Every finding on record at Julia Temple Healthcare Center

Based on record review and interviews, the facility failed to establish an effective antibiotic stewardship program to monitor for antibiotic use for one (#40) of one resident reviewed for antibiotic use out of 51 sample residents. Specifically, the facility failed to: -Have an effective antibiotic stewardship program by mapping infections timely; and, -Have an effective antibiotic stewardship program to ensure Resident #40 was not given an antibiotic unnecessarily. Findings include: I. Failure to have an effective antibiotic stewardship program by mapping infections timely A. Professional reference According to The Centers for Disease Control and Prevention (CDC) Core Elements of Antibiotic Stewardship for Nursing Homes, (2024), retrieved on 12/11/24 from https://www.cdc.gov/antibiotic-use/hcp/core-elements/nursing-homes-antibiotic-stewardship.html Track the amount of antibiotic used in your nursing home to review patterns of use and determine the impact of new stewardship interventions. Antibiotic use data from nursing homes to improve antibiotic stewardship is important both for individual facility improvements and for public health action. B. Facility policy and procedure The Antibiotic Stewardship Program policy and procedure, revised November 2024, was received from the clinical nurse resource (CNR) on 12/10/24 at 9:00 p.m. It documented in pertinent part, The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. At least one measure associated with antibiotic use will be tracked monthly, as prioritized from the facility ' s infection control risk assessment and other infection surveillance data. C. Record review Record of the infection mapping for the month of December 2024 was requested from the IP on 12/10/24 at 1:00 p.m. The infection preventionist (IP) said she was unable to provide the infection mapping as she did not complete it until the end of the month (see interviews below). D. Staff interviews The IP was interviewed on 12/10/24 at 1:00 p.m. The IP said the facility had a monthly infection control meeting and a monthly quality assurance and performance improvement (QAPI) meetings with the medical director to discuss house-acquired infections, trends in illnesses and some antibiotic review if clarification was needed. She said at the end of each month, she mapped out all the infections from that month to identify trends in infections. The director of nursing (DON) and the CNR were interviewed together on 12/10/24 at 5:00 p.m. The DON said infections should be mapped out as soon as they were identified. He said this was important so the facility can determine if there was a pattern in infections. 50219 II. Failure to have an effective antibiotic stewardship program to ensure Resident #40 was not given an antibiotic unnecessarily. A. Resident #40 1. Resident status Resident #40, age 83, was admitted on [DATE]. According to the December 2024 computerized physicians orders (CPO), diagnoses included dementia, cognitive communication deficits and generalized muscle weakness. The 10/9/24 minimum data set (MDS) revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) assessment score of 11 out of 15. The assessment revealed the resident was always continent of bowel and bladder and required supervision or touching assistance for toileting hygiene. The assessment did not indicate Resident #40 was on an antibiotic. 2. Record review The incontinence care plan, dated 6/3/2020, revealed Resident #40 was at risk for complications associated with incontinence and had a history of urinary tract infections (UTIs). Pertinent interventions included encouraging fluids during the day, checking the resident as required for incontinence and observing the resident for any signs or symptoms of a UTI. A provider note, dated 11/5/24 at 3:40 p.m., revealed Resident #40 was seen by the physician per her representative ' s request. The note revealed the representatives had recently visited and noted a cognitive decline with Resident #40 and were concerned about a UTI. Resident #40 denied any urinary symptoms that day, said she felt well and appeared to be at baseline. In the assessment and plan, the note documented that the provider suspected the cognitive decline was due to the progression of Resident #40 ' s dementia but ordered bloodwork to rule out concern for an infection or electrolyte disturbance given the representative ' s concern. A progress note, dated 11/26/24 at 11:18 a.m,. revealed Resident #40 had a change in condition. Resident #40 had a functional decline and altered mental status. Resident #40 ' s vitals were taken at that time and were within normal limits and did not have a fever. Resident #40 ' s provider and representative were notified. A progress note, dated 11/26/24 at 1:10 p.m., revealed there was a lab sample waiting for pickup for Resident #40. A progress note, dated 11/26/24 at 1:45 p.m., revealed Resident #40 ' s provider had assessed the resident and a new order to obtain a urinalysis via a straight catheter was obtained and to perform a culture and sensitivity if indicated. -However, Resident #40 did not meet the McGeer criteria to obtain a urine sample. Resident #40 had an acute onset of altered mental status, but did not have fluctuating behavior, altered level of consciousness, or inattention during her assessment (see below). Additionally, Resident #40 did not have a three point decrease in functional ability in her activities of daily living (ADLs), was afebrile, and did not yet have current bloodwork results available for review for elevated white blood cell counts. A provider note, dated 11/26/24 at 3:40 p.m., revealed Resident #40 was evaluated by the facility nurses ' request due to increased confusion and altered gait. Resident #40 was pouring sugar packets onto the table at breakfast instead of into her coffee. An unidentified certified nurse aide (CNA) reported to the provider Resident #40 was having new urinary incontinence and frequency. There was concern for infection or possible reaction to a vaccine Resident #40 had received the day prior. In her exam, Resident #40 was more confused than usual and denied any suprapubic tenderness or pain. The provider ordered bloodwork as well as a urinalysis with urine culture to evaluate further. A progress note dated 11/27/24 at 8:34 a.m. revealed Resident #40 ' s functional ability had improved, appetite increased, and confusion had decreased. A progress note dated 11/27/24 at 11:45 a.m. revealed Resident #40 ' s urinalysis results were received and reviewed by the provider. A new order was received from the provider for Bactrim (antibiotic) twice a day for five days. A progress note dated 11/27/24 at 11:55 a.m. revealed a change of condition form for Resident #40. The note documented Resident #40 had a UTI and vitals were assessed at that time. All vitals were within normal limits and no fever was reported. The provider and Resident #40 ' s representatives were both notified. An infection surveillance report dated 11/27/24 at 1:18 p.m. revealed which criteria Resident #40 met when reviewing the resident for antibiotic stewardship. For constitutional criteria, it was documented that Resident #40 had an acute change in mental status from baseline and an acute functional decline in ADLs. For ADLs, Resident #40 was marked mostly dependent for all areas for both baseline and current, and did not have any functional decline indicated. In the surveillance by body systems section, it was noted that Resident #40 had a UTI, acute dysuria (painful or uncomfortable urination), suprapubic pain, and a new or marked increase in urinary urgency. In the section for provider review, it was indicated that the antibiotic was reviewed with the provider to ensure it was a true infection, the right antibiotic, right dose, right route, and right duration. The infection preventionist note revealed it was a healthcare acquired infection and met criteria for infection. Additional notes revealed Resident #40 had a change of condition on 11/26/24 with increased confusion and decrease in functional ability. A urinalysis was ordered and the results showed +1 leukocyte esterase with a urine culture pending. The provider was notified and a new order received. Resident #40 was to start on an oral antibiotic for a UTI until 12/2/24. Bloodwork results for Resident #40 were reported to the facility on [DATE] at 8:44 a.m. A review of the bloodwork results revealed two abnormal values: -Nine hundred and ninty seven cells per microliter (uL) absolute monocytes, with a normal reference range of 200-950 cells per uL; and, -Twelve cells per uL absolute eosinophils, with a normal reference range of 15-500 cells per uL. Urinalysis and urine culture results for Resident #40 were reported to the facility on [DATE] at 10:11 a.m. A review of the urinalysis results revealed four abnormal values: -One plus leukocyte esterase, with a normal reference range of zero; -Six to ten white blood cells per high power field (HPF), with a normal reference range of zero to five; -Six to ten squamous epithelial cells per HPF, with a normal reference range of zero to five; and, -One plus ketones, with a normal reference range of zero. The urine culture did not have any bacterial growth. -However, Resident #40 remained on antibiotics after the urine culture results were received by the facility despite there being no bacterial growth on the urine culture (see interview below). Review of the November 2024 and December 2024 medication administration records (MAR) revealed Resident #40 received one tablet of Bactrim Ds 800-160 milligrams twice daily, starting at 7:00 p.m. on 11/27/24 and ending at 6:00 a.m. on 12/2/24. 3. Staff interviews The infection preventionist (IP) was interviewed on 12/10/24 at 1:08 p.m. The IP said the facility followed the McGeer criteria for determining infections in the facility. The IP said she spoke with the provider that ordered the antibiotic if said antibiotic was not meeting criteria, not the medical director (MD). The IP said she met with the MD once a month for an infection control meeting but would call the MD if she had any concerns. The IP said she did not call the MD to go over every antibiotic, but would get called if she had concerns and could not get ahold of the ordering provider. The IP said the MD did not review every antibiotic during their quality assessment meetings, only the antibiotics with which the IP had concerns. The IP said Resident #40 had a change of condition on 11/26/24, at which point the provider ordered a urinalysis. The IP said the urinalysis results came back on 11/27/24 and Resident #40 was started on Bactrim that day prior to her urine culture results coming in. The IP said Resident #40 met McGeer ' s criteria to collect a urinalysis as she had one plus leukocytes and altered mental status. The IP said Resident #40 ' s urine culture results were reviewed on 11/28/24. The IP said when a urine culture came back with no growth, they needed to discontinue the antibiotic. The IP said she was not sure how Resident #40 ' s urine culture was missed. The IP said the provider should wait for the urine culture results prior to using antibiotics so that the provider knows what bacteria has grown, if any, and so that the resident does not take an antibiotic unnecessarily. The IP said in reviewing the infection surveillance note the area indicating Resident #40 was having suprapubic pain may have been clicked by accident, as the resident did not have any pain. The IP clarified Resident #40 only had altered mental status, but did not meet any other criteria to collect a urinalysis. The IP said if Resident #40 did not meet criteria, a urinalysis should not have been ordered. The director of nursing (DON) and the clinical nurse resource (CNR) were interviewed on 12/10/24 at 5:12 p.m. The DON said the facility followed the McGeer criteria for determining infections in the facility. The CNR said if a physician ordered a urinalysis but the resident did not meet the McGeer criteria, the IP would notify the physician that they did not meet criteria and would document this in the medical record. The CNR said the resident had to meet McGeer ' s criteria in order to obtain a urine sample for a urinalysis. The DON said the IP reviewed residents ' lab work and communicated with the residents ' providers. The DON said the IP and the prescribing physician worked to make a determination with regard to the resident being on an antibiotic or if they should discontinue its use. The CNR said a culture and sensitivity were part of the McGeer criteria and that the provider needed to wait to see the culture results prior to starting an antibiotic. The CNR said the IP needed to look at the criteria the resident met and see if a urinalysis was indicated. The CNR said after the lab work was received, the IP needed to communicate with the resident ' s physician and tell them the labwork results and see if they could discontinue the antibiotic.

Based on observations, record review and interviews, the facility failed to ensure four (#366, #370, #27 and #43) of 12 residents out of 51 sample residents were provided the appropriate care and services of activities of daily living (ADL) to maintain or improve his or her abilities. Specifically, the facility failed to ensure Resident #366, Resident #370, Resident #27 and Resident #43 received cueing or assistance while eating. Findings include: I. Facility policy and procedure The Assisting Diners policy and procedure, revised May 2019, was provided by the nursing home administrator (NHA) on 12/11/24 at 9:26 a.m. It read in pertinent part It is the policy of this facility that dependent diners will be assisted with all meals in a manner that meets the individual resident's needs, promotes self-esteem and the highest practical level of independence. If verbal prompts are needed to initiate eating, opening mouth, swallowing, do these in a calm, pleasant manner. Offer drinks of beverages throughout the meal. Offer alternatives if foods refused. II. Resident #366 A. Resident status Resident #366, age 79, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO) diagnoses included aphasia (disorder affecting ability to understand and express language), dysphagia (difficulty swallowing) and dementia. The 11/24/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of seven out of 15. Resident #366 needed set up and clean up assistance with meals as well as partial assistance with planning regular daily activities. B. Observations During a continuous observation on 12/9/24, beginning at 9:46 a.m. and ending at 1:00 p.m., the following was observed: At 12:20 p.m. Resident #366 was served a room tray for lunch of orange chicken, rice, mixed vegetables, and a cookie. An unidentified certified nurse aide (CNA) who served her the lunch tray did not offer or encourage the resident to go to the dining room. The resident took a few bites. The staff did not provide cueing or physical assistance to Resident #366 during the meal. The resident ate less than 25% of her meal. During a continuous observation on 12/9/24, beginning at 3:30 p.m. and ending at 7:00 p.m., the following was observed: At 6:28 p.m. Resident #366 was served a room tray for dinner. An unidentified CNA did not encourage the resident to eat dinner in the dining room. The staff did not provide cueing or physical assistance to Resident #366 during the meal. The resident ate about 50% of her meal. During a continuous observation on 12/10/24, beginning at 11:45 a.m. and ending at 1:00 p.m., the following was observed: At 11:58 a.m. Resident #366 entered the dining room. At 12:16 p.m. she was served a plate of mashed potatoes, mixed vegetables, roast beef and fruit for lunch. At 12:21 p.m. Resident #366 had not taken a bite of lunch. The staff did not provide any physical assistance or cueing for the resident to eat. At 12:36 p.m. Resident #366 was asked by an unidentified nurse if she was going to eat. Resident #366 responded yes, however she still did not take a bite of food. The unidentified nurse walked away and did not provide any further cueing or assistance. At 12:48 p.m. Resident #366 was assisted back to the unit. She did not eat any of her meal. C. Record review The ADL care plan, revised on 11/22/24, documented Resident #366 had an ADL self-care performance deficit due to a recent fall and a diagnosis of dementia, which impacted her cognition. The interventions included providing set-up and physical assistance of one staff member with eating and encouraging the resident to eat her meals in the dining room. -However, according the observations during the survey process, Resident #366 was not provided the level of assistance in which the care plan documented she required. The nutritional risk care plan, revised on 12/1/24, documented Resident #366 was malnourished according to a mini-nutritional assessment conducted at the facility. The interventions included inviting the resident to attend activities that promote additional intakes, eating meals in the dining room, monitoring and reporting to the physician if the resident had any signs or symptoms of a decreased appetite, monitoring the resident's weights per facility policy, providing and serving supplements as ordered (Ensure Plus one carton, three times daily) and reviewing the resident's nutritional status in the nutrition at risk meeting as needed. The 12/1/24 dietitian progress note documented Resident #366's meal intake was sporadic, between zero to 75%. The meal percentage documentation record revealed from 11/21/24 to 12/10/24, Resident #366 ate zero to 25% on 19 occasions and refused to eat on three occasions. III. Resident #370 A. Resident status Resident #370, age 82, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included encephalopathy (brain disorder that causes brain dysfunction), dysphagia, dementia and moderate protein calorie malnutrition. The 11/17/24 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of three out of 15. Resident #370 required set up and clean up assistance with meals as well as partial assistance with planning regular daily activities. B. Observations During a continuous observation on 12/4/24, beginning at 9:45 a.m. and ending at 1:30 p.m., the following was observed: At 12:23 p.m. Resident #370 was served lunch of fish, green beans, rice and corn bread. Resident #370 was unable to find his silverware that was tucked in his napkin on his right hand side. He was eating with his hands. At 12:42 p.m. the food and nutrition resource (FNR) asked Resident #370 if he was doing okay. She did not offer any encouragement or cueing and did not offer to assist him with his silverware Resident #370 ate a few bites of his food. At 1:15 p.m.Resident #370 was assisted back to the common area. He had eaten less than 25% of his meal. During a continuous observation on 12/9/24, beginning at 3:30 p.m. and ending at 7:00 p.m., the following was observed: At 6:15 p.m. Resident #370 was served a room tray for dinner. He was sitting up in bed at about 80 degrees and slouched over. He took a few bites of food. The staff was not observed checking on the resident, providing cueing or any physical assistance. During a continuous observation on 12/10/24, beginning at 11:45 a.m. and ending at 1:00 p.m., the following was observed: At 12:00 p.m. Resident #370 was sitting in the dining room for lunch, sleeping in his wheelchair. At 12:15 p.m. Resident #370 received lunch of roast beef, mashed potatoes, mixed vegetables and fruit. He began to scoop up the food and eat with his knife. He did not receive any cueing or assistance from the facility staff observed in the dining room. Resident #370 finished his plate and began to scrape the plate in an attempt to get more food. Staff did not offer him any additional food. C. Record review The alteration in neurological status care plan, revised on 11/14/24, documented Resident #370 had a history of chronic microvascular ischemic (small blood vessels become damaged in the brain), dementia and a seizure disorder. The interventions included providing cueing and reorientation as needed. The ADL care plan, revised 11/17/24, documented Resident #370 had an ADL self-care performance deficit due to the diagnoses of encephalopathy, seizures and dementia which impacted his strength, balance, coordination, cognition and mobility. It indicated he required set up and one staff physical assistance with meals. The interventions included encouraging the resident to eat all meals in the dining room. The nutritional risk care plan, revised on 11/20/24, documented Resident #370 was malnourished according to a mini-nutritional assessment conducted at the facility. The interventions included inviting the resident to activities that promoted additional intakes, encouraging the resident to eat all meals in the dining room, monitoring and reporting to the physician if the resident had any signs or symptoms of decreased appetite; monitoring weights per the facility policy and reviewing as needed, providing and serving supplements as ordered (Ensure Plus one carton, three times daily, evening snack every night) and reviewing the nutritional status in the nutrition at risk meeting as needed. The meal intake documentation revealed Resident #370 ate 76% to 100% the majority of the time. It documented on 12/4/24, he ate 76% to100% during lunch, however this documentation was inaccurate as observations during the survey process showed Resident #370 had eaten less than 25% (see observations above). IV. Resident #27 A. Resident status Resident #27, age 89, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included fracture (break) of the upper left femur (thigh bone), fracture of the lower left ulna (bone in the arm) bone, stroke, dementia, dysphagia and moderate protein calorie malnutrition. The 11/4/24 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of seven out of 15. Resident #27 required substantial to maximal assistance with eating as well as partial assistance with planning regular daily activities. B. Observations During a continuous observation on 12/4/24, beginning at 9:45 a.m. and ending at 1:00 p.m. the following was observed: At 12:33 p.m. Resident #27 was in the dining room with a plate of fish, rice, green beans and corn bread. She was eating her corn bread. She did not receive any cueing or encouragement from staff. During a continuous observation on 12/9/24, beginning at 9:46 a.m. and ending at 1:00 p.m., the following was observed: At 12:12 p.m. Resident #27 was observed sitting in the dining room, drinking her water. At 12:18 p.m. she was served lunch, which consisted of orange chicken, rice, vegetables and a cookie. Resident #27 ate small bites of her meal. At 12:28 p.m., Resident #27 took a small bite of her chicken and was still chewing on that same bite of chicken at 12:33 p.m. The staff did not provide Resident #27 any cueing or encouragement during the meal. Resident #27 ate less than 25% of her meal. At 3:27 p.m. an unidentified CNA removed Resident #27's meal tray. During a continuous observation on 12/10/24 beginning at 11:45 a.m and ending at 1:00 p.m. the following observations were made: At 12:13 p.m. Resident #27 was served lunch which consisted of mashed potatoes, mixed vegetables, pot roast and fruit. At 12:19 p.m. Resident #27 had eaten only the mashed potatoes. At 12:35 p.m. Resident #27 ate some fruit. At 12:46 p.m. an unidentified nurse asked Resident #27 if she was going to eat. Resident #27 responded, no and the nurse walked away. At 12:49 p.m. Resident #27 was returned to the unit. She had eaten less than 25% of her meal. C. Record review Review of the record revealed that Resident #27 was malnourished according to the 11/7/24 mini nutritional assessment (MNA). The meal intake documentation revealed Resident #27 ate 51% to75% the majority of the time. -However, observations on 12/4/24, 12/9/24 and 12/10/24 showed Resident #27 ate 25% or less of her meals (see observations above). V. Resident #43 A. Resident status Resident #43, age 81, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included dementia, protein-calorie malnutrition, cognitive communication deficit and dysphasia. The 11/7/24 MDS assessment revealed Resident #43 had severe cognitive impairments with a BIMS score of three out of 15. TResident #43 required set up and clean-up assistance with meals. B. Observations During a continuous observation on 12/4/24, beginning at 9:45 a.m. and ending at 1:30 p.m., the following was observed: At 11:49 a.m. Resident #43 was in the dining room with the unidentified speech therapist. Resident #43 was served fish, green beans, rice and corn bread. -However, based on her dislikes documented in the electronic medical record (EMR), Resident #43 did not like fish. She was not offered a meal replacement. At 12:26 p.m. the unidentified speech therapist left the dining room. Resident #43 ate less than 25% of her lunch. The resident was not provided any cueing or assistance during the meal. On 12/9/24 during a continuous observation, beginning at 9:46 a.m. and ending at 1:00 p.m., the following was observed: At 12:17 p.m. she was served lunch which had mechanical soft orange chicken, mixed vegetables, rice and a cookie. At 12:32 p.m. Resident #43 spit out a mouthful of food onto her plate. She was moving the food around her plate but did not take any bites. The staff did not provide Resident #43 with cueing or encouraged her to eat. At 12:54 p.m. Resident #43 was removed from the dining room. She had eaten less than 25% of her meal. During a continuous observation on 12/9/24, beginning at 3:30 p.m. and ending at 7:00 p.m., the following was observed: At 6:01 p.m. Resident #43 was in her room sleeping. At 6:13 p.m. an unidentified CNA delivered the resident's dinner tray to her room. Once she delivered the tray, the CNA closed the bedroom door after exiting her room. During a continuous observation, on 12/10/24, beginning at 11:45 a.m. and ending at 1:00 p.m., the following was observed: At 11:55 a.m. Resident #43 was assisted to the dining room for lunch. At 12:11 p.m. the resident was served her meal which consisted of mashed potatoes, mixed vegetables and pot roast. She had a few bites of her vegetables and had a couple sips of her beverage. At 12:18 p.m. Resident #43 stopped eating after taking a couple bites of her vegetables and roast beef. She did not receive any cueing from staff. At 12:33 p.m. an unidentified CNA provided a cue, the resident took one bite and the CNA walked away. She did not provide Resident #43 any additional cueing. At 12:50 p.m. she was wheeled from the dining room to the common area. Resident #43 ate less than 25% of her meal. C. Record review The ADL care plan, revised 11/21/24, documented Resident #43 had a self-care deficit due to her diagnoses of dementia, protein-calorie malnutrition, cognitive communication deficit, and dysphasia. It indicated the resident required set up and one person physical assistance with meals. The interventions included encouraging the resident to eat all the meals in the dining room. The nutritional risk care plan, revised on 12/3/24, documented Resident #43 was malnourished according to the mini-nutritional assessment completed at the facility. The interventions included offering a meal replacement if she ate less than 50%, offering snacks in between meals, monitoring and reporting to the physician if the resident had any signs or symptoms of decreased appetite, monitoring weights per facility policy and reviewing as needed, providing and serving supplements as ordered (Ensure Plus one carton, three times daily, evening snack every night) and reviewing the resident's nutritional status in the nutrition at risk meeting as needed. It also documented her food preferences, such as dislike of fish and likes of mashed potatoes, fruit, ice cream, Coke, cookies, chocolate, scrambled eggs, fried potatoes, tortillas and bacon. The resident was prescribed a mechanical soft diet. The 12/3/24 nutrition progress note documented Resident #27's meal intake was sporadic and accepted 25 to 50% of supplements. It documented the resident's family said she was overwhelmed by large amounts of food and it would be beneficial to provide smaller meal portions. The meal intake documentation revealed from 11/11/24 to 12/10/24, Resident #27 ate zero to25% on 30 occasions and refused meals on 18 occasions. VI. Staff interviews CNA #14 was interviewed on 12/10/24 at 12:58 p.m. CNA #14 said the unit that Resident #366, Resident #370, Resident #27 and Resident #43 resided on, was a memory care and rehabilitation unit. She said some of the residents on the unit were independent and some needed full care. She said the CNAs got their information on the residents and the type of care that they need from the report at the beginning of their shift. She said the CNAs got some of their information from the computer and the therapy department/ She said a one person assist meant that the resident needed someone to stand by them or to give them cues either by touch or verbally. She said the amount of assistance that a resident might need can change from day to day. She said for dining assistance, the meal tickets had all the information on them which includes how much assistance they need, preferences and type of diet. She said they also watched to see who was not eating or was struggling and they would give them encouragement. CNA #5 was interviewed on 12/10/24 at 5:00 p.m. CNA #5 said Resident #366, Resident #370, Resident #27 and Resident #43 all needed assistance in the dining room. She said that if she saw a resident struggling with eating she would go over to help them. She said sometimes Resident #43 would refuse any help or encouragement. The director of nursing (DON) was interviewed on 12/10/24 at 6:23 p.m. He said the CNAs were scheduled on the same unit every shift so that there was continuity for the residents and the staff. He said the staff should have encouraged residents to eat their meals. He said that a one person assist meant that the resident needed cueing, encouragement, cutting up their meat and assisting the resident with eating.

Based on observations, record review and interviews, the facility failed to implement an activities program that met the interests of and supported the physical, mental, and psychosocial well-being of each resident for three residents (#79, #364 and #11) out of eight residents reviewed for activities of 51 sample residents. Specifically, the facility failed to: -Establish activity preferences and meet the socialization needs of Resident #79 and Resident #364; and, -Invite Resident #11 to group activities and ensure accurate activity documentation. Findings include: I. Facility policy and procedure The Activity Policy and Procedure Manual, revised November 2017, was received from the clinical resource nurse (CNR) on 12/10/24 at 9:00 p.m. It read in pertinent part, Should a resident be considered medically or mentally incompetent, or physically unable to participate in such programs, an entry will be made in the resident's medical record (chart) stating fully the reason(s) for the restriction(s). Such an entry will be signed and dated by the person recording such data. 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) Residents on a formal one-to-one program will have documentation in medical records regarding the type and length of the visit and the individual's response to the visit. 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 #79 A. Resident status Resident #79, age 78, was admitted on [DATE]. According to the December 2024 computerized physicians orders (CPO), diagnoses included Alzheimer's disease, traumatic brain compression and cognitive communication deficits. The 9/18/24 minimum data set (MDS) revealed the resident was severely cognitively impaired and was unable to perform a brief interview for mental status (BIMS) assessment. The assessment revealed the resident's preferred language was Spanish and he needed an interpreter to communicate with health care staff. The 12/21/23 MDS revealed the resident had been interviewed to determine his activity preferences. The resident indicated it was somewhat important for him to have books, newspapers, and magazines to read, to listen to music he liked, to be around animals, to keep up with the news, to do things with groups of people, to go outside to get fresh air, to participate in religious services or practices, and to do his favorite activities. B. Resident representative interview Resident #79's representative was interviewed on 12/10/24 at 9:16 a.m. Resident #79's representative said Resident #79 did not really do much aside from sit in his wheelchair. Resident #79's representative said the facility staff assisted Resident #79 to a position in the common area next to a table by the television and sometimes gave him activities he could do like going through the newspaper. Resident #79's representative said the physical therapy team gave him puzzles he could do and provided him with therapy. Resident #79's representative said she did not think the activities staff spent time with Resident #79 and that he was mostly on his own. Resident #79's representative said Resident #79's first language was Spanish. Resident #79's representative said Resident #79 used to understand a small amount of English but due to his disease process, he had forgotten it. Resident #79's representative said most of the facility staff spoke English but some of the staff spoke Spanish when communicating with Resident #79 and he appeared to understand them. C. Observations On 12/4/24 at 10:07 a.m. Resident #79 was sitting in his wheelchair at a table in the common area. Resident #79 was sitting under the common area television and had his back turned to the rest of the residents in the common area. An unidentified certified nurse aide (CNA) offered the resident a stack of newspapers which were all written in English. Resident #79 was groaning and quietly crying out. At 4:16 p.m. Resident #79 was sitting in his wheelchair at a table in the common area. Resident #79 was sitting under the common area television and had his back turned to the rest of the residents in the common area with no meaningful activities observed. On 12/5/24 at 8:47 a.m. Resident #79 was sitting in his wheelchair at a table in the common area. Resident #79 was sitting under the common area television and had his back turned to the rest of the residents in the common area. At 8:58 a.m. activities assistant (AA) #3 entered the common area and began interacting with residents. Resident #79 was sitting in his wheelchair at a table in the common area in the same position. Resident #79 was intermittently quietly crying out. -AA #3 did not interact with Resident #79. At 9:15 a.m. Resident #79 was sitting in the same position in the common area asleep. At 9:28 a.m. Resident #79 was sitting in the same position in the common area asleep. AA #3 announced to the common area she was going to do exercises in the dining room and invited multiple residents to join her. -AA #3 did not invite Resident #79 to join her in the activity. At 9:37 a.m. licensed practical nurse (LPN) #4 assisted Resident #79 to his room for a nap. Resident #79 was observed during a continuous observation, beginning at 2:45 p.m. and ending at 4:15 p.m. The following was observed: At 2:45 p.m. Resident #79 was sitting in his wheelchair in the common area with his wheelchair angled away from the television and his back turned to the rest of the residents in the common area. At 3:01 p.m. AA #3 set up a table under the television in the common area so Resident #79 could look at magazines. Resident #79 was still sitting in his wheelchair angled away from the television. AA #3 told Resident #79 he could look at magazines after his shower and left him in his wheelchair approximately three feet away from the table. AA #3 announced to the common area she was going to do puzzles in the dining room and asked if anyone wanted to join her. -AA #3 did not directly invite Resident #79 to the puzzle activity nor wait for the resident's response when she announced the activity to the common area to see if Resident #79 would be interested in participating At 3:07 p.m. Resident #79 propelled himself in his wheelchair so that he was facing the television and table in the common room. Resident #79's head was down and he was groaning and intermittently crying out. CNA #10 was in the common area helping another residents but did not assist or address Resident #79. At 3:15 p.m. Resident #79 was slowly propelling himself toward the table and intermittently groaning and crying out. CNA #10 was sitting and doing computer work in the common area approximately ten feet away from Resident #79 but did not address Resident #79. At 3:18 p.m. Resident #79 reached the table and began picking up and looking at magazines which were published in English. At 3:22 p.m. Resident #79 was grabbing the edge of the table and trying to pull himself closer to the table. At 3:34 p.m. Resident #79 had propelled himself away from the table and was looking at the wall with no meaningful activity happening. AA #3 was sitting in the common area next to the resident conducting a word game. AA #3 did not attempt to include Resident #79 or interact with him. At 3:35 p.m. Resident #79 began to grasp the edge of the table and tried to pull the table to himself. At 4:05 p.m. Resident #79 was sitting in the same position in his wheelchair. An activity was being conducted in the dining room. -AA #3 did not invite Resident #79 to the activity in the dining room. At 4:06 p.m. Resident #79 was crying and grabbing the edge of the table. An unidentified CNA was sitting in the common area doing computer work. At 4:07 p.m. another resident was standing next to Resident #79, rubbing his back and talking to him. Resident #79 began crying louder. The unidentified CNA called the other resident's name and told her to stop but did not address Resident #79. At 4:10 p.m. the other resident was still rubbing Resident #79's back. Resident #79 was crying intermittently. At 4:15 p.m. the other resident left Resident #79's side. Resident #79 was sitting in his wheelchair approximately two feet away from the table and looking at the floor. Resident #79 was intermittently crying. The unidentified staff member was sitting in the common area approximately ten feet away from the resident doing computer work. On 12/9/24 at 8:49 a.m. Resident #79 was sitting in his wheelchair with his head down at a table in the common area. Resident #79 was sitting under the common area television and had his back turned to the rest of the residents in the common area. At 2:15 p.m. Resident #79 was sitting in the same position in the common area at the table. Resident #79 was tracing his finger along a blank piece of paper. On the table next to him were several newspapers, all written in English, and one coloring book page. At 2:23 p.m. AA #4 delivered the daily newspaper to Resident #79. The newspaper was written in English. Resident #79 was sitting in his wheelchair in the same position and crying out intermittently. -AA #4 did not read the newspaper or offer to translate the newspaper. At 2:57 p.m. Resident #79 was looking at the newspaper. At 3:03 p.m. Resident #79 was sitting in his wheelchair an arm's length away from the table. Resident #79 was looking vacantly away with no meaningful activity occurring. At 3:23 p.m. Resident #79 was sitting in his wheelchair in the same position sleeping. At 5:54 p.m. Resident #79 was assisted in his wheelchair from the dining room after dinner to the table in the common area. Resident #79 was crying out and tracing his finger on a magazine. The magazine was published in English. On 12/10/24 at 9:41 a.m. Resident #79 was sitting at the table under the television in the common area in his wheelchair. Resident #79 was staring at the daily newspaper from the day prior, written in English. At 10:07 a.m. Resident #79 was sitting with CNA #11 in the back corner of the hallway while CNA #11 worked on the computer. Spanish music was playing. At 10:08 a.m. CNA #11 left the hallway and the Spanish music stopped. At 10:09 a.m. AA #4 invited residents sitting a few feet away from Resident #79 to join her in a stretching activity. -AA #4 did not speak with nor invite Resident #79 to the activity. At 10:14 a.m. CNA #11 returned to her computer next to Resident #79 and the Spanish music resumed playing. At 10:16 a.m. CNA #12 spoke with Resident #79 in Spanish and the resident responded but the response was not audible. Resident #79 was smiling as he listened to the music. At 10:22 a.m. AA #4 was handing out coloring pages in the common area. Resident #79 was still sitting in his wheelchair in the corner of the hallway listening to music. At 10:28 a.m. Resident #79 was asleep in his wheelchair by the CNA's computer. The music was no longer playing. At 10:30 a.m. AA #4 assisted Resident #79 to the dining room in his wheelchair to participate in the coloring activity. D. Record review The communication care plan, revised 9/20/24, revealed Resident #79 was at risk for communication problems due to his traumatic brain injury and because he primarily spoke Spanish. Pertinent interventions included anticipating and meeting his needs, providing a translator as necessary and being conscious of the resident's position when in groups, activities, and the dining room in order to promote proper communication with others. The activities care plan, revised 1/27/24, revealed Resident #79's preferred activities were few and included listening to music, going outdoors, watching movies, and reading the daily newspaper. Pertinent interventions included providing Resident #79 with materials for independent activities, inviting and encouraging the resident to participate in all scheduled activities, and that Resident #79 liked to sit in the common area with his peers and observe others. An activities progress note on 8/29/24 revealed Resident #79 was asleep so a formal one-on-one engagement could not be conducted. An activities progress note on 9/3/24 revealed Resident #79 went outside with an unidentified activities staff member to enjoy the nice weather as part of a formal one-on-one engagement. An activities progress note on 9/8/24 revealed Resident #79 was asleep so a formal one-on-one engagement could not be conducted. An activities progress note on 9/19/24 revealed Resident #79 listened to Spanish music with an unidentified activities staff member as part of a formal one-on-one engagement. An activities progress note on 10/3/24 revealed Resident #79 was asleep so a formal one-on-one engagement could not be conducted. A quarterly activity progress note, dated 10/22/24, revealed Resident #79 continued to not show interest in scheduled activities. Resident #79 sat in the common area with his peers, watched television and observed his surroundings. Resident #79 was part of the formal one-on-one engagement program with the activities staff. During the one-on-one engagements, Resident #79 enjoyed listening to music, talking about his family, and going outside. The formal one-on-one engagements took place at least three times per week. Resident #79 had shown interest in holiday-related social activities and going outside. Resident #79 would continue to be encouraged to join scheduled activities and be provided with materials for independent activities. An activities progress note on 10/24/24 revealed Resident #79 had a formal one-on-one activity in which the resident and the unidentified activities personnel listened to music and colored together. -Review of the resident's electronic medical record (EMR) on 12/9/24 did not reveal further documentation that Resident #37 consistently received three one-on-one activity visits per week. Review of Resident #79's social activity task log from 11/10/24 to 12/9/24 revealed the following: -On 11/11/24 at 11:36 a.m. the resident was watching television with others and participated in a snack social; -On 11/26/24 at 10:56 a.m. the resident was watching television with others and participated in a snack social; -On 12/2/24 at 11:48 a.m. the resident was watching television with others and participated in a snack social; and, -On 12/9/24 at 12:17 p.m. the resident was watching television with others and participated in a snack social. -No other activities of this kind were documented at the time of review. Review of Resident #79s mental activity task log from 11/10/24 to 12/9/24 revealed the following: -On 11/11/24 at 11:36 a.m. the resident was participating in a self-esteem workshop and reading; -On 11/26/24 at 10:55 a.m. the resident was participating in a self-esteem workshop; -On 12/2/24 at 11:47 a.m. the resident was participating in a self-esteem workshop; and, -On 12/9/24 at 12:16 p.m. the resident was participating in a self-esteem workshop and reading. Review of Resident #79's independent activity task log from 11/10/24 to 12/9/24 revealed the following: -On 11/11/24 at 11:37 a.m. the resident was actively participating in independent activities; -On 11/26/24 at 10:55 a.m. the resident was actively participating in independent activities; -On 12/2/24 at 11:49 a.m. the resident was actively participating in independent activities; and, -On 12/9/24 at 12:16 p.m. the resident was actively participating in independent activities. E. Staff interviews CNA #10 was interviewed on 12/9/24 at 6:14 p.m. CNA #10 said Resident #79 mostly spoke Spanish but spoke some English. CNA #12 was interviewed on 12/10/24 at 9:50 a.m. CNA #12 said Resident #79 loved to eat and it was his favorite thing to do. CNA #12 said Resident #79 liked to listen to Spanish music because the resident only spoke Spanish. CNA #12 said the activities staff brought Resident #79 a newspaper published in Spanish and the resident liked to look at the newspaper. -However, observations revealed the resident was provided a newspaper in English (see observations above). The activities supervisor (AS) was interviewed on 12/10/24 at 3:16 p.m. The AS said the facility had a daily newspaper that was able to be printed in Spanish for the facility's Spanish-speaking residents. The AS said the facility had five staff members that spoke Spanish and were able to read the daily newspaper aloud and translate it for any Spanish speaking residents. The AS said the activities assistants did a lot of one-on-one engagement with residents in Spanish, including listening to music and watching videos and movies in Spanish. The AS said most of the Spanish speaking residents also understood English and that they were able to participate in group activities in English. The AS said Resident #79 went outside three times a day when the weather was nice and the activities staff did one-on-one engagements with him. The AS said Resident #79 liked to talk and watch videos with the activities staff. The AS said Resident #79 liked to be in the common area, watch television, listen to music and read the newspaper. The AS said they were having issues with their daily newspaper account and had to switch to a different publication the last five days that could only be printed in English. The AS said the activities staff had been printing out the publication and reading it aloud in Spanish for the last five days. The AS said the activities staff also printed out news articles in Spanish for Resident #79. The AS said the activities staff documented their one-on-one interactions in the mental activity task log. The AS said Resident #79 was invited to all activities. The AS said Resident #79 was on a formal one-on-one program, which meant he received one-on-one engagements three times per week. The AS said the activities staff would document any refusals in the activity log. The nursing home administrator (NHA) was interviewed on 12/10/24 at 6:35 p.m. The NHA said the AS and her team did the activities assessments for the residents and made them resident centered. The NHA said he was not sure how often the activities team updated their assessments. The NHA said everyone should be invited to group activities. F. Additional information Beginning 12/10/24 at 4:38 p.m., multiple late entry formal one-on-one activity progress notes were entered into Resident #79's progress notes, starting on 12/7/24 and going through 8/15/24. 50315 III. Resident #11 A. Resident status Resident #11, age 83, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included unspecified dementia, cognitive communication deficit, muscle weakness and chronic respiratory failure with hypoxia. The 10/22/24 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of seven out of 15. She required partial/moderate assistance with hygiene, showering and dressing. She required supervision or touching assistance with walking and transferring. The MDS assessment documented that having books, magazines, and newspapers to read, listening to music, keeping up with the news, doing things with groups of people, doing her favorite activities, going outdoors and participating in religious services was very important to Resident #11. B. Observations During a continuous observation on on 12/4/24, beginning at 1:30 p.m. and ending at 4:30 p.m. the following was observed: At 1:30 p.m. Resident #82 was lying in her bed with the television turned on. AA #2 was walking around asking residents to attend a coloring activity in the dining room. Resident #11 was not offered to attend the activity. During a continuous observation on 12/5/24, beginning at 8:37 a.m. and ending at 11:00 a.m., the following was observed: At 8:37 a.m. Resident #11 was lying in bed with the television turned on and the door closed. AA #2 was offering hand massages to residents sitting in the living room. She did not offer a massage to Resident #11. At 10:22 a.m. the chaplain came to the unit and began a sing along with Christmas music. Resident #11 was not invited to the activity. During a continuous observation on 12/9/24, beginning at 8:30 a.m. and ending at 11:00 a.m., the following was observed: At 8:37 a.m.Resident #11 was lying in bed with her eyes closed and the door was closed. At 9:00 a.m. AA #2 was passing out daily chronicles and did not offer Resident #11 one. At 9:33 a.m. AA #2 started doing an exercise group with the residents sitting in the living room. Resident #11 was not offered to join. At 9:55 a.m. AA #2 was passing out snacks and did not offer resident #11 a snack. At 10:15 a.m. an unidentified chaplain started a church service in the living room. Resident #11 was not invited to attend. The chaplain finished the church service at 10:42 a.m. C. Resident interview and observation Resident #11 was interviewed on 12/9/24 at 2:00 p.m. Resident #11 was sitting up in bed with the television turned on and said she was hungry for a pizza. She said she liked to draw, color and watch movies. She said she loved animals and listening to music. She said she did not have time for church, but she enjoyed it. She started yelling out that she was hungry. There was an activity going on in the dining room where residents were coloring, eating snacks, listening to music and folding towels. -However, based on observations, Resident #11 was not invited to the activities going on in the dining room. D. Record review The quarterly activity assessment, completed 10/2/24, documented Resident #11's favorite activities were taking a nap, staying in her room and having a snack every hour, listening to music, playing bingo, balloon volleyball, sing-along, trivia, special events including holiday related activities, animal related activities, church services, community outreach, outside activities and coloring pictures. It was documented in the resident tasks that Resident #11 participated in a sing along and a drawing/painting activity on 12/4/24 at 4:08 p.m. -However, observations revealed Resident #11 was lying in her bed with the door closed alone at this time (see observations above). It was documented in the resident tasks that Resident #11 participated in religious services on 12/9/24 at 11:15 a.m. -However, observations revealed Resident #11 was lying in her bed with the door closed alone at the time of the religious service (see observations above). It was documented in the resident tasks that Resident #11 accepted a snack on 12/4/24 at 2:20 p.m., 12/5/24 at 9:04 a.m. and on 12/9/24 at 10:00 a.m. -However, Resident #11 was lying in bed with the door closed at this time. Staff was not observed offering a snack to Resident #11 at any of these times. It was documented in resident tasks that Resident #11 participated in watching television with others, a men's/women's/focus groups/wellness activity, meal/food/snack social, exercise group and abilities care on 12/4/24 at 4:08 p.m. -However, Resident #11 was lying in her bed with the door closed alone at this time. E. Staff interviews CNA #13 was interviewed on 12/9/24 at 3:45 p.m. CNA #13 said Resident #11 liked to participate in activities. She said she was able to walk by herself with supervision from staff and was forgetful and needed reminders from staff. AA #2 was interviewed on 12/9/24 at 4:15 p.m. AA #2 said Resident #11 used to be on a one to one program for activities but ended because staff were encouraging her to participate in group activities. She said she was actively participating in group activities and enjoyed bingo, coloring, music and church. She said she had refused the activity offered today because she wanted to take a nap. The AD was interviewed on 12/10/24 at 3:15 p.m. The AD said if a resident refused an activity, she would expect the staff to offer a different activity. She said if residents were not willing to participate in a group activity, staff should offer independent or one on one activities. She said Resident #11 participated in group activities lately and enjoyed music, bingo, pets and watching movies. She said if a resident refused an activity, she would expect staff to document refusals. The DON and the CNR were interviewed together on 12/10/24 at 5:00 p.m. The DON said Resident #11 mostly liked to be alone. The DON said she enjoyed some one to one activities, group activities and watching television. He said if she refused to participate in an activity offered, staff should document the refusal. 51163 IV. Resident #364 A. Resident status Resident #364, age 86, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included displaced intertrochanteric fracture of the left femur (break of the left upper thigh bone), history of falling, cognitive communication deficit and dementia. The 11/19/24 MDS assessment revealed Resident #364 had short term and long term memory problems and her cognitive skills for daily decision making was severely impaired per staff assessment. The assessment revealed she was dependent on staff or needed substantial to maximal assistance with the majority of her ADLs. The MDS assessment further revealed that it was very important to her to do her favorite activities, to go outside and get fresh air and keep up with the news. B. Observations On 12/4/24 at 3:06 p.m. an unidentified activities staff member was asking the residents if they wanted to go and play Bingo. The unidentified activities staff member did not ask Resident #364. At 3:54 p.m. Resident #364 was seen placing her forehead on the bedside table in the common area. The television was still playing in the common area, no other activities had been offered to her. During a continuous observation on 12/5/24, beginning at 10:30 a.m. and ending 5:00 p.m., the following was observed: At 10:50 a.m. Resident #364 was in bed and has tried to get up multiple times, each time staff has laid her back down in her bed. No one offered the resident a meaningful activity. During a continuous observation on 12/9/24, beginning at 3:30 p.m. and ending at 7:00 p.m., the following was observed: At 4:26 p.m. an unidentified activities staff member invited residents to do a word search. Resident #364 was not invited to participate. C. Record review The activities care plan, revised on 11/22/24 documented Resident #364 was dependent on staff for activities, cognitive stimulation and social interaction. The care plan documented that she preferred to watch sports, listen to music, go outdoors, gardening, conversing with others and her preferred hobby was to go shopping at the grocery stores. Interventions included inviting the resident to all scheduled activities and providing her with materials for individual activities as desired. The activities admission evaluation, dated 11/22/24 indicated that the resident was interested in exercise groups, sports, music, singing, shopping, going outside, and being around animals. According to the one on one activity tracker (11/15/24 to 12/10/24), Resident #364 had been provided one, one on one activity which was nail care on 12/6/24. According to the independent activity tracker, Resident #364 was active in exploring the environment, observing her surroundings, and walking/wheeling. D. Staff interviews CNA #14 was interviewed on 12/10/24 at 12:58 p.m. CNA #14 said that after the residents had been at the facility for a while the staff got to know them. She said when sundowning began to happen in the afternoon it was important to have activities to help redirect the residents. She said Resident #364 changed from day to day, she said that yesterday (12/9/24) she was up and wanted to get up and go but today she wanted to be left alone. The activities supervisor (AS) was interviewed on 12/10/24 at 1:15 p.m. The AS said all of the residents were on a one-to-one engagement program, which was when the residents were taken out of their room and the activities staff would sit with them and play games or whatever the resident liked to do. She said for residents that were really confused, they tried to find things that really connected with them, such as with Resident #364. She said that they were still trying to figure out what she was interested in. The AS said they also asked the CNAs and the residents family members what they had noticed that the resident liked. The AS said she expected her staff to invite all of the residents to the different activities that were occurring. The DON was interviewed on 12/10/24 at 6:23 p.m. The DON said that both the activities staff and the CNAs should have invited all of the residents to activities. He said when residents were exit seeking due to their confusion that staff should constantly be redirecting the resident. He said the staff should be taking the residents to activities as a redirection, even if the resident was confused.

Based on observation and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure staff followed appropriate hand hygiene during resident care; -Ensure shared vital signs equipment was sanitized between use; and, -Ensure appropriate infection control standards were followed during meals. Findings include: I. Ensure staff followed appropriate hand hygiene during resident care and ensure shared vital signs equipment was sanitized between use A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Recommendations for Hand Hygiene for Healthcare Workers, (2024), retrieved on 12/11/24 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, CDC provides the following recommendations for hand hygiene in healthcare settings. Know when to clean your hands: immediately before touching a patient and after touching a patient or a patient's surroundings. According to the CDC Recommendations for Disinfection and Sterilization in Healthcare Facilities, (2024), retrieved on 12/11/24 from https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/summary-recommendations.html#:~:text=Ensure%20that%2C%20at%20a%20minimum,once%20daily%20or%20once%20weekly, Clean medical devices as soon as practical after use. Perform either manual cleaning or mechanical cleaning. Perform low-level disinfection for noncritical patient-care surfaces and equipment (blood pressure cuffs) that touch intact skin. B. Facility policy and procedure The Hand Hygiene policy and procedure, revised October 2022, was received from the clinical nurse resource (CNR) on 12/10/24 at 9:00 p.m. It documented in pertinent part, Hand hygiene is one of the most effective measures to prevent the spread of infection. Use an alcohol-based hand rub containing at least 62% alcohol or soap and water for the following situations: before and after direct contact with residents, after contact with resident's intact skin, after handling used dressings and contaminated equipment and after contact with objects (medical equipment). C. Observations Certified nursing aide (CNA) #5 was observed on 12/5/24 during a continuous observation from 2:30 p.m. until 4:30 p.m. At 2:50 p.m. CNA #5 was walking around the Lavender unit with the vital signs cart. She walked into the dining room where the residents were sitting watching a movie. She measured vital signs on the first resident and documented it on a clipboard. She moved the cart to the second resident in the dining room and measured vital signs. She documented it on a clipboard and moved the cart to a third resident in the dining room. She measured vital signs on the resident and documented it on a clipboard. CNA #5 moved the vital signs cart into the hallway and measured vital signs on a fourth resident sitting in the hallway. She documented the vital signs and walked away from the cart. -CNA #5 did not sanitize her hands after each resident care before moving to the next resident -CNA #5 did not sanitize the vital signs cart between residents D. Staff interviews The infection preventionist (IP) was interviewed on 12/10/24 at 1:00 p.m. The IP said she provided hand hygiene education to staff multiple times a year. She said hand hygiene should be done before and after providing resident care, including taking vital signs. The IP said shared medical equipment, including a vital signs cart should be sanitized before and after resident use. The director of nursing (DON) and the clinical nurse resource (CNR) were interviewed together on 12/10/24 at 5:00 p.m. The CNR said it was expected that staff sanitize hands before and after resident care. She said this included when the staff were measuring vital signs. The DON said this was important to ensure germs did not spread from one resident to another. The CNR said she would expect staff to sanitize medical equipment before and after resident use. The DON said this was important to ensure germs did not spread from one resident to another. 51160 II. Failed to ensure appropriate infection control standards were followed during meals A. Professional reference The CDC (2024), Clinical Safety: Hand Hygiene for Healthcare Workers, was retrieved on 12/11/24 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html. It read in pertinent part, Perform hand hygiene before touching a patient, after touching a patient or their surroundings, immediately after glove removal. According to Treas, L.S., [NAME], K.L., & [NAME], M.H. (2022.) Basic Nursing: Thinking, Doing and Caring, (Third edition), pages 1601, 1604-1605, Use standard precautions to prevent the transmission of infection. Implement measures to prevent healthcare-associated infections (HAIs). HAIs are the leading complication of healthcare and one of the ten leading causes of death in the United States. Hand hygiene can remove transient flora (microbes acquired by touching objects or people). B. Observations On 12/5/24 at 3:00 p.m. CNA #3 opened a cookie from a cellophane package for Resident #24. CNA #3 handled the cookie with his bare hands as he handed it to Resident #24. CNA #3 had not performed hand hygiene prior to this interaction. On 12/5/24 at 3:28 p.m. CNA #3 was charting on a touch screen computer. When he was finished, he walked over to a table where Resident #54 was seated. He did not perform hand hygiene. Resident #54 had been eating peanut butter filled cheese crackers and some had fallen off of the plate onto the table. CNA #3 picked up the crackers off the table, with a bare hand, and placed them back onto the plate. CNA #3 attempted to remove the plate from the table, however Resident #54 prevented him from taking the plate as she was not finished eating. Resident #54 continued to eat the crackers. During a continuous observation that began on 12/9/24 at 8:20 a.m. and ended at 10:15 a.m. the following was observed: At 8:30 a.m. Resident #60 left the dining room leaving her plate on the table. At 9:03 a.m. after Resident #58 had finished his meal he propelled himself over to the table where Resident #60's plate remained. Resident #58 began to eat food from the plate and then left the dining room. -The staff did not redirect Resident #58 from eating off of Resident #60's plate. At 9:06 a.m. Resident #47 entered the dining room and sat in a chair which had Resident #60's partially eaten meal still on the table. Resident #47 began to eat the fruit from the bowl, then pushed the bowl and plate away. At 9:08 a.m. CNA #1 walked into the dining room and told Resident #47 that her plate had been placed on the table next to her. Resident #47 did not move from her seat and CNA #1 walked away without assisting the resident to move to the other table, or bring her plate to her where she was seated. At 9:13 a.m. the DON entered the dining room. After greeting Resident #47, the DON offered her a cup of coffee and a cookie. Unaware that the plate near Resident #47 was not hers, he encouraged her to eat more food, she declined. During a continuous observation that began on 12/9/24, at 5:33 p.m. and ended at 6:45 p.m., the following was observed: At 5:45 p.m. Resident #60 entered the dining room and was seated at a table. Resident #60 requested that the staff serve her only dessert. At 5:47 p.m. Resident #60 was served a cookie pudding dessert garnished with a wafer cookie. Resident #60 removed the wafer cookie and placed it on the table in front of her. At 5:58 p.m. after Resident #60 finished her first dessert and was offered a second by a staff member. Again, Resident #60 removed the wafer cookie garnish and placed it on the table in front of her. At 6:23 p.m. Resident #58 seated at the next table wheeled himself over to Resident #60 and took the two wafer cookies from her table and ate them. Resident #58 had been seated at a table with Resident #74 who had received feeding assistance from an unidentified staff member during his departure from the table. The unidentified staff member did not intervene when Resident #60 took the two wafer cookies off the table. At 6:26 p.m. Resident #58 was redirected back to his table and meal by the unidentified staff member providing feeding assistance to Resident #74. C. Staff interviews The IP was interviewed on 12/10/24 at 1:28 p.m.The IP said hand hygiene should be performed before and after handling food. The IP said food should not be touched with bare hands, especially if hand hygiene had not been performed. The IP said residents should not eat from other resident's plates. The IP said there was a potential for a negative outcome related to food texture, food allergies and the spread of potential infection. The DON was interviewed on 12/10/24 at 6:24 p.m. The DON said resident food should not be handled with bare hands. The DON said a clean, gloved hand could have been used to remove food from a package or the package could have been opened to allow the resident to take the food from the package. The DON said residents should not eat from each other's plates. The DON said there was a potential negative outcome in consuming the wrong diet texture for a resident along with potential food allergies and potential spread of an infection. The DON said residents consuming other resident food could alter the accuracy of documentation of meal intake percentages of food consumed by residents that required intake monitoring for weight loss or gain. The DON said the facility staff had the responsibility to serve a resident where they were seated or move their plate for them if it was on a different table.

Based on observations and interviews, the facility failed to ensure two (#19 and #44) of four residents out of 51 sample residents had the right to a dignified existence. Specifically, the facility failed to: -Ensure Resident #19 was provided dignity and privacy while removing medication patches; and, -Ensure Resident #44 was not placed in the hallway facing the wall by facility staff. Findings include: I. Facility policy and procedure The Residents' Rights and Dignity policy and procedure, dated November 2023, was provided by the nursing home administrator (NHA) on 12/10/24 at 9:00 p.m. It read in pertinent part, To be treated with consideration, respect, and full recognition of his or her dignity and individuality. II. Resident #19 A. Resident status Resident #19, age greater than 65, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), the diagnoses included dementia with anxiety and cognitive communication deficit (difficulty communicating related to attention and memory issues). The 9/25/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of two out of 15. B. Observations On 12/5/24 at 3:33 p.m. certified nurse aide with medication authority (CNA-Med) #1 entered the dining room during a group activity. Resident #19 was sitting in the dining room near other residents. CNA-Med #1 approached Resident #19 and asked her to lean forward in her wheelchair. CNA-Med #1 lifted her sweater and shirt which exposed her lower back and removed a lidocaine patch. On 12/9/24 at 3:32 p.m. CNA-Med #1 entered the dining room during a group activity, where Resident #19 was sitting near other residents. CNA-Med #1 approached Resident #19 and asked her to lean forward in her wheelchair. CNA-Med #1 then lifted her sweater and shirt which exposed her lower back and removed a lidocaine patch. C. Staff interviews The director of nursing (DON) was interviewed on 12/10/24 at 6:24 p.m. The DON said that a medication patch underneath clothing should not be removed in the dining room. He said Resident #19 should have been taken back to their room and provided privacy prior to having a medication patch underneath her clothing removed. III. Resident #44 A. Resident status Resident #44, age greater than 65, was admitted on [DATE]. According to the December 2024 CPO, the diagnoses included Alzheimer's disease, dementia and generalized muscle weakness. The 9/11/24 MDS assessment revealed the resident had short term and long term memory impairment with severe impairment in making decisions regarding tasks of daily life. She was dependent on staff for all mobility and used a wheelchair and was unable to self propel. B. Observations On 12/4/24 at 9:06 a.m. Resident #44 was sitting in her wheelchair in the back hallway, facing the wall. Resident #44 was faced away from other residents, the nurses station and the jazz music playing. On 12/5/24 at 10:38 a.m. Resident #44 was assisted to the back hallway and left in the corner, partially facing the wall, away from the nurses station and the common area where other residents were participating in a Christmas [NAME] sing-along activity with the chaplain. On 12/9/24 at 12:55 p.m. Resident #44 was sitting in her wheelchair in the back hallway, facing the wall, away from other residents. Christmas music played at the nurses station in the common area for residents. C. Record Review The communication care plan, dated 7/2/2020, read in pertinent part, be conscious of Resident #44's position when in groups, activities, dining room, to promote proper communication with others. D. Staff interviews The DON was interviewed on 12/10/24 at 6:24 p.m. The DON said a residents' placement in the hallway depended on their ability to propel themselves. He said Resident #44 was not able to propel herself. He said Resident #44 being placed in the back hallway or with the wheelchair faced toward the wall was not ideal. He said he preferred Resident #44 to be near others and be brought to the common area to be part of the Christmas music activity.

Based on record review and interviews, the facility failed to prevent abuse for one (#68) of three sample residents reviewed for abuse out of a sample of 51 residents. Specifically, the facility failed to ensure Resident #22 was free from physical abuse from Resident #68. Findings include: I. Facility policy and procedure The Abuse Prevention policy and procedure, revised July 2019, was provided by the clinical nurse resource (CNR) on 12/10/24 at 9:00 p.m. It read in pertinent part, It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. All employees of our facility will take action to protect and prevent abuse and neglect from occurring within the facility by ensuring the staff has the knowledge of individual residents' care needs, ensuring supervision of staff to identify inappropriate behaviors, assess residents, care plan and monitor residents with history of aggressive behaviors (such as entering other resident rooms, self-injurious behavior, communication disorders and resident totally dependent on staff). II. Incident of physical abuse between Resident #68 and Resident #22 on 9/2/24 The 9/2/24 abuse investigation documented there was a physical altercation between two residents. The residents were separated and assessed. Resident #22 had a red mark on her neck. The residents were interviewed and placed on 72-hour monitoring. Resident #68 was interviewed on 9/2/24 and she did not recall the incident but said she needed to pack. She said that she felt safe and was not fearful. Resident #22 was interviewed on 9/2/24 and said she had a disagreement with a lady about her jewelry. She said she felt safe and was not fearful. Resident #22 had a small scratch on the right side of her neck that did not require medical interventions. Four staff members were interviewed. Licensed practical nurse (LPN) #3 said she was at the nursing station when she heard the two residents talking. She did not see what happened but she heard Resident #22 say, No, it isn' t your room and then she rushed in to separate the residents. Five residents were interviewed on the unit and were not able to provide any additional information. III. Resident #22 - victim A. Resident status Resident #22, age 83, was admitted on [DATE]. According to the December 2024 computerized physician's orders (CPO), diagnoses included unspecified dementia, type 2 diabetes and muscle weakness. The 11/13/24 minimum data set (MDS) assessment documented the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of six out of 15. She required supervision with eating, dressing, bathing, toileting and walking. B. Record review The care plan, initiated on 6/10/24 and revised on 12/7/24, documented Resident #22 was at risk for depression and behavior problems related to dementia, disease process and depression. Interventions included discussing with the family/caregivers about any concerns (initiated 6/10/24), encouraging the resident to express her feelings (initiated 6/10/24), following the Level II pre-admission screening and resident review program (PASARR) recommendations (which included psychiatric case management, social interactions once settled into new facility and the resident had hearing aids (initiated 6/25/24), observing and documenting any signs and symptoms of depression to the nurse (initiated 6/10/24), offering the resident a piece of chewing gum (initiated 12/7/24), offering the resident to call a friend (initiated 9/6/24), offering the resident to go outside for a walk in the courtyard (initiated 9/6/24), reminding the resident to put her light low if she was reading when others were sleeping (initiated 12/7/24) and stopping and talking to resident when passing by (initiated 9/6/24). The interdisciplinary team (IDT) note, dated 9/3/24, documented that the IDT reviewed the incident from 9/2/24 around 8:50 p.m. It documented Resident #68 wandered into Resident #22's room. Resident #68 began packing up Resident #22's clothing. Resident #22 got frustrated and asked Resident #68 to leave but Resident #68 reported it was her room. Resident #22 told Resident #68 it was not her room. Resident #68 then scratched Resident #22 on the neck. The residents were immediately separated by staff. The nursing progress note, dated 9/3/24 documented Resident #22 was on follow-up for the altercation with another resident and no new concerns were identified. IV. Resident #68 - assailant A. Resident status Resident #68, age 82, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included Alzheimer's disease, muscle weakness, cognitive communication deficit and hypertension (high blood pressure). The 9/25/24 MDS assessment documented the resident had severe cognitive impairments with a BIMS score of two out of 15. She required supervision with eating, dressing, bathing, toileting and walking. The assessment documented that she had other behaviors not directed toward others (physical symptoms such as hitting or scratching, self-pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes or verbal/vocal symptoms like screaming) one to three times a week. B. Record review The care plan, initiated on 3/6/23 and revised on 9/26/24, documented the resident had potential for a behavior problem related to dementia. The goal was to be able to explore the neighborhood in a safe manner. The pertinent interventions included offering her to read her Bible, providing the resident with activities, putting the television on to the gospel channel, redirecting her away from other's space, reminding her where her room was, redirecting her with one-on-one time and reorienting what belongings were hers. The nurse progress note, dated 3/3/23, documented Resident #68 was wandering around the neighborhood and was not able to recall where her room was. The note documented when she was wandering into others spaces, this was agitating others. The staff continued to reorient her to new surroundings and assisted her with adjusting. The nurse progress note, dated 3/18/23, documented, Resident #68 continued to wander into other residents' rooms which irritated some residents. Resident #68 became aggressive with redirection from other rooms. Resident #68 also attempted to not let her roommate in. The staff redirected her and let her in but she was upset. The activities progress note, dated 7/3/24, documented Resident #68 continued to get agitated and territorial when others went in her room. The note documented that at times she did not let anyone go in her room. The nurse progress note, dated 7/18/24, documented Resident #68 was packing up her roommate's belongings and staff would redirect her to her side of the room and that those items were not hers. The resident became verbally agitated. The note documented that eventually she stopped packing and calmed down. The note documented the resident returned back to her baseline. The nurse progress note, dated 9/2/24, documented Resident #68 and Resident #22 had a fight. Resident #68 walked into Resident #22's room and started the argument. Staff ran in to separate the residents. Resident #68 scratched Resident #22 on her neck. The medical doctor (MD), the director of nursing (DON) and both families were notified. Both residents were stable and safe at the time of the documentation. One-on-one protocol was initiated for both residents. The social services progress note, dated 9/3/24, documented social services checked in with Resident #68 following the incident on 9/2/24. Resident #68 did not recall the incident, however, she did say that her son was coming to pick her up so she needed to pack. Resident #68 reported that she felt safe and was not fearful. The note documented social services would continue to follow and provide support as needed. V. Staff interviews Certified nurse aide (CNA) #12 was interviewed on 12/10/24 at 9:50 a.m. CNA #12 said when residents had altercations it was important to keep them separated and to keep an eye on them. CNA #12 said the unit kept activities and movies or shows going in the common area to keep the residents busy. CNA #12 said Resident #68 went into a lot of different rooms. CNA #12 said Resident #22 did not like it when people entered her room. CNA #12 said Resident #68 always thought she needed to pack up and get home to her children, so Resident #68 began packing up Resident #22's belongings. CNA #12 said the closets on the unit were all locked, but that Resident #68 was packing up the items that were on Resident #22's nightstand and bed. CNA #12 was interviewed a second time on 12/10/24 at 1:02 p.m. CNA #12 said Resident #68 was always trying to find a way out of the facility. CNA #12 said Resident #68 would get confused and agitated and go into another resident's room. CNA #12 said Resident #68 entered other residents' rooms a few times a week. CNA #12 said she could redirect Resident #68 by talking about religion or offering to call Resident #68's son. CNA #12 said when Resident #68 wandered into another resident's room, she would get agitated with that resident. CNA #12 said Resident #68 was fine when she first got to the facility but started wandering later on. Social worker (SW) #1 was interviewed on 12/10/24 at 1:55 p.m. SW #1 said Resident #68 knew where her room was when she first moved in and when her dementia started progressing, she started to wander around the unit more and into other residents' rooms. SW #1 said she would do this about three to four times a week. She said Resident #68 would exit seek and pack her belongings because she thought her son was coming to pick her up. She said the staff would intervene if they witnessed this occurring by offering for her to call her son, offering for her to read the Bible, redirect her to the chaplain, and listening to gospel music. She said in August 2024, she got into an altercation with another resident. She said because of that incident and the progressing dementia, she was moved into a different unit more suited for her needs. She said she was doing a lot better in terms of behaviors in the new unit. The DON and the CNR were interviewed together on 12/10/24 at 5:00 p.m. The DON said Resident #68 liked to walk around the unit and at one point started to wander into other residents' rooms. He said staff reported to him that Resident #68 would rummage through other residents' belongings. He said when residents start to wander, it could become a trigger for an altercation. He said the resident was redirected by staff and they utilized red stop signs banners that would be placed across a doorway. He said after the altercation between Resident #68 and Resident #22, the two residents were immediately separated and assessed. The DON said the residents were placed on 72-hour monitoring. He said Resident #68 had not shown any aggressive behaviors prior to this incident. -However, review of the resident's electronic medical record (EMR) revealed the Resident #68 had a history of behaviors (see record review above).

Based on observations, record review and interviews, the facility failed to develop and implement an effective discharge plan for two (#362 and #466) of two residents reviewed for discharge planning out of 51 sample residents. Specifically, the facility failed to: -Ensure Resident #362 and #466 and/or their responsible party were apprised of their progress and discharge planning; and, -Ensure the discharge planning process was documented in the residents' electronic medical records (EMR). Findings include: I. Facility policy and procedure The Discharge Planning policy and procedure, revised February 2020, was provided by the nursing home administrator (NHA) on 12/10/24 at 9:00 p.m. It read in pertinent part, It is the policy of this facility that discharge planning and evaluation will be provided by the social services staff for each resident. The discharge planning process focuses on the resident's discharge goals, the preparation of the resident to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The social services staff will ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. The social services staff member assigned to the resident regularly evaluates and re-evaluates the resident to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. Staff involved in the move in, transfer and move out process will ensure that the focus is the resident and their family and their needs and concerns. II. Resident #466 A. Resident status Resident #466, age 77, was admitted on [DATE]. According to November 2024 computerized physician orders (CPO), diagnoses included encounters for cerebral vascular accident (CVA: medical condition that occurs when blood flow to the brain is suddenly interrupted, which can lead to brain cell death and neurological damage), muscle weakness, unsteadiness on feet and history of falls. The 11/15/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status (BIMS) score of 14 out of 15. He required moderate to maximum assistance with all activities of daily living (ADL). The assessment indicated the resident's overall goal was to be discharged back into the community and active discharge planning was occurring. B. Resident interview and observation Resident #466 was interviewed on 12/5/24 at 9:37 a.m. Resident #466 said he was frustrated he had not been kept informed of his progress and did not know what specifically he needed to do to discharge home from the facility. He said nobody was in charge of the discharge process and nobody would take responsibility. He said he had requested a criteria for the goals he needed to meet with therapy or facility goals related to his care in order to facilitate his discharge from the facility more quickly. Resident #466 said he still had not been provided the discharge criteria he requested. Resident #466 said it was human nature for people to pass the buck but it was the responsibility of the facility staff to make the decisions and provide him with the information. He said he was not the person to decide if he could discharge home and he wanted someone to stand up and say they were responsible for providing the discharge information to him. He said he wanted someone to have a discussion with him and tell him what they needed from him for him to be able to discharge. C. Record review The discharge care plan, initiated 11/13/24, documented the goal for Resident #466 was to be able to verbalize and communicate the services required to meet his needs before discharge. The interventions included establishing a pre-discharge plan with the resident and family/caregivers, evaluating the resident's progress, revising the discharge plan as needed, recording the resident's abilities and strengths and determining resident's gaps in abilities with the resident and family/caregivers to determine if it would affect the resident's discharge. The 11/13/24 skilled weekly progress note, which included the NHA, social services, therapy, the MDS coordinator and nursing, documented Resident #466 had an anticipated maximum potential to be achieved in three to four weeks. The resident's plan was to discharge home with his spouse and home health services. The 12/4/24 physician medicine and rehabilitation follow up progress note documented the resident was anxious to get an update regarding his discharge timing. The physician documented he would coordinate with the discharge team. The physician further documented in the 12/4/24 progress note that Resident #466's anticipated maximum potential from his skilled stay would be achieved in one to two weeks and he would discharge home with his spouse and home health services. -A review of the resident's electronic medical record (EMR) did not reveal documentation the facility had met with Resident #466 and/or the resident's representative to discuss the resident's progress toward discharge or his progress status. -The EMR did not include documentation of an active discharge plan involving Resident #466 and his representative from the time of the resident's admission to the facility to his current status. D. Staff interviews Rehabilitation transitions director (RTD) #1, who was part of the facility's social services team, was interviewed on 12/5/24 at 4:59 p.m. RTD #1 said when residents were admitted to the facility, she met with the residents and the residents' representatives, either in person or via telephone, to sign admission agreements. She said the initial care plan was created within 48-hours of the resident's admission to the facility. The RTD said the initial goal of all residents was to return home with their family or to their prior living arrangement. She said it was social services responsibility to develop and revise the discharge care plan throughout the resident's stay at the facility, in conjunction with their progress with rehabilitation services. RTD #1 said the facility staff held a meeting amongst themselves on 12/4/24 to discuss Resident #466's progress. She said it was discussed that Resident #466 had met his maximum potential for rehabilitation and the plan was to discharge the resident home early next week (week of 12/9/24). She said she had advised Resident #466 on the afternoon of 12/5/24 about the upcoming discharge, but she said she had not yet communicated with the resident's representative. RTD #1 said she had not met with Resident #466 and/or the resident's representative to discuss the discharge plan or provided them with the Notice of Medicare Non-Coverage (NOMNC) to inform them the resident's Medicare skilled services benefits were ending. She said she would provide them with the information and the NOMNC on 12/6/24 for a planned discharge on 12/9/24. RTD #1 said following the meeting with Resident #466 and the resident's representative to create the initial plan of care, she did not document discharge planning within the resident's EMR. She said attempts to meet with residents and the residents' representatives occurred as often as possible but she said it was not documented in the resident's EMR. 51163 III. Resident #362 A. Resident status Resident #362, age 85, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included spondylosis without myelopathy or radiculopathy (condition that occurs when the spine degenerates without injuring the spinal cord or pinching a nerve) of the cervical region (neck), history of falling, cognitive communication deficit and dementia. The 11/25/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. She required substantial to maximal assistance or was dependent with the majority of her ADLs. The assessment indicated the resident's overall goal was to be discharged back into the community or to go back home and active discharge planning was occurring. B. Resident representative interview Resident #362's representative was interviewed on 12/5/24 at 11:02 a.m. The representative said he had not been included in the care planning process for Resident #362. He said he had not received any information and was not sure when the resident would discharge home. He said he would like to receive some information in order to plan for the resident's discharge. C. Record review The discharge care plan, revised 12/3/24, documented Resident #362 planned to discharge home with her spouse and home health care services. Interventions included coordinating with family to create and maintain personal shadow box; encouraging family and the resident to be involved with facility events and plan of care, establishing a pre-discharge plan with family and the resident, evaluating the resident's progress and revising the discharge plan as needed, evaluating and discussing the discharge plan with the family and the resident, identifying, discussing and addressing limitations, risks, benefits and needs for maximum independence and evaluating and recording the resident's abilities and strengths with the family to determine gaps in abilities which will affect the resident's discharge. The 11/22/24 progress note documented the initial care plan was verbally reviewed with social services and the resident's representative. It indicated the resident's goal was to return home with her spouse. The 12/9/24 progress note documented a NOMNC was issued to Resident #362 and the resident's representative. It indicated the resident's representative decided, that day (12/9/24), that the resident was to remain at the facility for long-term care. -However, the resident's EMR did not reveal any documentation of interdisciplinary (IDT) meetings regarding Resident #362's discharge plan or the progress that the resident was making towards discharge. -A review of Resident #362's EMR did not reveal documentation of an active discharge planning process. The facility did not document any meetings with the resident's representative to discuss Resident #362's progress toward discharge, a potential change to the discharge plan or to provide the resident's representative with any potential services for care at home. D. Staff Interviews RTD #1 was interviewed on 12/10/24 at 2:30 p.m. RTD #1 said within 72-hours of a resident's admission to the facility, the resident's discharge plan was reviewed with the interdisciplinary team, the family and the resident. She said all interactions and discussions regarding a resident's discharge plan should be documented in the resident's EMR. RTD #1 said up until she had called Resident #362's representative on 12/9/24, the resident's discharge plan was to return home with her spouse. RTD #1 was interviewed again on 12/10/24 at 5:30 p.m. She said she received a call from Resident #362's representative on 12/5/24, during the survey process. She said the resident's representative said he might want the resident to stay at the facility for long-term care. She said she had not had discussions related to the resident's discharge with the representative prior to the phone call on 12/5/24. The NHA was interviewed on 12/10/24 at 7:01 p.m. The NHA said all of the residents' discharge planning went through RTD #1's department. He said active discharge planning started at the residents' admission to the facility. He said the resident and the residents' families should be involved in the discharge planning process and it should be documented in the EMR.

Based on record review and interviews, the facility failed to ensure one (#113) of one resident received treatment and care in accordance with professional standards of practice out of 51 sample residents. Specifically, the facility failed to provide timely treatment when Resident #113 was experiencing several episodes of diarrhea. Findings include: I. Facility policy and procedure The Change of Condition Reporting policy and procedure, revised October 2020, was received from the clinical nurse resource (CNR) on 12/10/24 at 9:00 p.m. It read in pertinent part, It is the policy of this facility that all changes in resident condition will be communicated to the physician. All symptoms and unusual signs will be communicated to the physician promptly. Routine changes are a minor change in physical and mental behavior, abnormal laboratory and x-ray results that are not life threatening. The nurse will document the resident change of condition and response in nursing progress notes, on the 24-hour report or dashboard and update the resident care clan, as indicated in the clinical meeting. The licensed nurse responsible for the resident will continue assessment and documentation every shift for at least seventy-two (72) hours or until condition has stabled. II. Resident #113 A. Resident status Resident #113, age 71, was admitted on [DATE]. According to the November 2024 computerized physicians orders (CPO), diagnoses included cognitive communication deficits, muscle weakness, sepsis and syncope (a loss of consciousness for a short period of time, or fainting). The 11/18/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment revealed the resident was frequently incontinent of both bowel and bladder. B. Resident representative interview Resident #113's representative was interviewed on 12/10/24 at 2:00 p.m. The representative said Resident #113 was immobile and had severe diarrhea when he first admitted to the facility. The representative said Resident #113 requested an anti-diarrheal medication on 10/31/24, 11/1/24 and 11/2/24. The representative said she received a phone call on 11/2/24 from Resident #113 and he told her he was having diarrhea. Resident #113's representative said she called the facility and requested an anti-diarrheal medication for Resident #113. She said the facility ordered the medication for the resident the next day (11/3/24). C. Record review The October 2024 and November 2024 bowel movement and bowel continence records for Resident #113 revealed the following: -On 10/31/24 at 9:56 p.m. the resident had a large loose stool; -On 11/1/24 at 8:58 a.m. the resident had a loose stool at 8:58 a.m.; -On 11/1/24 at 3:17 p.m. the resident had a formed stool; -On 11/2/24 at 5:28 a.m. the resident had a large loose stool; -On 11/2/24 at 9:37 a.m. the resident had a loose stool; -On 11/2/24 at 4:16 p.m. the resident had a formed stool; -On 11/3/24 at 5:31 a.m. the resident had a large loose stool; -On 11/3/24 at 9:19 a.m. the resident had a large loose stool; and, -On 11/3/24 at 4:53 p.m. the resident had a formed stool. A daily skilled nursing note, dated 11/1/24 at 8:42 a.m., revealed no active gastrointestinal symptoms were observed for Resident #113. -However, Resident #113 had an episode of a large loose stool the night before (10/31/24). A nursing progress note, dated 11/3/24 at 12:17 p.m., revealed Resident #113 experienced diarrhea and nausea. The nurse called the physician and received orders for an anti-nausea medication and Imodium (anti-diarrheal medication). -However, Resident #113 had six episodes of large loose stools between 10/31/24 and 11/3/24 before a physician's order for an antidiarrheal medication was obtained (see above). A grievance report, dated 11/3/24, revealed Resident #113's representative expressed her concern about the fact that Resident #113 had been having diarrhea since 11/1/24 with no medications administered. Interventions listed for this report included speaking to the floor nurse, who spoke with the physician and received an order for Imodium. Review of Resident #113's November 2024 CPO revealed a physician's order for Imodium 2 milligram (mg) tablets. Give one tablet by mouth every six hours as needed for diarrhea for five days, ordered 11/3/24 at 12:19 p.m. The November 2024 medication administration record (MAR) revealed Resident #113 received two doses of Imodium on 11/3/24. The first dose was at 3:04 p.m. and was marked as being effective. The second dose was given at 8:18 p.m. and was marked as unknown for its efficacy. D. Staff interviews Certified nurse aide (CNA) #10 was interviewed on 12/9/24 at 6:14 p.m. CNA #10 said if a resident had diarrhea, she would alert the nurse. Licensed practical nurse (LPN) #5 was interviewed on 12/10/24 at 6:00 p.m. LPN #5 said if a resident had one bout of diarrhea, he would look at the bowel movement records and the resident and see if it was something concerning or maybe just a result of something the resident ate. LPN #5 said if the bowel movement was concerning he would alert the physician. LPN #5 said if a resident was having multiple bouts of diarrhea he would fill out a change of condition form in the resident's electronic medical record (EMR), alert the physician and follow the orders the physician gave. The director of nursing (DON) and the CNR were interviewed together on 12/10/24 at 5:12 p.m. The DON said when a resident had diarrhea, they were put on monitoring for 72-hours and the provider was notified. The DON said if the resident had any stool softeners in their orders, the stool softener would be put on hold. The DON said this procedure was done for even one bout of diarrhea. The DON said the provider needed to be notified if a resident had diarrhea, as the diarrhea could be occurring for a number of reasons, including medication side effects or a bacterial infection. The CNR said if Resident #113 was having multiple bouts of loose stools, the provider should have been notified timely. The CNR said the provider would take into account any medications the resident was on that could cause diarrhea as a side effect. The DON and the CNR reviewed Resident #113's record but were unable to locate any progress notes related to Resident #113's diarrhea prior to the note which documented the physician was notified and prescribed Imodium for the resident on 11/3/24.

Based on observation, record review and interviews, the facility failed to ensure supervision and interventions to prevent accidents for one (#88) of twelve residents reviewed for accidents of 51 sample residents. Specifically, the facility failed to ensure fall interventions were implemented for Resident #88 who had experienced several falls. Findings include: I. Facility policy and procedure The Fall Monitoring and Management policy and procedure, revised March 2024, was received from the clinical nurse resource (CNR) on 12/10/24 at 9:00 p.m. It documented in pertinent part, It is the policy of this facility that residents are assessed and evaluated to identify risks for injury due to falls, residents receive necessary treatment and monitoring after a fall and interventions are implemented to minimize risks for injury due to falls. The interdisciplinary team (IDT) will place a fall IDT note in the computer with verification of interventions or new interventions. II. Resident #88 A. Resident status Resident #88, age 77, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included unspecified dementia, history of falling, cognitive communication deficit, lack of coordination, unsteadiness on feet and muscle weakness. According to the 9/25/24 minimum data set (MDS) assessment, the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three of 15. The resident suffered one fall without injury since the previous MDS assessment. She required partial/moderate assistance for hygiene, toileting, showering, dressing and transferring. She required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance) for walking. She used a walker regularly in the past seven days. B. Observations During a continuous observation on 12/4/24, beginning at 9:15 a.m. and ending at 12:10 p.m. the following was observed: Resident #88 was in the dining room with a group of residents for an exercise activity. She wandered out of the dining room and into the hallway. She walked three laps in the hallway at 9:15 a.m. without a walker. A certified nursing aide (CNA) walked past her and did not offer a walker or assistance with ambulation. She sat down on a couch in the living room at 9:25 a.m. She was not wearing a soft helmet. During a continuous observation on 12/4/24, beginning at 1:30 p.m. and ending at 4:30 p.m., the following was observed: At 2:31 p.m. Resident #88 was sitting on a couch in the hallway. She got up by herself and walked toward another resident's room. She turned around and walked down the hallway. There was an unidentified CNA taking vital signs in the hallway and she did not offer to get Resident #11's walker or offer assistance with ambulation. She was not wearing a soft helmet. During a continuous observation on 12/9/24, beginning at 8:30 a.m. and ending at 12:40 p.m., the following was observed: At 8:45 a.m. Resident #88 was walking around the unit without a walker. CNA #6 walked past her and did not offer assistance with ambulation or a walker. She was not wearing a soft helmet. At 8:50 a.m. Resident #88 was walking around the hallway without her walker or assistance. She was not wearing her helmet. At 10:05 a.m. Resident #88 was observed holding onto a side railing in the hallway. A nurse was with and calling out for someone to get her a wheelchair. A CNA brought a wheelchair and they assisted the resident into a seated position into the chair. She was not wearing a soft helmet. At 12:30 a.m. Resident #88 was observed walking around the unit. There was an unidentified CNA that walked past the resident without offering a walker, wheelchair or assistance with ambulation. She was not wearing a soft helmet. C. Record review The care plan for falls, initiated 4/3/24 and revised 9/25/24, identified the resident had a history of dementia, seizure disorder, used high risk medications, had poor safety awareness, had muscle weakness, difficulty walking, unsteadiness on her feet, lack of coordination and history of falling. Interventions included ensuring the resident was wearing appropriate footwear when ambulating or wheeling in wheelchair (initiated 4/3/24), keeping needed items (water) in reach (initiated 4/3/24), maintaining a clear pathway free of obstacles (initiated 4/3/24) and, offering a soft helmet and hipsters (padded shorts) as resident allows (4/3/24). -However, observations revealed the resident was not wearing the soft helmet (see observations above). An additional fall care plan, initiated on 9/5/24 and revised on 11/28/24, revealed the resident had a fall related to poor balance and poor communication/comprehension. Interventions for the fall documented on 9/4/24 (initiated 9/5/24) included physical therapy (PT) to screen the resident, offering toileting after meals and routine blood work ordered for hyperthyroidism. Interventions for the fall documented on 9/26/24 (initiated 9/30/24) included PT to assess for new pain and report to floor nurse, recommended labs and medication review and to continue therapy. Interventions for the fall documented on 10/11/24 (initiated 10/14/24) included therapy to screen as indicated and offering rest periods after meals to address fatigue that may occur post-lunch. Interventions for the fall documented on 10/25/24 (initiated 10/28/24) included to continue PT/occupation therapy (OT)/speech therapy (ST) and to anticipate needs and assist to bed post lunch time as indicated. Interventions for the fall documented on 11/23/24 (initiated 11/25/24) included to assist with frequent repositioning in her wheelchair and to continue PT/OT/ST. Interventions for the fall documented on 11/27/24 (initiated 11/28/24) included to check for labs or urinary analysis (UA) and to continue PT/OT to address mobility and activities of daily living (ADLs). The December 2024 CPO indicated Resident #11 had an order to encourage to wear a soft helmet as the resident would allow, every shift for safety, ordered on 4/3/24. The CNA Kardex (instructions for care) identified that the resident required supervision and up to one staff participation using a gait belt for transfer and walking. It was documented to provide verbal cues for initiation and safe sequencing and to walk to/from meals and bathroom as the resident was willing. 1. Fall incident on 9/4/24 - unwitnessed The progress note on 9/4/24 documented that therapy reported to the nurse that the resident was sitting in the hallway on the floor. Prior to the incident she was walking around the unit. The resident had poor safety awareness with diagnosis of dementia. The 9/4/24 fall investigation documented the immediate action that was taken included the registered nurse (RN) assessed the resident and there were no visible injuries noted. A wheelchair was close to where the resident was sitting. The note documented the resident could have been attempting to sit in the wheelchair and missed it and ended up sitting on the floor. The resident had non-slip socks on, the floor around the resident was dry and free of clutter and there was adequate lighting. Initial vital signs were stable, neurological checks were initiated and the guardian and the provider were notified. The fall assessment from 9/4/24 documented the resident was oriented to person, Predisposing factors contributing to the fall included confusion, impaired memory, incontinence and wandering behavior. 2. Fall incident on 9/26/24 - unwitnessed The progress note on 9/26/24 documented that staff notified the resident sitting in the hallway, prior to that she was walking/wandering around the unit. She had dementia that made her have a poor sense of safety. The 9/26/24 fall investigation documented immediate action taken included the RN assessed the resident while she was sitting on the floor. The area was clean with no clutter and she was wearing non-slip socks. She appeared to be tired with generalized weakness. There were no neurological changes from baseline. There were no visible injuries noted. She was assisted by two staff members to a wheelchair. The provider and guardian were notified. Lab tests and medication review were recommended and neurological checks were initiated. The fall assessment from 9/26/24 documented the resident was oriented to person, predisposing factors contributing to the fall included gait imbalance, impaired memory, incontinence and wandering behavior. 3. Fall incident on 10/11/24 The progress note on 10/11/24 documented the staff last saw the resident sitting on a chair in the hallway. The staff heard a noise and observed the resident sitting on the floor. The resident was assisted by two staff members back into a wheelchair and sat by the television. The resident got up again after a couple hours and fell again. The 10/11/24 fall investigation documented immediate action taken included the resident was assessed by a nurse and helped up by two staff. No injuries were noted. All range of motion (ROM) were active, the resident was wearing non-slip socks, hipsters and the floor was free from clutter. Neurological checks were initiated and stable. The family and provider were notified. The fall assessment from 10/11/24 documented the resident was oriented to person, predisposing factors contributing to the fall included confusion and wandering behavior. 4. Fall incident on 10/25/24 - unwitnessed The progress note on 10/25/24 documented the resident was found sitting on the floor during rounds. The resident was unable to describe the incident due to unspecified dementia. A head to toe assessment was completed by the RN supervisor. The resident was stable and had no signs of pain or discomfort. The 10/25/24 fall investigation documented immediate action taken included a head to toe assessment. The resident had a black eye. She was assisted into the wheelchair with a gait belt. Neurological checks were initiated and vital signs were normal. She was at baseline for ROM. Responsible parties were notified. The fall assessment from 10/25/24 documented the resident was oriented to person, predisposing factors contributing to the fall included confusion, gait imbalance, impaired memory, incontinence, ambulating without assistance and wandering behavior. 5. Fall incident on 11/23/24- witnessed The progress note on 11/23/24 documented the resident had a witnessed fall. Before the fall, the resident was sitting in a wheelchair close to the couch in the common area watching television. The fall occurred while the resident was attempting to self-transfer to a nearby couch. The staff were unable to prevent the fall due to its unexpected and sudden nature. The RN was notified and assessed the resident. There were no visible injuries noted. Neurological checks were initiated and vital signs were normal. Responsible parties were notified. The 11/23/24 fall investigation documented the immediate action taken included notifying the RN, injury assessment by the RN and assisting the resident into a safe sitting position. The fall assessment from 11/23/24 documented the resident was oriented to person, predisposing factors contributing to the fall included confusion, incontinence, and wandering behavior. 6. Fall incident on 11/27/24 - unwitnessed The progress note on 11/23/24 documented the resident was found sitting next to her bed. The nurse went in to check on the resident and the resident had already gotten up by herself. A complete head to toe assessment was done by the RN supervisor. The resident denied any pain or discomfort. The room was well lit, free from clutter and the resident was wearing non-slip socks. The 11/27/24 fall investigation documented the immediate action taken included a head to toe assessment, neurological checks were initiated and vital signs were normal. Responsible parties were notified. The fall assessment from 11/27/24 documented the resident was oriented to person, predisposing factors contributing to the fall included confusion, incontinence, impaired memory, ambulating without assistance and wandering behavior. D. Staff interviews CNA #4 was interviewed on 12/9/24 at 2:45 p.m. CNA #4 said nobody on the unit wore a soft helmet on the unit where Resident #88 resided. He said Resident #88 needed assistance getting dressed daily and the staff assisted her in putting her hipsters on. CNA #13 was interviewed on 12/9/24 at 3:45 p.m. CNA #13 said Resident #88 was a high fall risk. She said she could walk but gets weak sometimes and the staff would get her a wheelchair. Licensed practical nurse (LPN) #2 was interviewed on 12/9/24 at 4:20 p.m. LPN #2 said Resident #88 was a high fall risk. She said interventions to prevent falls for her included offering hipsters, offering a wheelchair or walker, staff to supervise her,and for the staff to walk with her. She said the nurses and the CNAs were responsible for offering the resident to wear a soft helmet and hipsters. She said she could not find Resident #88's soft helmet. The director of nursing (DON) and the CNR were interviewed together on 12/10/24 at 5:00 p.m. The DON said Resident #88's mood and activity level fluctuated from day to day. He said sometimes she wanted to be left alone and other times she engaged in activities with others. He said she was working with therapy and used a walker and required the assistance of one to two staff members for ambulation. He said she got up on her own often and the staff were expected to intervene and walk with her when this occurred. He said based on assessment and previous falls, she was considered a high fall risk. He said fall interventions for her included wearing hipsters, a soft helmet, a fall mat beside her bed and ensuring her bed was in the lowest position. He said with the acuity of the resident population on the unit Resident #88 lived on, the staff were not able to keep an eye on everybody at all times. He said fall interventions were continually assessed and new ones were added if old ones were no longer working.

Based on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure one of three ice machines was clean and sanitary; and, -Ensure glassware was handled properly in two of four dining rooms. Findings include: I. Failure to ensure the ice machine was clean and sanitary A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It revealed, in pertinent part, Equipment food-contact surfaces and utensils shall be clean to sight and touch. The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Non food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Non food-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. (Retrieved 8/1/23) B. Facility policy and procedure The Cleaning Instructions: Ice Machine policy, undated, was provided by the registered dietitian (RD) on 7/27/23 at 12:38 p.m. It revealed in pertinent part, The ice machine and equipment (scoops) will be cleaned on a regular basis to maintain a clean, sanitary condition. If available, follow the manufacturer's cleaning and sanitizing procedures. C. Observations On 7/27/23 at 9:16 a.m. the following was observed on the Larkspur unit alongside the RD and the administrator in training (AIT): -The ice machine had brown build-up where the ice was dispensed into the ice holding tank and served to residents. -A piece of the machine in the back right hand corner had built-up brown debris. A rusted nail was holding the piece of the machine to the side of the machine. The RD and the AIT acknowledged the ice machine was not sanitary. The AIT said they would call the maintenance department to have the machine cleaned and serviced. D. Staff interviews The RD and the AIT were interviewed on 7/27/23 at 11:47 p.m. The RD said the maintenance department cleaned the machine monthly and an outside company came to the facility every six months to clean and service the machine. The RD said the last time the machine was serviced by the outside company was in May 2023. The RD said the facility maintenance department cleaned the machine on 6/26/23 and did not notice any abnormalities. The AIT said the ice machine was taken out of use and a service request was made. The AIT said the part of the machine that was rusted would be replaced or the facility will get a new ice machine. II. Failure to ensure glassware was handled properly A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It revealed in pertinent part, single-service and single-use articles and cleaned and sanitized utensils shall be handled, displayed, and dispensed so that contamination of food and lip-contact surfaces is prevented. (Retrieved 8/1/23). B. Facility policy and procedure The Handling of Clean Utensils and Equipment policy and procedure, dated August 2017, was provided by the RD on 7/27/23 at 12:38 p.m. It revealed in pertinent part, Clean equipment and utensils will be handled to prevent contamination. When handling cleaned and sanitized equipment and utensils, staff will avoid touching the parts that will come in contact with the food or the mouth (especially with silverware). C. Observations During a continuous observation on 7/24/23 beginning at 11:45 a.m. and ended at 1:01 p.m. the following was observed: -At 11:50 a.m. certified nurse aide (CNA) #4 took glasses off a tray and created two stacks of glasses with the top of the glasses facing up. CNA #4 held the two stacks of glasses against her scrubs. CNA #4 then went to each table in the dining room and put her fingers into the glasses and pinched to pick up two glasses at a time. CNA #4 touched the inside of the glasses and the part of the glass that residents drank out of. CNA #4 then moved a stool. CNA #4 went back to the tray of clean glasses and created two stacks of cups and held them against her scrubs again. CNA #4 began putting her fingers into the cups, pinching them to pick them up and placing them on the tables for the residents to use. -At 11:51 a.m. CNA #4 touched her ponytail and then began stacking cups against her scrubs and placing them on the table from the drinking rim. -At 12:01 p.m. CNA #4 grabbed a stack of styrofoam cups and picked them up from the drinking rim. CNA #4 picked up a plastic cup from the clean tray and put her fingers into the cup and then placed it on the table for a resident to drink. On 7/25/23 at 11:12 a.m. the following was observed: -An unidentified dietary staff member was holding a stack of cups. The cups were upside down and he was touching the rim of the cup that was on the bottom of the stack and had his other hand on other cups rims as he was stabilizing the stack of cups. As he was setting the cups on the table, he was touching the rims of the glasses that residents would drink out of. D. Staff interviews CNA #5 was interviewed on 7/27/23 at 11:44 a.m. She said cups should be held from the bottom to prevent contamination of the cup. The RD and the AIT were interviewed on 7/27/23 at 11:47 a.m. The RD said cups and glasses should be handled from the bottom of the cup. The RD said where a resident's mouth would touch the item should not be touched as it could contaminate the cup or utensil.

Based on observations, record review and staff interviews the facility failed to provide services for one (#3) out of 12 residents reviewed for professional standards of practice out of 47 sample residents. Specifically, the facility failed to ensure Resident #3's vital signs were monitored prior to the administration of a blood pressure medication. Findings include: I. Professional reference Kiziior, R. J., [NAME], K. J. (2023). Lisinopril. [NAME] Nursing Drug Handbook. Elsevier. P. 704. Obtain blood pressure, apical pulse immediately before each dose in addition to regular monitoring (be alert to fluctuations). II. Resident #3 A. Resident status Resident #3, age 86, was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), the diagnoses included dementia, diabetes mellitus and hypertensive (high blood pressure) chronic kidney disease. The 6/1/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with deficits in long and short term memory. The resident required the extensive assistance of one person for most ADLs. B. Observations On 7/26/23 at 7:03 a.m. certified nurse aide with medical authority (CNA/MA) #2 was observed dispensing and administering Lisinopril (blood pressure medication) 2.5 milligrams (mg) of Resident #3. CNA/MA #2 did not check for the resident's vital signs on the medical record, including the resident's blood pressure and pulse, prior to the administration. C. Record review The July 2023 CPO documented a physician order of Lisinopril 2.5 mg once a day for hypertension, ordered on 11/1/21. -The CPO did not document any vital sign parameters for when to hold the medication or when to notify the physician of irregular vital sign results. The July 2023 medication and treatment administration record (MAR/TAR) documented the resident's blood pressure and pulse was to be taken every morning and evening. III. Staff interviews CNA/MA #2 was interviewed on 7/26/23 at 7:06 a.m. She said the residents had vital signs taken first thing in the morning. She said she did not check for the vital signs because there were no parameters ordered. Registered nurse (RN) #2 was interviewed on 7/26/23 at 1:10 p.m. She said blood pressures and pulses should be obtained and checked prior to the administration of a blood pressure medication. She said, if there were no blood pressure parameters ordered, then the physician should be notified if the blood pressures were fluctuating outside of the resident's baseline vital signs. The director of nursing (DON) was interviewed on 7/27/23 at 1:45 p.m. He said the blood pressure and pulse should be monitored prior to the administration of a blood pressure medication.

Based on observations, record review and interviews, the facility failed to ensure one (#52) of two residents with limited range of motion received appropriate treatment and services out of 47 sample residents. Specifically, the facility failed to ensure Resident #52's palm splint was in place as ordered by the physician to prevent skin breakdown. Findings include: I. Resident #52 status Resident #52, age 80, was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO) revealed the following diagnoses dysphagia (swallowing difficulty), history traumatic brain injury, contracture of muscle right upper arm, contracture or right hand, contracture of right shoulder, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right sided weakness related to a stroke), dementia with behavioral disturbance and cognitive communication deficit. The 6/15/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status with a score of three of 15. She required extensive assistance of one person for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toileting and personal hygiene. The assessment revealed Resident #52 had limited range of motion to one upper extremity and limited range of motion to two lower extremities. She was receiving occupational therapy. A. Observations During a continuous observation on 7/24/23 beginning at 11:45 a.m. and ended at 1:01 p.m. Resident #52 was in the dining room without a splint to her right hand. Resident #52's fingers on her right hand were slightly bent, her thumb in between her fingers and her hand was held up to her chest. During a continuous observation on 7/25/23 beginning at 11:18 a.m. and ended at 12:29 p.m. Resident #52 was in the dining room without a splint to her right hand. On 7/26/23 the following was observed: -At 10:18 a.m. Resident #52 was in the dining room without a splint to her right hand. -At 10:33 a.m. Resident #52 had a splint on her right hand (see interview below). -Upon interviewing certified nurse aide (CNA) #4, he went to Resident #52's room, got the brace out of Resident #52's nightstand and applied it on Resident #52's right hand. B. Record review The musculoskeletal care plan, initiated on 7/9/19 and revised on 7/20/23, revealed Resident #52 had a history of fracture of the right humerus (leg fracture), history of a stroke, history of stroke with right elbow, right hand, right wrist and shoulder contractures and bilateral knee contractures. The interventions included: anticipating and meeting the residents needs, following physician orders for weight bearing status, following physician orders for therapy or treatment plans, providing pain medications as ordered by the physician and monitoring for side effects and effectiveness, monitoring for risk of falls, monitoring and documenting complications related to arthritis, providing position changes, providing occupational and physical therapy as needed and providing a right balm protector for day use as tolerated. The skin integrity care plan, initiated on 6/25/19 and revised on 3/19/21, revealed Resident #52 had potential impairment to her skin related to fragile skin and impaired safety awareness. The interventions included: performing daily skin checks during cares, encouraging good nutrition and hydration, following facility protocols for treatment of injury, keeping the skin clean and dry, monitoring and documing location, size and treatment of skin injury, reporting failure to heal, signs of symptom of infection and providing pressure relieving/reducing mattress and pillows to protect skin while in bed and out of bed. The July 2023 CPO revealed the following physician order: -Provide right palm protector during the day as tolerated, ordered 7/19/21 and discontinued on 7/27/22. -Provide right palm protector as tolerated every day shift, ordered 7/27/23 (during the survey, the order was clarified). The kardex (staff directive) indicated the staff were to provide a right hand palm protector for day use as tolerated, conduct a skin check pre and post use and notify therapy if there are signs or symptoms of intolerance. -A review of the resident's medical record on 7/26/23 at 3:00 p.m. did not reveal documentation that the brace was being applied to the resident's right palm as directed in the physician's order (see interview below). II. Staff interviews CNA with medication authority (CNA/MA) #2 was interviewed on 7/26/23 at 10:17 a.m. CNA/MA #2 said she was not sure where Resident #52's splint was located. CNA #4 was interviewed on 7/26/23 at 10:19 a.m. CNA #4 said Resident #52's splint was in her room. CNA #4 said Resident #52's splint should have been applied when she got ready for the day. CNA #4 said a CNA or a licensed nurse could apply the splint. Registered nurse (RN) #3 was interviewed on 7/26/23 at 3:09 p.m. RN #3 said occupational therapy was responsible for placing and taking off Resident #52's hand splint. The director of rehabilitation (DOR) was interviewed on 7/27/23 at 9:52 a.m. She said the CNAs or licensed nurses were responsible for applying the splint to Resident #52's hand. The DOR said the brace was in place to prevent skin breakdown. The DOR acknowledge the point of care documentation did not reveal Resident #52's splint had been offered to her. The DOR said the point of care documentation was not prompting the correct documentation for the staff and she would fix it. The DOR said Resident #52 was currently receiving occupational therapy for contracture management. The director of nursing (DON) was interviewed on 7/27/23 at 11:01 p.m. The DON said typically if a resident had a splint or brace a task was created on the point of care system. The DON said the CNAs are then able to document if the resident tolerated or refused the brace or splint. The DOR and the clinical resource (CR) were interviewed on 7/27/23 at 12:13 p.m. The CR said she would obtain a new order and ensure the electronic medical record prompted the correct documentation for Resident #52's splint. The CR said the electronic medical record should populate a question to the floor staff to document if the resident tolerated the splint or refused the splint. The CR acknowledge Resident #52's medical record did not have documentation indicating Resident #52's hand splint had been offered or refused.

Based on record review and interviews, the facility failed to ensure residents maintained acceptable parameters of nutritional status for two (#20 and #76) of five reviewed for nutrition status out of 47 sample residents. Specifically, the facility failed to ensure -Resident #76, who had a downward trending weight loss and was identified with pressure ulcers was provided nutritional interventions in a timely manner; and, -Resident #20 was identified with a continued weight loss and completed a timely quarterly nutrition assessment. Findings include: I. Professional reference [NAME], S., [NAME], A. (June 2022). The Impact of Nutrition on Pressure Ulcer Healing. British Journal of Nursing. https://www.britishjournalofnursing.com/content/nutrition/the-impact-of-nutrition-on-pressure-ulcer-healing/ retrieved on 8/2/23. A high-calorie diet and protein fortified foods or oral supplements are recommended for all patients at risk for developing a pressure ulcer and who are at risk of developing malnutrition. These supplements must be prescribed on an individual basis following a full risk assessment. II. Facility policy and procedure The Weights policy and procedure, reviewed May 2022, and provided by the nursing home administrator on 7/27/23 at 12:06 p.m. It read in pertinent part, The registered dietician (RD) or designee will review all significant/severe weight losses monthly or as needed; this may also be completed during the Nutrition at Risk (NAR) meeting. As part of this review, nutrition status will be assessed. The RD or designee will document the specific interventions used and determina monitoring system to evaluate the success of the interventions initiated. Nutrition at Risk (NAR) committee will meet weekly by the interdisciplinary team (IDT) (at least consisting of representation from nutrition and nursing), the RD or designee will determine and provide a list of residents to be discussed at the meeting. Progress notes from the meeting will be documented in each resident's EMR. The following residents may be included in the NAR list, at the RD's discretion: a. New admission/readmission, b. Tube feedings, c. Significant weight changes, d. Pressure ulcers, e. Fluid imbalance, f. TPN (total parenteral nutrition), g. Dialysis, h. Change of Condition. III. Resident #76 A. Resident status Resident #76, age 79, was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), the diagnoses included dementia, osteoporosis, hip fracture and diabetes mellitus. The 6/2/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with deficits in short and long term memory. He was totally dependent with the assistance of two people for toileting and required the extensive assistance of one person for bed mobility, transfers, dressing, eating and personal hygiene. It indicated that he was at risk for pressure ulcers but failed to indicate resident had unhealed pressure ulcers stage one or higher. B. Record review The nutritional risk care plan, initiated on 4/2/21 revised 12/23/22, indicated he was at a nutritional risk related to dementia, weight loss and generalized weakness. Interventions included diet as ordered by physician, honor resident rights to make personal dietary choices, invite to activities to promote additional intake, monitor and report as needed for signs of decreased appetite nausea and vomiting, unexpected weight loss, monitor to physician signs of malnutrition and emaciation, muscle wasting, significant weight loss, obtain and monitor lab work as ordered, occupational and speech therapy screen and evaluate for diet and self feeding, provide assistance and cueing with meals, provide supplements as ordered, RD to evaluate and make diet change recommendations and monthly weights if stable. The pressure ulcer care plan, initiated 6/28/23 revised on 7/10/23, indicated he had pressure wound to coccyx, right ischium, left heel and the right heel. Interventions included bunny boots for bilateral lower extremities, frequent repositioning in bed, up in the care foam chair as tolerated, monitor pressure areas for color, sensation, temperature, monitor and document wounds, monitor for signs and symptoms of infection, monitor for changes in wound, treat wounds per facility protocol. -A comprehensive review of the care plan failed to reveal personalized nutritional interventions to help prevent or promote wound healing after the development of pressure ulcers on 6/16/23 or address his downward trending weight loss. The resident's weight was documented as follows: -1/19/23 130.4 lbs (pounds) -3/22/23 130.2 lbs -4/17/23 129.9 lbs -5/17/23 126.5 lbs -6/6/23 124.4 lbs -6/23/23 121.2 lbs -A comprehensive review of the resident's weights revealed a weight loss of 4.19% in one month (5/17/23-6/23/23) and a loss of 6.19% in three months (3/22/23 -6/23/23). A comprehensive review of diet and supplementation orders revealed: -Mighty shakes three times a day for malnutrition, ordered 12/7/21 and discontinued on 7/4/23. -Regular diet, mechanical soft texture, thin liquids consistency, ordered 5/29/23. -Liquid protein every day for wound healing, ordered 7/3/23. -A comprehensive review of diet and supplementation orders revealed no new supplementation orders were put in place after the resident's weight started trending downward after April 2023. -A comprehensive review of diet and supplementation orders revealed that new interventions were not ordered until 7/4/23 after the development of four pressure ulcers (see below). In addition, the resident's Mighty Shake was discontinued on 7/4/23 that provided additional calories/protein. The July 2023 CPO revealed a physician order of admit to hospice, ordered on 7/4/23. The annual nutritional evaluation, effective 3/1/23, revealed the resident was on a regular diet with regular texture and thin liquids. His desirable weight was 136 lbs with a weight range of 123-149 lbs and had an estimated caloric need of 1680-1920 calories per day, with estimated protein needs 60-72 grams of protein per day. It documented his intake at meals were between 51-100%. A 4/23/23 nutrition progress note revealed the resident was reviewed in the NAR meeting and no concerns were noted. The RD recommendation included continuing the current diet and supplements as ordered and continue to monitor. -A comprehensive review of the nutrition progress notes revealed no further documentation after 4/23/23. A comprehensive review of the wound physician progress notes revealed a coccyx pressure ulcer identified on 6/16/23; right heel pressure ulcer identified on 6/26/23; left heel pressure ulcer identified on 6/26/23; right ischium was identified on 6/27/23; right lateral ankle was identified on 7/4/23; and the right lateral knee was identified on 7/25/23 (during survey). D. Staff interviews The RD was interviewed on 7/27/23 at 11:31 a.m. She said the RD monitored weights and monitors weekly reports and pulls the weight loss summary if there has been a significant weight loss trigger. She said the system they have in place triggers for significant weight loss if it was greater than 5% in 30 days. She said that if a significant weight loss has not been triggered than they monitor monthly weight loss reports for trending weight loss or rely on nursing to notify if there was a weight loss or pressure ulcer concern. She said that she was not aware of Resident #76's pressure ulcers until 7/27/23, during the survey. The director of nursing (DON) was interviewed on 7/27/23 at 1:42 p.m. He said when a pressure wound was identified the wound nurse or staff nurses notified the RD and placed them on a wound list so that these residents could be tracked, assessed and monitored. 40960 IV. Resident #20 A. Resident status Resident #20, age above 70, was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), the diagnoses included unspecified dementia, unspecified protein-calorie malnutrition, dysphagia (difficulty swallowing) and major depressive disorder. The 5/12/23 minimum data set (MDS) assessment revealed, the resident was unable to complete the brief interview for mental status (BIMS). His cognitive skills for daily decision making were severely impaired. He had no behaviors and did not reject care. He required extensive assistance with all of his activities of daily living. He held food in his mouth/cheeks after the meal. He received an altered diet. B. Record review The weight record revealed he had a 7.68% weight loss in four months: -On 2/5/23 the resident's weight was recorded at 153.6 lbs (pounds). -3/30/23 at 151.4 lbs. -4/28/23 at 145.0 lbs. -5/31/23 at 143.6 lbs. -6/24/23 at 141.8 lbs., which was a 11.8 lbs weight loss in four months. The nutrition care plan, revised 2/10/23, documented the resident had a potential nutritional risk related to altered mental status, Alzheimer's, chewing/swallowing difficulties and difficulty self feeding which required staff to assist with eating. Pertinent interventions were to follow the diet ordered by the physician, feeding assistance, monitor and report to physician as needed for decreased appetite and unexpected weight loss, offer and encourage snacks and fluids between meals, provide supplements as ordered, and registered dietician (RD) to evaluate and make recommendations. -The nutritional care plan had not been updated since the resident's weights were trending down. The July 2023 CPO included an order, dated 10/3/21, to provide a supplemental shake one time a day for mild protein calorie malnutrition. Review of a nutrition progress note dated 2/9/23 revealed: -Diet retained regular/puree/thin liquids. -Intake at meals were 50-100% most recently. -No new labs. -No new skin issues. -Continued on supplemental shake once a day. -Weights were currently stable. Recommendations: -Continue diet as ordered. -Continue supplemental shake once a day for now, offer and encourage fluids/snacks between meal. -Monitor intakes, weights, and adjust as needed. -This progress note was the last RD documentation and assessment for Resident #20. The resident's nutritional status had not been addressed for five months with his weight loss over four months. C. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 7/26/23 at 2:28 p.m. She said Resident #20 needed assistance with eating. She said the CNA was responsible for getting the resident's weight and documenting the weight in the resident's medical record. Registered nurse (RN) #2 was interviewed on 7/27/23 at 8:47 a.m. She said the CNA was responsible for obtaining a resident's weight. She said if the CNA was too busy, the nurse would obtain the weight. She said the resident's weight was then documented in the resident's medical record. She said the RD had access to the medical records and was responsible for following up on the residents' weight loss. She said she was not sure how often the RD reviewed the weights. The RD was interviewed on 7/27/23 at 11:32 a.m. She said the RD was responsible for obtaining a weekly report on weights for the NAR (Nutrition at Risk) meeting. She said she would add a resident to the NAR if they had a quarterly/annual assessment due or if a weight loss was triggered in the resident's medical record. She said Resident #20 did not trigger in the medical record and that was why he probably was missed. She said his weight loss and quarterly assessment should have triggered when due. She said she should have caught the weight changes. She said she would look into the computer based medical record to find out why he did not trigger.

Based on record review and interviews the facility failed to notify the physician timely for one (#2) of three residents reviewed out of seven sample residents. Specifically, the facility failed to notify the physician when the resident began refusing wound treatments to his bilateral lower extremities routinely. Findings include: I. Facility policy and procedure The Change of Condition Reporting policy and procedure, revised October 2020, provided by the director of nursing (DON) on 4/25/23 at 6:46 p.m. It revealed in pertinent part, It is the policy of this facility that all changes in resident condition will be communicated to the physician. All symptoms and unusual signs will be communicated to the physician promptly. Routine changes are a minor change in physical and mental behavior, abnormal laboratory and x-ray results that are not life threatening. The nurse in charge is responsible for notification of physician prior to end of assigned shift when a significant change in resident's condition is noted. All attempts to reach the physician and responsible party will be documented in the nursing progress notes. Documentation will include time and response. II. Resident #2 A. Resident status Resident #2, age 76, was admitted on [DATE] and readmitted on [DATE]. According to the April 2023 computerized physician orders (CPO), the diagnoses included dementia with behavioral disturbance, bipolar disorder, localized edema, hypertension (high blood pressure), dysphagia (swallowing difficulty), depression, alcohol abuse with alcohol induced disordered and altered mental status. The 3/16/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of two out of 15. He required limited assistance of one person for bed-mobility, dressing and toileting. He required supervision of one person for transfers, locomotion off unit and personal hygiene. He required supervision with set-up assistance for walking on the corridor and eating. The MDS assessment documented the resident was at risk for developing pressure ulcers/injuries and had two venous and arterial ulcers. It documented he had open lesion(s) on the foot. B. Record review The skin care plan, initiated on 1/8/23 and revised on 2/10/23, revealed Resident #2 had actual impairment to his skin related to fragile skin, skin discolorations, unsteadiness on his feet, altered mental status and unspecified psychosis. The interventions included: avoiding scratching and keeping hands and body parts from excessive moisture, keeping his fingernails short, encouraging good nutrition and hydration to promote healthy skin, floating heels as tolerated, following facility protocols for treatment of injury, having the wound team and provider following the resident and had provided monitoring and treatment orders, monitoring for side effects of antibiotics and over-the-counter medications, monitoring and documenting the location, side and treatment of skin injury, reporting abnormalities, failure to heal, signs or symptoms of infection or maceration to the physician, providing a pressure relieving/reducing cushion to protect the skin while in a chair, providing a pressure relieving/reducing mattress to protect the resident's skin when in bed, providing a diuretic for bilateral lower extremity edema, encouraging the resident to allow cares as tolerated as he often refuses care and skin checks, continuing to offer and encourage care as the resident often refused cares and using caution during transfers and bed mobility to prevent hitting arms, legs and hands against any sharp or hard surface. The 4/17/23 physician visit progress note documented staff had requested for the physician to see the resident today. The note documented the resident had essentially been refusing lower extremity dressing changes for three months. The note documented the physician was made aware of the extent of the issue last week. The nurse practitioner (NP) attempted to change the dressings on Friday (4/14/23) and there was no odor present. The note documented the physician entered Resident #2's room. Resident #2 was standing at the sink. The physician could not stay in the room more than 10 seconds due to the malodor (unpleasant smell) from the resident's bilateral lower extremities. The progress note documented multiple staff had tried to convince the resident to let them change the dressings but the resident refused and recently was combative. The resident refused to be sent to the hospital. Ativan (anti anxiety medication) was ordered prior to dressing removals and Cipro (antibiotic) twice a day for seven days. The note documented the resident may need stronger medications or to be sent to the hospital. The resident may need to be started on Zyprexa (antipsychotic medication) as his behavior was harmful to himself and his roommate. The 4/20/23 nurse practitioner progress note documented the facility staff requested the NP to see Resident #2. The complaint was related to Resident #2 refusing lower extremity dressing changes for over two weeks. The note documented many attempted had been made to change the dressings, but Resident #2 refused. The resident was ordered to be sent to the hospital as he was posing a risk to himself. A review of the April 2023 CPO revealed the following wound orders: -Wound treatment: Clean venous wounds to LLE (left lower extremity) with N (normal saline), pat dry, apply Xeroform (gauze dressing), Alginate (wound dressing), ABD (ointment), wrap with Kerlex (gauze bandage) and AC wrap (ace wrap) in the morning every other day., ordered 1/15/23 and discontinued on 4/19/23. -Wound treatment: Clean venous wounds to RLE (right lower extremity) wounds with N (normal saline), pat dry, apply Xerofrom (gauze dressing), Alginate (wound dressing), ABD (ointment) wrap with Kerlex (gauze bandage) and AC wrap (ace wrap) in the morning every other day, ordered 1/15/23 and discontinued on 4/24/23. A review of the March 2023 treatment administration record (TAR) revealed the resident accepted wound treatments to both his LLE and RLE on the following dates: -3/13, 3/19, 3/21, 3/23, 3/25, 3/27, 3/29 and 3/31/23. A review of the April 2023 TAR from 4/1/23 through 4/19/23 revealed the resident refused all wound treatments to his LLE and RLE. -Review of the resident's medical record revealed the physician was not notified of the resident's increased refusals of wound care until the physician saw the resident on 4/17/23. III. Staff interviews The NP was interviewed on 4/25/23 at 1:30 p.m. She said Resident #2 developed weeping edema and cellulitis in January 2023. She said the resident had refused wound care on and off, but began refusing all treatments in April 2023. She said she was unsure of when the physician was notified of the resident's increased refusals. The DON was interviewed on 4/25/23 at 5:28 p.m. He said Resident #2 developed bilateral lower extremity venous ulcers in January 2023. He said Resident #2 had refused wound care on and off for several months. The DON said Resident #2 received wound care treatment on 3/31/23 and then started refusing all wound treatments. He said the facility had tried multiple interventions to encourage the resident to allow wound treatments. The DON said Resident #2 was sent to the hospital on 4/20/23 as he became a danger to himself, since Resident #2 was not allowing staff to change his wound dressings.

Based on record review, observations and interviews, the facility failed to ensure the resident right to be free from abuse, neglect, misappropriation of property, or exploitation for three (#2, #3, and #4) out of seven sample residents reviewed. Specifically, the facility failed to prevent two resident to resident altercations between Residents #2 and #3, and Residents #4 and #5. Findings include: I. Facility policy and procedure The Abuse Prevention policy, revised July 2021, was provided by the director of nursing (DON) on 8/2/21 at 1:15 p.m. It read, in pertinent part: It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals. The employees of our facility will [MEDICATION(S)] to protect and prevent abuse and neglect from occurring within the facility by: -Staff knowledge of the individual residents' care needs. -Supervision of staff to identify inappropriate behaviors. -Assess, care plan, and monitor residents with history of aggressive behaviors, behaviors such as entering other residents ' rooms, self-injurious behavior, communication disorders, or total dependence on staff. If suspected perpetrator is another resident: -Separate the residents so they do not interact with each other until circumstances of the reported incident can be determined. -If a room change is appropriate, advise residents' families of the change and room location. II. Altercation between Resident #2 and Resident #3 A. Resident to resident altercation On 7/19/21 a progress note revealed Resident #2 was approached by Resident #3 who yelled at him, called him names, and hit him on the face. In response, Resident #2 retaliated by hitting Resident #3 in the face three times. The staff responded to the residents yelling at each other, the residents were separated, interviewed, and assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The residents were interviewed, Resident #2 stated Resident #3 approached him and started yelling. Resident #3 stated he needed to defend people because Resident #2 was getting on the girls. Both residents agreed they had made poor decisions and they should not have acted the way they did. The residents were separated and placed on increased monitoring and 15 minute checks for Resident #2. Resident #3 was placed on one to one monitoring for 72 hours. The facility investigation was started immediately and staff were interviewed. Staff interviews revealed Resident #2 was in the nurses station taking medications and talking to staff about a shower immediately preceding the incident and Resident #3 was at baseline behavior of walking on the unit with no agitation or behaviors noted. Both Resident #2 and #3 had care plans and medications reviewed and Resident #3 had medication changes. B. Resident #2 Resident #2, age 68, was admitted on [DATE]. According to the July 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/15/21 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status score of 11 out of 15. He exhibited no behaviors. He required supervision or minimal assistance with his mobility and activities of daily living. Review of the resident's progress notes from February 2021 to present revealed no other resident to resident altercations had occurred while a resident in the facility. C. Resident #3 Resident #3, age 66, was admitted on [DATE]. According to the July 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/28/21 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status score of one out of 15. He exhibited continuous disorganized thinking and inattention. He required supervision with his mobility and extensive assistance of one staff member with activities of daily living such as dressing, toileting and personal hygiene. Following the resident to resident altercation, Resident #3's [MEDICATION(S)] (antipsychotic medication) was increased and [MEDICATION(S)] (antipsychotic medication) was restarted after being discontinued after a gradual dose reduction on 5/31/21. The resident had no further aggressive behaviors since the altercation. Review of the resident's progress notes from February 2021 to present revealed no other resident to resident altercations had occurred while a resident at the facility. D. Interview The DON was interviewed on 8/2/21 at 3:00 p.m. She stated the resident to resident altercation did occur and the residents described the incident immediately following. She stated neither resident had been involved in an altercation prior to the incident and neither has since the altercation. She stated the medication changes for Resident #3 had been effective in decreasing agitation and the resident had responded well to the changes. III. Altercation between Resident #5 and Resident #4 A. Resident to resident altercation On 7/20/21 a progress note read Resident #5 approached Resident #4 and asked her for the car keys, when she responded she did not have the keys, he struck her on the left cheek. The residents were separated and Resident #4 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility investigation was started immediately and Resident #5 was removed from the common area and staff remained with him until he calmed down. The staff caring for the residents were interviewed and stated Resident #5 was wandering the unit per his baseline behavior and approached Resident #4 and hit her cheek before they could intervene. B. Resident #4 Resident #4, age 75, was admitted on [DATE]. According to the July 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/11/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance of one staff member with ADLs and mobility. Review of resident's progress notes from March 2021 to present revealed she had not been involved with any resident to resident altercations. C. Resident #5 Resident #5, age 80, was admitted on [DATE]. According to the July 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/27/21 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status score of six out of 15. He required extensive assistance of two staff members with his ADLs and mobility. Review of Resident #5's progress notes from his admission on 6/22/21 to present revealed the resident exhibited some exit seeking and some agitation, though had not exhibited any aggression or been involved with any resident to resident altercations prior to or since the aforementioned altercation. Observations of Resident #5 were conducted on 8/2/21 at 2:20 p.m. The resident was in his wheelchair at the nurses station with a nurse sitting with him and engaging him in conversation. The resident was calm and cooperative with the nurse and sat quietly while the nurse assisted another resident to put on non-slip socks. Another staff member approached the resident and offered him a snack which he accepted and ate at the nurses station. D. Interviews Resident #4 was interviewed on 8/2/21 at 2:30 p.m. She stated she felt the incident was a fluke and would not happen again. She stated she was not afraid of Resident #5 and that he had barely hit her. She stated the staff were very good with him and kept a close eye on him at all times and if he became agitated, they redirected him with an activity, snack, or calm conversation. She stated she had not witnessed and was not aware of any other incidents involving Resident #5. The DON was interviewed on 8/2/21 at 3:05 p.m. She stated Resident #5 had not had any other aggressive incidents since the altercation with Resident #4. She stated the staff were aware of his behaviors and since the incident had kept him engaged and implemented strategies to keep him calm which had been effective in preventing any further incidents.

Based on record review and interviews, the facility failed to ensure a safe environment and adequate supervision to prevent accidents for one (#4) of three residents reviewed of six sample residents. The facility identified a skin alteration (laceration) on the resident's face on 4/28/21 and initiated an investigation. Approximately fifteen minutes later, the resident started complaining of left hip pain. The facility did not investigate the cause of the resident's hip pain or identify the cause of the skin alteration to the resident's face. Due to the facility failures, the resident required hospitalization for a fracture of the left femoral neck (left hip) requiring surgical intervention and a one centimeter (cm) laceration to her left cheek (see hospital summarization, record review). In addition, when the resident was readmitted from the hospital, the facility did not initiate interventions to prevent the resident from occurring further injury. Findings include: I. Resident status Resident #4, age 88, was admitted on [DATE], discharged to the hospital on 4/29/21 and readmitted on [DATE]. According to the May 2021 computerized physician orders (CPO), diagnoses included intertrochanteric (hip) fracture of the left femur (thigh bone) with orthopedic aftercare and a laceration of the left cheek (added 5/1/21). The 5/7/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. The resident required limited assistance of one person for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use and personal hygiene and was dependent on one person for bathing. She required extensive to total assistance of two people for walking in her room and the corridor. It indicated the resident had not had any falls since re-entry. She required the use of a wheelchair or walker for mobility. II. Resident representative interview Resident #4's representative was interviewed on 5/20/21 at 1:37 p.m. He said he was called at about 2:30 a.m. and told that his mother was complaining of hip pain so the facility got x-rays that showed her hip was broken so they sent her to the emergency room . He said the nurse he talked to did not know how the fracture occurred. He said he asked the facility again but never got an answer. He said he had not been told she had a laceration on her face. He said he saw it when she was at the hospital and assumed she got it the same time she broke her hip. III. Record review The 2/4/21 MDS assessment (before the incident) revealed the resident required supervision with set-up or assistance of one person for transfers, walking in her room and corridor and locomotion on and off the unit with the use of a walker. According to a 4/28/21 therapy consultation/screen progress note the resident was able to ambulate throughout the neighborhood using a four wheeled walker (4WW) with no loss of balance. It indicated the resident was able to perform active range of motion (AROM) to bilateral upper and lower extremities within functional limits with no signs or symptoms of pain and the resident had no falls in 2021. A 4/28/21 incident progress note, written at 10:04 p.m., revealed the resident was observed with a skin alteration of unknown origin to her left cheek that was cleaned and left open to air and had no indications of infection. It indicated the resident had no other visible injuries at the time of the assessment and neurological checks were initiated per facility policy. -No further description was given of the skin alteration. A PRN (as needed) skin evaluation with an effective date of 4/28/21 at 9:46 p.m. revealed the resident had a scratch to her left cheek/face. -No further description of the injury was given. Another 4/28/21 incident progress note, written at 10:36 p.m. revealed the resident started complaining of severe pain to her left hip with impaired range of motion (ROM) to the left lower extremity at 10:15 p.m. It indicated the provider was notified and orders were received for a STAT (immediate) x-ray of the left hip. A 4/29/21 nursing progress note, written at 12:01 a.m., revealed the resident continued to complain of pain to her left hip and the left lower extremity was warm to touch. It indicated the resident was repositioned for comfort and given Tylenol for pain. Another 4/29/21 nursing progress note revealed the results of the left hip x-ray were positive for a fracture. It indicated the provider was notified and the resident was sent to the hospital via ambulance at 2:30 a.m. The 4/29/21 hospital summarization revealed the resident presented to the center on 4/29/21 after an unwitnessed fall at her living facility the previous evening. It indicated the resident had a left intertrochanteric femur fracture and a one centimeter (cm) laceration to her left cheek repaired with a liquid adhesive. A 5/1/21 admission progress note revealed the resident arrived at the facility on a stretcher with a surgical incision to her left hip. A 5/3/21 provider progress note revealed the resident had a suspected unwitnessed fall on 4/28/21 and was complaining of left hip pain and had a left facial laceration. X-rays, done at the facility, showed a non-displaced intertrochanteric hip fracture, so the resident was transferred to the hospital for evaluation. It indicated the resident underwent an IM nailing (a metal rod inserted into the inner part of the bone) of the left femur on 4/29/21 after receiving a left hip block for [MEDICATION(S)] in the emergency room . A 5/3/21 nutritional summary revealed the resident was readmitted to the facility with a left hip fracture from an unwitnessed/presumed fall. The resident's care plan was updated on 5/10/21 to include: the resident has a post-surgical incision site to left hip with interventions to encourage good nutrition and hydration, monitor/document the location and use caution during transfers and bed mobility for left hip precautions in place. The fall care plan, last revised 5/13/21, revealed the resident was at risk for falls related to her diagnoses, medications, incontinence and cognitive impairment which may affect her ability to identify safety needs. Interventions included: -Anticipate and meet needs; -Avoid rearranging furniture; -Be sure the call light is within reach and encourage to use it to call for assistance as needed; -Ensure resident is wearing appropriate footwear when ambulating or wheeling in wheelchair; -Keep needed items, such as water, in reach; -Maintain a clear pathway, free of obstacles; and, -Needs a safe environment: floors free from spills and/or clutter; adequate, glare-free lighting, a working and reachable call light, the bed in the lowest position at night, handrails on the walls. The facility provided an incident report on 5/19/21 for the skin alteration of unknown origin to the left cheek, identified as a skin tear. The report indicated the resident was given a chair and was sitting close to the nurses station prior to the incident with no indications of injuries, pain or discomfort and then was observed with a skin alteration of unknown origin to her left cheek but no other visible injuries. -The facility did not provide an investigation of the fracture of unknown origin. The facility did not determine the cause of the fracture or the laceration to the resident's face. The facility did not implement interventions to prevent further injury to the resident immediately following the incident or when the resident returned from the hospital. IV. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 5/20/21 at 1:31 p.m. She said she was not at the facility when the resident got the fracture but she was told the resident had fallen. She said she was told she also got the cut on her face when she fell . The assistant director of nursing (ADON) was interviewed on 5/20/21 at 1:33 p.m. She said she was not at the facility when the incident occurred but recalled reviewing it the next day (4/29/21) in the morning meeting. She said the staff did not report the resident falling and thought the resident had a stress fracture. She said the resident was up singing and dancing earlier in the day. She said the area to the resident's cheek was superficial and that the resident probably scratched herself. CNA #2 was interviewed on 5/20/21 at 2:48 p.m. She said prior to the resident breaking her leg, she was pretty mobile. She said she thought if the resident had fallen and was near a chair, she believed the resident would be able to get herself onto the chair. She said she did not know for sure how the resident fractured her leg or how she got the cut on her cheek but she had been told the resident fell . She said the resident used to walk with a walker but now was in a wheelchair. She said she did not know of any new interventions the facility implemented when the resident returned from the hospital. The director of nursing was interviewed on 5/20/21 at 3:14 p.m. She said the staff did not report the resident falling so she assumed the fracture was spontaneous because the resident had severe osteopenia (loss of bone mass). -However, this diagnosis was not listed on the resident's CPO or electronic medical record (EMR). She said she had talked to the staff about the incident but did not document it. She did not feel the fracture needed to be investigated since the resident did not fall. The DON also stated that she had not read the hospital report sent back with the resident as she did not have time to read all reports sent back with each of the residents. -This statement confirms the injuries of unknown origin were not investigated to rule out abuse (F610) or to determine the root cause and analysis. V. Follow up On 5/20/21 at 4:08 p.m. the RN on duty at the time of the incident on 4/28/21, RN #2, was called with no response. A message was left and no return call was received. RN #2 was called again on 5/27/21 at 1:02 p.m. He said when he noticed the scratch on Resident #4's face, she was sitting in a regular chair by the nurses station. He said he liked to try and keep her by the nurse's station so he could keep an eye on her because she had increased anxiety. He said he started an investigation on the scratch because they did not know the origin of it. He said because it was a dementia unit, several residents walk aimlessly and she could have gotten scratched by one of them or she could have scratched herself. He said she was up walking around after that with her walker and then a little while later she was lying in bed and complaining of hip pain. He said they thought she had fallen in the bathroom and got herself up and to the bed. He said he contacted the provider to get an x-ray but it happened at shift change so he did not investigate it further. He said the night nurse got the report of the fracture and sent her to the hospital.

Based on interviews and record review, the facility failed to ensure one (#3) of three of six sample residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to file and follow-up on a grievance regarding Resident #3's missing hearing aids. Findings include: I. Resident #3 A. Resident status Resident #3, age 82, was admitted on [DATE] and discharged on [DATE]. According to the April 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/29/21 minimum data set (MDS) assessment revealed the resident was unable to complete the brief interview for mental status and the staff assessment for mental status revealed memory problem for short and long-term memory; unable to recall with cognitive skills for daily decision making scored as moderately impaired (decisions poor; cues/supervision required). He required extensive assistance with two persons for bed mobility, transfers, dressing, toilet use and extensive assistance with one person for eating, personal hygiene, and wheelchair locomotion. No behaviors or rejection of care. Ability to hear was adequate and a hearing aid was not coded. B. Resident representative interview The resident representative was interviewed on 5/20/21 at 5:45 p.m. She said she provided several items of clothing, and hearing aids when Resident #3 was first admitted to the facility. She said she discharged the resident from the facility on 4/29/21. She said when she went to visit him on 4/28/21, the social services supervisor (SSS) #2 told her they only had the clothing and they did not have the hearing aides, although registered nurse (RN) #1 went to look for them. He came back with a plastic cup and another resident's hearing aids. The resident representative said she spoke with the nurse at the hospital and she had confirmed the hearing aides were there when Resident #3 was transported from the hospital to the facility. She said when they visited 4/28/21, the SSS #2 handed them a bag with glasses and a ring and said to take them home. The resident representative said they made a verbal complaint to SSS #2 at that time about the residents' missing clothing (because he was not wearing the clothes they had brought him) and his hearing aids were missing. SSS #2 went to the laundry room and found the residents missing clothes, and the clothing concern was resolved. But there was no resolution with the missing hearing aids. She said she was told by the SSS #2 that he was not admitted with the hearing aids. The resident representative said that was not the case. She said she had never heard from the facility regarding Resident #3's missing hearing aids and she was never reimbursed for the hearing aids. The resident representative said the facility required them to sign admission paperwork on 4/28/21 and to sign the same admissions paperwork again on 4/29/21 at time of discharge, although they were not sure why and they never received a copy of either. The resident representative said they felt pressured to sign it quickly so they could leave. There was an admissions inventory list that listed three items listed- eyeglasses, dentures, and hearing aid. The resident representative said it was confusing because the hearing aid was marked as no and signed on the day of discharge. If marked no they did not have hearing aid at time of discharge then it would be accurate; if marked no to say they did not have hearing aids at time of admission then it was inaccurate. C. Record review The resident inventory sheet documented Resident #3 had the following items at the facility on 4/27/21 (the date of the residents admission): black underwear, two long sleeved shirts, one blue [NAME] brand sweater, one pair green pants, one pair socks, one pair [NAME] brand black shoes, one black baseball cap with broncos horse logo, hearing aids with black case, one leather belt, lower partials, men's watch, prescription glasses, and men's wedding band. -The facility was unable to provide documentation that a concern form had been completed regarding the residents missing items during the survey process (5/18/21-5/20/21). D. Staff interviews: RN #1 was interviewed on 5/20/21 at 11:30 a.m. He said the family was visiting with Resident #3 in the dining room and requested his hearing aids, but the family said the hearing aids RN #1 brought were not the residents. He said he could not recall if he had gotten the hearing aids out of the resident's room, the medication room or the medication cart. He said he looked on the admission record and it did not indicate the resident had hearing aids. He said he called the nurse that admitted him and that nurse said he did not have any hearing aids. He said he told SSS #2 about the hearing aids and he did not know what happened after that. Certified nurse aide (CNA) #3 was interviewed on 5/20/21 at 11:54 a.m. She said she has worked at the facility for six years and was familiar with the inventory process for new residents. She said the CNA marks all personal items on the inventory sheet and gives it to the nurse who keeps in the hard chart. She said hearing aids were often kept at the nurse station depending upon which unit. LPN #1 was interviewed on 5/20/21 at 12:02 p.m. She said the CNA would record all personal items on the inventory sheet for new residents. The inventory sheet then went to the nurse who will keep it in the hard chart next to the medical orders for scope of treatment (MOST) forms. She said hearing aids were kept in the nurse cart so they could recharge. SSS #2 was interviewed on 5/20/21 at 12:39 p.m. She said she had worked at the facility for over seven years and was the social services director for admissions and discharges. She said the CNA would fill out the inventory sheet for new residents' personal items. She said the clothing was then placed in a bag and sent to laundry to be labeled. She said hearing aids were labeled on the case. She said on the [MEDICATION(S)] unit (where Resident #3 resided) the hearing aids were stored in the medication cart. She said if a resident discharged and realized their hearing aids were missing something they could call in and she would fill out a blue concern form to document the call. The SSS #2 recalled Resident #3 and the family's concern. She said the clothing concern was resolved when she went to the laundry and found the clothes and that she was not aware of the hearing aids until after the resident was discharged . She thought she had a blue concern form but she could not locate it. The social services director (SSS #1) was present at the interview and they both acknowledged the inventory sheet that was filled out by CNA #4 when Resident #3 was admitted and the inventory sheet documented hearing aids with a black case. SSS #2 said if they did not find a missing item the process was to reimburse the family. -However, Resident #3's representative was not reimbursed for the missing hearing aids. CNA #4 was interviewed on 5/20/21 at 2:20 p.m. She said she has worked at the facility for three years and was very experienced with checking new residents personal items in on the inventory sheet. She said when a new resident comes in the CNA will fill out the inventory sheet then give it to the nurse and the resident clothes would go to the laundry to be labeled and the hearing aids would be locked in the medication cart. CNA #4 acknowledged recording Resident #3's personal items on the inventory sheet. She said her inventory sheet was accurate. She acknowledged that she visually saw the hearing aids by opening the storage case before recording it on the inventory sheet.

Based on record review and staff interviews, the facility failed to thoroughly investigate injuries of unknown origin involving one (#4) residents of three reviewed out of six sample residents. Specifically, the facility failed to investigate a laceration and fracture for Resident #4. Findings include: I. Record review According to record review on 5/19/21, the facility identified a skin alteration (laceration) on Resident #4's face on 4/28/21 and initiated an investigation for a skin injury of unknown origin, however, approximately fifteen minutes later, the resident started complaining of left hip pain. The provider was notified and orders for an x-ray were obtained. Cross-reference F689 accident/hazards. A 4/29/21 nursing progress note revealed the results of the left hip x-ray were positive for a fracture. It indicated the provider was notified and the resident was sent to the hospital via ambulance at 2:30 a.m. The 4/29/21 hospital summarization revealed the resident presented to the center on 4/29/21 after an unwitnessed fall at her living facility the previous evening. It indicated the resident had a left intertrochanteric femur fracture and a one centimeter (cm) laceration to her left cheek repaired with a liquid adhesive. The facility provided an incident report on 5/19/21 for the skin alteration of unknown origin to the left cheek, identified on the report as a skin tear. -The facility did not provide an investigation of the fracture of unknown origin. The facility did not determine the cause of the fracture or the laceration to the resident's face. II. Staff interviews The director of nursing was interviewed on 5/20/21 at 3:14 p.m. She said the staff did not report the resident falling so she assumed the fracture was spontaneous because the resident had severe osteopenia (loss of bone mass). -However, this diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she had talked to the staff about the incident but did not document it. She did not feel the fracture needed to be investigated since the resident did not fall. The DON also stated that she had not read the hospital report sent back with the resident as she did not have time to read all reports sent back with each of the residents. -This statement confirms the injuries of unknown origin were not investigated to rule out abuse or to determine the root cause and analysis (cross-F689 accident hazards). III. Facility follow-up On 5/20/21 at 4:08 p.m. the RN on duty at the time of the incident on 4/28/21, RN #2, was called with no response. A message was left and no return call was received. RN #2 was called again on 5/27/21 at 1:02 p.m. He said when he noticed the scratch on Resident #4's face, she was sitting in a regular chair by the nurse's station. He said he started an investigation on the scratch because they did not know the origin of it. He said because it was a dementia unit, several residents walked aimlessly and she could have gotten scratched by one of them or she could have scratched herself. He said she was up walking around after that with her walker and then a little while later she was lying in bed and complaining of hip pain. He said they thought she had fallen in the bathroom and got herself up and to the bed. He said he contacted the provider to get an x-ray but it happened at shift change so he did not investigate it further. He said the night nurse got the report of the fracture and sent her to the hospital.

Based on record review and interviews, the facility failed to provide services that met professional standards of quality according to accepted standards of practice for one (#6) resident out of six sample residents. Specifically, the facility failed to ensure nursing staff did not crush an extended/sustained release medication for Resident #6. Findings include: I. Resident status Resident #6, age 74, was admitted [DATE]. According to the May 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/11/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. The resident did not have any behaviors. The resident required the extensive assistance of two people for all of his activities of daily living (ADL). The resident received an antidepressant medication six out of seven days during the assessment period. II. Record review The 5/5/21 hospital discharge summary revealed speech evaluation recommended medications be crushed for administration so some of his medications had to be adjusted. It indicated the [MEDICATION(S)] 60 milligram (mg) was changed to [MEDICATION(S)] ([MEDICATION(S)]) 100 mg by mouth twice daily. -[MEDICATION(S)] and [MEDICATION(S)] were used interchangeably throughout the citation. The 5/6/21 physician admission progress note revealed the resident had dysphagia (difficulty swallowing) associated with dementia that appeared to be cognitive rather than mechanical so all medications were changed to chewable/crushable or liquid formulations. It indicated the resident was positive for increased muscle tone throughout with [CONDITION(S)] (spasmodic jerky contraction of groups of muscles) in the left leg greater than the right with overactive or over responsive reflexes. According to the May 2021 CPO, an order was entered into the electronic medical record (EMR) by the physician on 5/6/21 for [MEDICATION(S)] ER (extended release) SR (slow release) 100 mg extended release 12 hour one tablet by mouth two times a day for depression. Crush and give with food. A 5/8/21 note to the attending physician/prescriber from the consultant pharmacist revealed the resident ' s [MEDICATION(S)] was recently changed to [MEDICATION(S)] ER 100 mg twice a day for depression due to dysphagia and the need to crush medications. It indicated the resident had a [CONDITION(S)] disorder and [MEDICATION(S)] was associated with dose–related risk of seizures. It indicated for the physician to consider changing the medication or documenting the risk versus benefit for the current therapy. A 5/13/21 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . It indicated the neurologist was being consulted. A 5/17/21 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . III. Representative interview The resident ' s representative was interviewed on 5/25/21 at 1:26 p.m. She said the resident had an appointment with his neurologist on 5/21/21 and it was determined the resident ' s increased jerking movements were related to one of the medications the resident was taking, [MEDICATION(S)] ([MEDICATION(S)]), so they were tapering him off of it. She said she could already tell a difference. IV. Staff interviews The certified medication aide was interviewed on 5/20/21 at 11:35 a.m. She said Resident #6 took all of his medications crushed including his [MEDICATION(S)] SR. She said the pharmacy label on the card said to crush it so she did not question it. The pharmacist was interviewed on 5/20/21 at 12:31 p.m. He said [MEDICATION(S)] SR should not be crushed. He said no extended or sustained release medication should be crushed because it affects the release rate of the medications. He said [MEDICATION(S)] has an immediate release dose that can be crushed. After reviewing Resident #6 ' s record, he said the resident ' s [MEDICATION(S)] SR should not have been crushed. He said it appeared the physician had put the order directly into the computer system and clicked on the wrong type of [MEDICATION(S)] to be administered. He said the pharmacy should have questioned the order when it said to crush a sustained release medication and got clarification. He said it should have also been caught by the nursing staff at the facility and they should have got clarification. He said he was going to send a notification to the physician to have it changed. The pharmacy consultant was interviewed on 5/20/21 at 1:46 p.m. She said she was an independent contractor for the facility and did not work with the pharmacy the facility used. She said there was not a type of [MEDICATION(S)] ([MEDICATION(S)]) that could be crushed (this was not accurate) and she would have to research why the physician changed it. V. Facility follow-up The facility provided an email on 5/21/21 at 2:46 p.m. that included a statement from the pharmacy consultant. She said the physician ordered that specific medication for the resident and included specific instructions to crush and give with food. She said the order to crush the [MEDICATION(S)] was created in the electronic medical record system by the physician and verified and signed by the physician. She said the medication order was sent to the pharmacy for dispensing and since the physician wrote the order with specific instructions to crush and give with food, the pharmacy dispensed the medication per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident ' s primary physician was interviewed on 5/25/21 at 1:29 p.m. She said she was not aware the facility was crushing the [MEDICATION(S)] SR. She said he was supposed to be on the regular [MEDICATION(S)] so it could be crushed. She said she must have chosen the wrong tab when putting the order into the system. She said she would have hoped it would have been caught by someone and clarified with her. She said the resident was being taken off of the medication due to it causing myoclonic activity. She said she did not feel crushing the medication caused the resident any adverse effects.

Based on observations, record review, and interviews, the facility failed to ensure two (#2 and #5) of three residents out of six sample residents, who were unable to carry out activities of daily living, received the necessary services to maintain personal hygiene, and who required extensive assistance with activities of daily living (ADLs) received such assistance. Specifically, the facility failed to ensure adequate showers and bathing care, according to their schedules and preferences, was provided for Resident #2 and #5, dependent residents. Findings include I. Resident #5 A. Resident status Resident #5, age 76, was admitted on [DATE]. According to the May 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/27/21 minimum data set (MDS) assessment revealed the resident was moderately cognitively impairment with a brief interview for mental status score of eight out of 15. She required extensive assistance with one person for bed mobility, dressing, toilet use and personal hygiene. Limited assistance of one person for transfers, and walking. Supervision and set up for eating. She required physical help from one person in part of the bathing activity. She has behaviors such as wandering, and rejection of care for one to three days. B. Resident observation On 5/19/21 at 9:46 a.m. Resident #5 was observed wearing a gray shirt, tan pants, and slippers. She was going into her room with a certified nurse aide (CNA), it smelled strongly on the unit that could be smelled when entering the unit. -At 11:49 a.m. Resident #5 was observed sitting in the hallway. It smelled strongly when entering the unit. The resident was walking with a CNA holding her hand. The resident's hair was combed but greasy. On 5/20/21 at 11:00 a.m. Resident #5 hair was still greasy. C. Record review Per point of care documentation the Resident #5 received a shower Thursday 4/22/21 at 10:02 a.m., and a shower Thursday 5/13/21 at 8:37 a.m., in the past 30 days. -The resident only received a shower two times out of at least eight opportunities in 30 days. No resident refusals are documented. Per the electronic medical record (EMR) Kardex visual/bedside report the residents' bathing preference was every Monday and Thursday, day shift, with a preference for a female. -There was no indication of the resident's shower/bathing preference on her care plan. II. Resident #2 A. Resident status Resident #2, age 82, was admitted on [DATE] and discharged on [DATE]. According to the March 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/15/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance of one person with bed mobility, dressing and personal hygiene. Extensive assistance of two persons for transfers, walking in room, and toilet use. Total dependence of one person with bathing. In addition, supervision and setup help with eating. Use of walker and wheelchair, and [NAME] brace (to support spine) on at all times when out of bed. Frequent bowel incontinent and frequent urinary incontinent. No rejection of care or behaviors. B. Record review Per point of care documentation the Resident #2 received one shower 3/11/21 at 9:46 a.m. during her stay, and one sponge bath 3/16/21 at 4:05 p.m. in the 12 days that she resided at the facility. -No resident refusals are documented. Per the electronic medical record (EMR) Kardex visual/bedside report the residents bathing/showering preferences were not recorded and no bathing schedule was initiated. -There was no indication of the resident's shower/bathing preference on her care plan or in the resident's EMR. Resident #2 filed a grievance with the facility on 3/20/21 at 12:30 p.m. on her day of discharge. She expressed that she was upset that she had not been given a shower for days although she had requested it multiple times. No action at time of report or response by the facility was noted on the form. The follow-up action noted on the form was an attempt to call the resident two times, 10 days later on 3/30/21. The note said they were unable to reach the resident to determine times of concern and days. III. Staff interviews CNA #3 was interviewed on 5/20/21 at 11:54 a.m. She said if a resident refused a shower or bath, the staff would reapproach and try again later. If the resident continued to refuse a shower/bath, they would tell the nurse and the nurse would try to get the resident to bathe. The resident refusal would be documented in the tasks section of the EMR. Licensed practical nurse (LPN) #1 was interviewed on 5/20/21 at 12:02 p.m. She said if a resident refused to bathe, the staff would ask them later since the resident may be in a good mood. If the resident refused to bathe when the CNA asked, the CNA communicated with the nurse and it was documented. The CNA would document the shower, or refusal in the task section of the EMR. In general, most of the residents did not refuse to bathe. The director of nursing (DON) was interviewed on 5/20/21 at 3:01 p.m. She said there was a shower preference form that must be completed, it was recently implemented end of March 2021 after the issues with Resident #2 not getting her showers as preferred. She said they did a full house audit due to the allegations from Resident #2. She said they realized they did not have preferences in place. She said the facility now puts preferences into the tasks section under bathing in the EMR. She said new admissions should now have preferences discussed with social services and it was filled out at time of admissions. She said the process for shower refusals was the CNA offered a different time, notified the nurse, and documented in the tasks section of the EMR. The DON acknowledged the standard of shower documentation was to record in the tasks section and she said the task shower section was accurate (as indicated in Resident #2 and Resident #5's record of not getting their showers as preferred, see above).

Based on observation, record review and interviews, the facility failed to ensure one of four residents (Resident #89) reviewed for abuse out of 45 sample residents, was free from abuse inflicted by Resident #66. Resident #66, who was severely cognitively impaired and who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . His reactions to others, verbal and physical aggression, occurred quickly with very little escalation and with little to no precipitating event. On 8/7/19 at approximately 2:45 p.m., Resident #66 hit Resident #89 in face, causing swelling under both the resident's eyes, an abrasion over his left eyebrow, and scratches or lacerations on the right side of his forehead over his eyebrow. At the time, Resident #66 was on line of sight supervision and staff was expected to know where the resident was at all times. The failure of the facility to implement its supervision plan for Resident #66, given staff's knowledge of his aggressive behavior with very little escalation and no precipitating event, created a situation of immediate jeopardy with the likelihood of serious harm if not the facility's failure to implement its supervision plan was not addressed. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy On 8/7/19 at approximately 2:45 p.m., Resident #66 entered Resident #89's room and hit Resident #89 in the face, causing swelling under both the resident's eyes, an abrasion over his left eyebrow, and scratches or lacerations on the right side of his forehead over his eyebrow. At the time of the incident, Resident #66 was on line of sight supervision and staff was expected to know where the resident was at all times. The failure of the facility to supervise Resident #66 as planned and expected, given staff's knowledge of his aggressive behavior with very little escalation and no precipitating event, created a situation of immediate jeopardy with the likelihood of serious harm if not the facility's failure was not immediately corrected. On 8/7/19 at 7:11 p.m., the nursing home administrator (NHA) was notified the facility's failure to supervise Resident #66 as planned and expected created a situation of immediate jeopardy. B. Plan to correct the immediate jeopardy situation On 8/8/19 at 1:23 p.m., the clinical nurse consultant (CNC) submitted a final plan to remove the immediate jeopardy situation. It read as follows: Resident Specific: Resident #66 remains on Lavender and facility initiated 1:1 supervision on 8/7/19 at approximately 1700. All employees that provided 1:1 supervision to Resident #66 were trained by Social Worker LSW in regards to identifying escalating behaviors and indicators of psychosocial distress that may include change in person's baseline, crying, isolating, withdrawal, shouting or yelling. Home instead to assist in providing 1: 1 supervision starting on 8/8/ 19 at 1800, those employees will be trained prior to providing services in regards to Resident #66 escalating behaviors and indicators. Education will include interventions to assist in resident care, education will be provided by MSW, RN, or LSW. Resident #66 care plan updated on 8/7/19 to reflect 1: 1 supervision. Completed a QA and psych pharm review of the resident on 8/7/19 and started [MEDICATION(S)] 50mg daily on 8/8/19 for increase in sexual advances. Psych Pharm was on 8/7/19 at 1300, Resident #66 was reviewed prior to altercation which occurred during Psych Pharm. Resident #89 was moved to Primrose at approximately 5:00 p.m., Social Services assessed resident after the move and resident is adjusting well with no issues identified. Resident #89, Resident #98, and Resident #86 were assessed by Social Services LSW and showed no signs or symptoms of distress or psychosocial harm and provided with additional psychosocial support. Identification of Others: All residents on Lavender at risk to be affected. Completed observations of all residents on Lavender on 8/7/19 to identify if any residents show signs of psychosocial distress and agitation. Observations completed by Social Services LSW. No issues identified from audit. Systems and Measures: All staff to be educated on how to identify aggressive and unwanted sexual behaviors and intervene as needed. Staff education to be provided by either MSW, LSW, or RN. All education to be provided to staff prior to direct care with resident. All staff to be educated in person by 8/15/19. If staff are out of town, they will be educated prior to return to their scheduled shifts. Education listed below was initiated on 8/7/19 at 10:30 p.m. Facility completed a Call Them All Education over the phone in addition on 8/7/19 at 10:15 p.m. Call them All Education included a review of the education listed out below. Education Included the Following Possible interventions if behaviors are seen: Resident enjoys listening to swing music When there is intimate contact, check for consent and offer privacy. Redirect Resident away from nonconsenting individuals. Resident enjoys spending time outside, at times. Signs of Psychosocial Distress If you see a resident that is acting out of baseline, they may be experiencing psychosocial distress. Signs of psychosocial distress include: Crying Isolating/withdrawal The above education initiated on 8/7/19 at 10:30 p.m. Facility completed a Call Them All Education call on 8/7/19 at 10:15 p.m. to review education above and inform them to come and obtain education at facility prior to their shifts. Monitoring: Social Services or Designee to observe Lavender unit every shift for 5 days to monitor residents for psychosocial distress or behaviors outside of their baseline. Outside of baseline includes distress, crying, isolating, and withdrawal, shouting or yelling. The Lavender observation audit was initiated on 8/7/19 during evening shift and completed by Social Services LSW. If no issues identified with the every shift observation for 5 days, will decrease audit to 5 times weekly on various shifts x 12 weeks. This will determine if 1:1 supervision for Resident $66 effective. Social Services LSW/MSW to evaluate resident need for 1:1 supervision weekly after medication changes will review if 1:1 supervision may be discontinued. After 1:1 supervision is discontinued resident will have hourly checks by staff for 1 week, if no issues identified will decrease monitoring to twice a shift for 1 week. Any issues identified will be brought to QAPI to discuss for purpose of quality improvement. QAPI is scheduled for 8/9/ 19 and Medical Director has been contacted to review altercation and medications. C. Removal of immediate jeopardy On 8/8/19 at 3:15 p.m., the NHA was notified the facility's plan to remove the immediate jeopardy situation had been accepted based on initiation of 1:1 supervision of Resident #66, medication review of Resident #66, staff education and monitoring of Resident #66 and other residents in the unit for behavioral and psychosocial changes. However, deficient practice remained at a G level, the potential for harm. II. Facility policies and procedures on abuse prevention The facility Abuse Prevention and Reporting policy dated 11/18 was provided by the NHA and clinical nurse consultant (CNC) on 8/15/19 at 9:05 a.m. The policy read, Residents will be free from verbal abuse, physical abuse, mental abuse, sexual abuse, involuntary seclusion, neglect, and exploitation. Residents were not to be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants, or volunteers, staff or other agencies serving the residents, family members or legal guardians, friends, or other individuals. The policy defined physical abuse as intentional action of inflicting bodily injury including but not limited to hitting, slapping, pinching, kicking, etc. II. Failure to ensure Resident #89 was protected and remained free from abuse inflicted by Resident #66. A. Resident #66 1. Resident status Resident #66, age [AGE] years old, was admitted [DATE]. According to the August 2019 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/27/19 minimum data set (MDS) assessment documented the resident was severely cognitively impaired with the brief interview for mental status exam (BIMS) of one out of 15. The staff assessment indicated the resident had symptoms of [CONDITION(S)] with difficulty concentrating on activities, disorganized thinking and rejected care. He required extensive assistance from one staff for transfers, dressing, toileting and personal hygiene; supervision and set up from one staff for bed mobility, eating and ambulation. The resident's care plan documented he had advanced dementia with behaviors. He had an inability to concentrate, inability to problem solve, ineffective coping, and repeated incidents. He was disoriented to place, wandered daily, not aware of his room location and wandered in and out of rooms, opened and closed doors. The plan read: -The resident acted aggressively when others told him to get out of their rooms, or did not respond positively to him, or if others challenged him. His reactions to others occurred quickly with very little escalation, often his initial response was aggressive. He took daily antipsychotic medication to help control his negative reactions towards others. -Staff were to monitor for physical aggression towards others; striking out, grabbing others and their belongings. His physically aggressive episodes came on quickly and with little to no precipitating event. -Staff were to monitor the resident when he was in the common areas as much as possible to reduce inappropriate physical interactions with other residents; intervene as necessary to protect the rights and safety of others; approach and speak in a calm manner; divert his attention and remove him from the situation and take to an alternate location as needed. Staff were to also monitor the resident when he was walking in the common areas and redirect him if he was wandering or following others; redirect him away from other residents who have the potential to be verbally aggressive or yell out as this can cause him to react in a physically aggressive manner. 2. Previous incidents of Resident #66's aggressive behavior A progress note dated 12/15/18 documented the nurse standing by the medication cart heard a female resident screaming no. When the nurse turned toward the scream, Resident #66 slapped the female resident once with his open right hand on the left side of her face. The nurse documented that a staff member from Activities stated she saw Resident #66 reaching for the female resident's legs. The residents were observed a few seconds later, pushing each other. The nurse wrote, As we were trying to stop it, he hit her on her left side of her face. The female resident put her hand over her face and started to cry. A behavior note dated 2/13/19 documented Resident #66 was in the dining room with activities personnel when he walked over and lifted a table off the floor several times before throwing it at another resident, just missing the resident. When staff attempted to redirect him, the resident became physically aggressive toward staff and started hitting, punching and kicking. Once staff was able to get him in the hallway, he seemed to calm down. 3. Incidents 8/7/19 a. On 8/7/19 at 10:25 a.m., Resident #66 was observed holding hands with a female resident as they walked down the hall to the common area. As they sat on the couch next to each other, they continued to hold hands; their hands were clasped and rested on the couch between them. Then, Resident #66 pulled the female resident's hand towards him and placed it on top of the area near the zipper to his pants. The female resident immediately pulled her hand away. The NHA, director of nursing (DON), master of social work (MSW), social services (SS) and the clinical nurse consultant (CNC) were interviewed on 8/7/19 at 5:48 p.m. about the facility's response to the above observation that morning. They said due to Resident #66's inappropriate behavior with the female resident, Resident #66's supervision was increased to one to one supervision of Resident #66, when needed. The MSW clarified and stated, in addition to a medication change, staff increased the supervision of Resident #66 to within line of sight; he was placed on active monitoring for 72 hours, behavior charting and line of sight supervision. Staff were to always know where Resident #66 was and keep him in line of sight. b. Failure to monitor Resident #66 as planned, contributing to physical abuse of Resident #89 on 8/7/19 with injuries and the likelihood of further abuse and serious harm. Resident #89, age [AGE] years old, was admitted [DATE]. According to the August 2019 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's behavior care plan, initiated 3/23/19, revealed the potential for inappropriate behavior towards staff and the potential for aggression towards others, specifically those in his personal space. He became agitated when residents of lower cognitive ability were in his personal space. Interviews with staff revealed on 8/7/19 at approximately 2:45 p.m., Resident #66 entered Resident #89's room and hit him in the face. Resident #89 was heard yelling to staff to get Resident #66 out of his room. Staff stated the incident was not witnessed, although the resident was on line of sight supervision and staff were always to know where he was (see above). Observation: On 8/7/19 at 5:12 p.m., Resident #89 was seated outside of his room surrounded by staff. There was red material resembling blood on face and in his hair and beard. There was swelling under both of his eyes, which was purplish-red in color. He had an abrasion over his left eyebrow, scratches or lacerations on the right side of his forehead over his eyebrow. His nose was crooked. He grimaced and put his hand on his forehead. He stated he was not well. Record review: The 8/7/19 incident was reviewed at an interdisciplinary team (IDT) meeting on 8/8/19. The team documented Resident #89 was found in his room with bleeding and he had bruising to his face and ear. Resident #66 was found in the room with Resident #89. He had blood on his knuckles. Both residents were removed from Resident #89's room. Staff attended to Resident #89's injuries and Resident #66 was placed on one to one supervision. Resident #89 was assessed by the registered nurse (RN) and neurological checks were initiated which were found to be at Resident #89's baseline. The director of social services and DON spoke with Resident #66 at approximately 3:15 p.m. and he could not recall incident. His hands were noted to be slightly edematous (swollen) but no signs or symptoms of discomfort were noted. The activities director (AD) reported that upon seeing Resident #89, Resident #66 stated he had done that (while looking at the resident's bruising). Resident #89 was moved to another unit for increased safety as Resident #66 appeared to be targeting Resident #89. Staff interviews: RN #4 was interviewed on 8/7/19 at 5:01 p.m. The RN stated at 2:45 p.m., Resident #89 had an unwitnessed injury. He stated staff heard the resident calling for help. When staff entered the resident's room, they saw the resident bleeding from the nose and Resident #66 had blood on his right fist. He said the police were called and the residents were cleaned up. He said Resident #89 was moving to another unit. The NHA, DON, MSW, SS and the CNC were interviewed on 8/7/19 at 5:48 p.m. -The DON stated Resident #66 had behaviors, had punched others in the past and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said there had been no warning signs of the incident with Resident #89. -The MSW stated that based on his history of reported resident to resident incidents, Resident #66 was put on 72 hour monitoring to document behaviors and the behavior of the victim including fear and distress. She said staff increased the supervision of Resident #66 and supervision within line of sight after the morning incident with the female resident (see above). She said staff were to always know where Resident #66 was and keep him in line of sight. -The SS said she did not know what happened with the line of sight supervision that was put in place after the morning incident. The CNC stated, We're still investigating and said that due to his behavior, the team regularly reviewed him at quality assurance performance improvement (QAPI) meetings. -The CNC said Resident #66 was now receiving one to one supervision and Resident #89 was moved to a bedroom on another unit for safety. The NHA said when in an altercation, Resident #66 goes back to that same person. Regular visitor interview: A regular visitor to the facility was interviewed on 8/14/19 at 3:53 p.m. He stated he stopped in to see the NHA and was told about a critical incident; specifically, that Resident #66 had an encounter with behaviors. He stated the NHA told him the reason for the incident was no staff was available to stop it.

Based on record review and interview, the facility failed to take timely and sufficient steps to prevent the development of pressure injuries, affecting one (#103) of two residents reviewed for pressure injuries out of 45 sample residents. Resident #103 was admitted to the facility on [DATE] at risk for developing pressure injuries due to her [DIAGNOSES REDACTED]. The facility failed to implement timely and sufficient measures to minimize her risks. On 7/16/19, four days after admission, the resident developed a pressure injury to her left heel that progressed to a stage 3 pressure injury that was painful, became infected and required antibiotics. Findings include: I. Professional reference The National Pressure Ulcer Advisory Panel (2016) NPUAP Pressure Injury Stages, retrieved from: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages revealed the following pertinent information: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. -A stage 2 pressure injury is partial-thickness skin loss with exposed dermis. Granulation tissue, slough and eschar are not present. -An unstageable pressure injury is an injury with obscured 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. -A deep tissue pressure injury (DTPI) is a persistent non-blanchable deep red, maroon or purple discoloration resulting 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. The National Pressure Ulcer Advisory Panel (2017) NPUAP Pressure Injury Stages, retrieved from: http://www.internationalguideline.com/static/pdfs/16-NPUAP-EPUAP-PPPIA%20ClassificationAssessmentMonitoring%20Extract%20of%20the%20CPG% 7.pdf revealed interventions for prevention and treatment of [REDACTED]. Assess the pressure ulcer initially and re-assess it at least weekly. Signs of deterioration (e.g., increase in wound dimensions, change in tissue quality, increase in wound exudate or other signs of clinical infection) should be addressed immediately. -Assess and document physical characteristics including: location, Category/Stage, size, tissue type(s), color, periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. II. Facility policy The wound management policy, revised (MONTH) (YEAR) was provided by the director of nursing (DON) on 8/15/19 at 11:30 a.m. It read in pertinent part, It is the policy of this facility to have a central consistent flow sheet to enable medical staff to evaluate (the) status of wounds. A wound is identified as an Arterial Ulcer, Diabetic Neuropathic Ulcer, Pressure Ulcer, [MEDICAL CONDITION] Ulcer, Surgical Wound and Lacerations . Each wound will be measured in centimeters weekly. Measurements, size and depth, drainage, odor, color and a short statement on progress (or lack of) will be documented. III. Resident #103 [NAME] Resident #103 was admitted at risk for developing a pressure injury due to her [DIAGNOSES REDACTED]. Resident #103, age 68, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The hospital discharge date d 7/12/19 revealed Resident #103's weight was 256 pounds (lbs) on 7/10/19 and on 7/12/19 her weight was 292 lbs. She had left hip surgery with a dressing in place. It also documented that [MEDICAL CONDITION] to the surgical site was normal post-surgical which could cause stiffness and discomfort which could last for weeks. Recommendations included to ice the affected area, elevate the extremity, and wear (compression) stockings for a total of two weeks during the day only. The resident's initial admission record dated 7/12/19 revealed Resident #103 had a left hip incision with 21 staples, weakness to left lower extremity, and [MEDICAL CONDITION] was present. No other skin issues were identified. The 7/19/19 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of 15. She did not exhibit behaviors or resist care. She required extensive two-person assistance with bed mobility, transfers, dressing, toileting, and hygiene. She had an impairment to one lower extremity. The assessment read she was at risk for developing pressure injuries and had a pressure reducing device to her chair and bed. Turning and repositioning were not documented as an intervention or treatment. B. Discovery of pressure injury after admission On 7/16/19, four days after admission, Resident #103 developed a pressure injury on her left heel that progressed to a stage 3 pressure injury that was painful, became infected and required antibiotics. An incident note dated 7/16/19 at 9:34 p.m. revealed Resident #103 had an open area to her left heel that was draining. It measured 5 cm (centimeters) x (by) 10 cm. She had 1 + (amount of pitting) [MEDICAL CONDITION] to both lower extremities. The physician and family were notified and treatment orders were obtained. Registered Nurse (RN) #4, who assessed the resident's heel on 7/16/19, was interviewed on 8/13/19 at 3:09 p.m. He said when he assessed Resident #103's left heel wound, there was an open area with a small amount of serosanguineous (thin watery pink or red fluid that contains red blood cells) drainage. The wound was covered with a layer of skin and it looked as though it could have been a blister that popped. He said since there was a layer of skin covering the heel, he was unable to see the wound bed. He said Resident #103 had [MEDICAL CONDITION] to her bilateral lower extremities and redness to the left lower leg because of her [MEDICAL CONDITION]. The Physician Assistant (PA) progress note dated 7/21/19 revealed Resident #103's left heel wound was assessed by the P[NAME] It read Resident #103 had localized 2 + [MEDICAL CONDITION] to her bilateral lower extremities (legs and feet) and the left was greater than the right. She had a large, draining, open wound/blister, stage 2 pressure ulcer to the left heel, with a healthy granulation bed (healthy wound tissue) and [DIAGNOSES REDACTED] (reddening to the skin); treatment included starting diuretics and staff to apply soft boots at all times as Resident #103 was resting her heel on the foot pedal. Another PA progress note dated 7/23/19 revealed Resident #103's left heel wound had worsened. Resident #103 had a red streak extending proximal to the heel. The extremity was painful and warm to touch. The wound to the left heel was no longer stageable and the granulation bed was covered with slough (necrotic/dead tissue). There was a large amount of dark green drainage and the wound had a foul odor. The treatment included to continue diuretics, start an antibiotic, and add an enzymatic wound debridement treatment to the heel. The PA was interviewed on 8/19/19 at 10:30 a.m. She said she assessed the resident's left heel wound as a stage 2 pressure ulcer on 7/21/19. She said she observed the wound bed completely which appeared to be granular tissue. She said the wound worsened quickly because on 7/23/19, the wound was full of slough. She said Resident #103 had increased [MEDICAL CONDITION] to the left lower extremity and the wound to the left heel appeared infected so the wound treatment was changed and an antibiotic was started. A wound physician note dated 7/30/19 read the left heel wound was assessed, etiology pressure, unstageable due to necrosis. The injury measured 6.7 cm x 10.3 cm, depth was not measurable, it had 60 % (percent) of thick adherent devitalized necrotic tissue and 40 % granulation tissue. Surgical debridement of the necrotic tissue was performed to help aid in healing. The wound physician was interviewed on 8/13/19 at 9:43 a.m. He said he assessed Resident #103's wound for the first time on 7/30/19, and had staged the left heel wound as unstageable. He said he provided surgical debridement to the left heel wound to aid in healing. 2. Observation and interview On 8/13/19 at 2:14 p.m. the DON, registered nurse (RN) #2 and RN #3 were observed providing wound care to Resident #103's left heel and left lower posterior extremity. They performed hand hygiene and donned gloves. The RNs removed the dressings to Resident #103's left heel which revealed a moderate amount of serosanguineous drainage. Staff cleansed the area with normal saline and the DON measured the area. She said the left heel measurement was 4.5 cm x 8.5 cm. The wound bed to the heel was yellow, black with granular tissue present and the surrounding tissue was intact. The resident had [MEDICAL CONDITION] to the lower extremity and there were no signs and symptoms of infection. RN #2 said he did not know what stage the wounds were because he typically did not complete wound care as Resident #103's treatment was completed on another shift. RN #3 said he had been on vacation and that day was the first time he assessed Resident #103's wounds. C. The facility failed to timely implement interventions to minimize the resident's risk for pressure injury. 1. Facility response to resident's risks before the discovery of the resident's left heel injury. An initial care plan was completed on 7/12/19. It read Resident #103 had an activities of daily living (ADL) deficit related to dementia, reduced mobility, and left [MEDICAL CONDITION]. Interventions included physical therapy (PT), occupational therapy (OT) and resident ability to safely perform ADLs. It also documented Resident #103 had skin impairment related to left hip incision. Interventions included Resident #103 would have no complications related to skin injury, educate the resident, family and caregivers of causative factors and measures to prevent skin injury and encourage nutrition and hydration. A revision was made to the care plan on 7/15/19 to read Resident #103 needed pressure relieving/reducing mattress and pillows to protect the skin while up in the chair and while in bed and change the resident's position every two hours to facilitate lung secretion movement and drainage. Soft boots were added to the treatment administration record (TAR) on 7/16/19 after discovery of the pressure injury. 2. Facility response to resident's risks after the discovery of the resident's left heel injury. An interdisciplinary (IDT) note dated 7/18/19 (after the discovery of the resident's pressure injury) revealed Resident #103's mattress provided offloading to heels prior to wound development. However, another revision to the care plan was made on 7/19/19 that read an air mattress was added. D. Failure in the facility's response to the resident's risks for pressure injury Record review and interviews revealed facility failures to take timely and sufficient measures to minimize the resident's risk for pressure injury and to prevent further skin breakdown prior to and after the discovery of the pressure injury. 1. Record review revealed that prior to discovery of the resident's left heel injury, there was no evidence of a comprehensive assessment by the interdisciplinary team (IDT) regarding Resident #103's known risk factors on admission ([MEDICAL CONDITION], dementia, [MEDICAL CONDITION]). 2. Record review revealed no evidence the 7/12/19 hospital discharge recommendations (see above; to apply ice the surgical site, elevate the extremity, and have the resident wear compression stockings during the day for a total of two weeks) were implemented. The July, 2019 Medication Administration Record [REDACTED]. Moreover, although PA notes above as well as interview referenced the resident's [MEDICAL CONDITION], and an IDT summary dated 8/14/19 indicated [MEDICAL CONDITION] was a factor in the development of the resident's injuries, review of the daily skilled notes dated 7/13/19, 7/14/19, 7/15/19, and 7/16/19 revealed no documentation of [MEDICAL CONDITION]. 3. Record review revealed the facility failed to document the characteristics of the resident's injuries upon discovery, in order to monitor wound progress. Review of the 7/16/19 incident documenting discovery of the resident's left heel injury failed to include characteristics of the wound such as what type of wound it was (pressure or non-pressure), description of the tissue type, color, periwound condition, wound edges, and if it had odor or not. The DON and MDS coordinator (MDSC) were interviewed on 8/14/19 at 4:58 p.m. The DON said if the staff discovered a resident had a new wound they should complete a risk management form (internal incident form) with the description and measurements of the wound. She said the floor staff typically did not stage wounds; however, the weekend supervisor and one other nurse who were wound care certified would stage wounds. She said the wound physician assessed resident's wounds weekly and either she or the MDSC would round with the physician. (However, see above; the wound physician said he first saw the resident's left heel injury, identified 7/16/19, on 7/30/19.) The clinical nurse consultant (CNC) and DON were interviewed on 8/15/19 at 12:00 p.m. The CNC, too, said the floor nurse would not stage wounds. She said if the nurse identified and assessed a wound, he or she needed to describe what it looked like, document the size, and characteristics, and all of the information would be placed under risk management, and it would be reviewed by the IDT. She said they would put interventions in place and have the wound physician assess the wounds during their weekly rounds. She said the nurse should have described what Resident #103's left heel wound looked like, including the characteristics on 7/16/19. 4. Record review and interview revealed the facility failed to implement measures to ensure pressure relief to prevent the development of lower extremity injuries and to promote healing. a. Floating heels and turning and repositioning the resident There was no documentation in Resident #103's record that staff were floating the resident's heels. And, although on the (MONTH) MAR indicated [REDACTED]. CNA #3 and CNA #6 were interviewed on 8/13/19 at 2:44 p.m. They said they worked on the resident's unit 2:00 p.m. to 10:00 p.m. They said they knew Resident #103 very well. They said they tried to elevate Resident #103's heels as she allowed. They said they were not told to float Resident #103's heels and if they did, they would document it in the resident's electronic record. CNA #6 said they were not told to turn or reposition Resident #103 every two hours but if they did, they would have documented it in the resident's record. b. Mattress See above; an IDT note dated 7/18/19 revealed Resident #103's mattress provided offloading to heels. Moreover, an IDT note with a summary of the resident's wounds on 8/14/19 read in pertinent part that prior to wound development, Resident #103 was on a standard mattress with offloading feature. However, observation of the mattress and interview with the manufacturer revealed otherwise. Specifically: The DON and MDS coordinator (MDSC) were interviewed on 8/14/19 at 4:58 p.m. The DON said the facility's standard mattresses all had an offloading feature at the foot of the mattress, which was an incline. She said since the mattresses had the offloading feature, staff were not instructed to float residents' heels. Following the interview, a standard facility mattress was observed with DON on the Larkspur unit. She said they purchased the standard mattress with an offloading feature for all the resident rooms in the facility. This was the type of mattress Resident #103 had prior to the air mattress. The mattress had a slight incline at the end of the mattress moving toward the head of the bed; however, the DON agreed if a resident was lying in bed, the resident's heels would still touch the mattress if not floated. A representative from the mattress manufacturer was interviewed 8/19/19 at 9:15 a.m. She said the three tier mattress with the heel slope feature in the foot section enhanced pressure reducing properties, but specifically it cradled and protected the heel and would not necessarily float or offload the heel meaning a patient's heel would come into contact with the bed. E. Current status of left heel pressure injury The wound physician assessed Resident #103's wounds again on 8/6/19 and 8/15/19 (date of survey exit). The left heel wound was documented as a stage 3 pressure wound. The 8/15/19 assessment revealed Resident #103's left heel wound was a healing stage 3 pressure wound. It measured 3.5 cm x 4.6 cm depth not measurable. It had 30 % slough and 70% granular tissue and surgical debridement was performed.

Based on interviews, observations and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for six (#14, #91, #69, #185, #94 and #111) of ten sample residents, and the residents received adequate supervision to prevent accidents. Specifically: --For residents #14, #91, #69 and #185, the facility failed to assess the residents' safety to have a lock on an egress door. The facility failed to equip all staff with the appropriate key to open the door when a resident was in distress or in an instance of emergency. The facility's failure to keep facility residents safe created a situation of immediate jeopardy (IJ) with the potential for serious harm, --The facility failed to implement measures to ensure that resident #94 had a plan which was individualized and effective in protecting other residents, and --Resident #111 was transferred in an unsafe manner. Findings include: I. Immediate Jeopardy A. Findings triggering Immediate Jeopardy Rooms #300, #304, and #318's doors locked from outside. On 10/2/14 at 9:28 a.m., resident #14 was in his room with the door closed. His calls for help were heard in the hallway outside his room. The door to his room was closed. The call bell light outside of his door was not illuminated. -At approximately 9:29 a.m., the resident continued to yell for help from inside his room. The door to the resident's room was locked and could not be opened. A key lock was visible in the door knob. Keys for entry into the secured units did not unlock the door. -At 9:33 a.m., the resident continued to yell from inside his room for assistance. The door was locked and could not be opened to provide observation and assistance. -At approximately 9:34 a.m., the housekeeping aide (HA#1) got a key to unlock the door. The resident was lying on his bed with his legs dangling above the floor. The bed frame was approximately two and half feet off the floor. The bed control was on the floor, out of reach of the resident. The resident ' s call light cord was coiled, hanging on the wall, and out of reach of the resident. The resident did not have a fall mat or any fall precautions in place. -At approximately 9:40 a.m., licensed practical nurse (LPN #1) placed the call bell device and the bed control device within the resident's reach. In an interview on 10/2/14 at approximately 9:32 a.m., HA #1 said she did not have the special key needed to open the door of the resident's room. She would ask a Certified Nurse Aide (CNA) for a key. The resident #14 was interviewed on 10/2/14 at approximately 9:36 a.m. The resident stated the bed was so high his feet did not touch the floor. He stated the remote to control the bed was out of reach. He stated he had been yelling for assistance for approximately ten minutes before help was provided. The resident stated he normally used the red button, but could not reach it. In an interview on 10/2/14 at approximately 9:37 a.m., LPN #1 stated the resident had cognition problems and intermittently understood the use of the call light. The LPN acknowledged the resident knew the use of the call light at the time of the observation and he should have had the call light placed within reach. The LPN acknowledged the call light was wrapped against the wall and the bed controls were on the floor. She affirmed the resident was unable to touch his feet to the floor because of the position of the bed. In an interview on 10/2/14 at 10:30 a.m., HA#1 said she learned the previous day a special key was needed to unlock the resident's room. She stated she did not hear the resident yelling from his room, and she had not yet cleaned his room. She stated since the earlier observation (see above), she had been issued her own key to access the resident's room. She reported there were three rooms and four residents in the Sage Unit who required a special key to gain access to their rooms. On 10/2/14 at 10:45 a.m. the DON stated the facility was currently working on cutting extra keys for room #'s 300, 304 and 318 to give to each of the facility staff. She added the facility missed some staff members and that not everyone had access to these three rooms. Staff interviews beginning at approximately 10:00 a.m., revealed that four residents had locks on their doors within the secured Sage unit. The social service supervisor (SSS) was interviewed on 10/2/14 at approximately 10:15 a.m. The SSS stated the facility was divided up into five different areas. Four of the areas were secured units. Columbine was the highest level of function of all of the secured units. Sage unit was a higher functioning unit and most of the residents were aware of their surroundings and able to communicate. Lavender was a moderate functioning unit and the majority of the residents were ambulatory. Larkspur was the lowest functioning and majority of the residents were in wheel chairs and end stage Alzheimer's disease . The only non-secured unit was Primrose. The SSS stated that there were three rooms with four residents which had a lock put on their doors which opened with a key. She stated that the residents had complained of other residents entering the rooms and therefore a lock was placed on their doors. The SSS stated that the decision to put the lock on their doors was an interdisciplinary team (IDT) decision. She stated that a formal assessment tool was not used. She stated a stop sign across the door was tried however, was not adequate. She stated that the residents were able to use the key and open the locks and therefore, the locks on the doors were permitted. She stated that although a resident had a zero for a brief interview for mental status, that the resident still had the ability to insert a key into the door and be able to use it. The SSS stated the resident #14 had the lock on his door since admission. Resident #91 had the lock on his door since May or June of 2014. On 10/2/14 at 11:07 a.m., HA #2 was interviewed. He stated he did not have a "C" key to access the three rooms on Sage with a locked door. He reported he did not know what a "C" opened. HA #2 said he had three coded keys (P, HK, SCI) which opened various doors. On 10/2/14 at 11:10 a.m., the activities generalist (AG #2) was interviewed. She reported she had not heard of "C" key and did not know what the key would open. She stated she had five keys (P, H, N, CLH, AC); she said she did not have a "C" key. The nursing home administrator (NHA) was interviewed on 10/2/14 at approximately 10:30 a.m. The NHA stated that there was not a policy on locking of the resident room doors. He stated that he was aware the three rooms had locks however; he was not involved in the decision to placing the locks. He stated that was an IDT decision. He stated that the correct key was being handed out to all staff. On 10/2/14 at 12:02 p.m. the facility receptionist stated she received ten "C" keys from the maintenance department for the facility staff who will work evening shift, she added the maintenance director was distributing the "C" keys to the staff who did not have one. On 10/2/14 at 12:18 p.m. the maintenance director stated he distributed approximately 40 keys to the facility staff this morning. B. Notification of Immediate Jeopardy Based on staff interviews above, which revealed inconsistent assessments, lack of safety precautions in place, call light not within reach and staff did not have the appropriate key to enter the room, the NHA and the director of nurses (DON) were notified on 10/2/14 at 1:02 p.m., that the facility's failure to develop a specific plan for supervision and assessment of residents #14, #91, #69 and #185 while in a room with an exterior lock, and no specific approaches on how to safely and effectively supervise, care and egress for a resident behind a locked room door, created a situation of immediate jeopardy with the potential for serious harm. C. Plan to Remove Immediate Jeopardy The facility's final plan to remove immediate jeopardy was submitted on 10/3/14 at 11:14 a.m. The plan read: Abatement Plan: Resident Specific: Locks that were requested by residents (#14, #91, #69 and #185) were removed at (1:15) p.m. Residents had a head to toe assessment by the director of nurses and assistant director of nurses on 10/2/14 and no injuries identified. Locks will not be used for resident room egress doors any longer. Identification of others: All residents with locks have the potential to be affected. No other resident room egress doors have locks. Policy and Procedure updated that the facility will no longer implement residents' requests for locks on residents' room egress doors. Other means of providing privacy and least restrictive care will be utilized. Systems and Measures: All staff have a universal "P" key to unlock doors in the bathroom. Maintenance educated that locks will not be installed for resident room egress doors on 10/2/14 and will not be replaced here after per in-service sheet "A". New hire maintenance will be educated upon hire and education will be annually. Everyone in our facility is responsible for answering call lights, and therefore, all departments and all staff have/will complete a Resident Safety in-service which contains information pertaining to call light use and placement. In-service training will continue until all staff have received the information. Each staff member is being in-serviced prior to starting their next scheduled shift. This will be accomplished by each staff member receiving a phone call with the in-service information from the Executive Director or designee by end of business 10/3/14. This will be followed up a 'face to face" in-service completed by the Director of Nursing or designee to be completed by 10/7/14. Monitoring: Issues identified will be reviewed during the monthly QAPI meeting for the purpose of process improvement. The DON will bring the information to AQPI and it will be reviewed at the 10/10/14 meeting and each meeting for the remainder of the year and then annually there after as needed. The facility was notified on 10/3/14 at 2:50 p.m. that the Immediate Jeopardy was removed at 2:30 p.m. However, deficient practice remained at an E level (potential for more than minimal harm at a pattern) based on the facility's systematic failures identified during survey 10/1/14 - 10/10/14, including the lack of assessments, lack of safety precautions in place, and call light not within reach for resident use. D. Residents affected by the immediate jeopardy 1. Sample Resident #14: Sample resident #14, [AGE] years of age, was originally admitted to the facility on [DATE] and re-admitted on [DATE] from an acute hospitalization . According to the 10/14 CPO the resident had [DIAGNOSES REDACTED]. According to a significant change minimum data set ((MDS) dated [DATE], the resident was moderately cognitively impaired scoring a 7/15 on the brief interview for mental status (BIMS). The resident had moods to include little interest or pleasure in doing things, feeling down or depressed, feeling tired or having little energy, feeling bad about self and feelings of being better off dead during the review period. The resident had behaviors of physical and verbal aggression directed towards others. The resident required limited assistance for bed mobility and extensive assistance of one staff for transfers. The resident's balance was compromised due to limitations in range of motion (ROM) to one side (left side) upper and lower extremity. Observations: On 10/2/14 at 8:40 a.m. the resident's door to his room was closed. The door handle was observed to have a key hole. The licensed practical nurse (LPN #1) was asked to check and see if the resident was in his room so he could be interviewed and had not been seen in the general milieu. The LPN stated she did not have the key as she had given it back to the Certified Nurse Aide with Medication Administration Authority (CNA-Med) and would go and get it again. Upon return with the key to the resident's room, and after knocking quietly and unlocking the door, the resident was observed lying in bed with his eyes closed. On 10/3/14 at 9:30 a.m. the resident's door to his room was closed, there was a regular door handle now on the door (no lock) and the mesh "Stop Sign" was across the door way at eye level. After knocking on the resident's door it was opened by a staff member. The staff member, a certified nursing aide (CNA #15) stated she was providing the resident with 1:1 supervision. CNA #15 stated she was not sure why the resident was on 1:1's. On 10/6/14 at 9:00 a.m. the resident was observed in his room with a 1:1 sitter. The mesh "Stop sign" was across the door frame above the door handle. For the remainder of the survey from 10/6/14 through 10/10/14 (conclusion of the survey) the resident remained with a 1:1 sitter (staff CNAs) and the mesh "Stop sign" across the door frame whenever he was in his room. Record review showed the resident had experienced a fall on 9/22/14. The nurses note documented the resident was found on the floor by the CNA. The resident was attempting to get himself back into bed. Review of the medical record failed to show an assessment was completed in regards to the lock placed on the egress door to his room. Interviews: The social service assistant (SS #1) was interviewed on 10/1/14 at 12:25 p.m. The SS #1 stated the resident had paranoid delusions and has had several altercations with residents wandering into his room so the lock was put on there to prevent other residents from wandering into his room. SS #1 stated the resident key lock required a "C" key and that staff and the resident himself had a key to it. On 10/6/14 at 1:09 p.m. the DON was interviewed regarding the resident's fall on 9/22/14. The DON stated following an incident the nurse will do a formal assessment and then initiated the incident report in the computer system. The DON stated the IDT will then review the incident the following day. The DON stated the review of the resident's fall revealed the resident was found in his room on the floor around 7:55 p.m. during rounds by the CNA. The DON stated to her knowledge the resident was capable of self-transfers. She stated his medications were reviewed as part of the investigation as well and that a fall mat and bed height at a safe level was implemented. In an interview on 10/10/14 at 12:04 p.m., LPN #1 stated when she observed the resident on 10/2/14; the resident was at risk for a fall since he was partially off the bed, or one hip off the bed or seen half way off the bed. She said the bed control should have been placed next to him and she expressed the resident could not place his feet on the floor because of the height of the bed. The LPN confirmed the resident' s call light was not within reach and it should have been, even though his abilities to use the call light were inconsistent. The LPN confirmed HA #1 did not initially have a key to access the resident's room. She stated staff without a key to access the resident ' s room would be unable to get to the resident and determine why he was calling out for help. 2. Sample Resident #91: Resident Status: Sample resident #91, [AGE] years of age, was admitted to the facility on [DATE]. According to the 10/2 CPO the resident had [DIAGNOSES REDACTED]. According to an annual MDS dated [DATE] the resident had no cognitive impairment scoring a 15/15 on the BIMS. The resident had no mood or behaviors during the assessment period. The resident was independent with most activities of daily living requiring only supervision/oversight. Observations: On 10/1/14 at 12:15 p.m. CNA #8 was observed delivering a lunch tray to the resident's room and was observed to remove the mesh "Stop sign" and then to unlock the door with his key. Upon entering the resident's room the resident was asked if he would be willing to be interviewed and he stated yes, that would be fine On 10/2/14 at approximately 1:30 p.m. the resident's door was observed to now have a regular door knob; without a lock and the mesh "Stop sign" was still in place across the door frame, three inches above the handle. For the remainder of the survey, and from the last observation made on 10/2 above, through 10/10/14 (conclusion of the survey) the resident remained with his door closed and the mesh "Stop sign" in place at varying positions ranging from directly across the door handle to six inches above the handle. On 10/8/14 beginning at 4:00 p.m. through 4:25 p.m. observations were made of a wandering male resident going to the resident's room a total of three times and jiggling the door handle but not completely opening the door. During the observations there was no staff in the area. Record review: Review of the resident's comprehensive care plan(s) provided by the facility on 10/2/14 (during survey) revealed the following pertinent care plans in place: -Agitation care plan originally initiated on 9/6/12 with a target date of 8/11/14 with the word "CANCELLED" in front of it documented in pertinent part, "(name of resident) exhibits agitated and aggressive verbal and physical behaviors ...(name of resident) does not like when others invade his space/touch his items ..." Goal: "(name of resident) will not injure self or others daily." Approaches: " ... (Name of resident) likes having a single room and his behaviors have decreased since moving to his own room and having privacy. (Name of resident) is able at this time to have his own lock and "P" key for the room." A second copy of an "active" care plan was also provided almost identical to the one above with an initiation date of 6/19/13 and a target date of 11/11/14. -Safety care plan for use of Courtyard initiated 2/20/13 with a target date of 11/1/14 documented in pertinent part, "(name of resident) has the ability to use the courtyard independently ..." Goal: "(name of resident will have access to the courtyard when he requests ..." Approaches: " ...staff to assist (name of resident) in getting in and out of the neighborhood to the courtyard ...place (name of resident) on 15 minute checks while out in the courtyard." Review of the resident's physical record revealed a call-light assessment, found in the social service section tab, with no date when it was conducted. The assessment documented in pertinent part the resident was able to demonstrate he could push the call light when initially asked to do so. There was no second attempt to show the resident's capability to use the call light since he "passed" initially. Review of the resident's electronic record revealed a SS note dated 10/2/14 at 4:40 p.m. The note documented in pertinent part, "message left for (name of legal representative) re: lock on (name of resident) door being removed today until all staff are trained and have in possession a "C" key. The lock will be replaced once staff is trained and an assessment is completed on (name of resident) showing his ability to successfully use key." Review of a SS note dated 10/6/14 at 4:55 p.m. documented in pertinent part, "correction to previous note. Locks will not be used on residents' doors. Message left for (legal representative) with this new information." Review of the resident's physical and electronic record on 10/2/14 at 11:00 a.m. revealed no consent, order or documentation for the use of the room door lock (private room). There was no formal assessment found or evidence of monitoring for the safe use of a door lock. Interviews: On 10/1/14 at 12:25 p.m. SS #1 stated the lock was there based on the resident's request for privacy and to keep other residents out of his room. The SS #1 stated the resident had very high cognition and has had the lock on his room door since he moved on to the Sage unit. SS #1 stated he did not officially require a locked unit and could go out into the courtyard by himself with his key. On 10/1/14 at 12:30 p.m. CNA #8 was interviewed and asked why the resident had a lock on his door and she stated because the resident appreciated his privacy. On 10/2/14 at 10:35 a.m. resident #91 stated he was able to open the room door from outside with the key. He added he was not assessed by the facility staff if he was safe and independent with entry to his room using the key. On 10/6/14 at 2:14 p.m. SS #1 was interviewed a second time. SS #1 confirmed that she had received training last week regarding residents with locked doors, keys needed and resident call light use. SS #1 stated that the residents on the Sage Unit with locks on their doors occurred at different times and they each had their own key. She stated that a few weeks ago the residents' key locks were changed from "P" keys to the "C" keys because the "P" keys were "universal" meaning they could open all locks to the outside, including the elevator located on Sage unit. SS #1 stated that she and the NHA went to each of the residents with key locks last week and explained to them and their legal representatives that the locks were going to be removed from the doors until all of the staff were trained on the use of the "C" key and until a proper assessment could be conducted regarding their ability to use the key before the lock could be placed back on the door. SS #1 stated she was not exactly sure what the final decision would be regarding replacing the locks in the future. SS #1 stated resident #91 was pretty upset about the change and was hoping to get the lock placed back on his door. On 10/8/14 at 11:40 a.m. the resident was interviewed regarding the removal of the lock from his room door. The resident confirmed he no longer had a lock on his door and that he "should" have a lock on there because people are coming in and out of his room (other residents) since the locks have been removed. The resident stated they are attracted to his bathroom for some reason and think they can come in and use it. The resident stated he has used the call light (which is now clipped to his bed and he states is much easier to get to since before it was "up on the wall") once or twice for staff assistance due to wanderers. The resident stated the "Stop sign" does nothing to prevent people from coming in. He stated he was concerned also about someone coming in and taking his things. The resident stated he thought it was a ridiculous thing removing the locks from the doors. He stated when he first moved to the room there was not a lock and he asked for one to be put on. The resident stated he was not given much of an explanation on why the lock was removed and he thought it was because the lock was broken. On 10/10/14 at 11:00 a.m. SS #1 was interviewed a final time. She was asked if there had been any incidents of residents entering resident #91's room. SS #1 stated the resident himself reported that people have been coming in especially at night and when they open the door it wakes him up and he becomes annoyed. SS #1 stated since the lock was removed from the resident's room he has become more isolated and has not left his room. The medical director (MD) was interviewed on 10/10/14 at 9:15 a.m. The MD stated that he was unaware of the locks being placed on the egress doors to the residents' rooms. 3. Resident #69 Sample resident #69, age 76, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 8/11/14 Minimum Data Set (MDS) showed a score of zero out of 15 on the resident's brief interview for mental status (BIMS). This indicated severe cognitive impairment. Section G showed the resident required extensive assistance with bed mobility, transfers, locomotion on the unit, toileting and personal hygiene. The resident was not steady and only able to stabilize with staff assistance for surface to surface transfers. She used a wheelchair as an assistive device. Observation: On 10/2/14 at 10:40 a.m. resident #69 was observed to have a lock on the egress door. On 10/2/14 at approximately 1:30 p.m., the resident's door was observed to have a regular door knob, without a lock and the mesh "Stop sign" was in place across the door frame. Record Review: On 10/7/14 at approximately 12:40 p.m., medical records supervisor (MRS) reported the facility did not have a signed consent form for the use of a locked resident room door on the Sage unit. A review of the 5/15/14 through 10/2/14 telephone orders failed to evidence a referral or consent to implement a locked door on the resident's door in the Sage unit. The 10/14 Treatment Administration Record (TAR) failed to show any tracking or monitoring of the locked door on the resident's room. There were no scheduled checks seen on the TAR. There was no space or location on the TAR to sign off that staff had routinely and consistently checked on the resident with a locked resident room door on a secure unit of the facility. A review of the interdisciplinary team (IDT) notes available in the resident's clinical record dated 7/23/14 and 7/30/14 failed to show any discussion regarding the utilization of a locked door on a secure unit. The IDT notes showed the facility discussed the resident's urinary tract infection and care needs. A review of resident progress notes from all disciplines between 4/14 and 10/7/14 failed to show any discussion regarding utilization of a locked door for the resident on a secure unit. The comprehensive care plan was reviewed and no information could be found to show the facility initiated, evaluated, updated, or determined the use of locks on the resident's door should be implemented. There was no information to show a focus, goal, or approaches were discussed in regards to having a locked door applied in a secure unit. Interviews: On 10/7/14 at 12:55 p.m., the resident was interviewed with her spouse present (spouse was a resident (#185) of the facility and her roommate). Resident stated she was not happy with the removal of the lock on the door. She said the stop sign covering the door was not sufficient and residents continued to jiggle the door knob. During the 45 minute interview, no resident was observed to jiggle the door knob. 4. Resident #185 The resident #185 was admitted to the facility 4/30/14 with [DIAGNOSES REDACTED]. Quarterly MDS assessment dated [DATE] revealed the resident had clear speech, made self understood and was able to understand others. The resident had cognitive impairment and scored a 00 out of 15 for the brief interview for mental status. He required supervision with bed mobility, transfer, walking, dressing, eating, toilet use and personal hygiene. He had no falls or falls history. The resident was receiving daily antipsychotic and antidepressant medications. On 10/2/14 at 10:40 a.m. resident #185 was observed walking in the hallway. He stated he had the key to his (and his wife's) room door and was able to open the lock with his key to enter the room. The resident stated that other residents wandered into his room several times per day and sometimes used his bed to lie down. Review of the Physician order [REDACTED]. The medical record failed to show any evidence that an assessment was completed to show any discussion regarding utilization of a locked door for the resident on a secure unit II. Improper technique with use of gait belt transfer Sample resident #111, age 85, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 6/29/14 Minimum Data Set (MDS) showed the resident had both short-term and long-term memory problems. His cognitive skills for daily decision making were severely impaired and the resident never/rarely made decisions. Section G revealed the resident required extensive assistance with transfers between surfaces to and from wheelchair, chair, and standing position. The resident needed physical assistance from two people as support during transfers. The MDS further showed the resident was not steady when moving from seated to standing position and surface to surface transfers. Observations: On 10/3/14 at 9:35 a.m., two certified nurse aides (CNA #1 and CNA #2) transferred the resident from his manual wheelchair into a recliner chair near the nurse's station. CNA #2 pushed the resident to the side of the recliner and applied the gait belt around the resident's stomach. CNA #1 and CNA #2 attempted to transfer the resident from his chair however, the resident did not bear weight as they tried to transfer the resident and he had to be placed back into his wheelchair. The resident's positioning in his wheelchair was observed to have him half out of the chair: he was left sitting far forward in the wheelchair. CNA #2 and CNA #1 tried to transfer the resident a second time. CNA #2 moved the resident's wheelchair closer to the recliner. CNA #2 and CNA #1 both grabbed hold of the gait belt around the resident and rapidly sat the resident into the recliner. The gait belt was observed to move towards his high back as his shirt lifted during the transfer. The two staff members did not have control of the resident as they transferred the resident into the chair. He was not slowly and safely placed into the chair. He did not participate in the transfer; and there was no pivot transfer or slow placement into the chair. The resident appeared non-weight bearing during the transfer. Interviews: On 10/3/14 at 9:40 a.m., the licensed practical nurse (LPN #2) was interviewed. The LPN stated she observed the transfer conducted by CNA #1 and CNA #2. LPN #2 said the gait belt was too loose during the transfer which resulted in the belt going up the resident's back during the transfer. She expressed the gait belt should have been tightened with enough space to grab hold of the belt during transfer. LPN #2 reported staff should have had more control during the transfer to prevent accidents and to ensure the resident's safety. On 10/3/14 at 10:25 a.m., CNA #1 was interviewed. She said her responsibilities included assisting residents with transfers. She reported during the transfer of the resident today, the resident did not bear weight to assist the staff during the transfer into the recliner, though he usually did bear weight during such transfers. The CNA stated the resident was not slowly and safely placed into the chair during the transfer. The gait belt was loose, causing the belt to move up his back. CNA #1 stated the resident should have been reapproached or equipment could have been considered when the resident elected to not participate in the transfer nor bear weight. On 10/3/14 at 10:41 a.m., CNA #2 was interviewed. She stated she had a responsibility to assist residents with surface to surface transfers. She stated gait belts were used to ensure residents did not fall during transfers. She stated the resident required two people to complete the transfer and on this date, the resident was not willing to bear weight during the transfer. She stated at most a one inch gap was needed between the resident and the correctly-applied gait belt. She stated the loosely-applied gait belt was the cause of the belt moving up the resident's back during the transfer. She stated the resident was not slowly and with control transferred into the recliner because he was not willing to bear weight. On 10/08/14 at 12:16 p.m., the director of nursing (DON) and assistant director of nursing (ADON) were interviewed. The DON said the gait belt should have been properly applied for a safe transfer and staff should have had control of the transfer to ensure the resident was safely placed into the recliner chair from his wheelchair. The DON stated if the resident was not willing to bear weight during the transfer and at times

Based on observations, staff interviews and record review, the facility failed to provide adequate care and services for wound prevention and timely management for three of 60 sample residents (#164, #140 and #38). Specifically: -Resident #164 was known to be at risk for skin breakdown and delayed healing; he was diabetic and reported to have [MEDICAL CONDITION]. The facility failed to timely assess the resident's skin breakdown on his toes, first identified 9/21/12. Moreover, the resident's areas of skin breakdown were not monitored and the status of his wounds communicated to the physician. When the wounds were assessed by the nurse practitioner on 10/5/12, the wounds had worsened and additional wounds were identified. On 10/8/12, the resident was discharged to the emergency room for further treatment. -Resident #140 and #38's skin conditions were not identified, monitored and tracked. The findings include: A. Facility Policy The facility skin management policy was requested and was provided by the Director of Nursing (DON) on 12/11/12. The policy which was last reviewed on 9/10, indicated the following in pertinent part: "Develop a comprehensive care plan if indicated following evaluation ...Care plan must be individualized and designed to meet the need of the particular resident ...Consider the following care plans ....Skin breakdown ...Non-pressure ulcers ...Skin bleeding/Bruising." The policy indicated that on admission, all areas of skin breakdown, excoriation, discoloration must be documented on the Comprehensive Admission Assessment, by a licensed nurse. The policy indicated in pertinent part, "Wounds identified after admission ...a licensed nurse must assess/evaluate a resident's skin at least weekly. All areas of breakdown ...discoloration ...unusual findings must be documented on the Nurse's Narrative Notes or ...Non-Pressure Ulcer Site Sheets." The policy indicated evaluation/assessment of each wound whether admitted with or developed after admission. The Policy read in pertinent part, "assessment/evaluation should include but not be limited to ...Measuring the wound ...describing the nature of the wound ...pressure, stasis ...Describe the characteristics of the wound ...describe the process of healing ...barriers to healing ...Communication ...Any changes in the condition of the resident's skin as identified daily, weekly, monthly or otherwise must be communicated to ...The resident's physician." B. Resident Failures 1. Resident #164 Closed record review revealed that [AGE] year-old resident #164 was admitted from the hospital to the facility on [DATE]. According to the physician admission notes dated 9/10/12, resident #164 had [DIAGNOSES REDACTED]. According to the DON (see interview below), the resident also had a [DIAGNOSES REDACTED]. a. Resident Status The admission minimum data set (MDS) assessment dated [DATE], revealed: -The resident understood others and others understood the resident. On the Brief Interview for Mental Status (BIMS), the resident scored 3 (able to correctly complete only one question of the interview). The resident had signs/symptoms (s/s) of [MEDICAL CONDITION] which included inattention and disorganized thinking. The resident's behavioral symptoms included inattention and disorganized thinking. The MDS indicated the resident rejected care and had behavioral symptoms of wandering. -The resident required extensive assistance of two persons for transfer, toileting and bathing. He required extensive assistance of one staff for walking in his room, locomotion off unit, dressing and personal hygiene. The resident needed limited assistance of one staff for bed mobility, walking in corridor and eating. He used a wheelchair and walker as mobility devices. -The resident fell without injuries after he was admitted to the facility. -The resident was coded with risk for pressure sores and was coded without pressure ulcers. The MDS indicated no other ulcers, wounds or skin problems. -The resident received occupational therapy (OT) five times a week. Braden Risk Assessment Scales On 10/12/12, the skin breakdown assessment tool for resident #164's indicated a score of 12 (a score at or below 12 on the Braden's scale were indications of high pressure sore risk). Care Plans Care plan review revealed a plan, 'Identification of risk factors for skin breakdown.' The care plan was dated 12/10/12, however, in a brief interview with the DON on 12/12/12 at 3:00 p.m., she clarified that date was when the computer system generated the resident's closed (inactive) record and no other date was on the care plan. The care plan read in pertinent part: -"Ulceration or interference with structural integrity of layers of skin caused by prolonged pressure related to immobility, incontinence, cognitive impairment, [MEDICAL CONDITION] to LLE (left lower extremity) with open area r/t (related to) blisters, caused by excess fluids." -The goals for the care plan read in pertinent part, "Maintain intact skin integrity. Target date 12/11/12 ...show no signs and symptoms of infection." -The approaches included encouragement of elevation of LLE as much as possible for reduction of [MEDICAL CONDITION], even if resident was non compliant. Instruct resident not to propel wheelchair with LLE, staff would assist resident. Medications as ordered by physician (MD). The approaches included "skin assessment q (every) week to identify any skin issues if any...Tx (treatment) as ordered to area(s) per orders ...re-evaluate/notify MD for modifications as needed slow healing/non-healing/changes in wound." The care plan indicated no specific wounds, although the resident was found with skin breakdown to his toes on 9/21/12 (see below). After the physician was notified of the wounds on 9/25/12, the wounds were assessed by a Nurse practitioner (NP) and treatment was initiated. However, the care plan was not updated for identification and treatment of [REDACTED]. b. Status of skin on admission - Extremities free of skin breakdown A "Comprehensive Resident Admission Assessment (CRAA)," dated 8/9/12, indicated that the resident's skin condition was normal, his pedal pulses to his right (R) and left (L) foot were palpated with no indication of problems. The resident had weakness to bilateral lower extremities (BLE) and no deformities to those extremities. The resident had full range of motion (ROM) in all extremities, including full ROM in Foot-including ankles and toes). -The CRAA read in pertinent part, "SKIN INTEGRITY ...Document and stage Pressure and Circulatory Ulcers ...Document all other ulcers, wounds and skin problems ...Site ...Abrasion LLE ...Scab ...RLE." -The diagram of a person indicated skin problem (scabs) on the (R) shin and indicated no skin problem to the LLE or skin problems to the resident's bilateral toes as documented in the assessment above. No marks were made on the diagrams for indication of "scabs" or skin breakdown on any of the resident's toes. -The CRAA area entitled "ADDITIONAL COMMENTS," was left blank. The form was signed by the registered Nurse (RN) who performed that assessment on 8/9/12. Nurse's admission notes dated 8/9/12 at 8:40 p.m., read in pertinent part, "Pt. (resident) arrived at 2000 (8:00 p.m.), accompanied by 2 EMT (emergency medical team) ...Pleasant and cooperative...No c/o (complaints) of (abdominal) abd. Discomfort. Skin pink, warm and dry. Bruises to RUA (right upper arm), R antecubital, L hand and LFA (left forearm). Redness to R elbow and scrotum. Scar tissue to L and R buttocks. Multiple small bruising to abd.. Abrasion to LLE. Toenails long and thickened (but no note of skin breakdown on toes). Denies pain/discomfort. Resting comfortably in bed at present. Orders verified ...on call for Dr.(MD) ... see TO (telephone orders) for new orders." There was no indication that the resident had scabs or wounds to his toes on admission to the facility, as indicated by admission notes dated 8/9/12 and CRAA dated 8/9/12. Physician initial visit Progress Note dated 8/10/12, which included assessment of pedal pulses revealed no scabs on the resident's feet. The note read in pertinent part, "PHYSICAL EXAM ... CARDIOVASCULAR ...no systolic murmur, no diastolic murmur, 2+ carotid, radial, femoral, and pedal pulses; no [MEDICAL CONDITION] ...SKIN: Warm and Dry ...ASSESSMENT." Physician visit Progress Note dated 8/13/12 13:01 (at 1:01 p.m.) read in pertinent part, "CARDIOVASCULAR: Negative for chest pain, palpitation and pedal [MEDICAL CONDITION] ...MUSCULOSKELETAL: Negative for arthralgias, back pain, joint stiffness and myalgias. INTEGUMENTARY: Negative for rash and sores." Review of physician notes, weekly skin assessment and nurse's notes revealed no documentation of open areas or wounds on the resident's toes or elsewhere between 8/9/12 through 9/25/12. Review of Treatment Administration Records (TARs) for 8/12 and 9/12 revealed weekly skin assessments were completed and also showed no skin breakdown was documented on the TARs. c. Discovery of skin concerns - failure to assess, monitor, and notify physician in a timely manner A nurse's note dated, 9/21/12 at 7:06 a.m., read in pertinent part, "CNA (certified nurse aide) notified this nurse, about bruises on the resident's forehead, when resident was in his chair. On assessment, I observed couple of bruises on the residents Rt (right) forehead. Resident at this time denies any pain or discomfort. VSS (vital signs) are WNL (within normal limits). Neuro (neurological) checks initiated and is WNL. Resident is in W/C (wheelchair) at this time, with no other issues. Monitoring continues." An investigation report regarding the above incident was requested and provided. Reviewed in the presence of the DON, the report, identified as "Incident Report Incident of Unknown Origin (IRIUO)" and dated 9/21/12. It read in pertinent part: -"disoriented, confused ....unwitnessed (fall) ...Areas of injury Bruising/hematoma ...forehead ... ankle (L) ...Toe (R, L) ...MD notified ...POST BRUISE ASSESSMENT ...(R) forehead, (L) inner ankle ...BL toes open areas consistent with shoes rubbing on skin." -The form further indicated the following, "List recent Behaviors that may contribute to Bruise(s) ...Resident several attempts of unassisted transfer...Ambulation status WC...History of falls (yes)...did any residents have behaviors that May Contribute to this residents Injury? No ...POST BRUISE ASSESSMENT ...Nurse completing this form (Licensed Practical Nurse's name ...date 9/21/12 ...Registered Nurse/RN Assessment Completed By (RN name) 9/24/12... (Corrective Action) Treatment obtained (See TO TX book). Continue (with) weekly skin assessments done by Licensed Nurse." Review of Physician Telephone Orders (PTO) dated 9/24/12, read in pertinent part, "Monitor bruise on (R) forehead q shift until resolved." -There were no orders 9/21 - 9/24/12 to treat the resident's bruising/hematoma left ankle or toe wounds, although, per DON interview 12/12/12, the resident had a [DIAGNOSES REDACTED]. -There was no documentation that showed the toe wounds were measured or monitored, as expected per facility policy (see above) or that action was taken to address the resident's shoes (see above; open areas on toes (BLE) which the nurse documented as "consistent (with) shoe rubbing on toes..."). -There was no indication that the facility initiated care for the resident's toes or that the physician was made aware of the wounds, first observed on 9/21/12. -There was no reference to toe wounds in the nurses' notes on 9/24/12, even though the IRIUO, completed by the RN, noted treatment began on this date. Rather, the nurses' notes dated 9/24/12 at 12:45 p.m., read in pertinent part, "continue to monitor for bruising to left (instead of right) forehead ...stable, no open areas." d. Failure to assess and monitor wounds following discovery - Failure to timely notify physician of changes in skin condition. Nurses' notes on 9/22/12, 9/23/12 and 9/24/12, on every shift, noted the resident's forehead bruise was being monitored; however, there was no documentation on these dates that the resident's wounds on his toes were monitored or that the physician was notified of those wounds until 5 days later, on 9/25/12 at 9:31 p.m. Documentation 9/25/12: -At 03:12 a.m., five days after open areas were observed on the resident's toes, a nursing note, read in pertinent part, "Resident A&O x1. All needs anticipated by staff. Superficial round (1cm by 1cm) skin tear noted to L ankle during assessment at 0230 (2:30 a.m.). Part of the skin tear is over a bruise. No bleeding. Cleaned with NS and left open to air. No S&S (signs and symptoms) of infection. Non [MEDICAL CONDITION] noted also to the L leg. Left leg elevated on pillow. No S&S of pain. Resident resting comfortably on bed. No behavior." -This nursing assessment failed to identify that the resident had wounds on his toes, although the IRIUO initiated on 9/21/12 noted the wounds and an assessment completed by the RN on 9/24/12, noted 'treatment' had begun. -At 9:31 p.m., a nursing note read in pertinent part: -" Noted dark purple bruise to L ankle ...approx. 4.0(X)3.0cm.(length and width) with abrasion 1.0(X)1.0 cm open areas to top of L great toe and L 2nd toe. These areas were previously scabbed;" -However, it was unclear from the nurses' notes 9/21 - 9/25/12, when those areas were observed with scabs as there was no documentation other than the IRIUO dated 9/21/12 regarding the resident's toes. -The note continued, "BLE [MEDICAL CONDITION]: 1+ RLE, 2+ LLE, pedal pulses difficult to find. Open areas cleaned with NS, pat dry and covered with band aid. No c/o (complaints of) pain. Called ...Dr (physician) ...re; (reference) above multiple skin issues." -At 9:30 p.m., the physician was notified of the resident's left toe wounds and initial physician treatment orders (PTO) for the resident's wounds on his toes, as well as his [MEDICAL CONDITION] were obtained. The PTO dated 9/25/12 at 9:30 p.m., read in pertinent part, "Cleanse affected area to top of (L) great toe and (L) 2nd toe ...(with) NS (normal saline) pat dry cover (with) band aid, (change) qd (everyday) until healed. Monitor bruises/abrasions to (L) ankle for s/s of infection until resolved." Documentation 9/26/12 - 10/3/12: Documentation 9/26/12 - 10/3/12, revealed no documentation of measurements or actual location of multiple open areas of the resident's left toe wounds. Specifically: A Nursing Note Text on 9/26/12 at 12:19 p.m., read in pertinent part, "Resident continues on monitoring for bruise to left inner ankle and open areas to toes, skin prep applied around skin, dressing intact on toes. BLE swollen with left greater than right, feet elevated per nursing measure, no s/s of acute distress noted. Will continue to monitor." A Nursing Note Text on 9/26/12 at 20:19 (8:19 p.m.) p.m., read in pertinent part, "Res. on monitoring for bruise and abrasion to L ankle. Open area to L great toe and L 2nd toe. No signs of infection to affected areas. BLE [MEDICAL CONDITION]. L>R. Pitting [MEDICAL CONDITION] to L foot. Pedal pulses difficult to find. Elevated while in bed." A Nursing note on 9/30/12 at 7:18 p.m., read in pertinent part, "Resident is s/p fall with witnessed with no late injuries. FU (follow up) for open areas to L toes and [MEDICAL CONDITION] on L foot. No s/sx of infection were noted on open areas and LLE. Fluid oozing out of 2 blisters and L leg. Performed Tx based on orders from TAR. VS were WNL. Able to move all 4 extremities. No c/o pain or discomfort during the shift. Has bed alarm and mat for safety. Had a restless sleep." -There was no documentation that indicated the MD was notified that the resident had blisters (or location of blisters), on this date. A Nursing Note dated 10/1/12 at 1:51 p.m., read, "Resident on FU for [MEDICAL CONDITION] on LLE and open areas monitoring on toes of LLE. No s/sx of infection noted on the open areas on LLE. New order of TAO to be applied on open areas qd (every day) and covered with sterile dressing qd until healed. Updated on TAR and computer ... Requires 1 person extensive assist for transfers, ambulation, hygiene, and toileting. Has bed alarm and mat for safety. No c/o pain during shift. Will continue to monitor LLE." A Nursing Note on 10/3/12 at 7:46 p.m., read in pertinent part, "Res. on monitoring for L foot open blisters and multiple open areas to the toes. No signs of infection noted. BLE remains [MEDICAL CONDITION], L>R, decreased drainage noted. Elevated while in bed. Dressing changed this afternoon, remains intact and dry. No c/o pain. No respiratory distress noted." Review of the resident's TAR revealed that a weekly skin assessment was done on 10/4/12. There was no documentation of the extent of the resident's wounds or measurements on that date. A Nursing Note on 10/5/12 at 2:36 p.m., read, "Resident A&Ox1. No s/sx of chest pain or [MEDICAL CONDITION]. PPP on 4 extremities. Abd soft, nontender, with + BS on 4 quadrants. Incontinent of bladder and bowel. Skin is warm, dry, and intact. LLE Tx changed by wound nurse. Tx on TAR and computer updated. Previous [MEDICATION NAME] order DC'd (discontinued) and changed. Refer to physician's orders [REDACTED]. BMP for 8th was filed. Uses w/c for ambulation and locomotion with extensive assistance. Extensive assistance on transfers, toileting, hygiene, dressing, bathing, and bed mobility. Limited assistance during meals. Complied with medications and staff care. LLE had no s/sx of infection. Will continue to monitor LLE." In summary, after 9/25/12, the only other wound assessment with measurement and description was done by Nurse Practitioner (NP) and was dated, 10/5/12, 10 days after the resident's wounds were identified. e. Documentation of Declining Status of Resident Wounds - Transfer out of Facility Nurse Practitioner Assessment 10/5/12: The NP assessment was documented on the "Wound Care-Skin Integrity-Evaluation (WCSIE)," form on the same date when nursing staff documented no [MEDICAL CONDITION] and skin intact (see above) and revealed the following: A - "Wound 1 Left lateral foot ...date of onset ...9/25/12 ...Assessment date ...10/5/12 ...Exudates ...Very Heavy ...Thickness ...Partial Thickness ...Etiology ....Vascular Ulcer ...Size (LXW cm) length x width in cm ...5.0X5.0 ...Depth (about) 0.2 ....Drainage Consistency ...Serous ...Acquisition ...Facility acquired" B - "Wound 2 Left medial foot ...date of onset ...9/25/12 ...Assessment date ...10/5/12 ...Exudates ...Very Heavy ...Thickness ...Partial Thickness ...Etiology ....Vascular Ulcer ...Size (LXW cm) length x width in cm ...1.50X2.00 ...Depth (about) 0.2 ....Drainage Consistency ...Serous ...Acquisition ...Facility acquired" C - "Wound 3 Left top foot ...date of onset ...9/25/12 ...Assessment date ...10/5/12 ...Exudates ...Very Heavy ...Thickness ...Partial Thickness ...Etiology ....Vascular Ulcer ...Size (LXW cm) length x width in cm ...7.00X9.50 ...Depth (about) 0.2 ....Drainage Consistency ...Serous ...Acquisition ...Facility acquired." D - "Wound 4 Left great toe, 2nd, 3rd and 5th (toes) ...date of onset ...9/25/12 ...Assessment date ...10/5/12 ...Exudates ...Very Heavy ...Thickness ...Partial Thickness ...Etiology ....Vascular Ulcer ...Size (LXW cm) length x width in cm ...0.5X9.50 ...Depth (about) 1.00 ....Drainage Consistency ...Serous ...Acquisition ...Facility acquired." The NP evaluation on the WCSIE dated 10/5/12 further read in pertinent part, "Evaluation Comments ...two open areas to left great toe, measurements above are for left great toe and the medial great left toe 0.9X1.2 ...cm ...100% yellow slough, Left 2nd toe 1.6cm X0.8cm ... Left 3rd great toe 0.5cmX1.3cm ...100% yellow slough and Left 5th toe 0.4cmX0.4cm ...50% thin yellow slough. Left 2nd and 3rd toe Marked [DIAGNOSES REDACTED]. Started out as clear fluid blisters that are no longer intact. Left upper top foot 3.0cm X3.9cm ...100% pink viable tissue. Left medial ankle1.0cm X1.4 ...100% viable tissue ... Try and keep let elevated as much as possible ... Left lower medial leg 2.0cm X1.5 ...100% stable black eschar...Skin prep." Nurses' notes 10/6 -10/8/12: On 10/6/12 at 6:05 a.m., nurses' note, indicated worsening condition of the resident's [MEDICAL CONDITION] and wounds. Nurse's notes read in pertinent part, "Resident removed dressing to left foot. Sat on side of bed through night and ultimately removed dressing. Wound is raw appearing and foot is swollen with weeping [MEDICAL CONDITION]. Resident becomes agitated upon attempting to re-dress wound." On 10/6/12 at 12:38 p.m., nurses' note read in pertinent part, "Resident on monitoring d/t L foot weeping [MEDICAL CONDITION], and open areas. Dressing changed. PA (Physician Assistant) at beside to assess pt. New orders, CBC, BMP today, US LLE to R/O [MEDICAL CONDITION], and wound to eval and treat. BMP on 10/11 ...Orders noted, and lab notified. CBC and BMP drawn per stat orders. Ultrasound to be done 10/7/12. Resident denies pain to LLE. No s/sx of discomfort noted." On 10/8/12 at 4:41 a.m., nurses' note read in pertinent part, "Resident continues on monitoring for wound to anterior surface of left foot. Area is wrapped and resident has not attempted to remove dressing material. Resident has been awake most of night; slept from 2:00 a.m. to 4 a.m. Sitting quietly in w/c and watching TV. Moves feet back and forth in w/c as though propelling self. No s/s of pain." On 10/8/12 at 9:41 a.m., nurses' note read in pertinent part, "Noted LLE open blisters and wounds are worsening, with mild necrotic tissues. No odor noted. 4+ [MEDICAL CONDITION]. LLE is cold to the touched ...Dr ...was here and assessed the wounds, ordered to send Res. to ... ER. Unit manager spoke with ... Res (residents) Son ...spoke with (staff name) at ... ER ...Amb (ambulance) to transport (take resident to ER)." Transfer and Discharge Notes: Review of Transfer to Hospital form dated 10/8/12, read in pertinent part, "Reason for Transfer ...Change in LLE wounds, Poor circulation to LLE, worsening of wounds." "NURSING DISCHARGE NOTES," read in pertinent part, "Change in condition that mandated discharge/Transfer ...Change in wounds to LLE." The PTO dated 10/8/12 read in pertinent part, "Cancel order to send pt (resident) to ...wound clinic ...Send to ...ER for LLE wound F/U (follow-up)." f. Staff Interviews On 12/11/12 at 4:20 p.m., the DON was interviewed and stated, "He had [MEDICAL CONDITION] on admit ...I can't answer why no scab on toes was documented on admit on 8/9/12 assessment ... He was admitted with a [DIAGNOSES REDACTED]." In summary: -The facility failed to ensure that resident #164 was timely assessed and monitored in order that he could receive necessary and timely treatment and services when he acquired wounds after admission to the facility. Per record review, the wounds were measured once, over a week after the wounds were initially measured. -The facility failed to timely identify measures for the promotion of healing when the resident developed wounds on his toes and failed to timely notify the physician for orders to promote healing of wounds. -The resident's wounds worsened and multiplied and he was transferred to the hospital for further treatment less than a month after the wounds were acquired. 2. Resident #140 Resident #140, age [AGE] years, was admitted to the facility on [DATE]. According to the 12/2012 Computerized physician's orders [REDACTED]. According to the 9/25/12 admission Minimum Data Set (MDS), resident #140 had adequate hearing and vision without use of corrective devices. Resident #140 had clear speech and usually understood others and was usually understood by others. The MDS showed resident #140 to have severe cognitive impairment as evidenced by a Brief Interview Mental Status score of 3/15. During the MDS observation period, resident #140 exhibited [MEDICAL CONDITION] and verbal behaviors, other behaviors and rejection of cares on one to three days. -Resident #140 required limited assistance with bed mobility, transfers, and eating. Resident #140 required extensive assistance with walking in the room and corridor, locomotion on and off the unit, dressing, toileting and personal hygiene. -Resident #140 was frequently incontinent of bowel and bladder. -Resident #140 had falls in the month prior to admission and the two to six months prior to admission. Resident #140 had two falls with no injury in the time between admission and the completion of the MDS. -Resident #140 received antidepressant and antipsychotic medications on each day during the MDS observation period. a. Observations On 12/5/12 at 11:44 a.m., resident #140 was observed seated in his wheelchair in the common area of his unit. Resident #140 had a bruise that was 4-5 cm on his forehead above the right eye. The bruised area was swollen and yellowing with areas of violet and purple. Resident #140 was not able to express the source of bruise. On 12/6/12 at 10:10 a.m., resident #140 was observed in the unit common area. The resident had a bruise on the forehead above the right eye. On 12/9/12 at 4:48 a.m., resident #140 was observed; the resident had a fading bruise on his forehead above his right eye. On 12/12/12 at 9:59 a.m., resident #140 was observed seated in his wheelchair in the common area of his unit. Resident #140 continued to have a bruise on his forehead above his right eye. The bruise was faded and was less swollen. b. Record Review On 12/10/12 the clinical record for resident #140 was reviewed. Information related to resident #140's forehead bruise included: -The 12/2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Apply ice to right forehead as tolerated until resolved. Dx (diagnosis) hematoma 12/1/12." Ice was applied 12/2/12, 12/3/12 and 12/4/12. On 12/5/12, a place to mark application of ice read, "Healed." -Nurse's progress notes were reviewed. The presence of a hematoma to the forehead of resident #140 was noted on 12/2/12, 12/3/12 and 12/4/12. The injury was not measured or described in detail in any of the notes. No notations of the presence or healing status forehead bruise/hematoma were identified in the nursing notes after 12/4/12. -The "LN - Skin Assessment/Evaluation -PRN/Weekly" documents in the clinical record stopped on 11/25/12. -The "LN - Nursing Summary - Weekly" nursing assessment dated [DATE] showed that resident #140 had no skin issues that were old or new. No documentation of bruising or injury to the forehead was present on the form. c. Staff Interviews On 12/11/12 at 11:31 a.m., the DON was interviewed about tracking resident bruises. The DON stated that staff should review documentation and determine if the bruise is new. The DON stated that staff should document the presence of visible bruises that were old and new on assessment forms or nurse's notes. The DON stated that nursing staff had been directed to use the "LN - Nursing Summary - Weekly" to document skin problems such as bruises. On 12/11/12 at 3:04 p.m., the Registered Nurse (RN) that served as the Unit Manager (UM) for resident #140's unit was interviewed regarding the bruise on resident #140's forehead. The UM reviewed resident #140's clinical record and provided the following comments: -The UM stated that resident #140's forehead bruise was the result of a fall forward from his wheelchair on 12/2/12 at 7:08 p.m. The fall was witnessed at a distance by staff. -The UM stated that the bruise currently on resident #140's forehead was the bruise from the 12/2/12 fall. -The UM reviewed the nurse's notes then stated the last note that specifically referenced the forehead injury was on 12/4/12. The UM was unable to demonstrate that the forehead injury was measured or described. -The UM stated that a hematoma to the right forehead was noted as an injury in the nurse's notes on 12/2/12. The UM stated that resident #140's injury included swelling to the bruised area. -The UM stated that an ice pack to the hematoma site was ordered and placed on the MAR. -The UM reviewed the MAR indicated [REDACTED]. -The UM stated it was her expectation that the bruise be tracked until it was resolved. -The UM stated she was not able recall how to view the skin tracking information in the new electronic record system. The UM stated that she would contact another staff member for assistance. On 12/11/12 at 4:17 p.m., the UM was re-interviewed about resident #140's bruises. The UM was able to access the skin reports. The UM showed the electronic record of a 12/9/12 nurse's report that included a section on skin. Per the 12/9/12 nurse's report form, resident #140 had no new or old skin issues. The UM stated that no notations on bruising were present. The UM stated the bruise that was on resident #140's head from 12/2/12 was still visible and should have been noted in the skin section of the 12/9/12 weekly nurse's report form. The UM was asked for a copy of the facility's bruise tracking and monitoring policy. The UM stated she did not think the facility had one but she would look for one. On 12/11/12 at 4:48 p.m., the UM stated the facility did not have a bruise tracking procedure or policy. The UM stated that it was facility protocol to follow-up on an injury for 72 hours. On 12/12/12 at 11:22 a.m., the DON was re-interviewed about bruise tracking. The DON stated that bruise tracking was not being completed as she would have it done. The DON stated the bruise or injury would be noted on documentation until it is no longer present. The DON stated that the facility had identified documentation of bruising/injuries as problem they were working to resolve. The DON confirmed that the facility did not have a protocol/procedure/policy in place to direct nursing staff on how bruising documentation should occur. 3. Resident #38 Resident #38, [AGE] years old, was admitted to the facility on [DATE]. According to the admissions record, the medical [DIAGNOSES REDACTED]. The 9/21/12 Minimum Data Set indicated the resident had memory problems. The resident had hallucinations and physical behaviors. The resident required extensive assistance with Activities of Daily Living. A 12/4/12 care plan identified the resident had dementia with behavioral disturbances (not all inclusive). The resident was at risk for harm to self and others as evidenced by wandering throughout the neighborhood, moving objects and people without regards to safety. The resident would shake objects, move objects, bang objects, striking out at others and was at risk for injury (not all inclusive). Another 4/15/11 care plan identified the resident was at risk for bruising related to behaviors of banging his arms into things as evidenced by bruises, mostly to forearms and hands. Staff was directed to monitor for discoloration, bruises, swelling, skin tears, redness and investigate all bruises thoroughly. Another 10/20/09 care plan identified the resident was at risk for impaired skin integrity related to incontinence, easily bruises and skin tears. Staff was directed to conduct weekly skin assessments by a licensed nurse every week. a. Observations Observations of the resident revealed he was ambulatory on the unit and had bilateral bruises. Specifically: On 12/5/12 in the afternoon, the resident was observed sitting on the unit floor independently after ambulating around the unit. On 12/6/12 at 6:50 a.m., the resident was observed ambulating around the unit independently; leaning and touching the floor at t

Based on observations, record review and interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (#98) of 19 sample residents. Specifically, a bruise of unknown origin was not followed up on timely. The findings include: An onsite revisit was conducted 2/7 through 2/8/13 resulting in a re-cite of F309, Care and Services for the standard survey ending on 12/12/12. Policy Review of the facility policy for skin monitoring and management documented in pertinent part, "Residents are assessed for bruises and wounds, residents receive necessary treatment and monitoring to promote healing . . ." Procedures: "The licensed nurse is responsible for assessing and evaluating the resident's skin condition on admission, readmission, discharge, and on a weekly basis." 1) Complete assessment and evaluation of the resident's skin. Identify any alterations in skin integrity upon admission, readmission, discharge, and on a weekly basis . . ." 2) document any alteration in skin integrity . . .describing the characteristics of the bruise or wound . . .describing the location of the bruise or wound . . ." 4) complete incident report for new bruising or wounds . . ." Sample resident #98, [AGE] years of age, was admitted to the facility on [DATE]. According to the 2/13 computerized physicians order (CPO), the resident had [DIAGNOSES REDACTED]. According to the annual minimum data set (MDS), dated [DATE], the resident had severe cognitive impairment and decision-making skills. The resident had mood behaviors of being easily annoyed or short-tempered having little interest or pleasure in doing things and difficulty falling/staying asleep. He had behaviors of wandering and rejecting cares. The resident required supervision for bed mobility, limited assist with transfers and extensive assistance with personal hygiene and toileting. Record Review: Review of the 2/13 treatment administration record (TAR), documented the following order: "weekly skin assessment on Monday 6-2 . . ." The last documented skin assessment was on 2/4/13. There was no documentation of any skin concerns at that time. Review of a care plan for potential in skin integrity, initiated 1/11/13, documented the resident was at risk related to fragile skin, incontinence, poor safety awareness, resistance to care at times and use of aspirin (anti-[MEDICAL CONDITION]). The approaches were to assess skin daily when assisting with ADL'S (activities of daily living) and shower, follow facility protocols for treatment of [REDACTED]. . ." Review of the bathing schedule on the [MEDICATION NAME] unit where the resident resided, revealed the resident's bath days were Mondays and Fridays. Review of the most recent pink skin assessment sheet (used for bath days) for the resident (for the week of 2/4/13), had the words "refused" written across the sheet. Observations: On 2/7/13 at 11:55 a.m., the resident was observed ambulating in the hallways and dining area of the [MEDICATION NAME] unit. The resident had a short sleeve shirt on at the time. There was a large circular bruise, light purple in color and the size of a small apple by visual observation on the resident's left lower inner arm. The resident was greeted by the surveyor but his speech was non-sensical. Interviews: On 2/8/13 at 3:07 p.m., a licensed practical nurse (LPN) evening nurse was interviewed. The LPN stated that she found the bruise on the resident on the evening of 2/7/13 around 8:00 p.m. The LPN stated she completed an incident report at that time. The LPN stated she assessed the bruise and placed the resident on 72 hour charting. The LPN stated it was not known how the resident got the bruise because he wanders and there were no witnesses. At 4:20 p.m. on 2/8/13, the nurse manager (NM) for the unit was interviewed. The NM stated that CNA'S (certified nursing assistants) were responsible for reporting any changes in resident's skin to the nurse right away because they are caring for them all the time. The NM stated resident #98 required a lot of care and oversight. At 4:42 p.m. on 2/8/13, in a second interview with the evening LPN above, she stated that the day nurse on 2/7/13 first brought the resident's bruise to her attention during the change of shift report at 2:00 p.m. on 2/7/13. The evening LPN stated the day nurse had a bad day yesterday and was not able to complete the incident report so it was passed on to her. On 2/8/13 at 4:49 p.m., a CNA who worked 11:00 a.m. to 7:00 p.m., and was familiar with the resident, was interviewed. The CNA stated she had not noticed the resident had a bruise before. At 4:52 p.m. on 2/8/13, a second evening CNA assigned to care for the resident, stated the resident required total care except for eating and mobility. The CNA stated he had not noticed any bruise on the resident and that the resident usually gets showered in the morning. The CNA acknowledged they are to notify the nurse right away if there are any bruises. On 2/8/13 at 5:15 p.m., the director of nursing (DON) was interviewed. The DON stated that although it was not spelled out in their policy she would expect if a bruise was found on a resident that the staff present at the time of the discovery be interviewed. The DON was informed of the above findings and the interview with the evening LPN. The DON stated she would have to check into the matter and provide follow-up information. At 5:55 p.m. on 2/8/13, in a follow-up interview with the DON, she stated she had spoken to the day nurse who worked on 2/7/13. The day nurse stated that she had noticed the bruise and that she had interviewed staff, but did not have it documented anywhere. The day nurse acknowledged to the DON that she did not fill out the initial report and passed it on to the evening nurse thinking it would be ok. The DON stated the nurse that finds the injury was responsible for doing the documentation. The DON acknowledged that policy was not followed and the nurse failed to follow the plan of correction from the recent recertification survey.