tube to the machine (O2 tank) and connected him to a machine." The friend/family further stated, "I looked at the machine it only showed O2 saturation of only 40%, when they put his finger on it ...Then the O2 saturations went up to between 45 and 50 (45-50%) ...I was looking at the monitor ...they called the ambulance within five minutes ...The ambulance people (EMS) checked the oxygen and said it was horrible ...they (EMS) said something was not right ...They (EMS) asked staff (facility staff) to bring another oxygen tank and staff (facility staff) said there was none ...The ambulance guy (EMS) took off running (to ambulance) to get O2 ...He came back and put him (resident #12) on a mask . . . The O2 numbers then went up to 90%...Everyone was relieved, he (resident #12) wanted to get out of there (discharge from the facility) ...I (family/friend) visited him (resident #12) at the hospital ...He is scared he does not want to go back there (return to facility)." Review of the EMS report, dated 4/30/11, was requested and faxed to the facility on [DATE]. Review of the EMS report revealed EMS was called at 2:43 p.m., and arrived at the facility at 2:44 p.m. The report read in pertinent parts, "Pt (patient/resident #12) complaint ...(low) SPO2 (oxygen saturations) ...Brief description: Pt ...(with low) SPO2 @ SNF (nursing home facility) when staff failed to notice pt (resident) O2 tank not working ...RR (respirations per minute) 10 ...Primary impression: Altered level of consciousness ...OXYGEN WAS ADMINISTERED (by EMS with ambulance equipment) ...VITAL SIGNS ...time 14:46 (2:46 p.m.) Respiratory 10 (respirations per minute) Fatigued ...SPO2 68%...Room Air ...14:46 (2:46 p.m.) ...Treatment (EMS initiated treatment) Oxygen ....15:46 (3:46 p.m.) ...SPO2 98% source (source of O2) supplemental." The EMS report further read in pertinent parts, "RESPONDED TO CALL ...FOUND PT (resident #12) UNCONSCIOUS WITH RESPONSE TO PAIN. PT WITH A NRB (non-re-breather) MASK ON FACE . . . RESIDENT'S FAMILY STATED THAT SHE ARRIVED AND FOUND PT LAYING IN BED AND LOOKING BLUE AND WOULD NOT RESPOND TO HER. STAFF AT SNF Skilled nursing facility) STATED THAT PT HAD CHRONIC SOB (shortness of breath) AND THEY (staff) WERE UNAWARE OF PATIENT STATUS UNTIL FAMILY ARRIVED TO SEE HIM ...ON-SCENE (on scene EMS interventions): PT NRB WAS CONNECTED TO EMS TANK AND GIVEN O2 AT 15 LPM (liters per minute). PT HAD INCREASED LOC (level of consciousness)." The resident was transported to the hospital by EMS. 4. Failure to accurately document the episode of unresponsiveness Nurses' notes, dated 4/30/11 at 3:30 p.m., read in pertinent parts, "Resident has been sent to Hospital (ER) by AM (morning-day shift nurse) per MD (physician) orders. Paramedics (EMS) transported resident out on stretcher. Resident A+O (alert and oriented) ...but slow in speech." Although the notes indicated the resident was discharged on the day shift, there were no day-shift nurses' notes addressing the resident's discharge, including the circumstances and condition of resident prior to discharge; or how the resident was transported out of the facility. Moreover, review of physician's orders [REDACTED]. The above findings were brought to the DON's attention on 5/3/11 at 12:30 p.m. She stated an incident report was to be completed for all incidents, regarding a resident's change of condition, that required hospitalization . The DON stated she would look for the incident report regarding the above findings. The DON acknowledged the resident was discharged to the hospital on [DATE]; and there was no documentation in regard to the reason or resident's condition prior to discharge. The DON further stated the resident had a history of [REDACTED]. On 5/3/11 at 4:00 p.m., in a follow up interview with the DON, she stated no incident report or additional documentation was found regarding the resident's condition prior to his discharge to the hospital. The DON stated, "the resident was discharged because he became unresponsive ...There was no incident report ...I completed one today ...The expectation is that incidents are reported and completed (investigation completed) and reported timely ...at the time of the incident." The incident report completed by the DON on 5/3/11 was provided and reviewed on 5/3/11 at 2:00 p.m. It read in pertinent parts, "(Resident #12) unresponsive didn't want to go to hospital. C/O (complaint of pain) ...meds ...with narcotics went unresponsive again." And though the resident was found unresponsive with O2 sat at 40%, and O2 equipment was alarming without staff response, the incident report omitted those findings. Moreover, there was no evidence that a thorough investigation was initiated by the DON on 5/3/11, or prior to the conclusion of the survey.

Based on observations, record review, resident and staff interviews, it was determined that the facility failed to provide care and services to attain or maintain the highest practicable physical well-being for one of nine sample residents (#8) who had recently sustained a fall with head injuries. Specifically: The facility failed to assess, monitor, and address resident #8's headache pain. The facility failed to timely obtain physician orders [REDACTED]. This failure contributed to the resident experiencing pain which she described as 10/10 on a scale of 1-10, with 10 being the highest level of pain. Findings include: A. Expectations for Pain Management 1. Professional References "Clearly, for many years clinicians have been placed in a challenging situation ... they had no standards for assessment and treatment ... Critical to correcting this is establishing a standard for assessing the existence and intensity ... if caregivers do not agree on a standard for assessing pain intensity, each is likely to assess pain differently ... the care of a single patient can vary from one caregiver to another, very likely resulting in unrelieved pain. ... Many studies have shown that either lack of pain assessment or the existence of differences between the clinicians' pain ratings and those of patients is a major cause of inadequate pain management. Source: McCaffery, Margo and Pasero, Chris, "Pain: Clinical Manual," 2nd edition, Mosby, St. Louis, 1999, pp. 5 and 36.) Further text in McCaffery M, Pasero C: Pain: Clinical manual, p. 732. Copyright 1999, Mosby, Inc. Standards for Pain, Assessment, Treatment, and Documentation, in pertinent part, states; -Patients will be promised attentive [MEDICATION NAME] care by being informed verbally and in writing at the time of their initial interview that effective pain relief is an important part of their treatment that their report of unrelieved pain is essential, and that staff will respond quickly to their reports. -Patients will be taught to use a pain rating scale. When patients are taught to use the pain rating scale, they will be asked to set a comfort (pain relief) goal. Patients will be told that pain rated above the goal . . . will trigger an [MEDICATION NAME] dose increase, additional [MEDICATION NAME], other pain relief intervention. -Pain ratings that are persistently above the comfort goal will trigger interdisciplinary review of the pain management plan and a modification in treatment. 2. Facility Policy The facility pain management policy was requested from the Director of Nursing (DON) on 3/22/11. The policy read in pertinent parts, "PAIN EVALUATION ...INTENSITY SCALE ...0 (zero) ...not Hurt ...8 ...Hurts Whole Lot ...10 ...Hurts Worst." B. Resident Failure Resident #8's medical record was reviewed, on 3/22/11 through 3/23/11. 1. Record review revealed resident #8, 89-years old, was initially admitted to the facility, on 1/24/11. The resident's initial admission [DIAGNOSES REDACTED]. As further set forth below, the resident was discharged to the hospital, 3/10/11, readmitted [DATE], discharged to the hospital 3/14/11 and readmitted [DATE]. The 2/24/11, Minimum Data Set (MDS) revealed the following: -The resident had no short-term or long-term memory impairments. The resident was understood by others and understood others. The resident had no behavioral symptoms. -The resident had no limitations with range of motion (ROM) in all extremities. The resident used a wheelchair (WC) or walker for mobility. The resident needed one staff with moving on and off of the toilet, but that the resident was independent with bed mobility, dressing, and personal hygiene. -The resident was independent with locomotion on the unit and needed limited assistance with locomotion off the unit. -The resident was continent of bowel and bladder. The resident received physical therapy (PT) and occupational therapy (OT). 2. Recent History (Cross-reference F323; accident hazards) a. Review of the resident's record revealed that, on 3/10/11, the resident had an episode of near-[MEDICAL CONDITION]. Physician (MD) acute visit notes, dated 3/10/11, read in pertinent part, "weak, pale ...unable to stand up ...ASSESSMENT AND PLAN: [MEDICAL CONDITION] - Acute." Physician notes, physician orders [REDACTED]. b. The resident returned to the facility 3/13/11. Nurse's notes, dated 3/14/11 at 6:00 p.m., read, in pertinent part, "Resident sent to (hospital name) following a fall ... (with) bleeding in the head. On the bottom of the initial notes, there were (undated without a time) notes written by a different person (not identified as a nurse or by any title next to the signature). The undated notes read in pertinent part, "addendum: CNA answered call light and the resident requested for her bed to have her linen straightened. The attending CNA requested the resident to stand next to the bed as she straightened the linen. The CNA asked the resident if she was dizzy or had problems standing and the resident denied ...dizziness + ....[MEDICAL CONDITION] ...The resident fell to the floor next to the bed." c. The resident returned to the facility on [DATE]. Review of the hospital discharging physician summary, dated 3/17/11, indicated discharge [DIAGNOSES REDACTED]. The hospital discharge physician report, dated 3/17/11, read in pertinent part, "(Resident #8) ... presented to (hospital name) after having a mechanical fall in a ....facility. She was found to have a subarachnoid and subdural hemorrhage, where she was initially evaluated (CT scan on 3/14/11 at ER) ...She also sustained a scalp laceration, which was repaired at (hospital name)." A hospital physician (MD) History and Physical report, dated 3/14/11, read in pertinent parts. "RADIOLOGY: Head CT showed small contrecoup hemorrhage and contusion of the right frontal lobe, subarachnoid hemorrhage and subdural hemorrhage." 3. Pain Management Plan Care Plan: The resident's pain care plan was initiated, on 3/4/11. It read that the resident was at potential for alteration in comfort related to day-to-day living. The care plan read in pertinent part, "Denies pain at this time." -The goal for that care plan read in pertinent part, "Pain management interventions will be effective during the next review period. (5/4/11) -The approaches to care plan read in pertinent part, "Monitor for non-verbal signs ...flinching, crying, grimacing ...provide medications as ordered and continually assess effectiveness ...encourage resident to rate pain on a scale of 1-10 ...Educate resident not to wait too long to request needed pain medications ...contact physician prn (as needed) if current pain medication/management appears to be ineffective." There was no indication that the pain care plan was reviewed after she returned to the facility, on 3/17/11, following her fall 3/14/11 with head injuries. There was no documentation that an acute care plan was initiated. Physician order [REDACTED]. Review of physician orders [REDACTED]. The MAR indicated [REDACTED] 4. Failure to Timely Address the Resident's Pain On 3/22/11 at about 1:00 p.m., the resident placed her call light on. Upon entering the resident's room, resident #8 was observed lying on her bed and grimacing. The resident stated she needed to be changed (needed incontinence care) and stated that her head hurts "a lot." The surveyor approached the nurses' station and informed staff/students that the resident needed assistance. Three students went into the resident's room and shortly after that, the MDS coordinator (MDSC) entered the room too. The resident stated that she needed to be changed and stated that she was in pain - that her head hurt. The MDSC stated to the resident that she would notify the resident's nurse for medication administration. At that time, the resident stated to the MDSC, in pertinent part, "The Tylenol is not working." The MDSC did not assess the resident's pain or ask the resident to rate her pain. However, shortly thereafter, the MDSC was observed to notify the Registered Nurse (RN) of the resident's pain. The MDSC further notified the RN that the Tylenol was ineffective for the resident's pain management. On 3/22/11 at about 1:30 p.m., about 30 minutes after the resident complained to the MDSC, the RN was observed to pour Tylenol for the resident. The RN was observed as she gave the resident Tylenol and stated to her, "I only have Tylenol for you." The RN offered no other alternatives for pain relief. The RN did not assess the resident's pain or ask the resident to rate her pain. On 3/22/11 at 3:30 p.m., review of the resident's 3/11 MARs revealed no documentation of administration of Tylenol, on 3/22/11 at 1:30 p.m., or documentation of pain relief or lack of relief by 3:30 p.m. on 3/22/11. Review of nurses notes, dated 3/22/11 at 1:00 p.m., read in pertinent part, "Res (resident) C/O (complained of) HA (headache). Tylenol 650 mg PO (by mouth) prn given to relieve discomfort ...res felt a bit better. Will notify other staff to follow up." -review of the resident's medical record revealed [REDACTED]. -Review of the resident's nurses' notes revealed no documentation the resident's physician was notified that Tylenol was ineffective in managing the resident's pain. On 3/22/11 at 3:30 p.m., these findings were brought to the attention of the Nursing Home Administrator (NHA) and the RN. Both the NHA and RN were interviewed at that time. -The RN acknowledged that the MDSC had told her that the resident's head was hurting and that the resident complained that Tylenol was ineffective for pain relief. The RN stated, "She (resident) told me that her head was hurting ...I felt that Tylenol was strong enough ...Only Tylenol was ordered for her ...I gave her Tylenol to see if it would work ...I followed up to see if Tylenol worked ...she stated that she (resident) felt only a little bit better." -The NHA stated, "My expectation is to call the physician (MD) and notify him so the resident's needs for pain management are met ...We need to get meds (medications) ...protocol is to follow up with MD ...The Nurse Practitioner (NP) just did some training on pain management." At that time, the NHA asked the surveyor to excuse the RN as the NHA wanted the physician called right away. The NHA instructed the RN to call the MD right away and obtain orders for proper pain management for the resident. Nurses' notes revealed that the RN notified the physician/NP about the ineffective pain relief for resident #8 at about 3:30 p.m. on 3/22/11, after the surveyor brought the above findings to the facility's attention. Nurses' notes, dated 3/22/11 at 3:30 p.m., read in pertinent part, "Notified (NP name for MD name) regarding res C/O HA and also Tyl (Tylenol) not helping. (NP name) states will call (MD name) to get orders for another pain med (medication). That she (NP) will call me (RN) back. Notified PM Nx (nurse), administrator, ngrs (nursing)." On 3/22/11 at 5:30 p.m., about four hours after the resident had complained of ineffective pain relief, RN notes read in pertinent part, "Asked PM Nx if he received any other orders from (NP) as we (RN and NP) discussed. Nx replied 'No.' Notified ... (MD) urgent line. New orders received. [MEDICATION NAME] 5/500 mg 1 tab (tablet) PO prn and to pull (take) two tabs from E (emergency) Kit. Faxed new orders to pharmacy. Also pulled [MEDICATION NAME] 5/500 2 tabs from E Kit. Notified res family regarding new med." On 3/22/11 at 8:00 p.m., RN notes read in pertinent part, "Administered Vico ([MEDICATION NAME]) 5/500 tab as prescribed." The narcotic count sheet also indicated that the [MEDICATION NAME] was given at 2000 (8:00 p.m.) This administration was several hours after the order was received and about seven hours after the resident complained of ineffective head pain relief. The 8:00 p.m., RN notes indicated that at that time, the RN assessed the resident's pain level. RN notes read in pertinent parts "Res C/O HA (headache) rate 10 on a scale of 10. Notified PM Nurse to follow up." On 3/24/11 review of the 3/11 MAR indicated [REDACTED]. On 3/24/11 at about 1:00 p.m., the Director of Nursing (DON) and NHA were asked to clarify when the resident initially received [MEDICATION NAME] for headache pain. At about 3:00 p.m., the DON provided documentation that clarified, on 3/22/11 at 8:00 p.m., the facility E Kit was accessed and that the resident was administered 1 tab of [MEDICATION NAME] for pain. On 3/24/11 at 3:00 p.m., the DON was asked to further clarify nursing documentation regarding the assessment and timeliness of obtaining and administration of PRN medication administration on 3/22/11, after the resident complained at 1:00 p.m. of ineffective pain relief from Tylenol. -The DON stated, "I expect the MD should be notified within the hour (when the resident complained of ineffective pain relief from Tylenol) for orders for relief from complaints of unrelieved pain ...We have to measure the intensity of pain on a 1-10 scale ...If the attending physician refuses (fails to respond timely with new orders) to meet the resident's needs, we call the Medical Director physician (MDP)." -The DON acknowledged that the facility failed to timely and appropriately assess and implement additional measures to address the resident's unrelieved pain. The DON stated, "We failed to acknowledge that Tylenol was not effective for the resident's complaint of headaches ...The RN informed the resident that Tylenol was the only medication ordered for the resident and failed to ensure a call was placed to the attending physician to present the resident's pain case and receive physician orders [REDACTED]. -The DON further stated, "The RN failed to appropriately assess, specifically using the 'Bakers Pain Scale' (1-10 pain scale) to determine intensity of the initial complaint of pain or measure the effectiveness or ineffectiveness of administration of Tylenol, according to the Bakers' Scale [MEDICATION NAME] was not given timely." -The DON acknowledged that the resident was not administered [MEDICATION NAME] for seven hours after she complained of ineffective pain relief from Tylenol. The DON stated that she would continue to educate nursing staff.

Based on record review and staff interviews, the facility failed to ensure two (#2 and #8) of nine sample residents received adequate supervision and assistive devices to prevent accidents. Specifically: (1) The facility failed to ensure resident #8's orders and plans for transfer assistance were communicated to staff and implemented. Resident #8, who was hospitalized [DATE] and diagnosed with [REDACTED]. The facility failed to ensure these orders were communicated to staff and implemented. On 3/14/11, the resident fell in her room while being attended by a certified nurse aide (CNA). The resident sustained [REDACTED]. Resident #8 was readmitted to the facility on [DATE]. Review of the hospital discharging physician summary, dated 3/17/11, indicated discharge [DIAGNOSES REDACTED]. Physical and Occupational Therapy (PT/OT), dated 3/18/11, recommendations were for 2-person extensive assistance with transfers. Although written in the care plan, staff was unaware of the resident's transfer assistance needs and failed to transfer the resident as recommended, care planned, and in a manner consistent with facility policy. (2) The facility failed to implement the use of a safe smoking device for resident #2 as care planned. The findings include: I. FALLS A. Facility Policy The fall management policy was requested and provided by the Nursing Home Administrator (NHA) on 3/22/11. Only the transfer piece of the fall management program policy dated 4/07 was provided. No further fall management policy pieces were faxed after exit (3/23/11) as requested. The fall or transfer management policy read in pertinent part: "Safe Lifting and Movement of Resident ...Assessing Transfer Needs of residents...The transferring needs of residents shall be assessed on an ongoing basis. Resident transferring and lifting needs shall be documented in the care plan. Assessment of the resident's transferring needs should include: Mobility of the resident (degree of dependency) ...Size of resident ....Weight-bearing ability ...cognitive ability ...review the residents care plan for any special needs of the resident." The Policy further read in pertinent part, "Gait Belt Policy and Procedure. It is the policy ...to always use a gait belt with any resident that is not completely independent. If the resident is unsteady with their gait or unable to transfer them, a gait belt should always be used. There is no exception to this rule." B. Resident Failure Resident #8, 89-years old, was initially admitted to the facility on [DATE]. The resident's initial admission [DIAGNOSES REDACTED]. As further set forth below, the resident was discharged to the hospital 3/10/11, readmitted [DATE]. Physician discharge summary dated 3/13/11, indicated a [DIAGNOSES REDACTED]. The resident was discharged to the hospital 3/14/11 and readmitted [DATE]. The 2/24/11, Minimum Data Set (MDS) revealed the following: -The resident had no short-term or long-term memory impairments. The resident was understood by others and understood others. The resident had no behavioral symptoms. -The resident had no limitations with range of motion (ROM) in all extremities. The resident used a wheelchair (WC) or walker for mobility. The resident needed one staff with moving on and off of the toilet, but that the resident was independent with bed mobility, dressing, and personal hygiene. -The resident was independent with locomotion on the unit and needed limited assistance with locomotion off the unit. -The resident was continent of bowel and bladder. The resident received physical therapy (PT) and occupational therapy (OT). 1. Episode of Syncope - Orders Resident #8's medical record was reviewed, on 3/22/11 through 3/23/11. Review of the resident's record revealed that on 3/10/11, the resident had an episode of syncope. Physician (MD) acute visit notes dated 3/10/11 read in pertinent part, "weak, pale ...unable to stand up ...ASSESSMENT AND PLAN: Hypotension - Acute." Physician notes, physician orders [REDACTED]. The resident was discharged from the hospital back to the facility on [DATE]. Review of Hospital Physician (MD) Discharge orders and MD instructions, dated 3/12/11 (for discharge from the hospital on [DATE]), read in pertinent part, "Discharge [DIAGNOSES REDACTED]." Review of facility physician admission orders When sitting to standing, let pt stand for 1-2 minutes before ambulating." 2. Fall 3/14/11 - Facility Failures Nurse's notes, dated 3/14/11 at 6:00 p.m., read, in pertinent part, "Resident sent to (hospital name) following a fall ... (with) bleeding in the head. Got a call from the hospital saying they were trying to do a C(T) scan ...they will call us back on how she was doing." On the bottom of the initial notes, there were (undated without a time) notes written by a different person (not identified as a nurse or by any title next to the signature). The undated notes read in pertinent part, "addendum: CNA answered call light and the resident requested for her bed to have her linen straightened. The attending CNA requested the resident to stand next to the bed as she straightened the linen. The CNA asked the resident if she was dizzy or had problems standing and the resident denied ...dizziness + ....vertigo ...The resident fell to the floor next to the bed." Record review revealed the resident was hospitalized [DATE] - 3/17/11. The hospital discharge physician report, dated 3/17/11, read in pertinent part, "(Resident #8) ...presented to (hospital name) after having a mechanical fall in a ....facility. She was found to have a subarachnoid and subdural, where she was initially evaluated (CT scan on 3/14/11 at ER) ...She also sustained a scalp laceration, which was repaired at (hospital name)." A hospital physician (MD) History and Physical report dated 3/14/11, read in pertinent parts. "RADIOLOGY: Head CT showed small contrecoup hemorrhage and contusion of the right frontal lobe, subarachnoid hemorrhage and subdural hemorrhage." a. Failure to ensure discharge/admission orders [REDACTED] Record Review: Care plan review revealed the resident's care plan for falls was not updated until 3/14/11, after her fall. The resident's fall risk care plan was initiated, on 2/4/11, and was updated, on 3/14/11, following the fall on 3/14/11. The care plan read that the resident was at risk for falls and at risk for injuries related to decreased vision, decreased mobility and psychotropic medication use. -There was no documentation that the care plan was reviewed and revised on 3/10/11 following her episode of near-syncope and hypotension (see above). -There was no documentation that the care plan was reviewed and revised, on 3/13/11, when the resident was readmitted with specific instructions to stand for 1-2 minutes when moving from sitting position to standing position prior to ambulation. -There was no documentation that an acute care plan was initiated to address the resident's condition and safety risks upon her readmission with [DIAGNOSES REDACTED]. Interview: On 3/22/11 at 1:45 p.m., the Registered Nurse (RN) who was in charge of the resident's care, on 3/14/11, and who was called to assess the resident after the resident fell was interviewed. -The RN stated that she was the RN on duty when the resident fell on [DATE], and she was summoned to assess the resident after she fell . -The RN stated she interviewed the CNA who was attending the resident when the resident fell . The RN stated that the CNA told her that the resident placed her call light on and the CNA responded to the call light. The RN stated, "The CNA explained to me how it (fall) all happened ... The resident got up on her own ...so the CNA could pull her blankets up ...then she fell ......The CNA said the resident... walked away from the bed, then she (resident) fell ...she was ways away from her bed, when I saw her after she fell ...She did not fall towards the bed." The RN further indicated that when she interviewed the CNA, the CNA did not report that any special instructions for ambulation were followed. -The RN, when asked if she was aware of the resident's transfer needs and if those needs were communicated to the CNA, on 3/14/11, stated that she (RN) worked every Tuesday at the facility and was very familiar with the resident prior to the fall. -The RN stated, "Before she went to the hospital (on 3/14/11), she was able to stand by herself ...I have never seen her unsteady. She says she can walk ...The only instructions she has and I know of is stand by assist." -The RN stated that she was not aware if any special instructions for the resident that day, other than bringing the resident's walker to her bedside. The RN stated that she was unaware that the resident was to stand for 1-2 minutes from sitting to standing prior to ambulation, after the resident returned from the hospital on [DATE]. b. Failure to identify staff's failure to communicate and implement discharge/admission orders [REDACTED] The facility's investigation of the resident's fall, on 3/14/11, was requested and provided by the Director of Nursing (DON) on 3/22/11. Review of the investigative/accident follow-up/report of the resident's 3/14/11 fall was, dated 3/17/11. -The report indicated that the resident fell , on 3/14/11, and read in pertinent part, "Resident fell (3/14/11) while OOB (out of bed) while CNA was preparing bed for res (ident) ...Res hit back of her head on floor with bleeding noted and was transferred out to ...ER." -The report "Summary of investigation (reasonable conclusion)," read in part: CNA unaware of resident's decline - left resident standing unassisted at b/s (bedside) ...while preparing bed for the res to retire ...Res's knees buckled and res fell to the floor hitting her head on floor." -The report indicated that the resident's care plan was updated, on 3/17/11, and "Recommendations/New interventions," included, in part "CNA to attend instruction on safe Txfers (transfers) ...(with) PT (physical therapy) ...Res to 2-person txfer upon return (from) hosp (hospital). PT screen for falls." Review of incident report made no reference to staff's failure to communicate and implement the discharge/admission orders [REDACTED]. There was no documentation that staff was educated on reviewing and communicating discharge/admission orders [REDACTED]. 3. Facility response to resident fall 3/14/11 Record Review: Review of the resident's care plan for falls (see above) revealed the plan was reviewed 3/14/11, after the resident's fall and discharge to the hospital ER. The care plan read, in pertinent part: "3/14/11. Reviewed ...Resident had a fall ... (with) hitting head - lac (laceration) to back of head. The approaches were updated on 3/14/11 to read in pertinent part, "Send res. to ER for eval (evaluation) and tx (treatment) ...Monitor the site upon return for healing ...Change to 2-person transfer. The care plan further read to read in pertinent part, "3/14/11 Weakness ... (secondary) to syncope ... (secondary) ...hypertension." The goals were updated on that date as, "Resident will remain free from injuries ... (secondary) to syncope X 90 days. "The care plan approaches were further updated on 3/14/11, in pertinent parts, "When sitting to standing let resident stand for 1-2 min (minutes) before ambulating." A Physical/Occupational Therapy (PT/OT) evaluation was initiated on 3/18/11. Review of the PT/OT notes revealed that the resident was totally dependent, maximum assistance on staff for bed mobility and transfer from chair/bed and bed mobility. In addition, the resident was totally dependent on staff with her gait. The notes read in pertinent part, "Due to documented physical impairments and associated functional deficits, the patient (resident) is at risk for: falls dizziness, easily fatigued." Interview: On 3/22/11 at 2:00 p.m., the facility PT and OT were interviewed together about resident #8's transfer needs. -The OT stated, "She is so weak since she returned from the hospital (3/17/11) ...With transfers, she is a 2 person transfer ...she needs 2 person maximum assistance for transfer for safety." -The PT stated, "She cannot ambulate right now ...she has poor balance for ambulation ...We did staff training for 2-person transfer (for resident #8) ...two people must transfer the resident, not one, for safety due to her (resident's) safety." 4. Failure to implement safety precautions on readmission 3/17/11 Observations: On 3/22/11 at 12:30 p.m., instead of a two person transfer as indicated by the care plan, PT and interdisciplinary committee (IDT) recommendations, observations revealed that one CNA instead of two staff was observed as she transferred the resident from bed to wheelchair (WC). Specifically: -On 3/22/11 at 12:30 p.m., the CNA who was on duty was observed as she transferred the resident from bed to wheelchair. The CNA stated that she was very familiar with the resident and provided her care on a regular basis. -The CNA stated that she was able to transfer the resident by herself, the MDS coordinator and three nursing students who had originally responded to the resident's call light, all left the room at that time. -The CNA was observed as she assisted the resident into a sitting position towards the edge of the bed. The CNA was observed as she held the resident from the back across the shoulders. The CNA then swung the resident into sitting position and dangled the resident's legs at the edge of the bed. Although the CNA had a gait belt tied around her waist, the CNA was not observed to use that gait belt, as indicated by the facility policy. -The CNA placed shoes on the resident's feet then pulled the resident's wheelchair close to the bed so that if the resident fell , she would fall back onto her bed. The CNA then grabbed the resident's pant in waist area at the back. Without the use of a gait belt, the CNA pivoted the resident into the WC. The resident staggered as the CNA placed the resident in the WC. -The resident sat for about two minutes in her WC and asked to go back to bed. Again, without the use of a gait belt or assistance from another person, as indicated by the care plan, the CNA pivoted the resident back to bed. Interviews: On 3/22/11 at 12:00 p.m., the CNA above was interviewed about any special instructions with regard to the resident's transfer needs. The CNA stated that she had worked at the facility for over four years and was familiar with the resident and regularly took care of the resident. -The CNA stated that she was able to transfer the resident by herself. The CNA stated that the resident was able to stand up "a little bit." The CNA stated, "Nothing new was told to me on her (resident) for getting her up since she came back from the hospital ...I grab her by the pants all the time then I put her in her WC ...she is able to stand a little bit ...not much (standing) ...Nobody has told me how to transfer her since she came back from hospital ....I have no special training to get her up ...Here is my gait belt ...I did not use gait belt, she (resident) is easy, she is not heavy ...she is easy to move with no belt ...Nothing special was told to me when transferring her (resident) ...I work with her every day." On 3/22/11 at 1:45 p.m., the RN was notified that the CNA was observed transferring the resident from bed to chair and chair to bed by herself. The RN was asked if she was aware of any new transfer techniques after the resident was readmitted to the facility on [DATE]. -The RN stated that there were no special instructions about transferring the resident on the 24 hour report, on 3/22/11. Furthermore, the RN stated that there were no special instructions indicated when the RN received report that morning. -The RN stated, "I work with her every Tuesday. Usually CNAs do get her up ...I think she is stand by assist ...The only report I got was that her Foley catheter was d'ced (discontinued), nothing else was new ...I was not here when she returned from the hospital ...it's been about a week (since she returned from the hospital) ...In report I was not told about of anything new about transfers ...nothing is on the 24 hour report." -The RN stated that this was her first time working with the resident since the resident returned from the hospital (3/17/11). The RN stated, "When getting her up the CNA should put gait belt on her, then stand on side, in case she falls ...there are no special transfer instructions since she (resident) came back ...stand by instructions are the only ones ...when she came back from the hospital there were no new transfer instructions." The RN repeated, "When she (resident #8) came back there was nothing special (about ambulation or transfer) that was passed on in report ..." 5. Nursing Home Administrator Interview The Nursing Home Administrator was interviewed, on 3/22/11 at 3:00 p.m. -The NHA explained the incident and investigation of the 3/14/11 fall, stating, "(Resident #8) called for the CNA (put call light on) to fix her bed. The CNA went in to assist the resident. The resident was sitting up, she (resident) stated that she could stand, she lost her balance and fell back ...The CNA should have had a chair to sit resident down ...The CNA was disciplined, we had therapy (PT/OT) train her on proper transfer techniques." -The NHA continued, "She (resident #8) was a standby assist ...it was not communicated to the CNA when the resident returned from the hospital (on 3/13/11 after evaluation for syncope and hypotension) ...She is a 2-person transfer now." The NHA made no reference to discharge/admission orders [REDACTED]. The NHA was informed of the observations above when the CNA transferred the resident by herself and of interviews with the CNA and RN, indicating they were unaware that the resident required a 2-person transfer for safety. It was also brought to the NHA's attention that although the CNA had a gait belt tied around her waist, she did not use the gait belt when transferring resident #8. -The NHA stated, "CNAs are expected to always use a gait belt when transferring residents ....I am surprised that that CNA did not use a gait belt ...she was educated on gait belt use ...(Resident #8) is a 2-person transfer since she returned from the hospital (3/17/11) ...The ADON put it on the care plan on 3/17/11, for staff to follow ...The CNAs can read the care plan ...I will address with the CNA to see why they transferred the resident that way." -The NHA stated that staff had been educated in proper transfer techniques. However, there was no indication that staff had been educated on reviewing and discharge/admission orders [REDACTED] II. SMOKING A. Facility Policy The facility policy titled "Tobacco Product Policy" documented, in pertinent part: "...Each resident has the right to utilize tobacco products, should s/he so choose to do so. However, every resident has different strengths and limitations that may impact his/her ability to utilize tobacco products independently. Therefore, some residents may require supervision to utilize tobacco safely ... Procedure: ...Residents who have been assessed to be unsafe/supervised will be supervised by staff at each designated smoking/tobacco time and in designated smoking areas only ..." B. Resident Failure Resident #2, age 62, was admitted to the facility, on 5/30/08, with [DIAGNOSES REDACTED]. 1. Resident Status The resident's most recent Minimum Data Set (MDS), dated [DATE], documented the resident scored a 7 out of 15 on the cognitive assessment, which indicated the resident had cognitive impairments. The resident did not display any physical or verbal behavioral symptoms. The resident required assistance with transferring, dressing, eating, ambulation, toilet use, and personal hygiene. 2. Observations Resident #2 was observed, on 3/22/11 at 1:30 p.m. A CNA gathered smoking materials from the locked cabinet and asked the resident if he was ready to smoke. The resident agreed and went outside into the smoking area. The CNA gave a cigarette to the resident and lit it for him. The resident had two small reddish-brown spots by the knuckle on his middle finger of his right hand, and small burn holes on the left side of his pants around the area of his knee. The CNA did not provide a smoking apron or any other adaptive smoking equipment for the resident. The resident was able to lift the cigarette to his lips without assistance; however, the CNA assisted the resident occasionally with ashing the cigarette. Resident #2 was again observed in the smoking area, on 3/22/11 at 3:30 p.m. A different CNA accompanied the resident. The CNA put a smoking apron on the resident, gave him a cigarette, and lit the cigarette. No other adaptive smoking equipment was used. The CNA occasionally ashed the resident's cigarette for him. When the resident reached the end of the cigarette, the CNA tried to take the cigarette away from the resident; however, she was not quick enough. The remaining ashes and the lit part of the cigarette fell on to the resident's apron, and the CNA took the cigarette butt away from the resident to dispose of it. The resident was observed during the supervised smoking times two more times, on 3/23/11. Each time the resident wore a smoking apron, however, he did not use any other adaptive equipment, and the resident held his own cigarette. The resident had different pants on than the previous day; these pants, too, had several small burn holes in the left pant leg around the knee area. 3. Record Review The resident's facility care plan, last reviewed 2/15/11, documented the problem of, "(Resident name) is a supervised smoker and he is at risk for injury. (Resident name) has a history of smoking his cigarettes to the point where they may burn his fingers/hands. (Resident name) is an unsafe smoker. (Resident name) is at risk for injury due to visual deficits." The approaches included, in pertinent part, "Provide (Resident name) with an apron. Staff will assist (resident name) with smoking by holding his cigarette using a modified button puller to prevent the need for (resident name) to hold his own cigarette." The resident's Safe Smoking Evaluation, dated 2/23/11, documented, in pertinent part: "Observations: ...Resident is able to light cigarette safely with a lighter- YES Resident smokes safely- YES Resident utilizes ashtray safely and properly- YES Resident is able to extinguish cigarette safely and completely when finished smoking- YES" The back of the safe smoking evaluation contained a summary of evaluation. The box for "Resident must be supervised by staff, volunteer or family member at all times when smoking" was checked, along with "Resident must wear smoking apron at all times." The comments section documented, "Pt (Patient) is on secure unit. Staff will keep smoking materials and will be a supervised smoker. Must have a smoking apron." 4. Interviews A CNA was interviewed, on 3/22/11 at 3:30 p.m. The CNA stated the resident required a smoking apron as long as she had known the resident. The CNA continued that the resident had difficulty ashing the cigarette at times and she would assist him with it. The CNA stated she noticed the reddish-brown marks on his finger that looked similar to burns, but the CNA said she was not sure if they really were burns. The Registered Nurse (RN) was interviewed, on 3/23/11 at 9:30 a.m. The RN stated the resident required supervised smoking and needed a smoking apron, but did not use any other adaptive equipment. The RN stated the scabs and the reddish-brown marks on the resident's hands and fingers were from the resident self-propelling himself very quickly in circles and bumping his hands on the doors and walls. The RN stated all the residents were supervised smokers, and the staff would give the residents their cigarettes and light them; however, the RN said the staff at times would come back into the building after the cigarettes were lit and watch the residents from inside the door until the residents were done smoking. Another CNA was interviewed, on 3/23/11 at 2:20 p.m. The CNA stated the resident would smoke through the filter of the cigarette so he needed to be monitored. The CNA also stated resident #2 refused to give the CNAs the cigarette sometimes, even though it was finished. The CNA stated the resident did not become combative, just refused to hand over the cigarette butt unless the CNA just took it from him. The CNA stated the resident used a smoking apron, but did not utilize any other adaptive smoking equipment. The CNA stated the resident needed to be monitored closely during smoking so that he did not get burned. The Social Services Director (SSD) and Social Services Assistant (SSA) were interviewed, on 3/23/11 at 11:20 a.m. -The SSD and SSA stated that social services were responsible for completing the smoking assessments for each resident that smoked on a quarterly and as needed basis. The SSD and SSA stated they looked for how safe the resident was while smoking, checked for burn holes in the resident's clothing, and if the resident was able to comprehend and follow the facility's smoking policies. -The SSD and SSA stated the Interdisciplinary Team (IDT) would determine if the resident needed any adaptive smoking equipment. The SSD and SSA were not aware the resident's care plan for smoking indicated he should be using additional adaptive equipment other than a smoking apron, and neither was able to explain what a "modified button puller" was. The Director of Nursing (DON) was interviewed, on 3/23/11 at 1:15 p.m. The DON stated the marks on the resident right hand on the middle finger were "nicotine marks" as the resident had a tendency to smoke through the filter of the cigarette. The DON stated that was part of the resident being on supervised smoking. -The DON stated the resident would become angry at the staff if the staff tried to remove the cigarette before the resident was finished with it. The resident's right hand was again observed with the DON present. The resident's right hand middle finger had two small slightly raised reddish-brown spots with scaly skin surrounding the spots. The DON again stated they were nicotine marks, and not burns. -The DON continued that the resident was a supervised smoker and the staff should be taking away his cigarette before he smoked through the filter. The DON was not aware of the resident using any adaptive smoking equipment other than the smoking apron. The DON also stated the staff should remain outside with the residents while smoking and should not be inside the building. In a follow-up interview with the SSA and SSD at 2:35 p.m. on 3/23/11, the SSD stated a modified button puller was used to assist the resident holding the cigarette farther away from his fingers. The SSD stated modified button pullers were available, but the resident did not use them. The SSD stated the resident may have refused in the past; however, she was not sure. Documentation of any refusal for using the adaptive equipment was requested, but none was provided by the end of survey 3/23/11. The NHA was interviewed, on 3/23/11 at 4:15 p.m. The NHA stated the facility expectation was that the staff would remain outside with the resident during smoking times, and would provide any necessary adaptive equipment, such as a smoking apron. The NHA stated she was aware that staff would observe through the doors. However, she said staff had been re-educated and the Environmental Services Director randomly monitored to ensure staff remained outside during supervised smoking times.

Based on observation, record review, and staff interview, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and two (#19, #21) of 22 sample residents, received adequate supervision and assistance devices to prevent accidents. Specifically, the facility failed to supervise resident #21 and intervene adequately to prevent falls. Subsequently, resident #21 fell while unsupervised in the courtyard and suffered a chin laceration requiring sutures. She then fell in the facility and sustained severe head lacerations requiring surgical intervention. Also, the facility failed to evidence a complete investigation and new fall prevention interventions after an unwitnessed fall for resident #19. The findings include: 1. Resident #21, age 54, was admitted to the facility on [DATE]. According to the face sheet, printed 10/20/10, [DIAGNOSES REDACTED]. According to the 8/6/10 minimum data set (MDS) assessment, the resident had impaired short and long-term memory. She had moderately impaired cognitive skills, made poor decisions, and required reminders, cues, and supervision in planning, organizing, and correcting daily routines. She was sometimes able to make her needs known and sometimes able to understand the communication of others. The resident wandered daily, which was not easily altered. She required total assistance with toileting, personal hygiene, and bathing; required extensive assistance for transfers and dressing; and required supervision only for the other activities of daily living, including walking in her room, in the corridor, and locomotion on and off the care unit. She resided in a secure unit for residents with dementia, and had an unsteady gait. 1. 10/18/10 Fall: Review of the 10/17/10 NN written at 4:00 p.m. revealed the resident was "walking in a stooped posture faster than usual pace." The resident exhibited grabbing behavior towards other residents at times and pacing through the hall, but could be redirected. The same date at 8:00 p.m., the resident continued to pace hallways with some aggressive behavior. Review of the 10/18/10 Nurse's Notes (NN) revealed at 1345 (1:45 p.m.), the resident was found outside in the secured unit courtyard sitting on the ground with a laceration to the left eyebrow and an abrasion to the left arm. The resident was unable to verbalize what or how the injuries occurred. Physician orders [REDACTED]. Review of the facility's "Incident/Accident Investigation Follow-Up" (IAIFU) revealed the resident was found on the ground in the fenced-in patio, near a flower pot, outside of the building. The resident sustained [REDACTED]. The fall was unwitnessed. The resident was discovered on the ground when viewed by staff through a resident's window. Review of a 10/20/10 physician's Telephone Order (TO) revealed orders for laboratory tests: a complete metabolic panel, ammonia level, complete blood count, and a urinalysis. The 10/18/10 fall care plan documented the resident had a laceration to the left eye brow as a result of the fall. The goals were the resident would not fall, and would have no pain or decreased pain. Approaches included: monitor for new injury/infection and check on the resident every 15 minutes. In an interview on 11/30/10 at approximately 2:00 p.m., the Director of Nursing (DON) explained every-15-minute checks were a short-term intervention for 72 hours where staff would determine the whereabouts of a specific resident every 15 minutes. She said the expression that a resident was a "one-to-one" meant one staff person would stay with a particular resident at all times. She said this, too, was a short-term intervention for resident safety, until the Interdisciplinary Team (IDT) could determine the best way to meet the resident's needs. Review of the Neurological Assessment Flow Sheet revealed serial assessments 10/18/10 to 10/21/10. Review of the 15 Minute Check Tracking form evidenced checks from 10/18/10 at 1345 (1:45 p.m.) through 10/18/10 at 2045 (7:45 p.m.), no checks from 2000 (8:00 p.m.) through 2145 (9:45 p.m.), then every 15 minute checks through 10/21/10 at 1830 (6:30 p.m.). The 10/20/10 IDT review of the 10/18/10 fall revealed the following interventions: continue activities, manage pain, assess for signs and symptoms (S/S) of infection of abrasion of left eyebrow, assess for healing, implement 15 minute checks for 72 hours, and notify physician of change of condition or decline. Physician evaluation on 10/20/10 revealed no prior falling. The physician noted the resident was walking hunched-over now. The physician noted the resident had no serious injury as a result of the fall. Laboratory studies were ordered to rule out infection or electrolyte imbalance. Risperdal (an antipsychotic drug) was started the day before to diminish the resident's behavioral issues. The resident's Fall Risk Assessment and Interventions (FRAAI), done 10/18/10, showed the resident had a fall risk score of "12." Cognitive status was unchanged; she was easily distracted, with periods of altered perception or awareness of surroundings, episodes of disorganized speech, periods of restlessness and lethargy, her mental function varied over the course of the day, and she wandered. According to the key at the bottom of the page, a score of "7+" indicated higher risk. Intervention #1, reverse of the form, showed every 15 minute checks were initiated, and the resident was wearing non-skid socks. The FRAAI done 10/19/10 was the same. There were no additional comments on the reverse of the form. 2. 10/24/10 Fall: Review of the 10/23/10 NN at 0100 (1:00 a.m.) revealed the resident walking from door to door "fast" and showed signs of agitation (no symptoms described). At that time, she was medicated with Ativan (anti-anxiety drug) 0.5 milligrams (mg), "took a nap and relaxed." Review of the 10/24/10 NN revealed at 1630 (4:30 p.m.), the nurse found the resident on the floor at the end of the hall after hearing a "thud." She was found by the nurse leaning against a door and the wall. There was no injury observed, but she was diaphoretic (sweaty) and had a rapid heart rate of 115 beats per minute (bpm). She had no fever. The nurse called the laboratory for the urine culture, which revealed bacterial sensitivity to specific antibiotics (ABX). A TO was obtained for ABX treatment of [REDACTED]. Review of the facility's IAIFU revealed the following interventions: medication review, physician review, and therapy review to identify possible cause for the falls. The therapy review noted medications changed 10/4/10, 10/8/10, 10/10/10, 10/19/10, 10/24/10, and 10/25/10. The recommendation was the resident receive increased supervision. The nursing staff conducted serial neurological assessments 10/24/10 through 10/27/10. Review of the 5/7/10 fall care plan, reviewed/revised 10/20/10, 10/24/10 and 10/28/10, revealed the unwitnessed event on 10/24/10 was a possible fall to the buttocks. There was no injury at the time. Approaches listed included continue with activities, manage pain, implement 15 minute checks for 72 hours, notify physician of change of condition or decline, and continue encouraging the resident to call for help when ambulation was unsteady. The 10/25/10 IDT review of the 10/24/10 event documented it was a possible unobserved fall. The interventions were the resident would be encouraged to call for help when ambulation was unsteady and to continue to assess for pain or bruising. Because of the resident's history of grabbing behavior toward a specific male resident as well as other residents, staff was to continue to monitor the resident when she was close to others. Review of an 11/16/10 physician evaluation revealed 10/20/10 laboratory results were within normal limits except for evidence of a UTI, treated with Macrodantin (an antibiotic). Medication changes would continue with a goal to keep the resident calm. The physician wrote the resident wandered and shuffled. He noted the resident had "lots of akathisia behavior" (motor restlessness, and intolerance of inactivity). Review of the FRAAI done 10/27/10 showed the resident had now suffered one to two falls. The cognitive indicators remained the same as above. The sum of the points indicated at the bottom of the page showed a score of "12." However, adding the actual points indicated in the assessment was "18," a 50% increase over the score nine days earlier. There were no additional intervention comments on the reverse of the form. 3. 11/25/10 Fall: Review of the 11/25/10 NN for the 6:00 a.m. to 2:00 p.m. (day) shift revealed the resident was discovered sitting on the ground in the South Park fenced-in courtyard, with blood on her hands. She had a 3-cm (approximately 1.2 inches) long by 1-cm (approximately 0.4 inches) deep laceration on her chin. The resident was unable to verbalize how she got the wound. The resident was combative with staff as pressure and an ice pack were applied to the area. The physician was contacted and ordered transport to the Emergency Department (ED) for treatment. Review of the facility's IAIFU revealed a Certified Nurse Aide (CNA) put the resident in her bed at 10:05 a.m. Staff was in another room, and when staff went to check on her, she was not in her room. She was found by staff later (time unspecified) on the ground in the facility's South Park fenced-in courtyard. Nurse #18 concluded the resident lost her footing and fell , though the fall was described as unwitnessed. At 11:00 a.m., she was transported to a local ED for treatment of [REDACTED]. In interview on 12/1/10 at 10:00 a.m., nurse #8 confirmed he was on duty 11/25/10 from 6:00 a.m. to 2:00 p.m. He said the resident sometimes walked with her head down, but had not done so on 11/25/10. He said staff was in the habit of checking on each resident's location every 10-15 minutes, especially those who were able to move from place to place on their own. He said that just prior to this fall, the resident was not on every-15-minute checks. When they discovered the resident was no longer in her room, staff conducted a room to room search in the nursing unit, but the resident could not be located. He said the resident was found alone outside, sitting on the concrete of the South Park secured unit courtyard. She had a 3-cm linear wound to her chin. She was unable to tell staff how she got the chin wound. He confirmed the unit entry to the courtyard was not locked, and no alarm sounded when any resident left the building through that door to enter the fenced-in courtyard. He said the area where the resident was found on the concrete was approximately 25 feet from the doorway, and was not within the view of staff through a window, and was visible to staff only if they opened the building exit door into the fenced-in courtyard. Observation of the unit's fenced-in courtyard on 12/1/10 at approximately 10:00 a.m. revealed more than 15 half-dollar-sized maroon spots on the concrete patio approximately 10 feet from the corner of the building between resident rooms and the doorway entering the courtyard. This area was only visible when a person exited the doorway and stood in the courtyard outside the door. In telephone interview on 12/2/10 at 11:25 p.m., CNA #13 confirmed she worked 11/25/10, though she did not observe the resident fall. She said she laid resident #21 down on her bed, and at that time, the resident closed her eyes. She said in the past, the resident would close her eyes and sleep when placed in bed. CNA #13 left the room to assist another CNA labeling a new resident's clothing. The CNA said about 20 minutes later, she went back to resident #21's room to check on her and discovered she was not in bed. After alerting the nurse and the other CNA, all rooms were searched. The resident was located sitting on the ground in the fenced-in courtyard. The resident was conscious and fighting staff as the nurse did an assessment. After assessment, the resident was walked into the building, and the nurse called the doctor and the ambulance. Review of the 11/25/10 NN written at 7:00 p.m. revealed the resident returned to the facility accompanied by family. The chin wound was sutured. The resident was "physically aggressive" and medicated with as-needed Ativan. The resident was observed to have a bruise on her left shoulder, a quarter-sized abrasion on her left knee, and she had a "very small" abrasion on the top of her left hand. 4. Fall 11/26/10: Review of the 11/26/10, 6:00 a.m. to 2:00 p.m., NN revealed the resident continued to be aggressive and was medicated with as-needed Ativan. The resident "ran into wall" and had a large laceration above her left eye and a smaller laceration below her left eye. The resident went to the hospital by ambulance for treatment. The facility's IAIFU was not yet complete. According to the interim investigation, the resident was observed by a facility maintenance employee as she ran rapidly past him toward the locked unit doors. She lowered her head and struck the corner of the wall, then fell to the floor. According to a second witness, an activity employee, the resident had been "bothering" (no further description noted) another resident. When advised to keep her hands to herself, she started to walk away from the activities employee, then began to run rapidly down the hall. She was wearing socks, and ran at a full stride run into the outer corner of the doorway where the TV room met the hallway. Though the resident was at high risk for falls, there was no evidence the staff intervened when she began running down the hallway. In an interview on 12/1/10 at 10:25 a.m., the facility Maintenance Director confirmed he was standing approximately 19 feet from the outer corner where the doorway of the TV room met the hallway. He said the resident put her head down and ran rapidly toward the corner of the wall, then fell to the floor. He did not see blood on the wall, but observed blood on the floor. She was running away from him, so he could not tell how high on the corner she hit, but he was sure she hit the corner of the wall. In addition, he could not tell if she impacted the floor as she fell , or if she tried to block her fall with her arm or hand as she fell to the floor. In an interview on 12/1/10 at 10:30 a.m., the activity employee stated he was standing by the doorway to enter the patio, assisting another resident, when resident #21 started to walk away from him down the hall. He observed her from behind. He said she appeared to trip while running and hit the corner of the wall at the entry to the TV room, closest to the locked unit doors. He did not observe anything on the floor. He confirmed she was wearing socks with the treads on the bottom, but no shoes. In an interview on 12/2/10 at 10:55 a.m., nurse #6 said she did not observe the resident fall as she was in another resident's room providing care with the door closed. She heard the maintenance employee call for a nurse. She entered the hallway to see the resident seated on the tile floor, next to the wall. She had non-skid socks on with treads on the bottom. This was her usual footwear. She said prior to the injury, the resident had been aggressive toward staff and residents, and was always trying to grab other people. She said the resident did not have visual impairment and did not wear glasses. She said the resident's behaviors were at their norm, which included putting her hands around the neck of others and trying to choke them. She said she had been walking bent "just a little bit forward." She said in addition to the two non-medical employees who viewed the fall, other residents were present, though they had impaired memory. She said the resident had recently undergone several medication changes due to increasing aggression. In an interview on 12/2/10 at 11:30 a.m., CNA #13 said she was cleaning a closet in another resident's room with the TV and radio on. She said she heard the nurse say "she fell ." When CNA #13 opened the door to the room, she saw resident #21 lying on the floor, with her back to her, and observed blood on the floor. She did not observe the incident. She said over the last 10 days, she had observed the resident bump into things, like the nurse's medication cart or the meal tray cart. She said the resident would turn too quickly as she went into a room and would sometimes bump her arm into the wall. She said she mentioned this to the nurse who assured her this would be put on the 24-hour report. She did not recall when she advised the nurse of this behavior. The CNA did not mention any interventions put in place to address the behavior. Review of the ED record for 11/26/10 revealed the treating plastic surgeon observed "substantial trauma to the left orbital region's soft tissue, with left eyebrow abrasions. It is split down to the bone and a large amount of tissue had been avulsed (absent) from the brow." Laceration #1 was described as approximately 3 cm extending from the upper eyelid to mid forehead (vertical). Laceration #2 was on the lower lid, approximately 3 cm transverse (horizontal). The orbicularis muscle was lacerated. The wounds were closed by absorbable sutures in two layers each. The CAT scan (radiology study) was negative for fracture of the frontal sinus or the left orbit (bony structure supporting the eyeball). 2. Resident #19, age 57, was admitted to the facility 9/23/10. According to the 11/10 computerized physician orders, [DIAGNOSES REDACTED]. According to the 11/11/10 MDS assessment, the resident had impaired short and long-term memory. He had severely impaired cognitive skills and made few, if any, decisions about his daily routine. He was able to make his needs known and understand others. He required the extensive assistance of one person for most activities of daily living, except transfers, which required the assistance of two persons. He was continent of bowel and bladder. The resident resided in a secured unit. Observation on 11/23/10 at 2:37 p.m. revealed resident #19 laying on the bed, asleep. His wheelchair was at his bedside with a sensor alarm. Observation on 11/24/10 at 9:50 revealed resident #19 in wheelchair at the nursing desk, coloring with crayons on paper, then placing his head down on the desk and appearing to sleep. Observation on 11/30/10 from 9:18 a.m. to 9:29 a.m. revealed resident #19 seated in a wheelchair at the nurses' desk, his head tilted toward the right shoulder. His eyes were closed. In interview on 11/24/10 at approximately 9:50 a.m., nurse #21 said staff kept an eye on resident #19, as he will try to go anywhere, or try to stand up. 1. 9/25/10 Fall: Review of the 9/25/10 NN at 6:40 a.m. revealed at 0505 (5:05 a.m.), the resident was found by staff lying flat on the floor beside his bed, face up. He had a skin tear above the right eyebrow. Review of the 9/23/10 NN at 2200 (10:00 p.m.) revealed the safety measures in place were low bed and alarms to the bed and wheelchair. Review of the 9/24/10 NN at 0220 (2:20 a.m.) revealed the resident was at high risk for falls and was closely monitored. He was unable to sleep, and was medicated with Trazadone and Ambien (both to promote sleep) with fair relief. The 09/23/10 2200 (10:00 p.m.) Daily Interdisciplinary Notes (DIN) revealed the resident tried to get up from his wheelchair five times. Review of the 9/23/10 1800 (6:00 p.m.) TO revealed orders to implement the following safety measures: low bed, floor mattress, and chair and bed alarm. A 9/24/10 TO clarified physical therapy (PT) to evaluate and treat the resident for therapeutic exercise activity, gait, and neuromuscular re-education five times a week for 30 days. A 9/24/10 TO clarified occupational therapy (OT) orders for activities of daily living, functional mobility retraining, bilateral upper extremity therapeutic exercises/reconditioning, neuro/balance re-education, and treatment modalities including cognitive skills development five times a week for 30 days. Review of the 9/25/10 post-fall care plan revealed the resident was found lying on the floor face-up at 5:05 a.m. with a skin tear to the right eye brow. Interventions were to continue with the helmet, needs hip protectors, continue with bed and chair alarm, every-15-minute checks, and toileting every two hours. Review of the 9/23/10 Fall Risk Assessment (FRA), part of the Admission Data Set form completed on that date, revealed the resident had a total score of "11." The key at the bottom of the FRA revealed a score of 7-14 indicated a moderate risk resident and care plan was indicated. It went on to explain a low score did not always indicate low risk, and any resident with a fall should be considered high risk until fall-free for 180 days, and always use nursing judgment. 2. 9/28/10 Fall: Review of the reverse of the 9/28/10 Daily Skilled Nursing Note (DSNN) revealed at 1345 (1:45) p.m., the resident was found on floor by the locked entrance door to Estes Park by an administrative nurse (no longer employed there). The resident reported he was trying to look through the door's window and fell . He was uninjured. "The CNA has been educated to check chair alarm all the time and ensure it's in place." The 9/28/10 DSNN at 2200 (10:00 p.m.) revealed the resident was on serial neurologic checks and every-15-minute checks. Review of the IAIFU of the 9/28/10 fall revealed the resident was found on the floor by the locked door of the Estes Park secure unit where it entered into the facility's unlocked units. Evidence of the post-fall investigation and interventions were not provided prior to survey exit on 12/1/10. In interview on 12/1/10 at approximately 5:00 p.m., the Director of Nursing (DON) said the post-fall investigation and interventions could not be located. 3. 10/1/10 Fall: There was no nursing note of the 10/1/10 fall. Review of the "Incident/Accident Investigation Follow-Up" (IAIFU), written by the nurse on duty 6:00 a.m. to 2:00 p.m., revealed the resident sustained [REDACTED]. He was found on the floor beside the bed, bleeding. The fall was unwitnessed, and it was surmised he was attempting to get out of bed unassisted. Interventions were to continue therapy to increase muscle strength and endurance and to provide activities for the resident during his waking hours. The wound was sutured at a local Emergency Department (ED). Review of the 10/1/10 nursing Skin Assessment revealed an approximately 3-cm long wound above the left eyebrow. Review of a 10/1/10 provider visit revealed the resident had fallen and the wound likely needed glue or sutures. Review of a 10/1/10 at 10:00 a.m. telephone order revealed the resident was to get treatment for [REDACTED]. In interview on 12/1/10 at approximately 6:15 p.m. at the facility exit, the Nursing Home Administrator (NHA) said the IDT had focused on the resident attempting to get up from his wheelchair.

Based on observation, record review, and resident and staff interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for two of 18 sample residents (#1 and #5). Specifically: -Resident #1 had breakthrough pain which was inadequately treated. This failure contributed to resident pain. -Resident #5 did not receive her routine scheduled pain medication in a timely manner. Findings include: 1. Reference According to Taylor, Carol R.; 6th Edition, Fundamentals of Nursing: The Art and Science of Nursing Care, Lippincott Williams & Wilkins, 2008, Pg. 1402, chronic pain tends to consume the entire person. It demands total attention so the patient has limited resources to take care of other matters of daily living. It is physically and emotionally exhausting and tends to result in depression and irritability. Chronic fatigue usually accompanies chronic pain. -Lack of an obvious response to pain does not mean the patient is without pain. Careful assessment is especially important to understand what the patient is experiencing. -Affective (Psychological) Responses in pertinent part include: Withdrawal, stoicism, anxiety, depression, anger, fatigue, hopelessness, and powerlessness. 2. Resident #1 Resident #1, a [AGE] year old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to her admission Minimum Data Set (MDS) completed on 3/11/10, the resident had minimal cognitive impairment; she required the extensive assistance of two or more staff members for transferring, ambulation, dressing, personal hygiene and bathing. Although the Admission Nursing Assessment, dated 3/3/10, documented resident #1 had no pain at the time of admission, the admission MDS documented the resident had pain on a daily basis. Because the resident was documented as having no pain on admission, the character of the resident's chronic pain (per questions on the admission document) was not assessed. Specifically: -Under the section marked as "Pain Status", it read, "Are you currently experiencing any pain?" It was marked "No". The directions read that if the answer was "No," staff were not to proceed with the rest of the questions. -These questions included: Describe any areas of pain; the origin, type, pain scale rating; what makes pain better or worse and "What is an acceptable level of pain using a 0-10 pain scale?" Record review revealed the resident's pain tolerance level was not assessed or documented in the resident's record on admission. a. Resident Interviews On 6/29/10 at approximately 2:30 p.m. and 4:00 p.m., resident #1 was interviewed. -When asked how she was feeling, the resident stated, "I have a headache right now. I have pain in my back, and on the left side from the stroke." When asked if she was receiving any treatment or pain medication, she stated, "No." They keep telling me it's not time (referring to her routinely scheduled pain medication)." She stated, " ...this hurts." The resident was crying and grimacing. When asked to describe pain on a scale of 1-10 (0 being no pain and 10 being the worst pain) she stated her pain was at least an 8. -The resident stated in her subsequent interview that she had not received anything else for pain because the nurse said she wasn't due yet. She stated her pain was still atleast a 6 out of 10. The resident was anxious and expressed a feeling of powerlessness. She stated "I have no control over anything. I want to go home...they don't care about my pain." -The resident said she was often in pain but that her complaints were often ignored. She stated the nurses frequently either told her she had just recently had her pain medication or it was due soon. She acknowledged that she often became tearful but that she had suffered from chronic pain for many years. -The resident said she was involved in a very painful transfer on 6/8/10. The resident said a Certified Nurse Aide (CNA) tried to transfer her by herself and when she did so, she (aide) fell over onto the resident. The resident stated her pain level at that time was 10/10. b. Pain Management Plan On 6/29/10 at approximately 3:15 p.m. the medical record of resident #1 was reviewed. The Medication Administration Record (MAR) revealed the following: The initial on-site visit of resident #1's primary physician took place on 3/8/10 and listed chronic pain as a current problem. The resident had a routine order for the following: -[MEDICATION NAME] (a narcotic pain reliever) 15 mg scheduled for 8:00 a.m., 12:00 p.m. and 8:00 p.m. -Tylenol 650 mg every four hours, scheduled at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m. The resident had the following PRN (as needed) medications ordered for pain: -[MEDICATION NAME] 600 mg (an anti-[MEDICAL CONDITION]) every six hours as needed for pain. -[MEDICATION NAME] 5/500 mg (a milder narcotic reliever than [MEDICATION NAME]) every six hours as needed for pain. The resident's care plan read, in pertinent part: -Problem Onset: 3/8/10 "(resident #1) has a history of generalized pain, neuropathic pain and she is at risk for an alteration in comfort. -Goal & target date: (resident #1) will be pain free or any pain she has will be reduced to an acceptable level for her within one hour post intervention x 90 days. -Approaches: ...Monitor (resident #1) for non-verbal signs as well, such as flinching, grimacing, crying, moaning, etc. Provide her with PRN (as needed) pain medication per MD order. Document her level of pain on a pain scale using 0-10 ...contact the physician if her current PRN pain medication/management appears to be ineffective ...document the effectiveness of (resident #1's) PRN pain medication if ineffective then notify the MD." The resident had a physician order [REDACTED]. It was to be rated on a scale of 0-10. The MAR stated only to assess pain each shift. It did not give the specific parameters of the pain scale. c. Failure to consistently address the resident's pain Review of the resident's pain assessments from 3/10 - 7/10 (through survey exit 7/13/10) and the resident's MAR and narcotic sheets revealed the resident was documented with pain; however, she did not consistently receive "prn" pain medication. The pain assessments revealed: (1) March 2010 - Pain was documented: 2 x's at 3 (level) 2 x's at 5 1 x 6 1 x at 8 1 x at 9 Review of the corresponding MAR and narcotic sheets revealed the resident received her routine pain medications; however, she was never administered her PRN pain medication ([MEDICATION NAME]) or [MEDICATION NAME] during the month of March, notwithstanding seven documented instances of pain. The pain assessments (per shift) were not specifically timed; therefore, there was no way to determine from the MAR, the relationship of the pain assessment to the administration of the resident's routine medications. (2) April 2010 - pain was documented: 7 x's at 2 (level) 4 x's at 3 1 x at 4 2 x's at 5 9 x's at 6 3 x's at 7 2 x's at 8 2 x's at 10 Resident #1 was administered her PRN pain medication ([MEDICATION NAME]) five times (according to the front of the MAR) during the month of April, notwithstanding 30 documented instances of pain per the pain scale. The pain flow sheet (on the back of the MAR) documented the [MEDICATION NAME] being given just twice in April, with results only documented as + (positive). According to the pain flowsheet, staff was to assess the pain on a scale of 0-10 prior to administering pain medication, then reassess afterwards. The two prn administrations (of five) documented on the flow sheet had the pre-treatment level of pain documented as a 9/10, with no post-pain intensity. The second documented prn administration on 4/15/10, had neither a pre or post treatment pain intensity documented. The other three [MEDICATION NAME] administrations (on 4/1, 4/8 and 4/9/10) were not documented on the pain flowsheet (back of the MAR) at all. The pain assessments (per shift) were not specifically timed; therefore, there was no way to determine from the MAR, the relationship of the pain assessment to the administration of the resident's routine and prn pain medications. (3) May 2010 - pain was documented: 2 x's at 6 (level) 1 x at 8 Resident #1 was administered her PRN pain medication ([MEDICATION NAME]) eight times during the month of May, although there were only three documented instances of pain on the pain assessment. The front of the MAR showed [MEDICATION NAME] was given seven times, for pain at a 5 once, a 6 twice, a 7 twice, an 8 twice. The follow up results were only documented in four instances. According to the pain flowsheet, staff was to assess the pain on a scale of 0-10 prior to administering pain medication, then reassess afterwards. The seven (of eight) [MEDICATION NAME] administrations documented on the flow sheet had the pre-treatment level of pain documented as for pain at a 5 once, a 6 twice, a 7 twice, an 8 twice, with no post pain intensity except on 5/31/10, when the pain was documented as having dropped from a 6 to a 1. The pain assessments (per shift) were not specifically timed; therefore, there was no way to determine from the MAR, the relationship of the pain assessment to the administration of the resident's routine and prn pain medications. (4) June 2010 - pain was documented: 0 x's The front of the MAR showed [MEDICATION NAME] was given two times, 6/8 and 6/11/10. According to the pain flowsheet, staff was to assess the pain on a scale of 0-10 prior to administering pain medication, then reassess afterwards. The two documented administrations of [MEDICATION NAME] on the flow sheet had the pre-treatment level of pain documented as at a level of 6; the second one on 6/11/10 was noted to be a 5, with no post pain intensity except on 6/9/10, when the pain was documented as having dropped from a 6 to a 2. There was no level documented and no follow up on the pain flow sheet and no evidence she had been medicated for pain on 6/11/10. See above; the resident stated she experienced pain at a level of 10/10 on 6/8/10 when she was transferred by a CNA who fell on top of her. There was no documentation of the resident's pain that day on the pain assessment or in the Nurse's Notes. See above; the resident complained of pain at a level of 8 during interview on 6/29/10. Review of the pain assessment for 6/29/10 revealed no pain was documented. (5) July 2010 (as of 7/12/10) - pain was documented: 1 x at 1 (level) 1 x at 4 Resident #1 was administered her PRN pain medication ([MEDICATION NAME]) one time during the month of July, on the 9th. She was documented as having no pain that day. According to the pain flowsheet (on the back of the MAR) they were to assess the pain on a scale of 0-10 prior to administering pain medication, then reassess afterwards. The one [MEDICATION NAME] administration (7/9/10) did not have pre or post pain intensity documented on the pain flowsheet (back of the MAR) at all. Review of the Nurse's Notes revealed the facility nurses did not document complaints of pain, assessments of pain, or response to PRN pain medication when it was administered. There was no evidence staff had asked the resident on admit or at anytime thereafter, what an acceptable level of pain was for her. d. Staff Interviews The Licensed Practical Nurse (LPN) in charge of medication administration for resident #1 was immediately notified of the resident's complaint of pain at approximately 2:35 p.m. on 6/29/10 after the resident was first interviewed (see above). He then spoke with the resident, who gave the same complaints of pain to him. He told her she had her pain medication and needed to give it time to work. According to the MAR, she had received [MEDICATION NAME] 15 mg at noon on 6/29/10, and was not scheduled to receive it again until 8:00 p.m. that evening. She also received her regularly scheduled Tylenol at noon and was not scheduled to receive it again until 4:00 p.m. Neither her PRN [MEDICATION NAME] nor her PRN [MEDICATION NAME] was offered to her. The same LPN was interviewed on 7/12/10 at approximately 2:10 p.m., in the presence of the Director of Nursing (DON), in regard to resident #1's pain. He acknowledged the resident cried frequently and grimaced often, sometimes for no reason. He stated that her pain was very difficult to assess at times. He acknowledged that crying and grimacing were both signs of pain. When asked why the resident did not receive any PRN pain medication on 6/29/10, he stated that she did not seem to be in significant pain at that time and that she had regularly scheduled pain medication ordered. When asked what time frame the pain assessments documented on the MAR represented, he stated he assessed residents at the beginning of the shift and documented that number. The resident's complaint of pain at an 8/10 level on 6/29/10 was conveyed to the LPN at the beginning of his shift. He acknowledged he did not document the resident's pain as reported to him by the resident on the pain assessment or in the Nurse's Notes. The new DON, who had been employed for one week at the facility when interviewed on 7/12/10, stated during the interview at approximately 2:30 p.m., that it was her expectation that residents' complaints of pain be taken seriously and addressed promptly. -The DON confirmed that PRN orders for pain management were to be followed because the physician ordered it in anticipation of breakthrough pain. -The DON also acknowledged that it was not acceptable for a nurse to not treat, monitor or report pain. -The DON stated that it was a "fair expectation" for all nurses to be able to appropriately and timely monitor and treat pain. -The DON also stated it was very important for the results of any PRN medications to be documented for the physician to determine the efficacy of treatment. She stated that all nursing staff would be re-trained on appropriate pain management. The Nursing Home Administrator (NHA) was interviewed on 7/12/10 at approximately 3:45 p.m. She stated that issues regarding medication administration had been reviewed with nursing staff repeatedly. She provided an undated Medication Pass Protocol. It was a list of specific dos and don'ts, but pain assessment or pain medication were not addressed. There was no sign in sheet to show which staff had been re-trained. She stated that pain management was addressed at every Quality Assurance (Q/A) meeting. When asked if she thought pain management was addressed appropriately, she stated it was an ongoing process. On 7/13/10 at approximately 10:30 a.m. a telephone interview with the facility Medical Director was conducted. He stated that they inherited a building with a lot of problems. He stated they conducted audits to ensure many issues (both from prior survey and complaint investigations) were being addressed. He stated that things were purported to have been done but that staff (specifically nursing) were not following through. He acknowledged the facility had a lot of staff turnover - it was in an effort to get the right staff in place. The Medical Director stated they discussed pain management at every QA meeting. He was not aware of specific issues with pain assessment, monitoring, documentation for resident #1. 3. Resident #5, [AGE] year old female, was admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses, according to her face sheet, that included circulatory disorder, [MEDICAL CONDITION], hypertension (high blood pressure), high cholesterol, constipation, [MEDICAL CONDITION], diabetes mellitus type II and depression. According to her most recent MDS, a quarterly completed on 4/16/10, she had modified independence with her cognitive skills; she had occasional episodes of verbal abuse and of being socially inappropriate; she required the extensive assistance of at least two staff for transfers, personal hygiene and bathing; was completely dependent on staff for dressing; and the assistance of one staff member with eating and toilet use. a. Observation and Resident Interview On 7/1/10 at approximately 10:30 a.m. the surveyor entered the room where resident #5 resided. The resident had asked to be contacted by the surveyor for the group interview. Resident #5 was asleep in her bed. There was a medicine cup full of pills on her bedside table. Resident #5 was awakened as requested, and asked if she knew how long the pills had been there. She said she did not know, and at times, she was "not too clear" in the mornings when she first woke up. When asked at the end of interview if she was in any pain, she stated she was and rated it a 6/10. Resident #5's roommate was observed at this time to be pacing around the room, going through things. Resident #5 was interviewed again at approximately 3:35 p.m. She stated she had not been asked about her pain but that the medications she got at 11:00 a.m. had started working an hour after administration, "around 12 or 12:15 p.m." b. Record Review Record review on 7/1/10 and visual confirmation with the licensed practical nurse (LPN) who prepared the medications, revealed the medications included [MEDICATION NAME] 5/500 twice a day at 8 a.m. and 8 p.m. a narcotic for pain relief and [MEDICATION NAME] HCL twice a day at 8 a.m. and 8 p.m. a non narcotic for pain relief. c. Staff Interview The LPN who was giving medications on 7/1/10 was interviewed at approximately 10:35 a.m. He was asked why the pills were left at the bedside. He stated he had left the room to wash his hands, although a sink was observed in the residents' bathroom. When asked how long the medications had been there, he stated he was not sure, perhaps 10 minutes. Because the medications were the ones scheduled to be administered to resident #5 at 8:00 a.m., the LPN was asked why the medications were being given over two and a half hours late. He stated, "I have 27 patients and can't do it all!"

Based on observation, record review and interviews, the facility failed to ensure the residents' environment was as free from accident hazards as possible; and failed to ensure one of 19 sample residents received adequate supervision and assistance devices to prevent accidents (#19). Specifically, the facility: -failed to provide adequate supervision to prevent sample resident #19 from elopement; -failed to ensure cigarette butts were properly discarded. The findings include: 1. Elopement Closed record review revealed sample resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 3/17/10 Minimum Data Set (MDS) coded the resident as having short and long term memory impairment and moderately impaired decision-making skills. Review of the resident's comprehensive care plan, dated 1/13/10 with a goal and target date of 4/13/10, specifically addressing the problem of dementia/mental disorder, included the problem of altered thought processes. The goal was for the resident to continue to verbalize his thoughts and feelings and to make his needs known to the staff on a regular/daily basis. Approaches to the problem included keeping the resident safe from hazards, administering medications as ordered and encouraging family involvement. Review of an elopement risk assessment, dated 1/11/10, revealed the resident was cognitively impaired with poor decision-making skills, ambulated independently and had a history of [REDACTED]. Review of admission social service (SS) notes, dated 1/21/10, revealed the resident was admitted from another long term care facility due to being a flight risk. The resident was placed on a secured unit. Review of SS notes, dated 2/22/10, revealed the resident had discussed transitioning from the locked unit to an open unit. The resident was informed by the social worker the interdisciplinary team (IDT) did not think it was appropriate to allow the resident to move to an open unit due to the risk of elopement (see weekly discharge readiness documentation below). Review of a "Weekly Discharge Readiness Assessment," dated 3/23/10, and signed by members of the IDT, revealed the resident had expressed a desire to be discharged from the facility. According to the assessment, the resident was not safe to live independently, but would agree to move into an assisted living facility. Review of a discharge readiness assessment dated [DATE], revealed the plan for placement was for the resident to transition to an open unit, and then into an assisted living facility. The assessment also included an entry documenting the resident's family member brought all of his personal and financial items to the facility and stated he no longer wanted to be involved with the resident. Review of a discharge readiness assessment, dated 5/11/10, revealed the resident was touring assisted living residences. Review of a physician's telephone order (TO), dated 5/11/10, documented the resident could transition to an open unit and was to wear a wanderguard (to alert staff of attempts to leave the facility without supervision). Review of nurse's notes, dated 5/11/10 at 3:00 p.m., revealed the resident was moved to a room on an open unit and a wanderguard was placed on his right wrist. At 9:12 p.m., according to notes, the resident was placed on 15 minute checks due to the risk of elopement. Documentation in nurse's notes, dated 5/12/10 at 6:30 a.m., 9:00 a.m. and 6:50 p.m., revealed the resident continued on 15 minute checks. An entry in the nurse's notes, dated 5/13/10 at 6:30 a.m., read, in pertinent part, "Resident alert can make needs known, no (zero with a slash) wanderguard on person last noc (night) @ 2300 (11:00 p.m.), resident stated she took it off, no (zero with a slash) attempts to leave, slept all noc no (zero with a slash) complaints. . ." An entry in the nurse's notes at 10:30 a.m. documented the resident appeared to be adapting comfortably to his new room and had no complaints. There were no further entries in the nurse's notes addressing the wanderguard. A late entry nurse's note, dated 5/14/10 at 5:00 p.m., revealed at 4:00 p.m. on 5/13/10, the resident was not found in the building. A search of the facility was conducted with no results. The facility management team and the local police department were notified. The resident was his own responsible party; and family was not involved with the resident. A nurse's note, dated 5/16/10 at 10:40 a.m., revealed the resident was located and was returning to the facility. Further review of documentation in the notes revealed a nursing assessment was performed and no concerns were identified. The note documented the resident stated no one could make him stay in the facility. Per the notes, the nursing home administrator (NHA) directed staff to contact the resident's physician. An order was obtained for the resident to leave the facility against medical advice. Review of a 5/16/10 telephone order (TO) read, in pertinent part, "TO PA (physician's assistant)/via administrator (first name) Resident may leave the facility AMA (against medical advice)". Review of the facility AMA Release document, dated 5/16/10, revealed the resident and the NHA signed the release. In an interview with the director of nursing (DON), on 5/19/10 at approximately 1:10 p.m., she stated the resident was supposed to be on 15 minute checks. She stated the last check on 5/13/10 was documented as occurring at 2:00 p.m. She stated the wanderguard was never located. The DON said when the police brought the resident back to the facility, they stated the resident was alert and oriented and could not be held against his will. In an interview, on 5/20/10 at 9:00 a.m., with a regular visitor to the facility, the visitor stated the resident was alert and oriented and was his own responsible party. The visitor verified the resident's family member abruptly withdrew support for the resident and the facility social worker was trying to secure a guardian. The visitor stated s/he had met with the resident in March and April of 2010, and had advocated for the resident to move to an open unit. The visitor was aware of the IDT's assessments and determination the resident was not safe to leave a locked unit due to the risk of elopement. The visitor also stated in April, the resident had begun touring assisted living facilities and agreed this would be an acceptable place for him to live. The visitor stated s/he was in the facility on 5/13/10 for a scheduled meeting with the facility. After the meeting, the visitor went to talk to the resident, however, the resident was not in his room, so s/he looked for him throughout the facility. The visitor stated s/he informed staff the resident was not in the building. The visitor stated the resident was supposed to be on 15 minute checks. In an interview with the NHA on 5/20/10 at 8:45 a.m., she stated the resident signed himself into the secured unit, and transitioned out after the 5/11/10 IDT assessment revealed he was safe to live on an open unit. She also stated the resident had toured numerous assisted living residences, but had not made a decision on any one in particular. The NHA said the resident had been wearing a wanderguard and was supposed to be on 15 minute checks. She stated the wanderguard had not been located. She stated on 5/13/10, the resident left the building, caught a bus and went downtown. Facility staff immediately went looking for the resident and the police were notified. The NHA added when the police returned the resident to the facility, they stated the resident was alert and oriented, and was not an elder in danger, so they could not hold him. The NHA stated the staff member responsible for not checking on the resident the day of his disappearance had been terminated. 2. Cigarette Butts On 5/18/10 at 11:50 a.m., observations documented in the Rocky Mountain Park Courtyard (Secured Unit) 25+ cigarette butts lying in the grass and planting areas (wood bark chips and leaves). The staff development coordinator (SDC) was immediately notified. The SDC observed/agreed the cigarette butts were laying in these areas. The SDC stated the cigarette butts should not have been in these areas and discarded cigarette butts should be placed in the provided smoking kettle. The SDC also stated residents were supervised during smoking periods. On 5/19/10 at 2:17 p.m., the nursing home administrator (NHA) provided the facility policy on "Tobacco (revised 1/19/10)." The policy documented in pertinent part: "all residents on the secure units are supervised during smoking times by staff." However, the policy did not document where discarded cigarette butts were to be placed. On 5/21/10 the facility provided additional documentation (via courier), which detailed the facility conducted rounds on the grounds twice a day and cigarette butts were not left on the grounds over a period of time throughout the day, nor was there an abundance of cigarette butts around on the grounds. The additional documentation did not elaborate on the responsibility of facility staff allowing supervised residents to discard cigarette butts into flammable materials (grass and planting areas containing wood bark chips and leaves).

Based on observation, interviews and record review, the facility failed to provide a resident environment as free of accident hazards as possible for residents, including five of 18 sample residents (#1, #2, #3, #5 and #12). Specifically, the facility failed to ensure: -Resident #3's lap tray was removed during meals, -Resident #1 was transferred properly to bed, -Resident #2 was adequately supervised, -Resident #12's fall and elopement interventions were in place, and -Resident #5's medications were not left at the bedside. -Broken equipment (shower chair) was not available for resident use. Staff failure to remove resident #3's lap tray resulted in a significant skin tear to her hand. Findings include: RESIDENT FAILURES A. Expectations According to the facility's plan of correction for the recertification survey of 5/20/10, all staff received an in-service regarding adequate supervision for residents at risk for elopement and all appropriate safety interventions were put into place by 6/23/10. The Director of Nursing (DON)/designee was monitoring supervision documentation weekly for completeness and the results were presented to QA (quality assessment) monthly. B. Resident Failures 1. Resident #3 Resident #3, [AGE] years old, was admitted to the facility on [DATE]. According to her face sheet she had [DIAGNOSES REDACTED]. According to her most recent Minimum Data Set (MDS), a quarterly completed on 6/18/10, she was severely impaired in her cognitive skills; was socially disruptive (hollering out) almost daily; she was totally dependent on the staff for transfers, dressing, eating, toilet use and personal hygiene; she had mild pain on a daily basis and had fallen in the last 31-180 days. a. Accident with Injury Review of the medical record on 6/30/10 for resident #3 revealed that she had sustained a skin tear to the back of her left hand on 6/28/10. -A Nurse's Note on 6/28/10 identified the resident had sustained a skin tear on her right forearm. -A late entry Nurse's Note on 6/29/10 clarified the location of the resident injury. The note read, in pertinent part: 1:00 p.m. "Spoke with (name) from (name) hospice in regards to skin tear on left hand from previous evening. (Hospice nurse) gave me an order to clean wound and place clear tegaderm (a dressing) over wound for 7-10 days. Watch for s/s (signs and/or symptoms) of infection ..." The nurse did not document the size of the skin tear. Review of the facility's incident report and interview with the Nursing Home Administrator (NHA) on 7/1/10 at approximately 11:45 a.m., revealed that on 6/28/10 a 17:40 (5:40 p.m.), a certified nurse aide (CNA) pushed resident #3 up to the dining room table for dinner. Resident #3 was in a geri-chair (a recliner) with a lap tray. The CNA did not remove the lap tray prior to pushing the resident up to the table, causing the skin tear. Review of the Medication Administration Record revealed the resident received "as needed" Roxinal 0.5 mg at 8:00 p.m. for increased calling out and pain at a level of 7/10 (with 10 being the worst pain). There was no documentation that the resident had received the "as needed" medication prior to this date in 6/10. b. Observations On 6/30/10 at approximately 3:45 p.m. the skin tear to the left hand of resident #3 was observed. The injury was approximately two inches by three inches in size; the skin was missing over that area and it was covered with clear Tegaderm (a wound dressing). The entire area of her left hand was bruised and discolored, ranging from red to purple. c. Facility Failures (1) Failure to remove the lap tray as care planned Review of the resident's care plan revealed, in pertinent part: -3/5/10 "Problem: Self care deficit ...She uses a recliner chair with tray table. Her gait & balance are impaired ...Approaches: ...Reclining chair with tray table for enabler. Check & remove tray table for activities, toileting, meals. . ." A RN (Registered Nurse) who often worked with resident #3 was interviewed on 6/30/10. She stated that the CNA who caused the injury pushed the resident up to the dining room table without removing the tray table. She stated that the resident's hand got caught between the tray table and the table and caused a skin tear. She stated the skin tear was approximately two inches by three inches and bled quite a bit. The RN stated that the wound could have been avoided had the tray table been removed as per the care plan. She also stated it was a community standard to always remove lap trays, safety belts etc. frequently during the day, but always at meal times. The NHA was interviewed on 7/1/10 at approximately 11:45 a.m. The NHA acknowledged that the lap tray should have been removed prior to the CNA sliding the resident up to the table. She stated the CNA had been verbally counseled, but she was unable to provide any documentation of this. She acknowledged she should have written up the counseling and further stated that they would be re-training all staff regarding the removal of trays, belts etc. at meal time. She also stated they were making a move towards not using geri chairs at all in the future. (2) Failure to timely retrain CNA There was no documentation as of 7/13/10 (exit date) that the CNA had received training on resident safety since the incident 6/28/10. 2. Resident #1 Resident #1, [AGE] years old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to her admission MDS completed on 3/11/10, the resident had minimal cognitive impairment; she required the extensive assistance of two or more staff members for transferring, ambulation, dressing, personal hygiene and bathing. a. Transfer 6/8/10 Resident #1 was interviewed on 6/29/10 at 2:30 and 4:00 p.m. -The resident said she was involved in a very painful transfer on 6/8/10. The resident said a CNA tried to transfer her by herself and when she did so, she (aide) hurt her left leg during the transfer because she bent it the wrong way. She stated the CNA then fell on top of her. The resident stated she was crying and told another CNA and nurse who responded that she was hurt. The resident stated her pain level at that time was 10/10. - The resident stated that no one ever came back and met with her in regard to the final results of the investigation of the incident. The resident stated that she was very afraid at the time it happened but the CNA had been transferred to another unit so she did not have to interact with her. She stated she would be afraid to have the CNA care for her again. Review of the facility records regarding the 6/8/10 incident revealed the following pertinent information: -A statement, dated 6/9/10 by the CNA, that read, "Once (resident #1) was in her gown we proceeded with a single person transfer." -A statement, dated 6/10/10 by the NHA that read, "Resident requires a two person transfer and will be care planned, (CNA name) will receive a verbal written (disciplinary action) for the inappropriate transfer and will receive training by therapy. b. Facility Failures (1) Failure to transfer resident #1 with the assistance she was assessed to need. See above; review of facility records revealed the CNA had transferred the resident by herself, although the resident required a two-person transfer, per MDS. On 7/1/10 at approximately 10:15 a.m. the NHA was interviewed and stated that the conclusion of the facility investigation was that the CNA performed an inappropriate transfer. She said the CNA was written up and referred to PT (physical therapy) for additional transfer training. (2) Failure to ensure CNA received timely transfer training On 7/1/10, during the interview that began at approximately 10:15 a.m., the NHA provided a copy of a form, titled "In-Service Training Report." It was dated 6/2010, with no specific date of the training listed. The topic was transfer training and it was signed by the CNA involved in the incident. Under Subject Cover, it read: -"Discussed and reviewed appropriate transfer & safety techniques with CNA. Focused on technique, clearing pathway, body mechanics, safety precautions, contra-indications (SIC), assistance & barriers to functional transfers. Staff member demonstrates an understanding of training." The Therapy Manager, a Licensed Physical Therapist (LPTA), was interviewed on 7/13/10 at 10:15 a.m. When asked for the specific date the CNA received the re-training for transfers, he stated it had not been done by him until 6/30/10, 22 days after the incident occurred. Review of facility staffing records revealed that during that time, the CNA worked 12 eight-hour shifts without re-training for appropriate transfers. He acknowledged that was true and could offer no explanation for the delay. The NHA was asked about the delay in providing additional training to the CNA. She could offer no explanation for delay but stated they would work on being timely. She stated that they had been without a DON (Director of Nursing) and had a lot of staff turnover, which made it difficult for her to be sure staff was doing what they were supposed to do. She confirmed, however, that the facility had a DON in place at the time of the incident. She stated that she counted on her department heads/managers to supervise their staff. Several attempts to interview the CNA involved in the 6/8/10 were unsuccessful. The RN (Registered Nurse) who responded to the initial incident no longer worked at the facility. (3) Failure to document resident condition following 6/8/10 transfer. The NHA was interviewed again on 7/11/10 at approximately 3:00 p.m. She was asked to provide the facility policy in regard to incident reporting. She gave the surveyor an undated policy/procedure entitled "Incident and Accident Reporting". It read, in pertinent part: "Upon determination that an incident or accident has occurred involving any resident, visitor or employee, the Charge Nurse will complete an assessment of the involved individuals to determine the extent of the injuries and render appropriate treatment if necessary." Review of resident #1's record revealed documentation of the resident's complaint about the incident on 6/8/10; however, there was no assessment of the resident's condition. The next Nurse's Note was 6/14/10, documenting that some lab results had been called in. On 7/1/10 at approximately 3:00 p.m., NHA confirmed there was no evidence that the Charge Nurse had completed an assessment of the resident after the 6/8/10 transfer. The NHA also supplied the surveyor with an in-house form entitled "Check Off Sheet For All Incidents" that she stated was to be used after each incident. It read: -"Nursing Note: ______ Must include a detail (SIC) statement of the incident, including time, location of incident, position of resident (Very Descriptive!!!!!), pre incident activity, clothing, footwear, assistive devices, alarms in use, vital signs and neuros, notifications and head to toe assessment including skin, range of motion, pain and mental status). -MD/Hospice Notified & Documented: ______ -Treatment order obtained, if appropriate: _____ -Family Notified & Documented: ______ -Nurse on call notified (Unit Manager if in the building): _____ Nurse on call/Unit Manager will notify DON and Administrator -Neuro checks initiated: _____ -15 minute checks initiated: _____ -Initial Skin Assessment complete: _____ -Witness statement if appropriate: _____ -Call light within reach? Y N Initial each item when complete or write N/A. This form is attached to incident report and placed in 24 hour book on unit for managers to continue with follow up. Nurse Signature:__________________ Date: _______" The NHA stated that the purpose of the form was to ensure all the required steps were followed in any incident. There was no completed form for the 6/8/10 incident. The NHA stated that getting staff to do what was required of them has been an ongoing problem and that she thought everyone was doing their jobs. 3. Resident #2 Resident #2, [AGE] years old, was admitted to the facility's secured all male unit on 2/24/10. According to his face sheet and history and physical, he had [DIAGNOSES REDACTED]. According to his most recent Minimum Data Set (MDS), a quarterly completed on 5/21/10, the resident had moderate cognitive impairment; he had the following behavioral symptoms: verbally abusive, socially inappropriate (including sexual behaviors) and resisting care; he required supervision for transfers, and ambulation; he required limited assistance for dressing, eating, toilet use and personal hygiene; he required physical assistance in part of bathing. He was noted to have an unsteady gait. a. Resident Status (1) Admission to all male secure unit Review of the initial part of the physician's progress note, written 2/25/10, read in pertinent part: -History and Physical: "Patient transferred from (name of sister facility) secured unit to all male secured unit here last p.m. due to recurrent sexual behaviors towards female residents. Here to resume therapies and supportive care... -Assessment and Plan: ...Schizophrenia - on Zyprexa - secured unit due to behaviors/wander risk..." Another physician's progress note, written 3/4/10, read in pertinent part: -"...Schizophrenia complicated by bipolar mood D/O (disorder) and sexual aggression- Improved security/function on secure unit..." (2) Transfer off secure unit A Nurse's Note, dated 6/16/10, stated the resident was transferred to the open unit on this date. b. Facility response to resident's status - failures related to discharge from the secure unit. (1) Record Review Review of a Nurse's Note, dated 6/16/10 read, "Order noted for Wanderguard placement for elopement risk, to check Wanderguard daily for elopement risk and to check skin integrity under the Wanderguard daily ..." Record review revealed an Elopement Risk Assessment, dated 6/21/10 (signed by by two Registered Nurses 6/28/10). It read that the resident was cognitively impaired with poor decision-making skills (i.e. intermittent confusion, cognitive deficits or disoriented). It documented that the resident was an elopement risk after being moved off the secured all male unit. Record review revealed a monthly summary (used to assess the resident condition monthly) dated 6/18/10, two days after the resident's transfer to the open unit. The summary, completed by a Licensed Practical Nurse (LPN) documented that resident #2 was "easily upset, expresses according to situation, and cooperative ..." and that he had a "Wanderguard in place for elopement risk." Review of the resident's current (June 2010) Treatment Administration Record (TAR) revealed the following orders: -6/16/10: Check Wanderguard placement and skin condition every shift - Elopement Risk. -6/16/10: Use Wanderguard tester to check for Wanderguard functional status every evening. It was to be checked each day at 9 p.m. Review of his care plan revealed some changes when the resident was transferred to the open unit. The changes were dated 6/16/10 and as having been reviewed by the IDT (Interdisciplinary Team) on 6/21/10. In regard to the Wanderguard, it read: "______ (resident #2) resides in the open unit. "______ (resident #2) requires a Wanderguard r/t (related to) elopement risk. No exit seeking x 90 days. Check W/G (Wanderguard) q (each) shift for placement & functioning. Redirect as needed for any s/s of exit seeking. As of survey exit 7/13/10, this care plan had not been discontinued. Review of the resident's care plan further revealed a care plan dated 3/2/10, addressing inappropriate, hypersexual behavior around females was discontinued 6/16/10, when the resident was transferred off the male unit. (2) Failures Record review revealed no documentation of a resident assessment prior to transfer to the open unit 6/16/10, and no order from the physician to transfer the resident to the open unit. The facility SW (Social Worker) was interviewed on numerous occasions, both in person and via telephone (6/29, 6/30, 7/2, 7/7 and 7/11/10). She stated that it was the decision of the Nursing Home Administrator (NHA) to transfer resident #2 out of the secure unit and that it was not a team decision. She acknowledged the appropriate assessment in regard to the resident's discharge to open unit was not done for resident #2. A facility Registered Nurse (RN) was interviewed on 6/29, 6/30, 7/1, 7/2 and 7/11/10 both by phone and in person. She stated the decision to move resident #2 was made by the NHA and was not a team decision. Review of the resident's record on 6/29, 6/30 and 7/1/10, revealed ten social service entries after admission. However, none of the notes addressed elopement or sexual behaviors. Cross-reference F250. c. Inadequate supervision after transfer off the secure unit. (1) Record Review Elopement Risk: Record review revealed the resident's Wanderguard was not consistently checked as care planned (see above). Specifically, review of the 6/10 TAR revealed the resident's Wanderguard placement was not consistently checked every shift; the TAR was signed off on 6/27/10 by the 10 p.m. to 6 a.m. shift; 6/28/10 by the 6 a.m. to 2 p.m. shift and the 10 p.m. to 6 a.m. shift; and 6/29/10 signed off by all three shifts. All other shifts were blank. Moreover, there was no documentation the Wanderguard functional status had been tested daily at 9:00 p.m. as planned. In an interview on 7/12/10 at approximately 3:45 p.m., the NHA produced social service notes dated 7/2, 7/4 and 7/7/10, that were not in the record when it was reviewed on 7/1/10. These notes (7/2 and 7/4/10) documented resident #2 was determined to no longer be an elopement risk and would wear a Wanderguard only on the weekends. During the week, he would be on 15 minute checks. Review of the record for 15 minute checks, revealed, a number of documentation omissions. Specifically: -6/17/10 No checks initialed from 3:30 a.m. through 5:45 a.m. -6/17/10 From 9:30 a.m. through 10:30 a.m. it was noted the resident was "Out washing cars." -6/20/10 No checks initialed from 5:30 a.m. through 6:00 a.m. -6/29/10 No checks initialed from 3:45 p.m. through 9:45 p.m. -6/30/10 No checks initialed from 11:00 a.m. through 12:00 p.m. Inappropriate sexual behavior: See above; record review revealed no care plan about the resident's history of sexually inappropriate behavior toward female residents and no plan to monitor the resident's behaviors. (2) Interviews A Registered Nurse (RN) was interviewed on 6/29, 6/30, 7/1, 7/2 and 7/11/10 both by telephone and in person. She stated she was uncomfortable with resident #2 being transferred to the open unit. She stated there were several female residents that were frail and vulnerable and she was concerned they were at risk for sexually inappropriate advances by resident #2. She also stated she was concerned about the resident's elopement risk, because she said she had observed resident #2 doing yard work only in the company of the NHA's [AGE] year old family member. She stated the Maintenance Director who oversaw the pair was not always in attendance. The former DON was interviewed via telephone on 6/30/10. She stated she was very concerned about resident #2 being outside doing yard work. She stated she saw him working on several occasions without the Maintenance Director being present. She stated the direct supervision of him during those times was often the NHA's [AGE] year old family member. She stated she expressed her concern to the NHA and was told "he will let me know if he (resident #2) tried to elope." She also expressed a specific concern about a female resident that had a behavior of being hypersexual and that she could easily be taken advantage of. That resident resided across the hall from resident #2. The resident's physician was interviewed on 6/30/10 at approximately 1:45 p.m. by telephone. She was asked about the resident being transferred off the secure men's unit. She stated he was doing better and had no behavior issues or elopement attempts that she was aware of. She stated she did not realize the resident was not assessed to determine appropriateness for transfer to the open unit. The NHA was interviewed on 6/30/10 at approximately 9:45 a.m. She said resident #2 was a "success story," and he was doing well, involved in activities and in the facility work program. She was asked about their policy for someone being admitted to one of their secure units; she stated a resident had to be assessed prior to a transfer off the secure unit. When told there was no documentation that resident #2 had been assessed prior to transfer in to the open unit, the NHA responded that she trusted her staff to do the "right things." On 7/13/10 at approximately 10:30 a.m. a telephone interview was conducted with the facility Medical Director. He stated resident #2 was a "success story". He went on to say that at one time the NHA had her family member watching over the resident (while outside doing yard work) but the family member had access to staff if needed. He stated the family member ([AGE] years old) was very mature. He also stated that "Hopefully he was being monitored." The Medical Director said he was unaware that an assessment had not been conducted prior to the resident's transfer out of the secure unit. Resident Interview An attempt to interview resident #2 was made on two separate occasions (6/29/10 and 7/1/10). On both occasions the resident was uncommunicative and only gave monosyllabic answers (yes and no). 4. Resident #12 Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to her admission MDS, dated [DATE], resident #12 had short- and long-term memory problems and moderately impaired cognitive ability. She sometimes understood others and others sometimes understood her. Resident #12 required limited assistance from staff for transfers and toileting but only supervision with ambulation on the unit. She required physical help with balance while standing. Resident #12 was receiving an antipsychotic and a diuretic 7 days a week. a. Record Review According to the hospital physician's admission note, dated 6/15/10, resident #12 was admitted for abnormal heart rhythm problems. She had a history of [REDACTED]. Resident #12 required a sitter while in the hospital. The facility had assessed resident #12's high fall risk on admission. Her fall risk score was 26 (7+ = high risk). The facility had assessed resident #12's elopement risk on her admission data set, dated 6/23/10. She was a high risk because of her [DIAGNOSES REDACTED]. There was no facility care plan for fall or elopement risk, 18 days after admission. Nurse's Notes, dated 7/1/10, revealed, "A/O x 1 (alert and oriented to person), confused, ambulates in her room only. Uses w/c (wheelchair) to move around." On 7/11/10 Nurse's Notes revealed resident #12 was using oxygen and was on fall precautions, "She's on O2 (oxygen) via n/c (nasal cannula) at 2 l/min (liters per minute). . . resident remains on fall precautions secondary to high fall risk." There was no documentation regarding resident #12's elopement risk or interventions. On 6/30/10 facility provided a list of residents on 15 minute checks. Resident #12's name was on the 15 minute check list. Review of purged records revealed resident #12 had been on 15 minute checks 6/23/10 - 7/1/10. The documented reasons for 15 minute checks of resident #12 were new (admission) and safety. b. Observations and Interviews At 1:10 p.m. on 7/11/10, the surveyor asked a certified nurse aide (CNA) for resident #12's 15 minute check documentation. The CNA said resident #12 was not on 15 minute checks because she was in the hospital. The medication nurse was interviewed on 7/11/10 at 1:15 p.m. He said resident #12 was not in the hospital and her condition had improved since admission and she was no longer on 15 minute checks. On 7/11/10 at 1:20 p.m. resident #12 was observed sitting on the side of her bed, eating lunch. She was pleasant when spoken to but was unaware of where she was. Resident #12 was not wearing a wander guard and no bed alarm was visible. The resident shifted her weight off and on the bed and no alarm sounded. She was wearing an oxygen nasal cannula with approximately 18 feet of oxygen tubing at her feet. She was wearing socks (non-grip) with one slipper. She said she was able to go to the bathroom by herself with her long oxygen tubing and could not find her other shoe. Resident #12 was observed again on 7/11/10 at approximately 2:30 p.m. while she was sitting on the side of her bed. She had the oxygen nasal cannula in her nose and was still wearing one shoe. A CNA came into her room to give her cares. Resident #12 abruptly stood up beside her bed and no alarm sounded. The CNA told her to sit down again but did not check the status of any alarm. On 7/12/10 at approximately 10:00 a.m. the DON and NHA were interviewed. The NHA said it was standard facility practice to place newly admitted residents on 15 minute checks for three days. The DON said she was new in the facility and would have to check about resident #12's fall precautions. At approximately 11:20 a.m. the DON said resident #12 had a pressure bed alarm in place. At 11:25 a.m., the DON and surveyor went to resident #12's room and observed her standing at her closet door, approximately 15 feet from her bed. There were no staff in her room and no alarm was sounding. Resident #12 was wearing an orthopedic brace on her right foot and a slipper on her left foot. As she turned to greet the DON and surveyor, her feet became tangled in her oxygen tubing. The DON examined resident #12's pressure bed alarm, located under her bed, and said it was not working. She said resident #12 should not be ambulating without supervision. On 7/13/10 at approximately 9:30 a.m. a facility medication nurse was interviewed and said at the change of every shift nursing reported to the oncoming shift. She said the CNAs reported to each other and if there were any changes in resident care, the information was reported to the CNAs by nursing. On 7/13/10 at approximately 10:00 a.m. the DON said resident #12's pressure bed alarm was not functioning because the batteries needed to be changed. She said the night shift was responsible to check alarm batteries and document the check on the MAR (Medication Administration Record). Review of resident #12's July 2010 MAR did not reveal any documentation of alarm battery checks. The NHA was interviewed on 7/12/10 at approximately 3:30 p.m. and said the recertification survey issues had been discussed in the June QA meeting. C. ENVIRONMENTAL FAILURES A. Medications left unattended 1. Observations 7/1/10 Observations on 7/1/10 at 10:30 a.m. revealed resident #12 and resident #5 were roommates. Both residents had modified independence with cognitive skills per their MDS (Resident #12's MDS was dated 6/24/10 and resident #5's MDS was dated 4/16/10.) On 7/1/10 at approximately 10:30 a.m. the surveyor entered the room where resident #5 resided. The resident had asked to be contacted by the surveyor for the group interview. Resident #5 was asleep in her bed. There was a medicine cup full of pills on her bedside table. Resident #5 was awakened as requested, and asked if she knew how long the pills had been there. She said she did not know, and at times, she was "not too clear" in the mornings when she first woke up. When asked at the end of interview if she was in any pain, she stated she was and rated it a 6/10. Resident #5's roommate was observed at this time to be pacing around the room, going through things. The LPN (Licensed Practical Nurse) who was administering medications that day was immediately brought to the room by the surveyor. He was asked why the pills were left at the bedside. He stated he had left the room to wash his hands, although there was a sink in the resident bathroom. He was asked to bring the pills to the medication cart to identify them. When asked how long the medications had been in the residents' room, he stated he was not sure, perhaps 10 minutes. The medications were the ones scheduled to be administered to resident #5 at 8:00 a.m. The medications were identified as the following: 1. Calcium 500 with Vitamin D twice a day (8 a.m. and 8 p.m.) 2. Vesicare 5 mg twice a day (8 a.m. and 8 p.m.) for reactive bladder. 3. Vitamin B12 1000 mcg each day at 8 a.m. 4. Multivitamin with minerals each day at 8 a.m. 5. Detrol Long Acting 4 mg each day at 8 a.m. for urinary urgency. 6. Metoprolol 50 mg twice a day at 8 a.m. and 8 p.m. for high blood pressure. 7. HCTZ 12.5 mg each day at 8 a.m. for high blood pressure. 8. Vicodin 5/500 twice a day at 8 a.m. and 8 p.m. a narcotic for pain relief. 9. Tramadol HCL twice a day at 8 a.m. and 8 p.m. a non narcotic for pain relief. 10. Celexa 10 mg twice a day at 8 a.m. and 8 p.m. for depression. 11. Trileptal 300 mg twice a day at 8 a.m. and 8 p.m., except Mondays, for seizure disorder. 12. Metformin HCL 500 mg twice a day at 8 a.m. and 8 p.m. for diabetes. After the medications were all identified the LPN was asked if resident #12 was confused. He said, "I'm not sure. She is new and I don't really know her." As the facility did not have a Director of Nursing (DON) present in the building, the Nursing Home Administrator (NHA) was advised of the incident. She stated she understood the seriousness of the situation and would take care of it immediately. (She and another staff member did a sweep of that entire unit, checking the bedside of each resident. There were no other medications noted to be at the bedside of any other residents in that unit. The NHA also had a Registered Nurse from another unit take over the medication cart from the LPN. Later, she had the LPN giving medication only under the direct supervision of the RN. She stated the LPN would be written up and a medication error would be completed.) 2. Unsafe Equipment On 7/13/10 at approximately 9:45 a.m. an observation of a resident shower room by the nurse's station, between Denver Park and South Park units, were made. There was a shower chair sitting inside the resident therapeutic tub (which was no longer used by residents). The back right wheel was noted to be missing, rendering the shower chair unstable and a safety hazard. A CNA present in the shower room at the time of the observation was asked about the shower chair, specifically why was it in the tub. She stated it was a back-up chair to use. When the missing wheel was pointed out to her, she seemed surprised and said that she might have attempted to use it. A second CNA in the shower room at the time of the observation was asked why the chair was in the tub. She stated it had not been there the day before when she left at approximately 3:00 p.m. She stated she did notice it was broken and assumed everyone knew. When asked what she was supposed to do upon discovering any malfunctioning and/or broken equipment, she stated she should have notified the Maintenance Director. On 7/13/10 at 9:55 a.m. the Maintenance Director was shown the broken shower chair. He was upset and stated he was not aware there was a broken piece of equipment available for resident use. -When asked what was supposed to happen in regard to malfunctioning/broken equipment, he stated there was a work order book at all the nursing stations. He also stated that the staff was to notify maintenance immediately of broken equipment. He said the procedure was that all broken equipment was to be taken down to the basement to be repaired or disposed of. -He stated the staff had been train