Every finding on record at Juniper Village - The Spearly Center

Based on record review and interviews, the facility failed to ensure two (#65 and #124) of eight residents were kept free from abuse out of 41 sample residents. Specifically, the facility failed to protect Resident #124 from physical abuse by Resident #65 and protect Resident #65 from physical abuse by Resident #124. Findings include: I. Facility policy and procedure The Abuse and Neglect policy, undated, was provided by the nursing home administrator (NHA) on 5/11/26 at 11:45 a.m. It read in pertinent part, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Alleged and substantial incidents, complete investigation reports, and if necessary, corrective actions taken, will be reported to the Resident's responsible party, Physician, Ombudsman, State Licensing Authority and Police Department as appropriate. II. Incident of resident-to-resident physical abuse between Resident #65 and Resident #124. A. Facility investigationThe 4/25/26 facility investigation was provided by the NHA on 5/13/26 at 4:56 p.m. The investigation revealed Resident #124 said something to Resident #65 as they were passing each other in the hallway. Resident #65 acted as if she was going to hit Resident #124. Resident #124 then slapped Resident #65's arm away and Resident #65 hit Resident #124 in the back of the head with a closed fist. No injuries were noted. The facility immediately intervened and placed both residents on 15-minute checks. B. Resident #65 (assailant)1. Resident status Resident #65, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included severe unspecified dementia, adult failure to thrive, alcohol abuse, anxiety disorder, depression and insomnia. The 3/30/26 minimum data set (MDS) assessment revealed, the resident had a short-term memory problem. Her cognitive skills for daily decision making were severely impaired. She had inattention and disorganized thinking which fluctuated. She had delusions and wandered one to three days out of the seven-day assessment look-back period. 2. Resident interviewAn attempt was made to interview Resident #65 on 5/11/26 at 10:57 a.m. However, the resident was not interviewable due to her cognitive impairment. 3. Record reviewResident #65's behavior care plan, revised 3/17/26, identified the resident had new disruptive behavior that included going into other residents' rooms and rummaging through their belongings. The care plan documented Resident #65 no longer had a sense of personal ownership. Interventions included ensuring the safety of the resident and others, establishing boundaries and limits with Resident #65, monitoring for environmental factors that may contribute to new behaviors and utilizing diversion techniques as needed. The psychotropic medication care plan, revised 3/26/26, revealed Resident #65 was prescribed psychotropic medications related to her disease process, depression, anxiety secondary to dementia with severe behavioral disturbances. Interventions included monitoring/recording/documenting behavior symptoms of pacing, wandering, disrobing, inappropriate response to verbal communication, violence /aggression towards staff/others, and entering other resident rooms.A behavior note, dated 4/25/26 at 10:37 a.m., revealed Resident #124 said something to Resident #65 when he wheeled past her. Resident #65 acted like she was going to hit Resident #124. Resident #124 slapped Resident #65 on her arm open handed. Resident #65 hit Resident #124 in the back of the head with a closed fist. There were no scratches or bruises on either resident. The physician, the on-call nurse and the residents'families were notified. Both residents were placed on every 15-minute checks and kept separated and safe. Neurological checks were initiated on Resident #124. C. Resident #1241. Resident statusResident #124, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the May 2026 CPO, diagnoses included Parkinson's disease, dysphagia, cognitive communication deficit, bipolar disorder, hearing loss and post-traumatic stress disorder.The 2/16/26 MDS assessment revealed, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He had inattention, which fluctuated. He wandered one to three days during the assessment look-back period and was able to propel his wheelchair independently. 2. Resident interviewResident #124 was interviewed on 5/14/26 at 10:03 a.m. Resident #124 said Resident #65 punched him in the back of the head. He said he did not know why she hit him. 3. Record reviewResident #124's behavior care plan, initiated 7/1/25, revealed the resident presented with episodic maladaptive behaviors during which he was physically aggressive towards other residents. Interventions included monitoring, documenting and reporting increased distress. A behavior note, dated 4/25/26 at 10:37 a.m., revealed Resident #124 said something to Resident #65 when he wheeled past her. Resident #65 acted like she was going to hit Resident #124. Resident #124 slapped Resident #24 slapped her arm open handed. Resident #65 hit Resident #124 in the back of the head with a closed fist. There were no scratches or bruises on either resident. The physician, the on-call nurse and the residents' families were notified. Both residents were placed on every 15-minute checks and kept separated and safe. Neurological checks were initiated on Resident #124. III. Staff interviewsLicense practical nurse (LPN) #1 was interviewed on 5/13/26 at 1:49 p.m. LPN #1 said she witnessed the altercation between Resident #65 and Resident #124. She said Resident #124 was going to his room and Resident #65 was leaving her room. She said as they were passing each other in the hallway, Resident #65 postured as if she was going to hit Resident #124. She said Resident #124 then pushed Resident #65's arm away and she made a fist and hit him in the back of the head. LPN #1 said Resident #65 had severe dementia with behaviors. She said Resident #65 wandered into other residents' rooms and Resident #124 had behaviors upon admission, but none at the time of the incident. Unit manager #1 was interviewed on 5/13/26 at 1:55 p.m. Unit manager #1 said Resident #65 liked to wander into other residents' rooms and was a high elopement risk. She said Resident #65 had dementia and no awareness of personal space and hit the doors. She said immediately following the incident, both residents were separated and put on 15-minute checks. She said both residents had medication reviews and increases to their medications. She said Resident #65 was very difficult to redirect and was not able to communicate her needs. The director of nursing (DON) was interviewed on 5/13/26 at 3:19 p.m. The DON said staff immediately intervened and separated Resident #65 and Resident #124. He said both residents were then placed on every 15-minute checks and medication reviews were completed for both residents. He said there was no evidence identified to suggest intent to cause harm.

Based on observation, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured and labeled in accordance with accepted professional standards for three of five medication storage carts and one of three medication storage rooms. Specifically, the facility failed to:-Ensure a Schedule IV controlled medication was properly stored in a refrigerator;-Ensure medications were labeled with open dates; and, -Ensure expired medications were properly disposed of. Findings include:I. Professional reference PharMerica (1/12/25) Abridged List of Medications with Shortened Expirations Dates, was retrieved on 12/8/25 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://pharmerica.com/wp-content/uploads/2025/01/PMC-[NAME]-Meds-with-Shortened-Expiration-Dates_012025_FINAL.pdf. it revealed in pertinent part, Once certain products are opened and in use, they must be used within a specific timeframe to avoid reduced stability, sterility and potentially reduced efficacy. Product-specific storage and expiration details can be found in the drug product's Package Insert (PI) under the 'How Supplied/Storage & Handling' section. A drug product's Beyond Use Date (BUD) is the manufacturer supplied expiration date OR the shortened date after opening (see BUD Notes below), whichever comes first. These In-Use medications should be labeled such that the 'date opened' is noted, clearly visible and securely attached to a part of the package to not be discarded. This date is to be referenced when auditing to clear medications prior to expiration.Pharmcare USA (4/9/23) Medication Disposal Practices in Assisted Living and Long Term Care, was retrieved on 12/8/25 from https://pharmcareusa.com/education/medication-disposal-practices-in-assisted-living-ltc/#:~:text=As%20an%20experienced%20healthcare%20professional,a%20legal%20and%20ethical%20obligation. It revealed in pertinent part, When medications are not disposed of correctly, they can pose serious threats to bother human health and the environment. Improper disposal can lead to accidental ingestions, overdose and even death.II. Facility policy and procedureThe policy for skilled medication storage, undated, was received from the nursing home administrator (NHA) on 12/4/25 at 12:09 p.m. The policy read in pertinent part, Expired, discontinued and/or contaminated medications will be removed from the medication storage area and disposed of in accordance with community policy. Medications requiring refrigeration will be stored in a refrigerator that is maintained between two and eight degrees Celsius (36 to 46 degrees Fahrenheit).III. Observations On 12/2/25 at 1:10 p.m. the Juniper hallway medication cart was observed with registered nurse (RN) #1. The following was observed: -Three insulin glargine (long acting insulin pens were opened and in the cart with no open date labeled on the pen. -One insulin Lantus (long acting insulin) pen was opened and in the cart with no open date labeled on the pen.-Umeclidinium inhalation powder (long acting inhaler) 62.5 micrograms (mcg) had no open date on it. -Wixela (fluticasone propionate and salmeterol powder, a long acting inhaler) 250mcg /50mcg had no open date on it. RN #1 said the insulin pens and inhalers should be labeled with an open date. She said she was going to check with her unit manager on what to do with them and check on the date they came to the facility from the pharmacy. On 12/2/25 at 1:36 p.m. the front side of Spruce hallway medication cart was observed with licensed practical nurse (LPN) #1 and assistant director of nursing (ADON) #1. The following was observed: -Two bottles of Visine eye drops (medication to relieve dry eyes) with open dates of 9/2/25 and 9/20/25.-A bottle of polyethylene glycol 400 1% tetrahydrozoline HCL 0.05% (medication to relieve dry eyes) opened 8/16/25. -A bottle of systane complete eye drops (medication to relieve dry eyes) opened 10/1/25. -A bottle of prednisolone acetate 1% eye drops opened 9/30/25.ADON #1 said over the counter eye drops expired within 60 days of opening the bottle. She said prednisolone eye drops expire within 30 days of opening the bottle. She said she was going to dispose of the eye drops that were opened past those expiration dates. On 12/2/25 at 2:30 p.m., the back side of Spruce hallway medication cart was observed with licensed practical nurse (LPN) #3 and RN #5. The following was observed: - Generic fiber powder expired July 2025.-Geri-Lanta regular strength (antacid medication) expired April 2024.-Metoprolol 25 milligram (mg) tablet expired 10/31/25.-Potassium tablet 10 mill equivalent (mEq) expired 11/30/25.-Insulin glargine 100 unit/ml vial opened 10/1/25 (expired 28 days after opening). -Equate Dry eye relief eye drops opened 9/1/25. -[NAME] colon helper (stool softener supplement) had no expiration date on the bottle.-A bottle of liquid lorazepam 2 milligrams/milliliter (mg/ml) was stored in the medication cart with instructions to keep it refrigerated. LPN #3 said she took it out at about 8:00 a.m. and had kept it stored in the medication cart since then. RN #5 said he was going to dispose of the bottle of Lorazepam and order a new one. He said he was going to dispose of the additional medications that had expired. On 12/3/25 at 10:15 a.m. Juniper hallway medication storage room was observed with RN #4. The following was observed: -A risperidone injection (antipsychotic medication) 37.5 mg was expired June 2025. RN #5 said he was going to give the medication to the unit manager to see what to do with it. IV. Staff interviews The director of nursing (DON) was interviewed on 12/3/25 at 2:26 p.m.The DON said that all medication carts and storage rooms were audited and all expired medications were disposed of. The DON was interviewed on 12/4/25 at 9:50 a.m. He said the individuals that opened a medication were responsible for labeling the medication with an open date. He said all medications aside from the cards that came from the pharmacy should be labeled with an open date. He said the ADON's were responsible for auditing the medication carts and storage rooms on a weekly basis. He said the importance of labeling medications with open dates is so that you know when they are expired. He said it was important to dispose of expired medications so they are not being administered to the residents.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on one of three units Specifically, the facility failed to:-Ensure Resident #122's oral stimulator was kept in a sanitary location;-Ensure housekeeping staff performed hand hygiene while cleaning resident rooms;-Ensure housekeeping staff wait the appropriate amount of dwell time. Findings include: I. Failure to keep Resident #122's oral stimulator in a sanitary location A. Facility policy and procedure The Infection Control policy and procedure, undated, was provided by the nursing home administrator (NHA) on 12/4/25 at 12:09 p.m. Iit read in pertinent part, Associates will be educated related to all infection control procedures, including personal hygiene requirements. The Community will follow guidelines for the prevention and control of Nosocomial Infections and standard precautions as provided by the Center for Disease Control in Atlanta Georgia. The Environmental Services- Housekeeping policy and procedure, undated, was provided by the NHA on 12/4/25 at 12:09 p.m. it read in pertinent part, Associates working in resident areas will follow strict hand washing procedures. General cleaning agents used must be effective in removing all types of germs and bacteria. Clean and disinfect environmental and medical equipment surfaces on a regular basis by using EPA-registered disinfectants in accordance with manufacturer's instructions. Clean surfaces contaminated with body substances; perform low-to intermediate-level disinfection on cleaned surfaces with an EPA-registered disinfectant in accordance with the manufacturer's instructions. The Hand Hygiene policy and procedure, revised 1/01/22 was provided by the NHA on 12/4/25 at 12:09 p.m. it read in pertinent part, Associates will wash their hands, after cleaning a room, after handling waste or linen, before and after applying gloves, anytime hands have possibly become contaminated, after contact with furnishings or medical equipment in the immediate vicinity of a resident. A. Observations On 12/2/25 at 12:39 p.m. Resident #122 was sitting in the common area in her wheelchair. Resident #122 was grinding her teeth. A red rubber device (later identified as an oral stimulator) was hooked to her wheelchair by a lanyard. Two different, unidentified staff members offered Resident #122 the oral stimulator to chew on using their bare hands and did not use hand hygiene before touching it and offering it to her. The staff members were clearing dishes from the dining room prior to touching the oral stimulator. Resident #122 put the oral stimulator in her mouth. On 12/3/25 at 8:51 a.m. Resident #122 was sleeping in her bed. The oral stimulator was attached to her wheelchair with the lanyard. The oral stimulator was touching the seat of the wheelchair. On 12/3/25 at 10:50 a.m. the lanyard was connected to Resident #122's wheelchair. Resident #122 was sitting up in her wheelchair on top of her Hoyer lift sling. Certified nurse aide (CNA) #2 pulled on the lanyard and the oral stimulator was no longer attached to the lanyard. CNA #2 then reached underneath Resident #122 and the Hoyer lift sling and pulled out the oral stimulator. B. Staff interviews The hospice registered nurse was interviewed on 12/3/25 at 10:54 a.m. She said Resident #122 grinds her teeth and said she had seen the restorative staff give her the oral stimulator to chew on. She said she had not seen it connected to her wheelchair before. The director of rehabilitation (DOR) was interviewed on 12/3/25 at 11:13 a.m. He said the device that Resident #122 was seen chewing on was called an oral stimulator. He said the device was used to help stimulate the tongue to help with swallowing. He said he was unaware that Resident #122 was still using the device. He said he would not recommend having it attached to the wheelchair. He said he would recommend the device be kept separate and cleaned after use. He said if the device was recommended by speech therapy, there would be a program and oversight. Licensed practical nurse (LPN) #4 was interviewed on 12/3/25 at 1:30 p.m. He said that sometimes Resident #122 put random things in her mouth. The speech therapist (ST) and the DOR were interviewed together on 12/3/25 at 1:43 p.m. The ST said she wrote for the use of the oral stimulator in July 2025 and August 2025 and it was discontinued in August 2025 when she stopped working with Resident #122. She said she was working with her for swallowing. She said the only time Resident #122 had the oral stimulator was when she was working with her and she would clean after each use. She said nursing staff was looking for something to help Resident #122 with grinding her teeth. She said the oral stimulator was mentioned that it could be used however, she did not recommend it for use. The infection preventionist (IP) was interviewed on 12/4/25 at 9:45 a.m. He said Resident #122 had an issue with grinding her teeth. He said speech therapy wanted to try the oral stimulator to see if it would help with Resident #122's grinding issue. He said he had spoken to the hospice staff and said that they were going to bump up her anti-anxiety medication which should also help with her grinding. He said he was also waiting to hear back from the DOR to see if there was a better option for her grinding. He said they were also going to see if they could get a dentist to assess her next week for a mouthguard. He said there were infection control issues with multiple staff touching the oral stimulator after removing dirty dishes and not washing their hands and trying to have her chew on it. He said the oral stimulator should be stored in a denture cup, cleaned and have it hanging so it is available for her to use but not have it filthy. The DOR was interviewed on 12/4/25 at 2:10 p.m. He said he would recommend the oral stimulator be cleaned before use. He said he would recommend using a small container, like a denture cup and soaking the oral stimulator with water and a denture tablet. He said if the lanyard were to be used with the oral stimulator, then the lanyard should be attached to the person and not the wheelchair. II. Failure to ensure hand hygiene and dwell time of chemicals was completed during cleaning of resident rooms A. Professional reference According to the Diversey (2025) product insert for Oxivir Five 16 Concentrate One-Step Disinfectant Cleaner, was retrieved on 12/8/25 from: Chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://asset.productmarketingcloud.com/api/assetstorage/604_1042b4ca-d408-4c5b-a238-85570274c56a/Original/PSS750_OxivirFive16-LTR_enV10HiRes%20(1).pdf, Use directions include spray surfaces and let the solution remain on the surface for a minimum of five minutes. Air dry, wipe surfaces to dry and remove any residue or rinse with portable water as necessary. B. Facility policy and procedure The Hand Hygiene policy and procedure, revised 1/1/22, was received from the NHA on 12/4/25 at 12:09 p.m. It documented in pertinent part, Associates will wash their hands before and after applying gloves. The Environmental Services/Housekeeping policy, undated, was received from the NHA on 12/4/25 at 12:09 p.m. It documented in pertinent part, Associates working in resident areas will follow strict hand washing procedures. C. Observations During a continuous observation on 12/3/25, beginning at 1:00 p.m. and ending at 1:20 p.m., the following was observed: Housekeeper (HK) #1 and HK #2 were cleaning resident room [ROOM NUMBER]. HK #1 began by donning (putting on) clean gloves. HK #1 sprayed down the windows with a window washer. HK #1 wiped down the windows with a rag. HK #1 removed the soiled gloves and donned clean gloves without performing hand hygiene. HK #1 sprayed down the bed and dresser with the window washer solution. HK #1 immediately wiped down each surface after she sprayed them with a clean rag. HK #1 removed her soiled gloves and without performing hand hygiene donned clean gloves. HK #1 sprayed down the sink and vanity area with Oxivir Five 16 concentrate solution. HK #1 immediately wiped down the sink area with a clean rag. HK #1 removed the soiled gloves and without performing hand hygiene donned clean gloves. HK #2 sprayed down the toilet with Oxivir Five 16 concentrate solution and immediately wiped it down. HK #2 cleaned the inside of the toilet with a bathroom cleaner. HK #2 removed her soiled gloves and donned clean gloves. HK #1 mopped the floor of the bedroom followed by the bathroom. HK #1 removed her soiled gloves and washed her hands. -HK #1 and HK #2 failed to perform hand hygiene between glove changes. -HK #1 and HK #2 failed to wait the dwell time for the Oxivir Five 16 concentrate solution. D. Staff interviews The maintenance supervisor (MS) was interviewed on 12/4/25 at 9:45 a.m. He said the dwell time for the Oxivir Five 16 concentrate solution was five minutes. The director of nursing (DON) was interviewed on 12/4/25 at 9:50 a.m. He said it was important to follow the appropriate dwell time while cleaning with chemicals so that the chemical was effectively cleaning the surfaces. He said hand hygiene should be completed before and after donning gloves to prevent the spread of germs.

Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for one (#77) of five residents reviewed for accident hazards out of 37 sample residents. R77 had severe cognitive impairments. On 3/19/25, the resident took a piece of bread from another resident's plate and ate it. R77 choked and required the Heimlich maneuver (abdominal thrusts used to clear food from a person's airway that is choking) to clear the food from his airway. The resident's care plan directed staff to assist R77 with controlling his rate of eating, monitoring the resident's bite sizes to ensure the resident did not choke and monitoring the resident to avoid the resident stuffing food into his mouth. Additionally, R77 was prescribed a mechanically altered diet. Observations during the survey revealed R77 received menu items that were not consistent with his prescribed diet order. The staff failed to provide supervision during meals to ensure the resident did not take food from other residents' plates or monitor the resident's bite sizes which put the resident at a continued risk of further choking incidents for R77. The failure to provide appropriate supervision during times of resident intake placed residents at risk for serious harm or death if not corrected immediately. On 4/25/25 at 10:11 a.m., immediate jeopardy was identified based on the facility failures above that created a situation of potential serious harm for R77, requiring immediate corrective action. Findings include: I. Immediate Jeopardy A. Situation of immediate jeopardy The facility failed to ensure staff provided appropriate supervision and implemented the identified care-planned interventions for R77 after the resident had a choking incident on 3/19/25. The facility's failure to ensure staff provided appropriate supervision and implemented care-planned interventions led to a continued risk of further choking incidents for R77. B. Imposition of immediate jeopardy On 4/25/25 at 10:11 a.m., the Nursing Home Administrator (NHA) was notified of the immediate jeopardy situation created by the facility's failure to ensure R77 received appropriate supervision during times of intake. C. Facility plan to remove immediate jeopardy On 4/25/25 at 4:37 p.m. the facility submitted a plan to remove the Immediate Jeopardy. The removal plan read: 1. Corrective action R77 will be served food per the physician's ordered diet of a mechanical soft diet. The Certified Nurse Aide (CNA) and/or nurse will provide R77 with supervision during times of intake to ensure he is eating safely. R77 will be placed on safety checks due to his behavior of taking other residents' food that is not within his prescribed diet texture. Any additional safety concerns or behaviors will be addressed, documented in the behavior log and will be updated on the care plan with appropriate interventions. The care plan and interventions will be reviewed and updated every quarter and with every change of condition. 2. Identification of others An audit was completed on 4/10/25 and determined 14 residents required assistance with intake. Each resident identified will be seated at a designated table in the dining room. The Restorative CNA or designee will provide active monitoring of those residents during each meal. 3. Systemic changes On 4/11/25 the facility's Diet Orders and Food Services policies were reviewed by leadership to ensure alignment with current best practices and regulatory standards. The DON (Director of Nursing)/designee provided education, starting on 4/11/25 and completed on 4/16/25, to the nursing staff of the requirement for supervision for the at-risk residents that were identified. CNAs and nurses will observe and supervise the at-risk residents identified for choking, appropriate meal texture and process of notification if an incident or concern arises. The Dietary Manager (DM) provided education, starting on 4/10/25 and completed on 4/11/25, to the cooks and servers on diet extensions to ensure proper diet textures, diet types, food procurement and scoop sizes. The kitchen will follow diet extensions at each meal. The cook appropriately prepares the meals following the diet extensions. The server sets up steam tables with all meals prepared by the cook and verifies that menus and extensions are correct. The server will plate the food based on the diet type report that is located on the steam table. The diet type report is updated as needed and with any new orders. The CNA will verify that the meal served matches the diet type report. One CNA and a nurse will be designated to each dining area for the entire meal service. One leadership member is assigned to meals to round and assist as needed. If a resident on eating supervision is given a snack, a CNA or designee must supervise the resident while they consume the snack. 4. Monitoring The DM/designee will audit the lunch meal on 4/25/25 to ensure extensions are served correctly. Additionally, three meals will be audited daily for one week, then one meal daily for three weeks, then five random meals per week until substantial compliance. The audits will be documented on a written log and concerns will be addressed immediately. The DON/designee will audit resident supervision on 4/25/25. Additionally, three meals will be audited daily for one week, then one meal daily for three weeks, then five random meals per week until substantial compliance. The audits will be documented on a written log and concerns will be addressed immediately. D. Removal of the immediate jeopardy The NHA was notified the immediate jeopardy was removed on 4/25/25 at 5:17 p.m. based on the facility's removal plan (see above). However, the deficient practice remained at a D level, no actual harm with potential for more than minimal harm that is not immediate jeopardy. II. Facility policy and procedure The Food Service policy and procedure, undated, was provided by the NHA on 4/25/25 at 3:30 p.m. It read in pertinent part, Special diets as prescribed by a physician are available. Mealtime assistance is available as needed, based on the resident service plan. III. Failure to ensure staff provided appropriate supervision and implemented care-planned interventions A. Resident #77 status R77, age 68, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included severe dementia with agitation and delusional disorders. The 2/10/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired and could never or rarely make decisions regarding tasks of daily life. The resident required partial to moderate staff assistance for eating and was dependent on staff for all other activities of daily living (ADL). The assessment documented the resident was receiving a mechanically altered diet. B. Observations During a continuous observation of the lunch service on 4/8/25, beginning at 12:11 p.m. and ending at 12:42 p.m., the following was observed: At 12:11 p.m. R77 was sitting at a dining table with several other residents. An unidentified staff member delivered R77's meal to him and the resident began eating independently. Staff did not provide the resident with supervision to ensure he was eating safely. At 12:14 p.m. R77 speared multiple whole baby carrots and sweet potato pieces on his fork and ate them in one bite. No staff member intervened and staff did not provide the resident with supervision to ensure he was eating safely. At 12:19 p.m. multiple staff members were delivering trays of food to residents throughout the dining room and in their rooms. Staff did not provide R77 with supervision to ensure he was eating safely. At 12:22 p.m. an unidentified staff member delivered a second helping of food to R77 and promptly returned to serving trays. The unidentified staff member did not provide the resident with supervision to ensure he was eating safely. At 12:28 p.m. R77 continued eating by himself. Staff did not provide the resident with supervision to ensure he was eating safely. At 12:36 p.m. R77 finished his second helping of food and remained at the dining table with other residents. At 12:42 p.m. an unidentified staff member cleared the plates from the dining table at which R77 was sitting. Staff did not provide the resident with supervision to ensure he did not take food from another resident's plate. During a continuous observation of the lunch service on 4/9/25, beginning at 12:10 p.m. and ending at 12:50 p.m., the following was observed: At 12:24 p.m. R77 was served a slice of pumpkin pie and ate it independently. Staff did not provide the resident with supervision to ensure he was eating safely. At 12:26 p.m. R77 self-propelled to another table in the dining room. R77 grabbed food off of another resident's plate and used that resident's spoon to eat her pumpkin pie. A resident from R77's usual table in the dining room saw what was occurring and yelled out to get the staff's attention. CNA #6 assisted R77 back to his original table and gave him the other resident's remaining pumpkin pie. CNA #6 did not provide the resident with supervision to ensure he was eating safely. At 12:31 p.m. R77 began self-propelling away from the dining room. CNA #6 tried to redirect R77 back to his table and said his food was there. CNA #6 assisted R77 back to his table in the dining room where he was served lunch and began eating. CNA #6 again did not provide the resident with supervision to ensure he was eating safely. At 12:33 p.m. Restorative Nurse Aide (RNA) #1 brought R77 a glass of juice and sat down next to the resident and began providing the resident with supervision and cues for eating more slowly. C. Record review The restorative care plan, initiated 2/26/24, revealed R77 required restorative nursing for dining. Pertinent interventions included assisting R77 with controlling his rate of eating, monitoring bite size to ensure the resident did not choke and monitoring self-feeding to avoid the resident stuffing food into his mouth. The ADL care plan, revised 1/30/24, revealed R77 had a self-care performance deficit due to his dementia. Pertinent interventions included R77 required staff assistance with eating. -Review of the resident's care plan did not reveal the facility identified the resident often took food from other resident's plates. Review of R77's April 2025 CPO revealed a physician's order for a regular diet with a mechanical soft texture, ordered 8/11/24. A progress note, dated 3/7/25 at 4:46 p.m., revealed R77 was observed in the dining room with a plastic soda bottle cap in his mouth. Staff were instructed to remove soda bottles from the dining tables and residents were reminded to throw their trash into the waste receptacles once they were finished with them. A progress note, dated 3/19/25 at 7:26 a.m., revealed R77 had an episode of choking during the previous meal. R77 appeared to be unable to swallow, speak, or cough. Nursing staff assisted R77 with an abdominal thrust and visible food was removed from his mouth. A Registered Nurse (RN) performed an assessment which indicated R77 was able to speak, eat and swallow. No injuries were noted at the time, vital signs were stable. Staff were to continue to observe the resident during meal times and cut his food into smaller pieces. R77's representative and physician were notified. An interdisciplinary team (IDT) note, dated 3/26/25 at 11:34 a.m., revealed R77 choked on an item that was not part of his diet texture. R77 had grabbed food from another resident's plate. R77 was monitored to ensure he was not taking food from other residents' plates. R77 sat at the restorative table while eating. The IDT team suggested the residents in the work therapy program be assigned to pick up plates when other residents were done eating. D. Menu extensions Review of the menu extensions from 4/7/25 through 4/13/25 revealed the following: The mechanical soft texture lunch meal for 4/9/25 included blackened fish, sweet potato wedges, green beans, and a pureed dinner roll. -However, R77 was served a vegetable blend instead of the green beans on the menu extensions (see observations above). IV. Staff interviews CNA #4 was interviewed on 4/10/25 at 9:16 a.m. CNA #4 said R77 spent most of his day wandering around the facility. CNA #4 said R77 sometimes tried to grab items from other residents. CNA #4 said R77 was redirectable when he tried to take other residents' items. CNA #4 said the staff had to monitor R77 during meals because he tried to take other residents' meals and drinks. CNA #4 said other residents would yell when R77 took food or drinks from other residents and would redirect him. Licensed Practical Nurse (LPN) #4 was interviewed on 4/10/25 at 9:53 a.m. LPN #4 said R77 liked to grab items and put them in his mouth so the nursing staff had to keep an eye on him. LPN #4 said she was not aware of any choking incidents R77 had. Nurse Manager (NM) #1 was interviewed on 4/10/25 at 3:26 p.m. NM #1 said the nursing staff had to redirect R77 from going into other residents' rooms and grabbing items in the dining room. NM #1 said the nursing staff needed to monitor R77, especially during mealtimes. NM #1 said the nursing staff were good at monitoring R77 and ensuring he did not put anything inappropriate in his mouth. NM #1 said he could not recall if R77 had experienced any choking incidents. The Director of Nursing (DON) was interviewed on 4/10/25 at 4:44 p.m. The DON said R77 had a tendency to grab food from other residents' plates. The DON said R77 had previously grabbed bread from another resident's plate and choked on it. The DON said if the nursing staff saw R77 grabbing food from another resident's plate they redirected him, which in turn made R77 try to eat or get rid of whatever he had grabbed faster than before. The DON said the facility had the resident work therapy program to help clean up the dining room so there were no trays sitting out and thus limiting the amount of food R77 could potentially grab. The DON said the nursing staff increased their monitoring of R77 during meals, and that the resident sat at the restorative dining table so the RNAs could supervise him during meals. The DON said the facility was also utilizing a feeding training program for non-clinical staff so they could help feed and monitor residents during mealtimes. -However, meal observations revealed staff were not supervising R77 when he was eating (see observations above).

Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance and performance improvement (QAPI) program committee failed to identify and address concerns related to accidents and safety of residents, which rose to the level of immediate jeopardy and created a situation that a serious adverse outcome was likely. Findings include: I. Review of the facility's regulatory record revealed it failed to operate a QA program in a manner to prevent repeat deficiencies and initiate a plan to correct F689 Accidents Hazards During the recertification survey on 5/23/24 F689 was cited at a L level scope and severity, immediate jeopardy to resident health or safety, widespread. During the abbreviated survey on 12/11/24 F689 was cited at a L level scope and severity, immediate jeopardy to resident health or safety, widespread. During the recertification survey on 4/25/25 F689 was cited at a J level scope and severity, immediate jeopardy to resident health or safety, isolated. F867 Quality Assurance Program During the recertification survey on 5/23/24 F867 was cited at a F level scope and severity, no actual harm with potential for more than minimal harm that is not immediate jeopardy, widespread. During the abbreviated survey on 12/11/24 F867 was cited at a F level scope and severity, no actual harm with potential for more than minimal harm that is not immediate jeopardy, widespread. During the recertification survey on 4/25/25 F867 was cited at a F level scope and severity, no actual harm with potential for more than minimal harm that is not immediate jeopardy, widespread. II. Cross-reference citation Cross-reference F689: The facility failed to provide appropriate supervision at meal times for R77, who had a history of choking. The facility's failure to provide supervision and assistance at meal times for a resident with a history of choking created a situation where a serious outcome was likely to occur and created an immediate jeopardy situation. III. Staff interviews The Nursing Home Administrator (NHA) was interviewed on 4/10/25 at 4:30 p.m. The NHA said the facility held a monthly QAPI meeting. The NHA said the facility team members, including the interdisciplinary team (IDT), also met daily and discussed potential risks to residents. The NHA said each day during the daily meeting, the team reviewed resident risks identified, how the risks were monitored and the expected outcome. The NHA said the facility developed corrective actions for identified risks that resulted from a collaborative discussion with the IDT. The NHA said there was a documentation binder that contained the problem that was identified, a system put in place or improved upon and how that situation was monitored. The NHA said each day any new issue that was identified was monitored. The NHA said a facility consultant performed an additional review of the facility's plan of correction. -However, the facility failed to identify R77 was not assisted and monitored during meal times, according to his care planned interventions, to ensure R77 did not choke.

Based on observations, record review and interview, the facility failed to ensure menus were followed to meet the resident's nutritional needs. Specifically, the facility failed to follow correct portions sizes to ensure adequate nutrition was provided to the residents. Findings include: I. Record review The menu extensions were provided by the Dietary Manager (DM) on 4/10/25 at 4:02 p.m. The menu extensions revealed in pertinent part: -A 1/2 cup serving of seasoned couscous to residents who were prescribed a regular diet, mechanical soft diet and therapeutic diets; -A 1/2 cup serving of pureed seasoned couscous to the residents who were prescribed a pureed diet; -A 1/2 cup serving of [NAME] vegetable blend regular, mechanical soft and therapeutic diets; and, -A 1/2 cup serving of the pureed [NAME] vegetable blend. II. Observations During a continuous observation of the lunch meal on 4/9/25, beginning at 12:01 p.m. and ending at 1:00 p.m., Dietary Aide (DA) #1 used the following scoop sizes: -A #12 scoop (1/3 cup) for the seasoned couscous for regular, mechanical soft and therapeutic diets; -A #12 scoop (1/3 cup) for the pureed seasoned couscous; -A grey slotted spoon (1/2 cup) for [NAME] vegetable blend regular, mechanical soft and therapeutic diets; and, -A #12 scoop (1/3 cup) for the pureed [NAME] vegetable blend. From 12:22 p.m. to 12:35 p.m. when DA #1 served residents the [NAME] vegetable blend, she filled the #12 scoop (1/3 cup) half to three-quarters full. She did not fill the #12 (1/3 cup) scoop full. DA #1 said she was running out of vegetables in her steam table container. -However, the menu extensions indicated the residents should have received a 1/2 cup scoop of vegetables (see record review above). At 12:35 p.m. DA #1 put approximately 1/8th of a cup of vegetables onto a plate and said that's all she wrote, as the vegetable blend steam table container was empty. At 12:38 p.m. a container of the [NAME] vegetable blend was delivered. From 12:38 p.m. through the end of service, DA #1 served heaping spoonfuls of the vegetable blend. At 12:58 p.m. DA #1 prepared a mechanically soft texture plate by scooping two #12 scoops of mechanically soft meat and one heaping 1/2 cup scoop of vegetable blend before serving it to the resident. DA #1 said the meal was supposed to include couscous as well, but she had run out of the couscous, so she was just going with it. -The #12 scoop (1/3 cup), measuring 2.67 ounces (oz), was 1.33 oz less than the 1/2 cup (4 oz) specified on the menu extension sheet for the seasoned couscous, pureed seasoned couscous and pureed seasoned vegetable blend. B. Staff interviews The DM was interviewed on 4/10/25 at 1:35 p.m. The DM said DA #1 should have been serving a full 1/2 cup scoop of vegetables for each plate. The DM said DA #1 must have thought she was going to run out of vegetables, so she was nervous and overthinking the issue. The DM said the dietary staff were incorrect in using the #12 scoops for each menu item, as they should have been using the #8 (1/2 cup) scoop.

Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen and one of two nourishment refrigerators. Specifically, the facility failed to: -Ensure safe and appropriate storage of food items in the nourishment room refrigerators; -Ensure ready-to-eat foods were handled in a sanitary manner to prevent cross-contamination in the main kitchen; and, -Maintain a clean and sanitary kitchen to prevent the harborage of pests. Findings include: I. Failure to safely and appropriately store food items A. Professional reference The Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 4/17/25. It revealed in pertinent part, Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit (F) or less for a maximum of seven days. The day of preparation shall be counted as day one. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. (3-501.17) The Hormel Code Date and Handling Information 2022, retrieved from https://www.hormelhealthlabs.com/wp-content/uploads/HHL-Code-Date_Handling-Sheet-11_2022.pdf on 4/17/25. It revealed in pertinent part, Hormel Vital Cuisine Might Shakes, Great Shake Plus, and Nutritious Juice Drink, Shelf Life: unopened: 15 months frozen, refrigerated: 14 days thawed, bedside: up to two hours. B. Observations On 4/7/25 at 9:16 a.m., the following items were observed in the main walk-in refrigerator: -One opened container of half and half, unlabeled and undated; -Three pitchers of lemonade, unlabeled and undated; and, -A plastic bag containing multiple hotdogs and hamburger patties, unlabeled and undated. On 4/8/25 at 1:16 p.m., the following items were observed in the Pinion unit nourishment refrigerator: -An opened jar of sugar-free peach preserves, undated; -A carton of caramel macchiato iced coffee, with an open date of 2/22/25 and an expiration date of 11/29/24; -Four thawed cartons of Mighty Shake (oral nutritional supplement), with a date of 3/12/25; and, -Three thawed cartons of Mighty Shake with dates of 3/8/25, 3/4/25 and 3/15/25. On 4/8/25 at 1:16 p.m. an opened bottle of grape jelly, dated 1/9/25, was sitting on the Pinion nourishment room counter with a container of bread and a jar of peanut butter. The grape jelly was room temperature, and instructions on the bottle ready to refrigerate after opening. On 4/9/25 at 10:39 a.m. two opened bottles of grape jelly were sitting on the main kitchen food preparation counter with a jar of peanut butter. The grape jelly was room temperature and instructions on the bottle ready to refrigerate after opening. C. Staff interviews The Dietary Manager (DM) was interviewed on 4/7/25 at 9:35 a.m. The DM said the hotdogs and hamburgers were leftovers from the night before (4/6/25). The DM said the undated lemonade pitchers were from the night before (4/6/25) and the undated half and half container was from that morning (4/7/25). The DM said there was a new dietary aide who served the beverages and was still being trained. The DM said the kitchen staff usually kept leftovers for three to five days before throwing it away. The DM was interviewed a second time on 4/10/25 at 1:35 p.m. The DM said one of the dietary aides went through the nourishment refrigerators throughout the facility, checked their temperatures and went through the refrigerator contents once per day. The DM said the dietary aide recorded the temperatures of the refrigerators daily but did not record that he had gone through the contents of the refrigerators. The DM said Mighty Shakes should be thawed the day they were to be consumed. The DM said she thought the nursing staff were not diligent in looking at the expiration dates for items brought in by the residents or their families. II. Failed to ensure ready-to-eat foods were handled in a sanitary manner A. Professional reference The Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 4/17/25. It revealed in pertinent part, Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. (3-301.11) B. Observations During a continuous observation of the lunch meal service on 4/9/25, beginning at 12:01 p.m. and ending at 1:00 p.m. the following was observed: At 12:46 p.m. Certified Nurse Aide (CNA) #7 entered the Pinion unit nourishment room and said she needed to make a sandwich. CNA #7 retrieved a plastic bag of bread, grabbed two slices of bread with her bare hands and placed them on a plate. CNA #7 applied jelly to one slice of bread using a knife, then applied peanut butter to the other slice of bread. CNA #7 used her bare hands to close the sandwich and then used her bare hand to stabilize the sandwich as she cut it in half. C. Staff interview The DM was interviewed on 4/10/25 at 1:35 p.m. The DM said ready-to-eat foods should be handled with gloves after performing hand hygiene. The DM said the instance of the CNA preparing the sandwich with her bare hands should not have happened. III. Maintain a clean and sanitary kitchen to prevent the harborage of pests A. Professional reference The Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 4/17/25. It revealed in pertinent part, The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by using methods, if pests are found, such as trapping devices or other means of pest control and eliminating harborage conditions. (6-501.111) Floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable. (6-201.11) In food establishments in which cleaning methods other than water flushing are used for cleaning floors, the floor and wall junctures shall be covered and closed to no larger than one millimeter. The floors in food establishments in which water flush cleaning methods are used shall be provided with drains and be graded to drain, and the floor and wall junctures shall be covered and sealed. (6-201.13) B. Observations On 4/8/25 at 1:16 p.m. the window in the Pinion unit nourishment room was open approximately eight inches and did not have a screen on the window. The window lead to the resident smoking patio. On 4/9/25 at 10:39 a.m. during a follow-up tour of the main kitchen, the following was observed: -The window in the main kitchen was open approximately four inches and did not have a screen; -The dishwashing area floor had an area of several square feet covered with standing water; -The food preparation area had several tiles that were cracked or missing; -There was a gap approximately two inches wide between the floor and the wall in the dishwashing area; -Several holes in the back wall of the dishwashing area; -The bottom five inches of the wall in the dishwashing area had dirt accumulated on it; -A glue trap was positioned below the dishwasher which contained thirteen dead cockroaches; and, -A glue trap was in the trash can next to the dishwashing area which contained more than fifteen dead cockroaches. On 4/9/25 at 12:12 p.m. the following was observed in the Pinion unit nourishment room: -The baseboard was separated from the wall with a gap of approximately 1.5 inches and when pressed, two ants came out from behind the baseboard; -An ant was observed running along the edge of an empty plastic container below the steam table; and, -A hole in the wall below the handwashing sink, approximately twelve inches wide by six inches tall. On 4/10/25 at 12:50 p.m. the glue trap under the dishwasher was no longer in place. C. Staff interview The DM was interviewed on 4/9/25 at 10:52 a.m. The DM said the kitchen staff did regular maintenance in the dishwashing area and used a squeegee to push any spilled water into the drain. The DM said the building was older, and any standing water was from water spilling while the kitchen staff were washing dishes. The DM said the windows in the kitchen should not be open. The DM said the facility staff needed to install the window screens and air conditioning units in the kitchen and satellite kitchen. The DM was interviewed a second time on 4/10/25 at 1:35 p.m. The DM said the facility's pest control company installed the glue trap below the dishwasher as a preventative measure and had just serviced the building a few weeks prior. The DM said there were cockroaches on the glue trap because of the trap's proximity to the drain. The DM said she had not seen any cockroaches in the food preparation areas. The DM said the staff may have thrown the glue trap away the night prior as they were cleaning the dishwashing area. The DM said the maintenance staff were aware of the holes in the walls of the dishwashing area and that there were active work orders for them. The DM said the kitchen maintenance work was all in progress. The DM said she was not aware of the hole in the wall below the handwashing sink in the Pinion unit nourishment room. -Pest control records and maintenance records were requested on 4/10/25 at 6:01 p.m. but were not received.

Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease. Specifically, the facility failed to: -Ensure enhanced barrier precautions (EBP) were followed for R45 and R78, -Ensure proper hand hygiene was followed during wound care for R78, -Ensure housekeeping staff followed appropriate hand hygiene processes when cleaning resident rooms; and, -Ensure high touch surfaces in residents' rooms were cleaned. Findings include: I. EBP and hand hygiene failures A. Professional reference According to the Centers for Disease Control and Prevention (CDC), Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDRO)'s, (4/2/24), retrieved on 4/15/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ target gown and glove use during high contact resident activities. EBP may be indicated (when contact precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status and infection or colonization with an MDRO. Examples of high contact resident care activities requiring gown and glove use for EBP include: dressing, bathing/showering, transferring, providing hygiene, changing linens changing briefs or assisting with toileting, device care or use (central line urinary catheter, feeding tube, tracheostomy/ventilator), wound care (any skin opening requiring a dressing). According to the CDC Clinical Safety, Hand Hygiene for Healthcare Worker (2/17/24), retrieved on 4/15/25 from https://www.cdc.gov/clean-hands/hcp/clinical-safety, Know when to clean your hands: immediately before touching a patient, before performing an aseptic task such as placing an indwelling device or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or patient's surroundings, after contact with blood, body fluids or contaminated surfaces and immediately after glove removal. B. Observations During a continuous observation of wound care on 4/9/25, beginning at 11:30 a.m. and ending at 12:00 p.m., the following was observed: Certified Nurse Aide (CNA) #5 donned (put on) gloves and turned R45 on his side. Registered Nurse (RN) #1 donned gloves and applied skin prep to R45's left heel deep tissue injury (DTI). -However, CNA #5 and RN #1 failed to don a gown prior to high contact care for R45. Nurse Manager (NM) #2 washed her hands and gathered supplies. NM #2 donned gloves and removed the old, dirty dressing covering R45's stage 3 pressure ulcer on the sacrum. NM #2 changed gloves and sanitized her hands after removing the dirty dressing. NM #2 cleansed the wound with saline and applied skin prep around the wound. She then applied calcium alginate soaked in Dakin's solution into the wound bed, covered the wound with a Mepilex dressing, dated and initialed the dressing. She changed gloves and performed hand hygiene between each step in the process. -However, NM #2 did not don a gown prior to starting wound care. During a continuous observation on 4/9/25, beginning at 2:37 p.m. and ending at 3:15 p.m., the following was observed: Assistant Director of Nursing (ADON) #1 and Licensed Practical Nurse (LPN) #1 entered R78's room with wound care supplies on a sterile field created on top of a movable table. ADON #1 washed her hands and donned gloves before beginning R78's wound care. LPN #1 also donned gloves and assisted ADON #1 by holding R78 in position. ADON #1 prepared the supplies on the sterile field and then used a sterile swab to remove the soiled packing from within R78's wound. -However, ADON #1 and LPN #1 failed to don a gown prior to starting R78's wound care. ADON #1 grabbed a new sterile swab, folded new packing material over the top and placed it on her sterile field. ADON #1 flushed the wound with saline (salt water), dabbed around the wound with sterile gauze and used the swab to press the new, clean packing into the wound. -However, ADON #1 failed to change gloves after removing the soiled packing from R78's wound. ADON #1 removed her gloves, washed her hands, donned new gloves, and applied a skin protectant around the wound. She placed sterile gauze over the wound and secured all four sides with paper tape. She removed her gloves, wrapped the supplies up within the sterile field, threw out the supplies and sanitized her hands. C. Staff interviews ADON #1 and LPN #1 were interviewed together on 4/9/25 at 3:36 p.m. ADON #1 said normally, only gloves were worn when doing dressing changes, even if the wound was infected. She said EBP was worn when there were weeping wounds or wounds with resistant organisms. She said she did not think she had any training regarding EBP and was not aware that they were supposed to be wearing gowns for dressing changes. She said the wound doctor had not been wearing a gown for dressing changes. She said she should have changed her gloves after taking out the old packing. LPN #1 said she just started orientation at the facility and did not remember learning about EBP precautions. The Director of Nursing (DON), who was also the facility's Infection Preventionist (IP #1), and IP #2 were interviewed together on 4/10/25 at 10:18 a.m. The DON said he educated staff about EBP last summer (2024) when the policy came out. He said there were isolation carts for residents with catheters, wounds and other infections. He said the staff had used EBP for a previous resident that had a fungal infection, but somehow, they had forgotten about the other reasons for EBP precautions. He said EBP was needed for high-contact activities like bathing, dressing, incontinence care and linen changes for those residents. He said face shields were provided for residents with catheters to protect from splashing. He said he did not realize the focus had been lost until yesterday (4/9/25). He said he had started adding orders and care plans for EBP in the residents' electronic medical record (EMR). IP #2 said that she had already started re-educating staff about hand hygiene and EBP. IP #2 said the packet for new employees had information on EBP but somehow it had been forgotten. She said she would also address hand hygiene and EBP at the upcoming skills fair in August 2025. II. Housekeeping failures A. Professional reference According to Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, retrieved on 3/21/25 from https://www.journalofhospitalinfection.com/article/S0195-6701(21)00105-5/fulltext, High-touch surfaces are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease). Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. B. Observations During a continuous observation on 4/8/25, beginning at 9:13 a.m. and ending at 9:53 a.m., the following was observed: An unidentified Housekeeper (HK) sanitized her hands and donned gloves. She entered room [ROOM NUMBER], which was a triple occupancy room. The HK sprayed the bathroom toilet with Oxivir 5 sanitizer, wet a clean cloth with water from the sink and wiped the outside, rim of the toilet seat and sides. She scrubbed the inside of the toilet with the toilet brush and flushed the toilet. She wiped the top and outsides of the toilet again with the cloth and then placed the used cloth in a bag on her supply cart outside the room. -The HK failed to change gloves after cleaning a dirty area (the bathroom) before moving to a clean area (the bedroom). The HK then sprayed the mirror and sink with glass and multi-surface cleaner and wiped the area with clean cloths. She placed the used cloths in the bag on the cart and grabbed new ones. She cleaned the surfaces of the bedroom furniture, bed frames and lights for the three resident areas, changing cloths between steps. She cleaned the windows with a new cloth and window cleaner. She swept and then mopped the floor, using new mop heads for each resident area. At 9:53 a.m. the HK removed her gloves, exited room [ROOM NUMBER] and sanitized her hands. -The HK failed to clean and sanitize the high touch areas in room [ROOM NUMBER] including door knobs, light switches and the call lights. C. Staff interviews The Maintenance Director (MTD) was interviewed on 4/10/25 at 3:45 p.m. The MTD said it was necessary that the housekeeping staff changed their gloves before entering each room for cleaning. He said the staff should remove their gloves before leaving the room and wash or sanitize their hands afterward. The MTD said the housekeeping staff required high touch surfaces like call lights and door knobs to be cleaned at least twice per week unless the resident had an infection. He said he just learned today that gloves should be changed twice during a room clean, so he planned to do education on that.

Based on record review and interviews, the facility failed to ensure residents and their representatives had a right to participate in the development and implementation of their person-centered plan of care for two (#102 and #41) of four residents out of 37 sample residents. Specifically, the facility failed to invite R102's and R41's representatives to participate in the care conferences to review the resident's plan of care. Findings include: I. Facility policy and procedure The Service Plan policy, undated, was provided by the Health Information Manager (HIM) on 4/10/25 at 4:45 p.m. It read in pertinent part, Residents will have a service plan developed at move-in and with a change of condition. The purpose is to assist residents in maintaining independence, individuality, dignity and privacy through a written plan of care. The service plan is completed at move-in based upon the resident evaluation and level of care determination and initial wellness evaluation. It is expected that the resident will participate in the development and review of the service plans in all communities. The family, if the resident agrees, may also be present. Participation by the resident, family and all team members will be documented in the medical record. II. Resident #102 A. Resident status R102, age greater than 65, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease, bipolar disorder (mental illness), post traumatic stress disorder, chronic pain and history of pulmonary embolism (blockage of arteries in the lungs). The 2/22/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status score (BIMS) of zero out of 15. The resident was dependent on staff for hygiene, bathing and dressing. The resident needed assistance with eating and was independent with transfers. B. Resident representative interview The representative for R102 was interviewed on 4/7/25 at 2:40 p.m. The representative said she was supposed to meet with the resident's care team once a month but did not have any meetings with them. She said the facility had not called to tell her how the resident was doing. She said she was unable to visit due to her recent schedule changes and the facility had not called her for the last care conference. She said she did not remember the last time the facility called her. C. Record review The 11/18/24 quarterly collaborative care review documentation was reviewed and revealed that R102's representative did not attend the care conference. The section of the review that indicated to document the names of people who attended the collaborative care review was left blank. The facility staff that were documented as present during review were clinical services. The 2/22/25 quarterly collaborative care review documentation was reviewed and revealed that R102's representative did not attend the care conference. The facility disciplines that were documented as present during the review were clinical services, social services and therapy. The names of facility staff who attended were listed. -A review of the R102's electronic medical record (EMR) revealed there was no documentation that the resident's representative or the resident was contacted to attend the care conferences on 11/18/24 and 2/22/25. III. Resident #41 A. Resident status R41, age less than 65, was admitted on [DATE]. According to the April 2025 CPO, diagnoses included anoxic brain damage and dementia. The 1/8/25 minimum data set (MD) assessment revealed the resident was severely cognitively impaired with a BIMS score of three out of 15.The resident needed supervision with dressing, hygiene, bathing and transfers. He was independent at mealtime. B. Resident representative interview R41's representative was interviewed on 4/7/25 at 2:30 p.m. The representative said she used to be involved in the care conferences and had not attended a care conference with the facility in over a year. The representative said she previously joined the care conferences by phone but the facility had not invited her to recent care conferences. The representative said R41 did not know where he was and thought he was still in high school. C. Record review The 7/8/24 quarterly collaborative care review documentation was reviewed and revealed that R41's representative was not documented as present for the meeting. The facility staff documented as present for the meeting were a nurse and social worker. The 10/8/24 quarterly collaborative care review documentation was reviewed and revealed that R41's representative was not documented as present for the meeting and listed the resident's representative as his major decision maker. The facility staff documented as present were a nurse, dietary, connections and social worker. The 1/2/25 quarterly collaborative care review note documentation was reviewed and revealed that R41's representative was not documented as present for the meeting. The facility staff documented as present during review were clinical services and social services. The section of the review available to document the names of people who attended the collaborative care review was left blank. -A review of the R41's electronic medical record (EMR) revealed there was no documentation that the resident's representative was contacted to attend the care conferences on 7/8/24, 10/8/24 and 1/2/25. IV. Staff interviews The Social Services Director (SSD) was interviewed on 4/10/25 at approximately 9:00 a.m. The SSD said the care conference schedule was sent to the facility concierge and the concierge informed the resident when their care conference was scheduled. The SSD said most residents did not want to attend the care conference. The SSD said a resident representative could join join a care conference by video, in person or on the phone and were are always given those options. The SSD said the facility could also print the care conference notes and give the notes to the representative. The SSD said the previous social services assistant could have contacted the representatives to attend the care conferences and would try to find documentation of those records. -However, documentation that the resident representatives were notified of the care conferences was not provided. Assistant Director of Nursing (ADON) #1 was interviewed on 4/10/25 at approximately 9:00 a.m. ADON #1 said usually when R102's representative visited the facility a face to face informal meeting was held with her. ADON #1 said the facility provided updates to the representatives if they were unable to attend a care conference. The Director of Nursing (DON) was interviewed on 4/10/25 at 3:00 p.m. The DON said resident representatives should be invited to care conferences and the social services staff invited the representatives.

Based on record review and interviews, the facility failed to provide written notification of room changes for one (#55) of two residents reviewed for notifications out of 37 sample residents. Specifically, the facility failed to: -Provide timely written notification of a room change and the reasoning to R55's; and, -Honor R55's room preferences. Findings include: I. Facility policy and procedure The Room/Roommate Changes policy and procedure, undated, was provided by the Nursing Home Administrator (NHA) on 4/10/25 at 5:27 p.m. It read in pertinent part, The social services representative will serve as an advocate for the resident's right to remain in their room placement unless the resident requests a room change, or the move is necessary for improved provision of medical or community life services. If a room change is deemed necessary, the Social Service Representative will obtain verbal consent from the resident and/or responsible party. This is documented in the community life progress notes or on a room change form. If the resident or responsible party refuses to authorize the proposed change, they are given notice five days before the change will occur. The resident or responsible party will be asked to sign the notification. They have the right to appeal the change within those five days. The appeal will be reviewed by the grievance committee and if further appeal is needed, the state health department. If the resident or responsible party chooses to appeal the proposed change, the room change shall not be made until the appeal has been resolved. The social service representative will complete the room change notice form and distribute to everyone on the notice. II. Resident #55 A. Resident status R55, age 81, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included bipolar-type schizoaffective disorder (mental disorder), borderline personality disorder and muscle weakness. The 1/9/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. B. Observations On 4/9/25 at 2:57 p.m. R55 and the Health Information Manager (HIM) were observed talking in the hallway near the Pinion unit nurse's station. The HIM was holding a room change notification and was explaining what the form was to R55. The HIM said the room change notification was from when R55 had moved rooms in December 2024. The HIM said the facility had forgotten about the room change notification forms and were catching up on them. The HIM said the room change notification document documented the resident wanted to move rooms. R55 said she had not wanted to move rooms and did not want to sign the document. C. Record review A progress note, dated 12/14/24 at 11:09 a.m., revealed R55 and her family members complained about the quality, size and placement of the room R55 was being moved to. A progress note, dated 12/14/24 at 11:50 a.m., revealed R55 was involved in a physical altercation with her roommate. Both residents were separated. Plans were underway to relocate one of the residents to a different room to prevent further conflicts. A room change notification form, dated 12/14/24, revealed R55 was moved to a different room on the same unit. The form documented the room change was due to safety. The form was signed by a social services staff member on 12/14/24. -However, the form did not document that the resident was provided written notification of the room change. A room change notification form, dated 3/24/25, revealed R55 was moved to a different room on a different unit. The form documented the room change was due to the resident wanting to move rooms. The form was signed by a social services staff member on 3/24/25. -However, the form did not document whether consent for the room change was obtained and the form was not signed by R55. -Review of R55's electronic medical record (EMR) did not reveal any notes pertaining to R55 requesting to move rooms or the room move itself. D. Staff interviews Nurse Manager (NM) #1 was interviewed on 4/10/25 at 3:26 p.m. NM #1 said the resident or their representative needed to agree to move rooms and sign the room change document prior to the room change occurring. NM #1 said the social services team prepared the room change document. The Social Services Assistant (SSA) was interviewed on 4/10/25 at 3:53 p.m. The SSA said the process for a room change began with talking to the resident or their guardian to see if they wanted to change rooms. The SSA said the facility staff sometimes showed the resident or their guardian the new room would look like in order to get them to agree to the room change. The SSA said the resident or their representative would sign and date the room change notification form. The SSA said information about the room change would be documented in the resident's progress notes. The SSA said they needed to obtain a signature from the resident or representative approving the room change prior to moving rooms. The SSA said the social services team members prepared the room change notification form. The SSA said the facility recently started using the paper room change notification form and were previously writing a progress note in the resident's EMR saying the resident or their guardian agreed to the room change. The SSA said the residents had to agree to sign the room change notification form prior to moving to a new room. The SSA said the room change notifications on 12/14/24 and 3/24/25 should have been signed by R55. The Director of Nursing (DON) was interviewed on 4/10/25 at 4:44 p.m. The DON said room change notifications were done by the social services department. The DON said the social service team members had the resident or their representative sign the room change document or get verbal consent over the phone prior to moving their room to indicate the resident or representative agreed to the room change. The DON said the room change on 12/14/24 was for R55's safety. The DON said when a room change was needed for safety the resident did not get to refuse the room change.

Based on record review and interviews, the facility failed to develop a comprehensive care plan for one (#110) of three residents reviewed for care planning out of 37 sample residents to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to ensure a comprehensive care plan was developed to address R110's functional abilities and activities of daily living (ADL). Findings include: I. Facility policy and procedure The Service Plan policy and procedure, undated, was provided by the Nursing Home Administrator (NHA) on 4/10/25 at 5:27 p.m. The policy read in pertinent part, Residents will have a service plan developed at move-in to assist residents in maintaining independence, individuality, dignity, and privacy through a written plan of care. The service plan is completed at move-in based upon the resident evaluation and level of care determination and initial wellness evaluation. II. Resident #110 A. Resident status R110, age less than 65, was admitted on [DATE]. According to the April 2025 computerized physicians orders (CPO), diagnoses included quadriplegia (paralysis of all four limbs), legal blindness, encephalopathy (condition that causes dysfunction of the brain, resulting in altered mental state, memory loss, and other neurological symptoms) and chronic pain. The 3/8/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. The resident was dependent on staff for all ADLs. The assessment documented the resident was always incontinent of bowel and bladder. B. Resident representative interview R110's representative was interviewed on 4/7/25 at 4:10 p.m. The resident representative said she consistently told the nursing staff when R110 needed to have his incontinence briefs changed. The resident representative said she and another family member did most of R110's hygiene care. C. Record review -Review of R110's comprehensive care plan, revised 3/23/25, did not reveal a care plan focus or interventions pertaining to R110's quadriplegia or ADL abilities. A progress note, dated 12/2/24 at 3:19 p.m., revealed R110 was screened for ADL abilities. R110 was found to be totally dependent on staff for all ADLs. A progress note, dated 12/2/24 at 8:20 p.m., revealed R110 needed help with ADLs and was legally blind. Review of R110's Kardex (a staff directive tool) revealed the following directives: -Offer fluids and record intake; -Two-hour turns; -Ensure appropriate visual aides are available to support R110's participation in activities; and, -R110 was able to: (specify strengths). -The Kardex failed to identify what specific strengths the resident had or what he was able to do. -Additionally, there was no information documented on the Kardex regarding R110's ADLs, including the resident's toileting and transfer needs. III. Staff interviews Certified Nurse Aide (CNA) #2 was interviewed on 4/9/25 at 3:11 p.m. CNA #2 said the staff knew what ADLs the residents needed help with by referring to the residents' electronic medical records (EMR) and by working with the residents and getting to know them. CNA #2 said the EMR indicated whether the resident needed a hoyer lift, if they needed to have their incontinence brief checked or if they needed repositioning. CNA #2 said R110 was fully dependent on staff for assistance with ADLs. CNA #2 said R110 needed to be repositioned at least every two hours and needed to have his brief checked every 30 minutes as he was frequently incontinent of urine. CNA #2 said R110 was not able to tell the nursing staff if he needed to be changed. Licensed Practical Nurse (LPN) #3 was interviewed on 4/10/25 at 10:32 a.m. LPN #3 said the residents' ADL care plans were created by the floor nurses, the restorative and therapy team and the facility's MDS coordinator. -LPN #3 was not able to find an ADL focus documented on R110's comprehensive care plan. LPN #4 was interviewed on 4/10/25 at 11:22 a.m. LPN #4 said residents' ADL information was found in their care plan and on the resident's Kardex. LPN #4 said the ADL care plan was completed by the Director of Nursing (DON) on admission. LPN #4 said R110 was totally dependent on staff for ADLs. -LPN #4 was not able to find an ADL focus documented on R110's comprehensive care plan. Nurse Manager (NM) #1 was interviewed on 4/10/25 at 3:26 p.m. NM #1 said the ADL section of the care plan usually included ability information for residents, including their assistance levels needed for showers, support with eating, grooming, toileting and repositioning. NM #1 said R110 was totally dependent on staff but could communicate his needs verbally. The DON was interviewed on 4/10/25 at 4:44 p.m. The DON said the Assistant Director of Nursing (ADON) completed the ADL care plans. The DON said the ADL care plan typically contained interventions regarding repositioning, toileting and hygiene. The DON reviewed R110's EMR and said the resident did not have an ADL care plan. The DON said R110 was total care and was dependent on staff for ADLs. He said the ADL care plan would normally be used to let the staff know how to meet his needs.

Based on observations, record review and interviews, the facility failed to ensure two (#46 and #98) of three residents received treatment and care in accordance with professional standards of practice out of 37 sample residents. Specifically, the facility failed to: -Ensure physician's orders to treat R46's skin condition on his hands were followed; and, -Ensure R98's skin rash was addressed in a timely manner. Findings include: I. Resident #46 A. Resident status R46, age 69, was admitted on [DATE]. According to the April 2025 computerized physicians orders (CPO), diagnoses included alcohol dependence with alcohol-induced persisting dementia, dermatitis and psoriasis. The 3/13/25 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of eight out of 15. The resident was independent for all activities of daily living (ADL). The assessment documented the resident did not have any issues with his skin. The assessment documented the resident received applications of ointments/medications to locations other than his feet. B. Resident interview and observations R46 was interviewed on 4/7/25 at 1:04 p.m. R46 said his skin was itchy and that it hurt to hold a cigarette when he smoked. R46 said the facility staff tried to use different lotions for him but they did not help his skin. R46 said the facility staff were not presently doing anything to fix his skin and he just had to live with it. R46's palms were covered with patches of thick scaly skin, irritated red skin and there were cracks in the skin between each of his fingers. R46 was itching his hands throughout the interview and had flakes of skin on his pants and his chair. C. Resident representative interview R46's representative was interviewed on 4/10/25 at 8:24 a.m. The resident representative said he had a care conference with the facility every three months and the facility called him with any changes in R46's condition. The resident representative said he was not aware of any skin issues R46 was having. The resident representative said the facility would call him if they changed any of R46's medications. D. Record review The ADL care plan, revised 3/13/24, revealed R46 had an ADL self-care performance deficit due to his dementia. Pertinent interventions included performing skin inspections, observing for redness, open areas, scratches, cuts and bruises and reporting any changes to the nurse. -Review of R46's comprehensive care plan, revised 4/8/25, did not reveal any focus or interventions related to R46's dermatitis or psoriasis. Review of R46's April 2025 CPO revealed the following physician's orders: Triamcinolone acetonide 0.1% cream (topical steroid) with instructions to apply to the right palm topically three times a day for psoriasis, ordered 2/17/25 and discontinued 4/8/25 (during the survey process). Clobetasol propionate 0.05% cream (topical steroid) with instructions to apply to both hands topically two times a day for dermatitis, ordered 4/8/25 (during the survey process). A progress note, dated 3/7/25 at 4:23 p.m., revealed R46 was seen by the dermatologist that day (3/7/25). The dermatologist said she had performed a biopsy on R46's right hand and instructed the resident to keep his hand dry for 24 hours. The dermatologist said she would discontinue the triamcinolone cream and R46 would need to gently wash his hands and apply vaseline to his hands for ten days. -However, the triamcinolone cream was not discontinued until 4/8/25 (during the survey). A wound note, dated 3/13/25 at 4:29 p.m., revealed R46 had improved palmar psoriasis. R46 refused treatment intermittently, citing discomfort using the cream. The resident's left palmar region was nearly resolved. Treatment included using clobetasol 0.05% ointment as directed. -However, clobetasol was not added to R46's orders until 4/8/25, and the resident continued to receive triamcinolone cream instead. A wound note, dated 3/20/25 at 3:05 p.m., repealed R46 had decreased plaques and dryness, and his left hand had almost resolved. Treatment included using clobetasol 0.05% ointment as directed. -However, clobetasol was not added to R46's orders until 4/8/25, and the resident continued to receive triamcinolone cream instead. An interdisciplinary team (IDT) note, dated 3/26/25, revealed R46 had palmar psoriasis with crusted plaques. R46 was refusing treatment as he said the prescribed cream was uncomfortable. The plaques affected both hands and the left hand had nearly resolved. An IDT note, dated 4/2/25 at 1:45 p.m., revealed R46 had palmar psoriasis with mild crusted plaques and no open lesions. R46 refused treatment intermittently and stated he had discomfort using the prescribed creams. R46 was provided with encouragement to keep up with the treatments but was intermittently noncomplaint, resulting in a slow or stagnant progress. The left palmar area was nearly resolved. R46 underwent a biopsy of both palms to rule out eczema versus psoriasis and the results were pending. Treatment included clobetasol 0.05% cream and vaseline applied twice daily to both hands. -However, clobetasol was not added to R46's orders until 4/8/25, and the resident continued to receive triamcinolone instead. Dermatology notes, dated 4/4/25, revealed R46 was seen to follow up on a previous biopsy. The dermatologist ordered clobetasol propionate 0.05% topical ointment, with instructions to apply to hands twice daily for thirty days. Notes revealed the dermatologist offered to re-biopsy R46's hands as the previous biopsy was lost in the mail, but the resident declined the biopsy. There was concern for psoriasis but a biopsy would be needed to confirm the diagnosis. Clobetasol was re-prescribed as R46 had not been using the ointment. -However, the facility again failed to add the clobetasol order to R46's orders until 4/8/25, and the resident continued to receive triamcinolone cream instead. -Review of R46's electronic medical record (EMR) did not reveal any consent forms for the resident to be seen by the dermatologist or have the biopsy collected (see interviews below). E. Staff interviews Certified Nurse Aide (CNA) #3 was interviewed on 4/10/25 at 10:10 a.m. CNA #3 said R46 had issues with the skin on his hands. CNA #3 said the wound care team ordered medications for R46, along with a glove to keep his hand moisturized. CNA #3 said R46's skin looked better than it did before as he used to not be able to open his hand without the skin cracking. CNA #3 said R46 was independent and denied lotion whenever it was offered to him because he did not like lotion. CNA #3 said she reported any skin issues to the nurse or the unit manager, who would then alert the wound care team and assess the resident to see if the resident needed any treatment orders. Licensed Practical Nurse (LPN) #3 was interviewed on 4/10/25 at 10:32 a.m. LPN #3 said R46 had psoriasis on his palms and was being followed by wound care. LPN #3 said if a resident received new physician's orders during ancillary appointments, she would call the doctor to verify the order and put it in the EMR before calling the pharmacy to see when the medication would arrive. LPN #3 said R46 had triamcinolone cream ordered twice a day to help his skin and she had just finished administering it to R46. LPN #3 verified R46 was had triamcinolone cream ordered for his hands, and produced a box of triamcinolone cream from her medication cart with R46's name on it and said that was the medication she had administered that morning (4/10/25). -However, the order for triamcinolone cream had been discontinued on 4/8/25, and R46 had a physician's order for clobetasol ointment, initiated 4/8/25. LPN #4 was interviewed on 4/10/25 at 11:22 a.m. LPN #4 said R46 had clobetasol cream in his April 2025 CPO but he did not have triamcinolone cream ordered. LPN #4 said when a resident's medication was discontinued, the remaining medication should be removed from the medication cart and placed in the medication storage room to be picked up by the pharmacy for disposal. LPN #4 said R46 should only be receiving the clobetasol cream that was presently ordered. Nurse Manager (NM) #2 was interviewed on 4/10/25 at 2:45 p.m. NM #2 said residents were sent with a packet each time they received ancillary services for the physicians to fill out regarding what was done and any new orders prescribed for the resident. NM #2 said the packets were often sent back blank, so the facility staff would call the ancillary service physician, request any new orders and add them to the resident's EMR. NM #2 said there were times when there were delays in adding physician's orders if she was not in the facility or there was a new floor nurse. NM #2 said R46 began complaining about issues with his palms starting in February 2025, at which time his hands looked like they had a raised rash. NM #2 said the wound care team at the facility prescribed R46 the triamcinolone cream and did a biopsy on his hands, but the biopsy was lost in the mail. NM #2 said R46 was noncompliant with putting the prescribed creams on his hands as he did not like the creams. NM #2 reviewed R46's chart and said the clobetasol cream was ordered as of 3/13/25. NM #2 said there was a progress note, dated 3/7/25, in the resident's EMR which indicated the triamcinolone cream was discontinued on 3/7/25 (see record review above). NM #2 said she was out of the facility during the period of time in which the new physician's orders were received so that may have affected the facility's processes and the physician's order may have been missed in her absence. NM #2 said clobetasol was ordered for R46 and had been filled by the pharmacy, so R46 should have been receiving that medication as ordered. NM #2 reviewed R46's MAR and said the clobetasol cream had been marked as administered that morning. -However, LPN #3 administered triaminolone cream to R46 on the morning of 4/10/25 (see LPN #3 interview above). NM #2 said R46's representative needed to sign a consent form in order for the resident to be seen by the dermatologist and to have the biopsy performed. NM #2 reviewed R46's EMR and could not find any dermatology or biopsy consent forms in his record (see record review above). The Director of Nursing (DON) was interviewed on 4/10/25 at 4:08 p.m. The DON said there was no reason which should have caused the delay in the switch from triamcinolone cream to clobetasol cream for R46. The DON was interviewed a second time on 4/10/25 at 4:44 p.m. The DON said the facility's medical records staff member started in January 2025 and had a backlog of medical records to input. The DON said the facility had an issue with ancillary physicians writing orders for residents and the facility not receiving them. The DON said the facility did not have a good process for transferring orders when the dermatologist came in and prescribed new orders for residents. II. Resident #98 A. Resident status R98, age 69, was admitted on [DATE]. According to the April 2025 CPO, diagnoses included bipolar-type schizoaffective disorder and major depressive disorder. The 3/15/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident was independent for all ADLs. The assessment documented the resident did not have any issues with her skin. B. Resident representative interview R98's representative was interviewed on 4/10/25 at 8:15 a.m. The resident's representative said she learned at the resident's most recent care conference that the resident had rashes on her upper thighs. The resident's representative said the facility thought her rashes were caused by her underwear being too tight due to R98's recent weight gain. The resident's representative said R98 did not have any rashes anywhere else on her body except on her thighs. -However, the resident had additional rashes on her abdomen, chest and buttocks/groin area (see resident interview and record review below). C. Resident interview R98 was interviewed on 4/10/25 at 11:17 a.m. R98 said she was not sure if there was an issue with the soap she was using, but she had been getting red spots on her chest and stomach due to her itching. R98 said she had some dry spots on her legs as well, but the itch cream that the nursing staff gave her helped with those. D. Record review Review of R98's April 2025 CPO revealed the following physician's orders: Lantiseptic skin protectant with instructions to apply to the buttock and groin area to relieve skin rash every shift and after shower, ordered 3/27/25 and discontinued 4/10/25 (during the survey process). Lantiseptic skin protectant with instructions to apply to the abdomen, chest, buttock and groin area to relieve skin rash every shift and after shower, ordered 4/10/25 (during the survey process). Refer to dermatology for skin rash to abdomen, chest, and buttocks/groin area, ordered 4/10/25 (during the survey process). A skin evaluation, dated 3/8/25 at 10:01 a.m., revealed R98's skin was clean, dry and intact. A skin evaluation, dated 3/17/25 at 8:53 a.m., revealed R98 had a generalized rash to her abdomen and her left and right buttocks. R98 had a rash noted to her upper and lower left abdomen and to both glutes (buttocks). -However, the skin evaluation did not reveal whether the physician was informed of the resident's rash. A progress note, dated 3/18/25 at 4:50 p.m., revealed R98 had red spots all over her body and redness between her buttocks. Interventions included performing a skin check to determine the severity of the rash, removing any wet or damp clothing and reviewing recent foods, drinks, and environmental changes for a possible cause. -However, the progress note did not reveal whether the physician was informed of the resident's rash. A skin evaluation, dated 3/25/25 at 9:44 a.m., revealed R98 had a generalized rash to her abdomen, her chest, and her left and right buttocks. Notes revealed R98 had a rash present under both breasts and under each arm. R98 said the rashes itched. A skin check was performed, and the physician and the Assistant Director of Nursing (ADON) were notified. -However, the physician was not notified of R98's rash until 3/25/25, eight days after staff initially noted the rash (see progress notes above). -Additionally, there was no physician's order entered into the resident's EMR for a treatment for the rash until 3/27/25 and the initial physician's order did not include treatment to the resident's abdomen and chest (see physician's orders above). A skin evaluation, dated 4/3/25 at 5:03 a.m., revealed R98 had a generalized rash to her abdomen, her chest, and her left and right buttocks. A progress note, dated 4/10/25 at 5:19 p.m., revealed R98 was receiving Lantiseptic skin protectant to her buttock area for her skin rash. R98's rash appeared to be improving in size, and the resident was encouraged to dry her skin after her shower and apply the cream. R98's skin was otherwise intact and had no signs or symptoms of infection. A progress note, dated 4/10/25 at 5:27 p.m., revealed R98's representative consented to a referral to the dermatologist for the resident's skin rash. -However, the referral for the resident to see a dermatologist for her rash was not obtained until 4/10/25, during the survey, which was over three weeks after the rash was initially noted and spread to other areas on the resident's body. E. Staff interviews CNA #4 was interviewed on 4/10/25 at 9:16 a.m. CNA #4 said R98 had a rash all over her body the week or two prior. CNA #4 said she notified the nurse right away if she noticed an issue with a resident's skin. LPN #4 was interviewed on 4/10/25 at 10:22 a.m. LPN #4 said R98 had a rash on her buttocks and had a cream prescribed to treat the rash. LPN #4 said whenever she was notified about a skin issue on a resident, she assessed the resident then called their doctor. LPN #4 said the doctor would then give an order based on whatever type of rash the resident had and she would apply the medication as prescribed. NM #1 was interviewed on 4/10/25 at 3:26 p.m. NM #1 said R98 previously had an issue with her skin, so the nursing staff called her physician and received a physician's order for an over-the-counter cream. NM #1 said the cream prescribed to R98 was just to be used after her showers to help with itching, as the resident was generally itchy due to the dryness of her skin. NM #1 was interviewed a second time on 4/10/25 at 4:00 p.m. NM #1 said R98 only had a skin rash on her buttocks. NM #1 said R98 did not have any rashes anywhere else on her body, and that they were only administering the prescribed cream on her buttocks. -However, R98 had rashes covering several areas of her body (see record review and resident interview above). The DON was interviewed on 4/10/25 at 4:44 p.m. The DON said he had spoken with NM #1 to see if the nursing staff had contacted R98's physician about the rash on her chest. The DON said NM #1 told him the nursing staff were administering the prescribed cream to R98's abdominal folds, glutes, and groin region. The DON said he would ask NM #1 to change R98's Lantiseptic order to include administering the cream to her chest. The DON said the facility planned to refer R98 to the dermatologist if her rash was not healed by 4/15/25.

Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to treat and prevent pressure injuries for one (#45) of three residents reviewed for pressure ulcers out of 37 sample residents. Specifically, the facility failed to: -Provide timely assessment by a qualified person; -Provide timely interventions and treatment after new wounds were found; -Notify key individuals (hospice, wound specialist, primary physician) to ensure timely interventions, assessments, and updated care plans, were in place to avoid wounds from worsening; and, -Ensure wound care documentation was thorough and accurate. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA (2019), retrieved on 4/16/25 from https://www.internationalguideline.com/guideline, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate at risk individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedure The Pressure Ulcer policy and procedure, undated, was provided by the health information manager (HIM) on 4/10/25 at 4:39 p.m. It documented in pertinent part, Residents are assessed for skin integrity and wounds upon move-in with documentation in the move-in assessment in the electronic medical record (EMR). Residents with a wound or skin integrity issue at move-in will have weekly skin assessments using the skin integrity evaluation in the EMR until the wound is healed. Residents without wounds or skin integrity issues or recently healed wounds will continue having weekly skin evaluations using the skin integrity evaluation weekly in the EMR. Follow the provider orders for specific wound treatments. Following the identification of wounds, the care plan will be updated to reflect. III. Resident #45 A. Resident status Resident #45, age 74, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included major depressive disorder, dementia, overactive bladder, hemiplegia (paralysis to one side of the body) and hemiparesis (one-sided muscle weakness) following a cerebral infarction (stroke). The 2/19/25 minimum data set (MDS) assessment documented the resident had a short term memory problem based on the staff assessment for mental status. A brief interview for mental status was not conducted due to the resident being rarely/never understood. The assessment documented the resident was dependent on staff for eating, hygiene, bathing, dressing, rolling side to side and transferring. The assessment documented the resident was always incontinent of bowel and bladder. The assessment indicated the resident was at risk for pressure ulcers and did not have any skin conditions at the time of the assessment. The resident had a pressure reducing device for the chair and the bed, turning and repositioning, nutrition or hydration interventions and application of an ointment/medication to somewhere other than to the feet. The assessment indicated the resident did not have rejections of care. B. Resident observations On 4/9/25 at 11:30 a.m. Resident #45's wound care was observed with nurse manager (NM) #2, registered nurse (RN) #1 and certified nurse aide (CNA) #5. The resident's left heel had a dark purple/maroon deep tissue injury (DTI) that RN #1 applied skin prep to. Both heels were in soft booties. Resident #45 had a large crater-like wound that was dark brown/black in color at the middle or center of the wound on his sacrum. The skin around the wound was white and red in color. The old dressing NM #2 took off was brown in color with a moderate amount of drainage from the wound. When NM #2 removed the soiled dressing, RN #1 put her shirt up to her nose to mask the scent of the wound. NM #2 said the smell of the wound was from the purulent drainage that was brown in color. She said it was a stage 3 wound. NM #2 cleansed the wound with saline, applied calcium alginate soaked in Dakin ' s solution to the wound bed, applied skin prep around the wound bed and applied a foam dressing to the wound. C. Record review The pressure ulcer plan of care, initiated 3/29/19 and revised 4/8/25 (during the survey), documented that Resident #45 had potential for pressure ulcer development because of his episodes of incontinence, poor nutritional intake and refusals for repositioning. The care plan documented he had an actual wound on his coccyx and a DTI to his left heel. The care plan goal was for Resident #45 to have no significant alteration in skin integrity through the next review period. Interventions included administering supplements as ordered though he often refused supplements (initiated 4/8/25, during the survey), an air mattress (initiated on 4/8/25, during the survey), a Broda chair (initiated 4/8/25, during the survey), coordination with hospice (initiated 4/8/25, during the survey), pain management (initiated 4/8/25, during the survey), wound round checks with the wound care team (initiated 4/2/25), skin prep to heels and heel protectors on while in bed (initiated 4/8/25, during the survey), staff to reposition resident every two to three hours, though he often refused (revised on 4/8/25, during the survey), urinal will be made available at bedside (initiated 3/29/19) and a weekly skin assessment and to notify the physician of any refusals (initiated 3/29/19). -The facility failed to update the skin integrity care plan with interventions related to the actual pressure injuries until 4/8/25, 18 days after the development of the coccyx pressure ulcer and 20 days after the development of the left heel unstageable DTI. -The facility failed to implement timely interventions to prevent Resident #45's facility acquired stage 2 pressure ulcer from progressing to a stage 3 pressure ulcer. A Braden Scale assessment (a tool used for predicting pressure ulcer risk), dated 3/11/25, documented Resident #45 was at risk for developing a pressure injury. The risk factors included not always being able to communicate discomfort, occasionally being moist, his ability to walk was severely limited or non-existent, he had very limited mobility, adequate nutrition and a potential problem for friction and shear (skin slides around). A review of the wound care provider ' s (WCP) note, dated 3/20/25, revealed Resident #45 had an unstageable DTI to the left heel from pressure. It measured 1.2 centimeters (cm) by 1.5 cm. The skin was intact with purple/deep maroon discoloration. Recommendations from the WCP included skin prep to the wound once daily, off-loading the wound and floating the resident ' s heels while in bed. -However, there were no wound care orders for the resident ' s left heel DTI until 4/10/25 (during the survey) after the discrepancy was brought to the attention of the facility (see physician ' s orders below). A review of the nursing progress note, dated 3/22/25 and written by RN #1, documented a new facility-acquired stage 2 pressure ulcer to Resident #45 ' s coccyx with partial thickness skin loss with exposed dermis. It documented that barrier cream was applied and to refer to the wound care team. -However, there was no documentation that the WCP was notified. There was no follow up from the wound care team until 3/27/25, five days later, when the WCP was at the facility and after the resident ' s wound had advanced to a stage 3 pressure ulcer. A review of the WCP note dated 3/27/25, revealed Resident #45 had a stage 3 pressure wound to his coccyx with poor healing potential. The wound measured 2 cm by 2 cm, had moderate to sero-sanguinous exudate and 100% granulation tissue. The treatment was a foam dressing with border three times weekly with skin prep to the peri wound, off load and reposition per facility protocol. A review of CNA documentation for repositioning every two hours revealed Resident #45 refused only one offer to reposition in the 31 days in March 2025. -However, there were 17 days out of the 31 days in March 2025 where it was documented that the resident was repositioned on his back several hours consecutively. A review of Resident #45 ' s April 2025 CPO revealed the following physician's orders for wound care: Clean area of coccyx with wound cleanser, pat dry, apply Medi-honey to open area, skin prep around the wound bed and cover with bordered foam dressing, ordered 3/31/25. -The wound care was ordered 11 days after the development of the pressure ulcer to the coccyx (see progress notes above). Air mattress ordered related to skin integrity/wounds, settings on automatic firm, ordered 4/8/25. -The intervention was ordered 18 days after the development of the pressure ulcer to the coccyx (see progress notes above). Heel protectors on while in bed, ordered 3/17/25. -However, according to NM #1, the facility did not start using booties on the resident until after the development of the unstageable DTI to the left heel (see NM #1 interview below). Clean area with wound cleanser, pat dry, apply skin prep to DTI on inner right heel every shift, ordered on 3/17/25. -However, the DTI was on the resident ' s left heel. -The April 2025 CPO failed to reveal wound care orders for the resident ' s left heel unstageable DTI. E. Staff interviews CNA #8 was interviewed on 4/9/25 at 10:48 a.m. CNA #8 said Resident #45 would refuse to eat sometimes if he did not like the food. She said the staff tried to offer him alternatives if he did not like the food. She said he was incontinent and needed total assistance for all cares, including eating, repositioning and toileting hygiene. She said he did not refuse to be repositioned or to get his brief changed. NM #2 was interviewed on 4/9/25 at 11:30 a.m. NM #2 said when there was a new skin condition, the nurse who noticed it put a wellness alert in the EMR. She said this alerted the unit manager to get a referral for the WCP to see the resident. She said Resident #45 was at risk for developing pressure ulcers prior to the development of the injuries due to his poor nutrition, refusing repositioning, refusing floating his heels and refusing the booties until recently. She said Resident #45 was dependent on staff for repositioning. -However, review of the CNAs repositioning documentation for Resident #45 revealed he refused only one repositioning attempt in March 2025 (see record review above). CNA #3 was interviewed on 4/10/25 at 9:07 a.m. CNA #3 said Resident #45 did not refuse care. She said the only thing he would refuse at times was eating meals and supplements. She said he got up occasionally out of bed for meals and showers. She said he was incontinent and did not use the call light. CNA #3 said the CNAs went in and repositioned him and checked his brief every two hours. RN #1 was interviewed on 4/10/25 at 9:30 a.m. RN #1 said she was the nurse for Resident #45 on a 3/22/25 when she noticed his coccyx wound worsened. She said she reached out to the resident ' s hospice team to request a visit since the nursing managers were not at the facility on weekends. -However, there was no documentation to indicate that RN #1 reached out to hospice or obtained any new physician's orders for wound care. The WCP was interviewed on 4/10/25 at 10:30 a.m. The WCP said the stage 3 coccyx wound and the left heel DTI wound on Resident #45 were caused by pressure. She said initially she was concerned the coccyx pressure wound was a Kennedy ulcer (end of life wound), but ruled that out. She said he was at risk for developing pressure ulcers due to poor nutritional status, dementia, limited mobility, being bed-bound and refusing nutritional supplements. The director of nursing (DON) and assistant director of nursing (ADON) #1 were interviewed together on 4/10/25 at 11:30 a.m. The DON said when there was a new skin condition discovered, the nurse would write a progress note, the unit manager would review it and put in a referral to the wound care nurse (WCN) and the WCN would reach out to the WCP. The DON said every resident with a new skin condition got a referral to the WCP. He said the primary care physician (PCP) very rarely managed any resident wounds. ADON #1 said she was the wound care nurse at the facility ADON #1 said Resident #45 developed the left heel DTI due to rubbing his feet against the mattress. She said once this was discovered, he started to use soft booties on his heels. She said he was not using the booties prior to the development of the left heel wound. She said he developed his coccyx wound when she was not working so another nurse should have gotten the referral to get the WCP involved. She said she was not aware of the resident ' s coccyx wound until 3/27/25. -However, there was no documentation that another nurse assessed the resident ' s coccyx wound, notified the physician on 3/22/25 or obtained wound care orders (see record review above).

Based on record review and interviews, the facility failed to ensure the hospice services provided met professional standard and principles that applied to individuals providing services in the facility for one (#78) of four residents reviewed for hospice services out of 37 sample residents. Specifically, the facility failed to ensure the hospice agency's notes were easily accessible to the facility staff and had consistent communication and documentation of hospice care visits and updates. Findings include: I. Facility policy and procedure The Hospice Program policy, undated, was provided by the Nursing Home Administrator (NHA) on 4/7/25 at 11:01 a.m. It read in pertinent part, When a resident has been diagnosed as terminally ill, the director of wellness will contact a hospice agency and request that a visit/interview with the resident/family be conducted to determine the resident's wishes relative to participate in the hospice program and to review available hospice (services) with the resident and/or responsible party. The hospice agency retains overall professional management responsibility for directing the implementation of the plan of care related to the terminal illness and related conditions, which includes, designation of a hospice registered nurse to coordinate the implementation of the plan of care, and provision of substantially all core services that must be routinely provided directly by the hospice associates and cannot be delegated to the community as outlined in current hospice regulations. II. Hospice Agreement The hospice agreement, dated 1/14/25, was provided by the NHA on 4/10/25 at 3:50 p.m. The agreement read in pertinent part, Hospice and the facility shall each maintain complete and detailed clinical records concerning each resident receiving facility services and hospice services under the agreement in accordance with prudent record-keeping procedures and as required. Each clinical record shall complete, promptly and accurately document all services provided to, and events concerning each resident, including evaluations, treatments, and progress notes. Hospice and the facility shall have each entry made for services provided to be signed by the person providing the services. Each record shall be readily accessible and systematically organized to facilitate retrieval by either party. II. Resident #78 A. Resident status R78, age greater than 65, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included high blood pressure, psoriatic arthritis (inflammatory disease affecting skin and joints), depression, anxiety, dementia, history of neck and left femur fracture, stage 3 pressure ulcer and senile degeneration of the brain (decline in cognitive function). The 2/25/25 minimum data set (MD) assessment revealed the resident had a short-term and long-term memory problem and his cognitive skills for daily decision making were severely impaired per staff assessment. The resident was dependent on staff for hygiene, bathing, transfers and repositioning in bed. The MDS assessment revealed R78 was receiving hospice services. II. Record review The hospice plan of care, dated 1/15/25, was provided by the NHA on 4/10/25 at 11:32 a.m. The hospice plan of care documented the resident's personal hygiene was to be maintained. Pertinent interventions included care was to be completed by a hospice Certified Nurse Aide (CNA) that included CNA visits twice a week to provide a shower, shampoo, shave, mouth care, assist with dressing and undressing, nail care (file only), and skin observations. R78's hospice binder, was retrieved from a locked room and provided by Assistant Director of Nursing (ADON) #1 on 4/9/25 at 2:20 p.m. The hospice binder contained weekly visit verification forms signed by the hospice nurses. CNA visit notes were present in the binder from a 1/17/25 joint visit with a hospice nurse. -However, no other CNA notes, verification of hospice CNA visits or provisions of activities of daily living (ADL) care by hospice for the resident were present in R78's hospice communication binder or electronic medical record. Hospice nursing assessments were not present in the resident's hospice binder or electronic medical record (see facility follow up below). III. Staff interviews Licensed Practical Nurse (LPN) #2 was interviewed on 4/10/25 at 11:15 a.m. LPN #2 said the hospice staff saw R78 every Tuesday and Thursday. LPN #2 said the hospice staff checked in with the nurse upon arrival and after providing care for R78. LPN #2 said the hospice staff also provided R78 his shower. LPN #2 said she had not noticed that the hospice staff were not coming according to planned visits. LPN #2 said a hospice nurse and hospice CNA might come the same day or sometimes two nurses came the same day. LPN #2 said a hospice nurse had asked for the facility's hospice binder last week but the hospice staff did not usually ask for the hospice binder. LPN #2 said hospice staff could ask any staff person at the facility for the hospice binder, but she had only been asked for the hospice binder once. Certified Nurse Aide (CNA) #1 was interviewed on 4/10/25 at 11:25 a.m. CNA #1 said hospice staff were frequently at the facility and provided showers twice a week to R78. The Social Services Director (SSD) was interviewed on 4/10/25 at approximately 9:00 a.m. The SSD said that the facility and hospice team met monthly to make sure residents' needs were met and the facility invited the hospice team to the care conferences for the residents assigned hospice care. The SSD said ADL care was the primary responsibility of the facility and hospice was to provide additional ADL support. The SSD said R78's showers were the primary responsibility of the facility staff. ADON #1 was interviewed on 4/10/25 at approximately 9:00 a.m. ADON #1 said hospice CNAs were supposed to come twice a week to see R78 and the hospice CNAs checked in with the nurses when they arrived. ADON #1 said the facility did not have the hospice CNA notes for R78 and were in the process of acquiring those (during the survey). IV. Facility follow up The Health Information Manager (HIM) provided R78's hospice notes on 4/10/25 at 12:57 p.m. (during the survey). A review of R78's hospice notes revealed a 2/6/25 hospice note that documented that a care conference took place on 2/5/25 without hospice being notified and hospice staff reinforced with the facility staff to include hospice in future care conferences. The hospice notes did not include documented visits twice a week by a hospice CNA.

Based on observations, record review, and interviews, the facility failed to ensure that one (#1) of three sample residents and other residents residing on the facility's third floor remained as free from accidents as possible. Resident #1 was admitted to the facility on [DATE] for long-term care. The resident was severely cognitively impaired and impulsive with poor safety awareness. At the time of admission, he was assessed not to be at risk for elopement. However, after admission, staff reported he was always on the move, standing near the doors and observing people passing in and out. By [DATE], the resident had become increasingly agitated and made several attempts to leave, setting off alarms when he attempted to open the doors. At approximately 1:08 p.m. that day, the resident eloped from the facility. Video surveillance revealed the resident, wearing shorts, a short-sleeved shirt, and flip-flops, followed a staff member through the emergency exit door (kitchen delivery door) on the first floor before the door, which was on a 15-second delay, relocked. Attempts to locate and contact the resident by phone were unsuccessful. He was located by the police two days later ([DATE]), approximately ten miles away from the facility, in critical condition. The resident was transported to the hospital by ambulance where he was pronounced deceased . The facility failed to provide the resident with adequate services and support to prevent his elopement. Despite staff knowledge of the resident's escalating behaviors on [DATE], their interviews revealed a conflicting understanding of the resident's level of supervision that day, and progress notes and care plans failed to document interventions to minimize his safety risk. The facility further failed to take adequate steps after [DATE] to prevent additional elopements. According to the director of nursing (DON), since the incident on [DATE], all staff had received education to wait 15 seconds after exiting the emergency door to ensure the door was locked, and a sign was placed on the doors as a reminder. However, on [DATE] at 12:35 p.m. (during the survey), observations revealed an unlocked door to the boiler room next to the emergency exit door. Another door in this room led to the outside. Both doors were unlocked and not secured with an alarm. All residents from the third floor had access to the unlocked doors. According to the nursing home administrator (NHA), the boiler room door was to be locked at all times and she was unclear why it had been left unlocked. The facility failures above created a situation of immediate jeopardy for serious harm, for Resident #1 and widespread potential for serious harm for facility residents on the third floor, that required immediate corrective action. Findings include: IMMEDIATE JEOPARDY I. Immediate Jeopardy A. Findings of immediate jeopardy Resident #1 was admitted to the facility on [DATE] for long-term care. The resident was severely cognitively impaired and impulsive with poor safety awareness. At the time of admission, he was assessed not to be at risk for elopement. However, after admission, staff reported he was always on the move, standing near the doors and observing people passing in and out. By mid-day on [DATE], the resident had become increasingly agitated and made several attempts to leave, setting off alarms when he attempted to open the doors. At approximately 1:08 p.m. that day, he eloped from the facility. Video surveillance revealed the resident, wearing shorts, a short-sleeved shirt, and flip flops, followed a staff member through the emergency exit door (kitchen delivery door) on the first floor before the door, on a 15-second delay, relocked. Attempts to locate and contact the resident by phone were unsuccessful. He was located by the police two days later, approximately ten miles away from the facility in critical condition. The resident was transported to the hospital by ambulance where he was pronounced deceased . The facility failed to provide the resident with adequate services and support to prevent his elopement. Despite staff knowledge of the resident's escalating behaviors on [DATE], their interviews revealed a conflicting understanding of the resident's level of supervision that day and progress notes and care plans failed to reveal interventions to minimize his safety risk. The facility further failed to take adequate steps after [DATE] to prevent additional elopements. According to the director of nursing (DON), since the incident on [DATE], all staff had received education to wait 15 seconds after exiting the emergency door to ensure the door was locked and a sign was placed on the doors as a reminder. However, on [DATE] at 12:35 p.m. (during the survey), observations revealed an unlocked door to the boiler room next to the emergency exit door. Another door in this room led to the outside. Both doors were unlocked and not secured with an alarm. All residents from the third floor had access to these unlocked doors. According to the nursing home administrator (NHA), the boiler room door was to be locked at all times and she was unclear why it had been left unlocked. The facility failures above created a situation of immediate jeopardy for serious harm, for Resident #1 and widespread potential for serious harm for facility residents on the third floor, that required immediate corrective action. B. Facility plan to remove the immediate jeopardy On [DATE] at 5:48 p.m., the NHA provided a plan to remove the immediate jeopardy situation. The removal plan read: The boiler door was locked by the NHA on [DATE] at 4:32 p.m. On [DATE] at 4:33 p.m. no other doors in the community were found to lead to an exit. The boiler room was verified to be secured at 4:32 p.m. by the NHA. The maintenance director or a designated team member will conduct daily verification of the boiler door lock each morning. All checks will be documented in TELS. Staff were educated that locked doors need to be locked at all times sent via SmartLinx messages on [DATE]. The NHA reviewed the SmartLinx report to verify that all staff received the education on [DATE] at 5:53 p.m. Signs were placed on the boiler room door stating this door to be always locked - [DATE] at 6 p.m. Education was provided to staff about the elopement procedure and wandering interventions. [DATE] at 5:45 p.m. to 6:30 p.m., and [DATE] at 5:30 a.m. - 06:40 a.m. The staffing coordinator and director of nursing provided the education. The education is recorded on a training sign in sheet. On [DATE] at 5:00 p.m. the social services director reviewed the most recent elopement assessments for all residents to ensure those residents identified as at risk for elopement have interventions in place to prevent elopement. C. Removal of immediate jeopardy The NHA was notified the immediate jeopardy was removed on [DATE] at 2:30 p.m. based on the facility's removal plan (see above). However, the deficient practice remained at a G level, isolated, actual harm. II. Facility Policy The Elopement, Wandering, and Wanderguard policy, undated, was received from the NHA on [DATE] at 3:30 p.m. It read in pertinent part: Purpose: To identify residents at risk for wandering and/or elopement attempts and provide systematic approaches to manage these behaviors. Procedure: 1. Obtain resident photo. Insert photo in the electronic health record. 2. Each new resident is introduced to associates and data gathering begins on prior history of elopement or wandering through interviews with resident and family members. 3. Elopement Risk Tool will be completed as part of move in, then as needed per quarterly Wellness Re-Evaluation or with a change of condition. 4. Associates will develop the Care Plan for the resident addressing the risk for elopement, through consultation with resident provider, Care Team, and Family for the best practice related to elopement/wandering behaviors. 5. Wanderguard(C) systems (where available and in use) may be utilized for residents who exhibit wandering and elopement risk behaviors. Wanderguard(C) is added to the Care Plan for the resident. 6. Door alarms and Wanderguard(C) systems where applicable, are armed and checked as per policy to maintain them in good working order. 7. Associates will respond to door alarms to identify if an unattended Resident has exited any secure environment. In the event a Resident does elope, see policy for Elopement/Missing Resident policy. 8. Care Plan development may initiate per provider order: 15, 30 or 60 minute checks for physical location monitoring of any high risk resident and document the ordered checks. 9. Associate allows Residents to move freely within the community. III. Resident #1 A. Resident status Resident #1, age less than 65, was admitted to the facility on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included diabetes type 2, metabolic encephalopathy, and schizoaffective disorder. The [DATE] minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of six out of 15. The resident was independent with most activities of daily living. He was able to ambulate without a walker or cane. B. Record review 1. Admission assessments and care plans The admission note on [DATE] indicated that the resident needed prompts about safety as he lacked safety awareness in general. The care plan for behaviors initiated on [DATE] revealed Resident #1 was verbally aggressive due to schizoaffective disorder. Interventions included administering medications as ordered, providing opportunities for positive interactions, intervening as necessary to protect the safety rights of others, and diverting attention. The care plan for cognition initiated on [DATE] revealed Resident #1 had impaired cognitive function and impaired thought process due to schizoaffective disorder. Interventions included engaging the resident in simple structured activities. The care plan indicated that the resident needed supervision and assistance with all decision-making. It did not mention that the resident had a personal phone, and what type of assistance he needed with the maintenance of it, such as charging. The resident did not have a care plan for wandering behaviors. The elopement evaluation completed on [DATE] (three days after admission), indicated that the resident did not wander and was not at risk for elopement. A review of the resident's record revealed no documented behaviors before [DATE]. 2. Events on [DATE] At midnight, a nurse's note documented that the resident was pacing, screaming at others, and wandering. Attempted interventions of offering food and providing a calm environment were not effective. At 5:31 a.m., a note documented the resident was wandering through halls, screaming and making disruptive sounds and upsetting other residents. The resident was offered food, provided a calm environment, and was redirected; however, the resident's behavior did not change. A late entry note completed on [DATE] with the effective date of [DATE] summarized the events that followed. The note documented: -The resident's physician was contacted in the morning and gave an order for the psychotropic medication (Olanzapine, 5 milligrams, one time only for schizoaffective disorder). The medication was administered at 12:31 p.m., and the resident was observed for effectiveness and was reported by staff as effective. -Around 11:00 a.m., the resident was asked if he would agree to be placed on the secured unit for temporary placement, and as his own responsible party, he refused. The resident was on increased observation and was noted at the nurses' station around 1:06 p.m. -At 2:00 p.m., staff were not able to locate the resident in the facility. They completed a thorough search of all rooms and closets and were not able to locate the resident. -At 3:05 p.m., the resident was identified as missing. The late entry on [DATE] summarized the events above, documenting that Resident #1 became increasingly agitated and made several attempts to leave, setting off alarms when attempting to open the doors. The resident was combative and unable to be redirected. Staff administered psychotropic medication and placed the resident on every 15-minute checks unofficially to make sure medicine did not cause drowsiness. However, a review of the documentation from [DATE] above revealed no documentation of 15-minute checks, and interviews with staff (see below) revealed there was a conflicting understanding of the resident's level of supervision on [DATE]. In addition, there were no interventions to minimize his safety risk beyond the administration of the psychotropic medication, including no evidence of outreach to the family for information on effective interventions to address his behavior and safety needs. Resident #1's spouse was interviewed on [DATE] at 12:16 p.m. She said no one from the facility told her that the resident was at risk for elopement and they did not discuss his safety or options they had to keep him safe. She said on [DATE], she was working and she got a call from the facility around 2:30 p.m. The staff on the phone told her they could not find her husband. She said she took time off work and called her husband's brothers who drove from another city and they all went looking for him. She said facility staff advised her to call his cell phone as he might recognize her name and pick up the phone. She said the phone calls did not go through. 3. Facility investigation The facility's investigation of the elopement, initiated on [DATE] and completed on [DATE], revealed that the resident was located by police on the morning of [DATE] outside of the fenced building which was approximately 10 miles away from the facility. The resident was taken to the hospital where he was pronounced deceased . The review of the surveillance video from [DATE] revealed Resident #1 was wearing a blue short-sleeved shirt, gray shorts, white socks, and dark flip-flops when he entered the elevator on the third floor at 1:06 p.m. The resident exited the elevator around 1:08 p.m. He turned right into the hallway where a staff member was leaving through the emergency exit (kitchen delivery door). The resident followed the staff member through the door. 4. Police Report The police detective was interviewed by phone on [DATE] at 9:15 a.m. He said the initial call from the facility was received around 1:30 p.m. on [DATE]. His report read: On [DATE] early in the morning, the resident was located by police about 10 miles away from the facility location. He was in the fenced area that he entered in the morning of [DATE] (per the surveillance camera in the area). Upon discovery, the resident was in physical distress, the night temperature in the area was ,d+[DATE] degrees Fahrenheit. The resident was wearing a blue hoodie-style shirt, gray shorts, and worn-out socks. He had no shoes. The resident had a flip phone with him which was uncharged. Based on the last signal records from the phone, the battery has been uncharged since [DATE]. The resident was transported to the hospital by ambulance where he was pronounced deceased . C. Staff interviews Staff interviews revealed a lack of documentation on the resident's behavior before [DATE], conflicting reports on his behavior before [DATE], and conflicting understanding of the level of supervision provided on the day he eloped. 1. The director of nursing (DON) was interviewed in the presence of the NHA on [DATE] at 9:40 a.m. and again on [DATE] at 4:38 p.m. The DON said that on admission Resident #1 was not at risk for elopement. The DON said a comprehensive elopement assessment was completed by social services. Residents were observed for seven days after admission to establish a baseline of their behavior. He said if anything was observed that would require an intervention it was usually discussed in daily meetings. The DON said the resident was on frequent checks because he was started on a new medication and staff were watching for its effectiveness. He said on [DATE], the resident left the building around 1:06 p.m. through the emergency exit door by following a staff member. He said staff searched the building and attempted to call the resident as he had a phone with him, but there was no answer. The DON said since the incident, the facility provided education to all staff in the building to wait 15 seconds after exiting the emergency door to ensure the door was locked. In addition, signs were placed on all doors as a reminder. 2. Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 12:25 a.m. She said when Resident #1 was admitted , he was physically active and, at times aggressive. He was always on the move and took the tour of the building. He would usually stand near the doors and observe people passing in and out. She said the resident knew where he was but he did not fully understand why he was here. She said on [DATE], she was working on a different unit when she was notified by the nurse that Resident #1 was missing. She said she assisted staff in searching the entire building and after the resident was not located, she contacted the police and the administrator. After that, she reviewed the surveillance video where she observed the resident leave through the emergency exit door on the first floor near the kitchen area. The resident followed a staff member who was leaving through the door. The alarm was not triggered as the staff member used the fob to exit the door and the resident followed right after him. She said she did not know if the resident was on 15-minute checks on that day as she was not working on that unit. She said she received education after the incident to wait 15 seconds before walking away from the emergency door exit as it takes 15 seconds for the alarm to reset. 3. LPN #2 was interviewed on [DATE] at 12:50 a.m. He said he was the nurse who admitted the resident on [DATE]. He said the resident was confused and did not know why he was at the facility. He said the resident had impulsive behaviors and poor safety awareness. He noticed the resident had poor safety awareness when he observed him eating as the resident was putting too much food in his mouth before he was able to chew and swallow. He said the resident's daily routine was to walk throughout the building. He said he was told by other staff that the resident made attempts to open the doors and set off alarms. He said he was told by LPN #1 that it was the responsibility of social services to complete an elopement assessment on admission. He said he completed his nursing assessment but not the elopement assessment. He said his last education on elopement was sometime in October or [DATE]. 4. Certified nurse aide (CNA) #1 was interviewed on [DATE] at 1:15 a.m. He said he worked with the resident only on one occasion. He said he was working on [DATE] and when he returned from lunch he observed other staff around the resident who was attempting to leave through the emergency exit. He said Resident #1 was not his resident and he did not know if he was on 15-minute checks. He said he does not remember when his last education on elopement was. 5. LPN #1 was interviewed a second time on [DATE] at 1:45 p.m. She was interviewed in the presence of the assistant director of nursing (ADON). The LPN said the elopement assessment was usually completed by the nurse who admitted the resident and it's usually done within the three days of admission. The ADON said that three days would allow staff to observe the resident and see his baseline behavior. She said all behaviors should be documented in progress notes. She said since the incident on [DATE], all staff were educated to wait 15 seconds for the emergency door to lock before walking away from it. She said a reminder sign was placed on every emergency exit door in the facility. 6. CNA #2 was interviewed on [DATE] at 1:50 p.m. She said Resident #1 had always wandered since he was admitted . She said at times he would have bizarre behavior such as sitting on the floor. She said the resident was independent and was able to walk everywhere. She said she did not know if he was on 15-minute checks. She said other staff told her that the resident made attempts to leave, but it never happened on her shift. 7. LPN #3 was interviewed on [DATE] at 1:55 p.m. She said Resident #1 walked a lot everywhere, he was constantly up and down the elevator all day long. She said staff kept an eye on the resident since he was always on the move but she did not know if he was on 15-minute checks. She said she did not work with the resident on [DATE]. 8. The staff member Resident #1 followed out the emergency exit was interviewed on [DATE] at 10:45 a.m. He said on [DATE] around 1:00 p.m. he stepped away from the kitchen for a smoke. He said he exited the building through the emergency exit door near the kitchen. He said he did not wait 15 seconds for the door to lock. He said he did not see the resident exiting behind him. He said he had been working in the facility for the last three months and upon hire he received education to wait 15 seconds for the door to lock up. He said he did not wait for the door to lock on [DATE]. He said he was very sorry as he was aware of the incident. He said he was re-educated again after the incident to follow the 15-second rule for the emergency doors. 9. The social service director (SSD) was interviewed on [DATE] at 12:10 p.m. She said elopement assessments in the building were completed by social services assistants who were assigned to the unit. She said nurses had a small section on the initial assessment where elopement was mentioned; however, a comprehensive assessment should be completed by social services within seven days of admission. She said the rationale for seven days was that every resident has to be accustomed to the setting of the facility and would be observed for seven days for behaviors. She said observations were made for every newly admitted resident, but they were not documented daily. All observations would be documented in the assessment form on day seven when it was due. She said Resident #1 was admitted as he met the criteria for a mental health diagnosis. She said his initial stay was perfectly calm and he did not express the desire to leave the building. She said he did not trigger the risk of elopement until [DATE] when he was in distress. On [DATE], she was a supervisor on call and when she received a call about Resident #1's escalating behaviors she instructed the staff to continue to monitor him. She said the facility offered the resident a move to the secure unit, but he refused. She said even though his cognition was severely impaired and he was not a good advocate for his own safety, the facility was obligated to follow his refusal for a secure unit as respect for his rights. She said the resident's wife was not contacted at this point because the resident was his own responsible party and his wife was only listed as an emergency contact (not power of attorney). She said the facility staff did keep an eye on him; they observed him at the nurse's station, and then in his room later. The resident was on the 15-minute checks, but he left the building within the 10 minutes. She said if staff observed Resident #1 wandering behaviors and attempts to leave the building before [DATE], such behaviors should have been documented and the care plan for elopement should have been created. She said the interdisciplinary team met every day to discuss any changes and she did not recall any changes in Resident #1's behavior until [DATE]. D. Facility response to the [DATE] incident. The DON and the NHA were interviewed together on [DATE] at 4:38 p.m. The NHA said once the incident was identified on [DATE], staff reviewed the resident's record, and the interdisciplinary team met for its daily interdisciplinary meetings and discussed the incident. She said it was identified through the investigation that the staff member did not follow the 15-second rule after exiting through the emergency exit door, and he did not check if anyone was following him. She said the staff member was educated on the 15-second rule upon hire and provided the education log for him. The staff member and all other staff in the building were educated and reminded to wait 15 seconds after exiting through the emergency exit doors. She said signs were placed on all doors throughout the building as a reminder to staff. The DON said starting on [DATE], the facility started education for all staff to ensure they were aware of residents at risk for elopement on all units. Binders were created with pictures and care plans of residents who were identified at risk for the elopement. All staff were educated on specific interventions that were in place and the location of the binders at the nurses' station. The NHA said the incident was initially reviewed in the quality assessment performance improvement (QAPI) meeting on [DATE]. There, the facility identified several missing points from the records, including that detailed behavior with interventions was not documented, the resident was not monitored consistently in the unit, staff on the other units were not aware of residents at risk, and several nursing notes were completed (including skin assessments) after the Resident #1 eloped from the building. The corrective action started on [DATE] and continued throughout [DATE]. IV. The facility's failure to take adequate steps after [DATE] to prevent additional elopements. A. Observations on [DATE] at 12:35 p.m. On [DATE] at 12:35 p.m. (during the survey) observations revealed an unlocked door to the boiler room next to the emergency exit door. Another door in this room led to the outside. Both doors were unlocked and not secured with an alarm. All residents from the third floor had access to the unlocked doors. According to the nursing home administrator (NHA), the boiler room door was to be locked at all times and she was unclear why it had been left unlocked. B. The maintenance director was interviewed on [DATE] at 3:41 p.m. He said the boiler required some service on [DATE]. The service company was in the building on [DATE] and after they left he did not check if the boiler door was locked. He said he received an education from the facility on [DATE] on ensuring all doors that should be locked are locked. He said he checked the entire building on the evening of [DATE] to ensure every locked door in the building was locked and all emergency exits were functioning properly. He said he did not identify any additional unlocked or dysfunctional doors. He said he also placed a sign on the boiler door that it must be locked at all times. He said all emergency exit doors were checked once every week and he provided a log.

Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance and performance improvement (QAPI) program committee failed to identify and address concerns related to accidents and safety of residents, which rose to the level of immediate jeopardy and created a situation that a serious adverse outcome was likely. Findings include: I. Facility policy and procedure The facility's QAPI policy was requested from the nursing home administrator (NHA) on 12/11/24 at 4:50 p.m. -However, the policy was not provided as requested. II. Repeat deficiencies Review of the facility's regulatory record revealed it failed to operate a QAPI program in a manner to prevent repeat deficiencies in F689 Accidents/Hazards. During a recertification survey on 5/23/24, F689 was cited at a L level scope and severity, immediate jeopardy to resident health or safety, widespread. During an abbreviated survey on 10/23/24, F689 was cited at a G level scope and severity, actual harm, isolated. III. Cross-referenced citations Cross-reference F689: The facility failed to prevent an elopement of the resident. On 11/30/24 Resident #1 left the facility by following a staff member through the back emergency exit door on the first floor. He was located by the police two days (12/2/24) later, approximately ten miles away from the facility, in critical condition. He passed away in the hospital upon arrival. Observations of the facility on 12/10/24 revealed the boiler room door was unlocked. The additional door in the boiler room was unlocked as well and led to the outside. The facility's failure to ensure staff were waiting 15 seconds for the door to lock behind them after exiting through the emergency exit and the failure to keep the boiler door locked at all times, created a situation of immediate jeopardy with widespread potential for serious harm. IV. Interviews The director of nursing (DON) and the NHA were interviewed together on 12/11/24 at 4:38 p.m. The DON said a comprehensive elopement assessment was completed by social services. Residents were observed for seven days after admission to establish a baseline of their behavior. He said if anything was observed that would require an intervention, it was usually discussed in daily meetings. The NHA said once the incident with Resident #1 was identified on 11/30/24, staff reviewed the resident's record, and all met for daily interdisciplinary team (IDT) meetings and discussed the incident. She said it was identified throughout the investigation that the staff member that Resident #1 followed through the door did not follow the 15-second rule after exiting through the emergency exit door and he did not check if anyone was following him. She said the staff member was educated on the 15-second rule upon hire and provided the education log for the staff member. The NHA said the staff member and all other staff in the building were educated and reminded to wait 15-seconds after exiting through the emergency exit doors. She said signs were placed on all doors throughout the building as a reminder to staff. The DON said, starting on 12/10/24, the facility started education for all staff to ensure they were aware of residents at risk for elopement on all units. He said binders were created with pictures and care plans of residents who were identified as at risk for elopement. The DON said all staff were educated on specific interventions that were in place and the location of the binders at the nurses station. The NHA said the incident was initially reviewed in QAPI on 11/30/24 and the facility identified several missing points from the records, such as detailed behavior with interventions was not documented, the resident was not monitored consistently in the unit, staff on the other units were not aware of Resident #1's elopement risk and several nursing notes were completed after the resident eloped from the building. The NHA said corrective action in response to Resident #1's elopement started on 11/30/24 and continued throughout 12/10/24. V. Facility follow up On 12/11/24 at 4:50 p.m., during the survey, the NHA provided a copy of the quality measure report. The report was initiated on 11/30/24 after Resident #1 eloped from the building. The report indicated that the facility identified poor documentation for timeline of events, delay in obtaining as needed medications, failure to monitor resident on the unit, staff from other units being unaware of residents who were at risk for elopement and staff not waiting for the exit door to alarm before walking away. The education to all staff on ensuring exit alarms reengaged before walking away doors was completed on 12/3/24. The protocol was initiated to share information between units on residents unable to leave units on 12/5/24.

Based on record review and interviews, the facility failed to ensure one (#2) of four residents reviewed for accidents out of seven sample residents remained free from accidents. Resident #2, who was non-weight bearing with a history of osteoporosis and was known to be at risk for pathological fractures (fractures caused by disease processes rather than trauma), sustained bilateral distal femoral fractures (thigh bone above the knee) during a transfer with a mechanical (Hoyer) lift into a wheelchair. During the facility's investigation, it was identified that the type of Hoyer sling being used was a split leg sling which required the sling straps to be placed under and crossed around the thighs while the resident was being lifted out of bed and being transferred to the wheelchair. It was identified that the placement of the straps caused pressure and external rotation on the resident's thighs while being lifted with the Hoyer lift and was consistent with the location of Resident #2's fractures. Due to the facility's failure to ensure Resident #2's lower extremities were handled without undue pressure and alignment was maintained during a hoyer transfer, Resident #2 sustained bilateral femoral fractures on 9/13/24 which resulted in hospitalization and an open reduction internal fixation (surgical repair) of the fractures. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 10/23/24, resulting in the deficiency being cited as past noncompliance with a correction date of 9/25/24. I. Incident on 9/13/24 The facility failed to ensure Resident #2's lower extremities were handled appropriately, without undue pressure and in alignment of her lower extremities during a hoyer transfer into a wheelchair. Due to the facility's failure, Resident #2 sustained bilateral distal femoral fractures on 9/13/24 which resulted in hospitalization and surgery to repair the fractures. Record review and interviews during the onsite investigation confirmed the deficient practice had been corrected and the facility was in substantial compliance at the time of the investigation on 10/23/24. II. Facility plan of correction A. Immediate action to correct the deficient practice for Resident #2 The 9/13/24 facility incident report identified Resident #2 was being transferred from her bed to her wheelchair by a Hoyer lift. Resident #2 was being lowered into her wheelchair when a popping noise was heard and Resident #2 complained of pain in her lower extremities. Resident #2 was evaluated by nursing staff and given Tylenol and a lidocaine patch (topical pain patch). After lunch on 9/13/24, the resident continued to complain of pain and the physician was notified. An x-ray of her right knee was ordered. A fracture of the right femur was confirmed and the resident was transported to the hospital for further evaluation. On 9/16/24 (three days after the incident), the facility conducted an investigation of Resident #2's accident. The facility interviewed all staff on duty who were involved in care for the resident on the day of the accident (9/13/24). All interviewed staff said Resident #2 was being moved from her bed to her wheelchair using a Hoyer lift and as she was being lowered into the wheelchair a popping noise from the resident's lower extremities was heard. She was evaluated by the nurse and given Tylenol and a lidocaine patch. Resident #2 continued to complain of pain and the physician was notified and a right knee x-ray was ordered. The 9/16/24 investigation documented Hoyer lift safety education and repeat demonstration, last calibration and safety inspection were performed on 6/28/24. The 9/18/24 interdisciplinary (IDT) risk management note identified during Resident #2's Hoyer lift transfer from bed to wheelchair, the resident complained of increased pain in her right knee. No deviations in the transfer or care were identified. The note documented that upon Resident #2's return from the hospital to the facility, the use of a full body sling would be implemented during Hoyer transfers for the resident to prevent pressure on the lower extremities. Additionally, the facility would report the resident's transfer injury to the sling manufacturer. The 9/18/24 vendor mechanical lift calibration log identified the facility's mechanical lifts passed the safety inspection on that date. The 9/25/24 inservice documented Hoyer lift transfer competency with full body sling and geri chair. The September 2024 quality assurance and performance improvement (QAPI) report in response to Resident #2's accident while being transferred on 9/13/24 was provided by the nursing home administrator (NHA) on 10/23/24 at 4:12 p.m. The QAPI report identified Resident #2's bilateral femoral fractures during a hoyer lift transfer and the use of a full body sling as an intervention upon her transfer back to the facility. It discussed training for staff on Hoyer lift transfers and the use of full body slings. The root cause analysis, undated, identified a review into staff education regarding Hoyer lifts and transfer training prior to incident and Hoyer and transfer training post incident. It identified Hoyer and mechanical lift calibration preventative maintenance before and after the incident. It identified an audit of damaged slings with none identified and to increase sling par level. It indicated a review of documentation of preexisting health conditions, medication and diagnosis list and physician documentation. B. Identification of other residents The facility completed an audit and identified other residents in the building who were at risk due to using the Hoyer lift for transfers. A total of four other residents were identified and assessed for appropriate Hoyer lift slings. C. Systemic changes Nursing leadership re-educated the nursing staff in regards to Hoyer lift safety and the use of full body slings in an effort to prevent further accidents with Hoyer lifts for facility residents on 9/16/24 and 9/25/24. D. Monitoring The IDT, the director of nursing (DON) and the assistant director of nursing (ADON) were responsible for identifying and ensuring all residents that required Hoyer lifts for transfers had the appropriate sling. They were additionally responsible for ensuring all nursing staff were provided the education and reeducation on the correct use of Hoyer lifts and full body slings. III. Professional reference According to the Food and Drug Administration (FDA) Patient Lifts Safety Guide (10/1/24), retrieved on 10/24/24 from https://www.fda.gov/medical-devices/general-hospital-devices-and-supplies/patient-lifts, To increase patient safety, use the correct type and size of sling for your patient. Select sling and sling bar based on manufacturer recommendations for the following criteria: type of transfer task, patient's medical condition, patient's size and weight, pressure sensitivity, need for full back support, need for head support, need for padding, patient' preferred or medically appropriate position. IV. Resident #2 A. Resident status Resident #2, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included dementia, fractures of left and right femur and osteoporosis. The 10/8/24 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. She was dependent with toileting, personal hygiene, bed mobility, transfers and required setup assistance with eating. B. Record review The osteoporosis care plan, initiated 11/14/23 and revised 9/23/24, revealed Resident #2 had osteoporosis related to non-weight bearing status, being female and elderly. Interventions included monitoring, documenting and reporting complications related to osteoporosis, including fracture, loss of height, kyphosis (thoracic curvature of spine) and pain. The pathological bone fracture care plan, initiated 1/10/24, indicated Resident #2 was at risk for pathological bone fractures due to osteoporosis and severe demineralization of bones. Interventions included handling the resident gently when moving her and maintaining body alignment. The Hoyer lift care plan, initiated 10/9/23 and revised 9/23/24, revealed Resident #2 required the Hoyer lift the all transfers. -However, the care plan failed to identify the new intervention of using a full body sling for all of Resident #2's transfers following the 9/13/24 incident where the split leg sling was identified as a causative factor of the resident's bilateral femoral fractures. According to the accident incident report, on 9/13/24 Resident #2 was being transferred from her bed to her wheelchair by a Hoyer lift. As the resident was clearing the bed and being lowered to the wheelchair, an audible popping sound was heard. Resident #2 began expressing more pain than normal and said that it was in her right leg. The certified nurse aide (CNA) notified the nurse to evaluate the resident's pain. Resident #2 was administered Tylenol and a lidocaine patch. The resident continued to complain of pain, the physician was notified and an x-ray of her right knee was ordered. The x-ray confirmed a fracture of her right femur and the resident was transported to the hospital for further treatment. According to the hospital discharge summary, dated 10/1/24, Resident #2 was admitted to the hospital on 9/13/24, after she experienced a right distal femoral fracture during a Hoyer lift transfer. The discharge summary further revealed it was discovered after the resident was admitted to the hospital and that she also had a left distal femoral fracture. Resident #2 underwent surgery on 9/15/24 for an open reduction internal fixation of her bilateral femur fractures. Resident #2 was readmitted to the facility on [DATE]. V. Staff interviews CNA #1 was interviewed on 10/23/24 at 1:42 p.m. CNA #1 said she and CNA #2 were transferring Resident #2 from the bed using a hoyer lift with a split leg sling that had straps that crossed under the thighs. She said as they were lowering her into her wheelchair they heard a popping sound. She said they finished lowering her into the wheelchair and she went to get the nurse to evaluate the pain that the resident was experiencing in her leg. Licensed practical nurse (LPN) #1 was interviewed on 10/23/24 at 1:45 p.m. LPN #1 said Resident #2 usually complained of pain while being transferred but 9/13/24 was the first day she continued to express pain after she was transferred into her wheelchair. She said Resident #2 continued to complain of leg pain after they had taken her to the dining room. She said she was given Tylenol and a lidocaine patch. She said Resident #2 continued to complain of pain and the facility contacted the physician and obtained physician's orders for an x-ray of the resident's right leg. She said after the x-ray was done, it was confirmed that there was a fracture in the resident's right femur. LPN #1 said Resident #2 was transported to the hospital via ambulance for further evaluation. She said after the resident was transported to the hospital, the facility found out that Resident #2 had fractures in both femurs. The DON was interviewed on 10/23/24 at 1:45 p.m. The DON said nursing staff, along with restorative nursing staff, had a meeting the following morning (9/14/24) after they found out that Resident #2 had bilateral femur fractures after being transferred into a wheelchair with a Hoyer lift. He said the staff did a demonstration using a split leg sling for a Hoyer lift during the investigation. He said during the demonstration, the Hoyer lift transfer, they identified that the straps from the sling that crossed under the resident's thighs caused the thighs to externally rotate and, depending on placement, could rest under the thighs above the knee. He said Resident #2 had a history of osteoporosis, was non-weight bearing and was at a high risk for fractures. The DONsaid the facility contacted the mechanical lift company to report the incident and the company told them they were not aware of a similarly reported incident. He said one intervention that was identified during the root cause analysis was to use only a full body sling to help keep Resident #4's legs in alignment and prevent contortion or pressure on the legs once she returned from the hospital. He said the other intervention the IDT identified was to conduct nursing staff reeducation on the use of Hoyer lifts and on the correct placement of the mechanical lift slings. He said they had enough full body slings in the facility to give to the four residents identified in the audit as using Hoyer lifts for transfers. VI. Facility follow up On 10/24/24 at 2:27 p.m., after the survey exit, the NHA sent a follow up email. In the email, the NHA said the IDT team, the DON and the ADON were responsible for ensuring the interventions identified were completed. She said reeducation with CNAs about Hoyer lift and proper slings began on 9/13/24 and continued 9/16/24, once the facility was updated from the hospital regarding Resident #2's bilateral femoral fractures. She said, to date, all nursing staff had been educated on the Hoyer lifts and slings. She said all identified residents that required the Hoyer full body slings had been distributed to the identified residents and the facility had a sufficient par level of the full body slings. The NHA said the facility was in the process of ordering additional full body slings to have on hand if needed. -However, despite the NHA's email indicating staff education for the Hoyer lifts started on 9/13/24 and continued on 9/16/24, according to the inservice education documents provided by the facility during the survey, the dates of the staff education were 9/16/24 and 9/25/24 (see facility plan of correction above).

Based on observations, interviews, and record review, the facility failed to have a plan to ensure staff were trained and had the necessary equipment to emergently evacuate residents from the facility, affecting the safety of all 130 facility residents. Review of the facility floor plans, observations, and interviews revealed three facility emergency exits that led to two outdoor courtyards. Each exit had an EXIT sign that pointed to the courtyard doors. Observation of the outdoor courtyards revealed one of the courtyards had three exits through gates secured with padlocks that required a key to unlock. Staff reported they did not know where to locate a key to release the padlocks on the gates. The second outdoor courtyard revealed one exit through a gate. This gate was secured with a C clamp (device to hold objects together), that required a tool to remove it. Staff reported they did not know how to remove the C clamp on the gate. The facility's failure to have a plan to ensure staff were trained and had the necessary equipment to evacuate residents from the facility emergently created a situation of immediate jeopardy with widespread potential for serious harm. Further review, observation, and interviews revealed the facility failed to take sufficient steps to prevent Resident #45's fall with injury and failed to develop and implement appropriate and effective fall interventions given the resident's known cognitive and functional limitations and behaviors. Findings include: IMMEDIATE JEOPARDY I. Immediate Jeopardy A. Findings of immediate jeopardy Staff interviews revealed the facility failed to have a plan that ensured the safe evacuation of residents from the facility in an emergency. Observations revealed the facility had three floors. Forty-six residents resided on the second floor and 84 residents resided on the third floor. Evacuation floor plans were posted on the wall on each floor. Directional arrows showed the path to follow in the event of evacuation. Review of the facility evacuation plans, observations, and interviews revealed the second floor plan had two stairwell exits and two ramp exits with egress doors that led to a courtyard with an egress gate. The gate was equipped with a broken magnetic lock and secured with a C clamp that required a socket wrench for removal so that staff and residents could evacuate from the second floor. Review of the facility evacuation plans, observations, and interviews revealed the third floor plan had an emergency exit through the recreation area (patio) that opened into a gated courtyard. The main exit from the courtyard had a padlock on the gate. The secondary path to exit the courtyard had a padlock on the gate, which led to another small fenced-in area with a padlock on the gate. Another path showed direction out another door, which led to the gated patio. The staff interviewed were unaware of any process to evacuate residents and reported they did not have access to keys to unlock the padlocks on the gates or knew how to remove the C clamp. The environmental services director (ESD) said he held the only key to all three padlocks and the C clamp required a socket wrench for removal. He said the C clamp was temporary but the padlocks on the gates were placed at the direction of the previous nursing home administrator (NHA) to keep outside people from getting in and keeping residents from leaving the community. Staff demonstrated a lack of understanding and training with the plan for evacuation and observations revealed the presence of physical barriers (padlocks and C clamp) that prevented staff and residents from evacuating the premises. The facility's failure to have a plan that ensured the safe evacuation of residents created a hazardous environment with the potential for serious harm, affecting 130 facility residents. B. Facility plan to remove the immediate jeopardy On 5/15/24 at 2:18 p.m., NHA provided a plan to remove the immediate jeopardy situation. The removal plan read: Plan of Correction: -All padlocks have been removed on 5/14/24 at 2:00 p.m. C clamp was removed on 5/14/24 at 3:30 p.m. The consultants provided interdisciplinary team (IDT) members training and education on never placing padlocks on emergency egress gates. -The ESD and consultants completed a walkthrough of the community on 5/15/24. Verified all locks were removed. Recommendations were made to change the layout of primary exit doors on 5/15/24. The ESD updated the emergency exit floor plan to reflect the necessary changes to the emergency exits on 5/15/24. Additionally, the ESD updated the emergency exit signage and removed emergency exit signs that will no longer be emergency exits on 5/15/24. All staff were re-educated on looking for emergency exit signs and new emergency exits on 5/15/24. -The community is purchasing a new emergency preparedness (EP) manual. This manual will arrive 5/16/24. The consultants will provide education and training with the NHA/ESD on the content of the EP manual 5/15/24. -All community staff (IDT members, licensed nursing, nursing assistants, dietary, housekeeping/maintenance) have been educated on the procedure to evacuate a resident in case of an emergency on 5/14/24 and 5/15/24 between 6:00 a.m. and 2:00 p.m. for first shift, second shift between 2:00 p.m. to 10:00 p.m. and between 10:00 p.m. to 6:00 a.m. for third shift. Specifically, staff received additional training and education on 5/15/24 on the following: Evacuation Procedure - 1. Staff members have been trained to pull fire alarm in the event of an emergency that would require potential evacuation / call 911. 2. Designate staff member to complete and maintain resident tracking 3. Evacuation exit doors /community evacuation floor plan 4. Phases of evacuation including Phase 1 ambulatory Phase 2 wheelchair dependent Phase 3 bed bound. -The community ordered five evacuation sleds for emergency exits with stairs. The emergency sled will be stored in the stairwell. When the sleds arrive the ESD will provide education and training with staff on how to use the emergency sleds. In the meantime, the ESD trained community staff on the use of a mattress to transport wheelchair or bed bound residents. -All community staff (IDT members, licensed nursing, nursing assistants, dietary, housekeeping/maintenance) have been educated on the location of the disaster preparedness binders and where to find them on 5/14/24 and 5/15/24 between 6:00 a.m. and 2:00 p.m. for first shift, second shift between 2:00 p.m. to 10:00 p.m. and between 10:00 p.m. to 6:00 a.m. for third shift. All departments have been provided the education with signatures. -When the new emergency manual arrives the community will remove old manuals. -The ESD /NHA confirms no other doors or exits have physical barriers. All secured /locked evacuation routes can be quickly opened to safely evacuate residents. -Emergency doors will be checked daily by the ESD or designee for one week for functioning and accessibility. The ESD or designee will check the emergency door weekly for a month and report to the QAPI committee for review and recommendations. Recommendations made by the QAPI committee will be executed by the ESD or designee. -Facility staff will continue to be trained on evacuation routes and procedures monthly during scheduled drills. -The IDT team will complete visual door checks on emergency exits to ensure there are no barriers present daily. The checks will be documented on an audit sheet. These visual checks will be conducted daily for 30 days. Findings of the audits will be reported to the QAPI committee for review and recommendations. The Administrator will be responsible to execute findings of the QAPI committee related to ongoing audits and frequency of the audits. -Emergency Preparedness will be reviewed monthly in QAPI and Safety Committee monthly for three months and quarterly thereafter. C. Removal of immediate jeopardy The NHA was notified the immediate jeopardy was removed on 5/16/23 at 5:07 p.m. based on the facility's removal plan (see above). However, deficient practice remained at a G level, with a potential for more than minimal harm that is widespread. II. Facility Policy The facility's evacuation plan was received from the NHA on 5/14/24 at 1:30 p.m. It read in pertinent part: -A Community specific Evacuation plan is developed and posted. -Residents and staff are trained on evacuation routes and procedures on a monthly basis during scheduled drills. -Routes for evacuation may change due to the location, therefore use the nearest exits, avoiding the fire, as directed by the individual in command. Evacuation is made to a fire safe area. The fire safe areas for the community are the parking lot across from the church which is located on the northeast corner of 30th and [NAME]. - The procedure for building evacuation is as follows. a. Residents in immediate danger shall be evacuated first. b. Residents closest to danger will be evacuated next (adjacent, across and above fire). c. Ambulatory residents shall then be assisted d. Residents who are unable to evacuate independently (due to cognitive, psychological, or physical reasons) shall be assisted next. -Evacuation, if necessary, is conducted under the direction of the Executive Director prior to the arrival of the Fire Department. III. Observations, interviews, and record review revealed the facility failed to have a plan to ensure staff were trained and had the necessary equipment to evacuate residents from the facility emergently. A. Observations Observations revealed the facility had three floors. Forty-six residents resided on the second floor and 84 residents resided on the third floor. Evacuation floor plans were posted on the wall on each floor. Directional arrows showed the path to follow in the event of evacuation. Three facility emergency exits led to two outdoor courtyards. Observation of the second floor courtyard emergency exit on 5/14/24 at 1:45 p.m. revealed the gate which allowed exit from the courtyard in the event of an emergency was secured with a C clamp and two screws. There was an illuminated exit sign above the door leading to the courtyard and an emergency exit route map posted on the wall that directed people to exit through the courtyard. Observation of the third floor courtyard emergency exit on 5/14/24 at 1:52 p.m. revealed a main gate to exit the courtyard, a side gate to exit the courtyard, and yet another gate to exit the side yard. Each gate was equipped with a padlock that prevented the gates from opening. There was an illuminated exit sign above the door leading to the courtyard and the side yard and emergency exit route maps posted on the wall which directed people to exit through the courtyard and the side yard. B. Staff Interviews Certified nurse aide (CNA) #7, who worked on the third floor, was interviewed on 5/14/24 at 2:03 p.m. She said she did not know the evacuation route in case of an emergency. She said usually she would get the residents who ambulate out first, probably down the stairs. She said if the stairway was blocked, she would go to the smoking patio but she did not know the protocol because that area was gated and locked. CNA #2 and CNA #3 were interviewed together on 5/14/24 at 2:06 p.m. They said in an emergency, they would secure each resident in their room. They both denied any knowledge of how to exit the building in the event of an emergency that required evacuation. Neither CNA knew how to open the gate in the courtyard or the C clamp and would have to ask the nurse how to exit in an emergency. RN #2, who worked on the third floor, was interviewed on 5/14/24 at 2:10 p.m. She said the evacuation process would depend on the emergency. She said if there was a fire, she would evacuate everyone out of the emergency doors, and avoid the elevator and gym. She said if there was a fire inside she would evacuate to the smoking patio; however, there were gates there that were currently locked. She said the only one who had a key was the environmental services director (ESD). RN #2 said if a resident was non-ambulatory and needed to evacuate down the stairs, she was not sure how this would occur. The environmental service director (ESD) was interviewed on 5/14/24 at 2:15 p.m. The ESD said he held the only key to all three padlocks and the C clamp required a socket wrench for removal. He said the C clamp was temporary to prevent second floor residents from exiting the facility while he waited for the gate to be repaired, but the locks on the gates were placed at the direction of the previous nursing home administrator (NHA) to keep outside people from getting in and keeping residents from leaving the community. The Maintenance assistant (MA) was interviewed on 5/14/24 at 2:20 p.m. He said he had worked in the facility for ten years, and in the maintenance department for four years. He said for an emergency, the alarm should be pulled and residents were to evacuate to the patio and through the gate and wait for help. The MA said when the fire alarm was pulled, the magnetic locks released, and for the padlock on the third floor gate, there was a key downstairs. The MA said he did not know the procedure for evacuating residents down the stairs. Licensed Practical Nurse (LPN) # 3 was interviewed on 5/14/24 at 2:20 p.m. She said she had worked for the facility for about [AGE] years and said staff received education regarding fire safety/drills. She said she was unsure if employees were provided training on the floor about evacuations. LPN #3 said staff escorted residents to their rooms and closed the door when the fire alarm was activated. She said if an evacuation was necessary, she would wait until instructed to evacuate residents. LPN #3 said residents were evacuated using their wheelchair or a sled. -LPN #3 demonstrated the fire escape door on the third floor opened after the alarm bar was depressed for 15 seconds. She had difficulty opening the door. She was unsure how long to depress the activation bar and it took 3 start-stop attempts to open the door. The alarm rang when she first depressed the bar and she was able to silence the alarm outside near the door frame with her key. -LPN #3 said she had never participated in an evacuation drill. She said they would work together and staff would carry residents down the stairs. She was unaware if the facility had evacuation supplies such as carry chairs or sleds. LPN #3 said she was unaware which employee would account for residents and staff during an evacuation and thought it would be the NHA. The NHA was interviewed on 5/14/24 at 2:30 p.m. The NHA said she was not aware of the C clamp on the second-floor courtyard gate or the padlocks on the three courtyard gates on the third floor. She was also unaware that the ESD reported he held the only key to the padlocks on the three gates in the third-floor courtyard. The NHA said in the event of an emergency that required evacuation of the building, she was confident staff would react appropriately and be able to determine how to safely evacuate residents from the building. Housekeeper (HK) #1, who worked on the third floor, was interviewed on 5/14/24 at 2:35 p.m. She said if there was a fire, do not use the elevator but take the stairs. She said she was not sure how to help the residents down the stairway; if they could not walk; it would be a problem. HK #1 said she was not sure how to evacuate from the smoking patio on the third floor. HK #2 was interviewed on 5/14/24 at 2:38 p.m. She said she had worked for the facility for two years. She said when the fire alarm was activated, her role was to help clear the common areas and hallways and see if residents were in a safe place. HK #2 said if an evacuation was necessary, they would use the buddy system. She said all the employees were strong and they would work as a team to carry residents down the fire exit stairs. The director of nursing (DON) and the ESD were interviewed together on 5/14/24 at 3:40 p.m. The DON said staff received basic fire safety education through computer-based training modules. The DON provided a copy of the new employee skills competency for the nursing department and fire safety was not listed. He said the competencies were all clinical in nature. -The ESD said that he was responsible for training staff in fire safety and held a fire drill one time a month. He said the computer tracking software system notified them where and when the monthly drill should be conducted. The ESD said after each drill he completed a fire drill evaluation form and the drill was reviewed during the next interdisciplinary meeting, usually the next day after the drill. -The ESD provided a copy of the fire drill assessment form and the form included an evaluation of staff response up to the point an evaluation would be necessary. The documentation did not indicate evacuations were practiced or discussed. -The DON said when a fire alarm was activated in the building, the fire panel displayed the location of the alarm in the building. He said the fire panels were located at each nursing station. He said if evacuation was necessary, the policy was to start with the room above the fire alarm as well as the room on either side. He said that if a larger evacuation was necessary, staff should assist residents behind the fire door where they would gain two to four hours of protection. The DON said the fire exit stairs were not the first choice for fire exits. The DON said the facility was constructed on a hill and each floor had a ground-level exit. The ground-level exit would accommodate those residents in wheelchairs or being moved in their beds. The DON said the door on the second floor that led to the courtyard was not a fire exit and said it was chained and locked. The DON said all the doors that have alarms attached open after depressing the activation bar. He said that staff would be available to open the door for those with lower cognition or physically unable to depress the activation bar. 50219 FALL PREVENTION Record review, observations, and interviews revealed the facility failed to ensure an environment free from the risk of accidents and hazardous situations for Resident #45. On 4/30/24, Resident #45 sustained a witnessed fall when she rocked herself out of her wheelchair. Resident #45 sustained a laceration to her face, was thought to have a broken nose, and was transported to the hospital. A care plan for the resident putting herself on the floor was added on 5/1/24. The only intervention added on 5/1/24 to this care plan was that Resident #45 would make her needs and wants known to staff. A full fall investigation was not carried out by the facility, as the director of nursing (DON) deemed the incident to be a behavior and not a fall. The facility failed to take sufficient steps to investigate Resident #45's fall with injury and failed to develop and implement appropriate and effective fall interventions given the resident's known cognitive and functional limitations and behavior. The facility failures contributed to a fall with injury. I. Facility policy The Fall Management policy (no date of creation or revision) was received from the NHA on 5/21/24 at 12:09 p.m. It read in pertinent part: If a resident experiences more than one fall, a collaborative discussion between the Wellness Director, ED (executive director), Connections Director, the family, and resident's physician will be held to review the resident's needs. Discussion may include changing current pharmacology, diet, increasing activities participation, or another alternate to enhance and promote the resident's quality of life. All interventions are documented in the resident's Service Plan and Health Plan. An incident report is completed and the incident report policy is followed. An incident/accident investigation will be completed and reviewed. II. Resident #45 A. Resident status Resident #45, age 81, was admitted to the facility on [DATE], transported to the hospital on 4/30/24 after a fall, and returned to the facility on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included dementia, cognitive communication deficit, and altered mental status. The 5/2/24 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of two out of 15. The resident was dependent and required supervision and assistance with all activities of daily living. The 2/21/24 care plan revealed Resident #45 was at high risk for falls due to confusion and unawareness of safety needs. Pertinent interventions included anticipating and meeting Resident #45's needs, reviewing information on past falls and attempting to determine the cause of falls, recording possible root causes, and altering or removing potential causes if possible. B. Observations and resident interview On 5/15/24 at 10:20 a.m., Resident #45 sat in her wheelchair in the dining room. Resident #45 was wearing anti-slip socks. She did not have any anti-tip bars or anti-rollbacks in place on her wheelchair. On 5/16/24 at 9:46 a.m., Resident #45 said her hand and her face hurt. Resident #45 had bruising present on both her face and her hands. Resident #45's left hand was red and swollen, especially around her knuckles. Resident #45's right hand had a purple and yellow bruise approximately three inches by four inches in size. Resident #45 had crescent-shaped bruising on her cheekbones and an inch-sized round bruise on her forehead that was covered with thin medical bandages. On 5/21/24 at 12:17 p.m. Resident #45 was in her bed. The bed was in the lowest position, and the fall mat was in place. C. Record review 1. Fall 4/30/24 A progress note dated 4/30/24 at 11:38 a.m. revealed Resident #45 was observed rocking herself forward and falling out of her wheelchair, resulting in a laceration to her forehead. A progress note dated 4/30/24 at 11:58 a.m. revealed Resident #45's representative was contacted by the facility staff regarding the resident's fall out of her wheelchair. A risk management report, dated 4/30/24 at 11:40 a.m., revealed Resident #45 fell forward out of her wheelchair and landed on her face on the floor. The note revealed Resident #45's fall resulted in a forehead laceration, bruising over her face, right hand, and left forearm, and a possible broken nose. The note revealed Resident #45 was frequently confused and not able to follow simple commands or make her needs known. Hospital notes, dated 4/30/24 at 12:03 p.m., revealed Resident #45 was transported to the hospital for evaluation after a fall. Diagnoses included a closed head injury and a laceration of the forehead. 2. Facility response to Resident 45's fall with injury Record review revealed the facility failed to comprehensively investigate the resident's fall to develop and implement resident-specific interventions based on her known cognitive, and functional impairments and known behaviors. The 4/30/24 24-hour report form revealed Resident #45 rocked herself out of her wheelchair, which was a behavior resulting from intentionally acting out. The report form revealed instructions to monitor Resident #45 for behaviors of rocking or propelling herself forward out of her wheelchair or bed when the resident returned from the hospital. A care plan dated 5/1/24 revealed Resident #45 putting herself on the floor by rocking forward in her wheelchair and vaulting herself to the floor. The intervention included was to have Resident #45 make her needs and wants known to facility staff members. But see above; the 4/30/24 risk management report read the resident was not able to make her needs known. A review of the May 2024 CPO revealed an order indicating Resident #45 was a high fall risk. Interventions in place from this order included purposeful rounding, proper non-skid footwear, and having her bed in the lowest position. The 5/1/24 24-hour report form revealed instructions to continue monitoring Resident #45 for behaviors and to intervene if the resident was seen rocking to prevent a fall. A post-incident investigation for falls was started on 5/1/24 at 9:28 a.m. but was not completed. A note on the risk management report from 5/1/24 revealed the risk management report was struck out by the DON because the incident was considered an intentional act and not a fall. Multidisciplinary care conference notes dated 5/6/24 at 3:13 p.m. revealed Resident #45 rarely verbally communicated her needs and had increased behaviors over the previous quarter. Occupational therapy (OT) notes from 5/14/24 revealed Resident #45 had a recent fall with resulting forehead laceration and facial bruising and that the resident demonstrated weakness and decline in coordination and self-feeding skills. The OT notes revealed Resident #45 had mild pain generally in her head and body over the prior five days at the time of the note. The OT notes revealed Resident #45 had impaired safety awareness, and was sometimes understood when communicating with others. C. Staff interviews Staff interviews confirmed the facility failed to comprehensively investigate the resident's fall to develop and implement resident-specific interventions based on her known cognitive and functional impairments and known behaviors. Registered nurse (RN) #1 was interviewed on 5/16/24 at 3:27 p.m. RN #1 said the standard procedures after a resident fell included starting neurological checks, doing a physical assessment, and initiating a risk management indicator on the resident's electronic medical record. RN #1 said physical and occupational therapy would then evaluate the resident to see if they had any changes in mobility that caused their fall. RN #1 said Resident #45 had a history of attention-seeking behaviors, but could not remember if the resident had any fall interventions. RN #2 was interviewed on 5/21/24 at 10:00 a.m. RN #2 said Resident #45 sometimes got agitated and called out, but could usually make her needs known. RN #2 said Resident #45 could call out for a nurse or CNA and ask for what she wanted. RN #2 said Resident #45 fell approximately three weeks ago. RN #2 said Resident #45 had leaned forward in her wheelchair and fell to the floor and she was sent out to the hospital. RN #2 said Resident #45's interventions included ensuring the resident did not transfer by herself, checking the resident frequently, using non-slip socks, and encouraging the resident to express what she wanted. CNA #1 was interviewed on 5/21/24 at 10:18 a.m. CNA #1 said Resident #45 preferred male staff members over females for care. CNA #1 said Resident #45 had difficulty focusing and needed cueing for eating. The CNA said it would sometimes take a while for her to process her needs and sometimes, Resident #45 would start screaming and would not be able to say what she needed, but eventually, the nurse could get an answer out of her. CNA #1 said Resident #45 flung herself out of her wheelchair a while ago. CNA #1 said the male CNA who usually worked with Resident #45 was out of town, so there were only female staff members working with Resident #45. The resident became overstimulated and threw herself out of her wheelchair. CNA #1 said Resident #45 had a tendency to [NAME] herself out of her bed or wheelchair, so the interventions they used for her included having a low bed and keeping a fall mat in place. CNA #1 said information regarding care areas like fall interventions was communicated verbally during orientation for new staff members during their walkthrough, but that nothing was written down in an area that was accessible for CNAs. The DON was interviewed on 5/21/24 at 11:01 a.m. The DON said the facility staff determined Resident #45 was having a fit and asking for the one male CNA she usually worked with who was out on vacation, so the resident started rocking in her chair and threw herself on the floor. The DON said the facility staff determined Resident #45 had a history of rocking and throwing herself out of her chair when she did not get her way. The DON said the instance in question was not a typical fall but was instead a behavior, and as such, they did not continue a fall investigation. The DON said the facility staff brought attention and awareness to Resident #45's behavior and that therapy had been in with her frequently. The DON said Resident #45 had not been assessed by physical therapy yet due to issues with insurance authorization. The DON said many of the residents at the facility had wheelchair accommodations like anti-rollbacks and anti-tip bars, but that they may not work if the residents got around the facility by self-propelling backward. The DON said that when care plans were updated, the interventions were placed as an order in the resident's chart and were communicated to the CNAs by the restorative or nursing staff. These communications are both verbal and written in a physical 24-hour report book. The DON said care plans should match what was ordered by the physician. The DON said if a resident was ordered for a low bed or fall mat, it should be in their care plan. When looking at Resident #45's risk management report, the DON identified and highlighted a note that said he had determined it was not a fall because it was a behavior and confirmed that was the case. D. Additional information Additional information was provided by the NHA on 5/23/24 at 1:51 p.m. This information included an updated care plan for Resident #45. The care plan revealed additional interventions for the focus of Resident #45 putting herself on the ground, including having a fall mat provided, having a low bed, and educating staff on being aware of and attempting to redirect Resident #45's behaviors.

Based on observations, record review, and interviews, the facility failed to provide residents residing on the second and third floors of the facility, including Residents #1, #182, #74, #73, #75, #92, #103, #67, #87, #95, #102, #14, #76, #115, #68, #7, #77, #112, #57, and #8, with an environment that supported and enhanced each resident's dignity, self-worth, sense of satisfaction, and control over their lives. Observations and interviews with residents and staff revealed facility practices that showed a disregard for residents' quality of life and were inconsistent with the facility Resident Rights policy to provide residents with a holistic program that provided respect, dignity, and compassion. Resident interviews and observations revealed restrictions on residents' day-to-day lives that were not supported by evidence the facility had considered their impact on residents' quality of life or that the restrictions were necessary to maintain a safe and healthy environment. Facility practices limited and/or precluded residents' ability to meet without staff at Resident Council; their ability to obtain money from their personal needs funds; their ability to access other areas of the facility; their ability to choose where to eat, the tableware to use, and the beverage to drink; their ability to have visitors 24-hours a day; their ability to participate in social activities; and their ability to participate and receive private communications by phone and mail. These restrictions contributed to residents feeling jailed, trapped, incompetent, bad, and angry. Observations confirmed such restrictions and also revealed staff was not responsive to call lights, contributing to residents feeling like no one cared. Observations further revealed residents lacked ready access to information on outside assistance from the state and survey results. The facility's failure to provide residents residing on the second and third floors of the facility with an environment that supported and enhanced each resident's dignity, self-worth, sense of satisfaction, and control over their lives created an immediate jeopardy situation with the likelihood of serious harm if not immediately corrected. Cross-reference F550, F585, F600, F603, F610, F689, and F699. Findings include: I. Immediate Jeopardy A. Findings of Immediate Jeopardy Based on observations, record review, and interviews, the facility failed to provide residents residing on the second and third floors of the facility with an environment that supported and enhanced each resident's dignity, self-worth, sense of satisfaction, and control over their lives. Observations and interviews with residents and staff revealed facility practices that showed a disregard for residents' quality of life and were inconsistent with the facility Resident Rights policy to provide residents with a holistic program that provided respect, dignity, and compassion. Resident interviews and observations revealed restrictions on residents' day-to-day lives that were not supported by evidence the facility had considered their impact on residents' quality of life or that the restrictions were necessary to maintain a safe and healthy environment. Facility practices limited and/or precluded residents' ability to meet without staff at Resident Council; their ability to obtain money from their personal needs funds; their ability to access other areas of the facility; their ability to choose where to eat, the tableware to use, and the beverage to drink; their ability to have visitors 24-hours a day; their ability to participate in social activities; and their ability to participate and receive private communications by phone and mail. These restrictions contributed to residents feeling jailed, trapped, incompetent, bad, and angry. Observations confirmed such restrictions and also revealed staff was not responsive to call lights, contributing to residents feeling like no one cared. Observations further revealed residents lacked ready access to information on outside assistance from the state and survey results. The facility's failure to provide residents residing on the second and third floors of the facility with an environment that supported and enhanced each resident's dignity, self-worth, sense of satisfaction, and control over their lives created an immediate jeopardy situation with the likelihood of serious harm if not immediately corrected. B. Facility plan to remove the immediate jeopardy situation On 5/20/24 at 3:15 p.m., the nursing home administrator (NHA) provided a plan to remove the immediate jeopardy. The removal plan read: Resident Council -Residents will be asked before each Resident Council whether they would like staff to attend the meeting or not. Residents are able to meet without staff present. -This question will be asked at the beginning of each Resident Council Meeting. A new Resident Council Form was implemented, to include this question and the resident's response. The resident's response will be documented in the minutes of each Resident Council Meeting. -Resident Council Meeting Minutes will be reviewed monthly during QAPI to ensure the above. Required Postings -Postings were updated with the correct contact information. -Postings are located in each neighborhood and are at the level that residents in wheelchairs can see them. -Postings will be monitored daily by the Leadership Team to ensure that they are in place, and at the proper level. Right to Survey Results -Survey Results Binder is located in the Front Lobby on the first floor, and the binder contains three years of surveys. -Residents have access to the Survey Results Independently. -NHA or designee will update the binder with all annual and complaint surveys moving forward and will ensure that the binder is in place Monday through Friday. Resident Rights and Quality of Life Services -Per the care plan and guardian input, (Resident #8) did participate in the birthday party on the second floor. -Resident #8's guardian was contacted on 5/16/24, to clarify resident's ability to move throughout the community. -Resident #8's care plan was updated to include guardian input and court-ordered placement stipulations regarding movement throughout the community. -A Resident Preferences Interview was conducted with resident #8 on 5/18/24, and her care plan was updated to reflect her preferences. -Resident #8's preferences will be updated as needed, and the community will maintain contact with resident's guardians for further care plan revisions quarterly and as needed. Meals on Second Floor -All residents are encouraged to eat in the dining areas. -If a resident chooses to eat in their rooms, a room tray will be provided. -The kitchen is open from 7:00 a.m. to 7:00 p.m. If a resident misses a meal, they can request food or a tray during these times. -Snacks are available in the neighborhoods 24/7. (Snacks include, but are not limited to sandwiches, chips, protein bars or other items that are substantial in nature). -The above was reviewed with all residents on 5/16/24, 5/17124, 5/18/24, 5/19/24, 5/21 /24, and 5/22/24. In addition, staff were educated on 5/17 /24, 5/18/24, and 5/19/24 by Nursing Home Administrator (NHA), Director of Wellness, (DOW), and Health Information Manager (HIM), on the above. -Dining Services will be reviewed with the Food Committee on a Monthly basis. Soda/Soda Cans -Residents can purchase and/or request soda any time that they wish. -Residents on the second floor will have soda served to them in a disposable cup for safety of all residents. This is due to residents potentially consuming the tabs and/or injuring themselves or others with the cans. -The above was reviewed with all residents on 5/16/24, 5/17 /24, 5/18/24, 5/19/24, 5/21 /24, and 5/22/24. In addition, staff were educated on 5/17 /24, 5/18/24, and 5/19/24 by Nursing Home Administrator (NHA), Director of Wellness, (DOW), and Health Information Manager (HIM), on the above. -The use of disposable cups for soda will be discussed monthly during the second floor Resident Council meetings. If any concerns are verbalized by residents, these will be addressed on an individual basis. If no incidents occur, the community may consider returning to the use of soda cans at some point in the future. Private Phones -There is a cordless phone at the Nurses' Station in each neighborhood, that is available to all residents, so that resident can hold a phone conversation in the area of their choice. Phones are accessible and available to residents at all times. -There are also stationary resident phones located throughout the community, and there is a private phone in the Town Hall Room on the first floor. All of these phones are available to the residents. -The above was reviewed with all residents on 5/16/24, 5/17 /24, 5/18/24, 5/19/24, 5/21 /24, and 5/22/24. In addition, staff were educated on 5/17/24, 5/18/24, and 5/19/24 by Nursing Home Administrator (NHA), Director of Wellness, (DOW), and Health Information Manager (HIM), on the above. -The use of cordless phones will be discussed monthly during the Resident Council Meetings for each neighborhood on a monthly basis. Disposable Silverware -Residents on the second floor will utilize plastic cutlery for the safety of all residents in the neighborhood. This is due to residents potentially harming themselves or others with regular metal cutlery. -This information is located in the Resident Handbook for all admissions to the second floor. -The above was reviewed with all residents on 5/16/24, 5/17 /24, 5/18/24, 5/19/24, 5/21 /24, and 5/22/24. In addition, staff were educated on 5/17 /24, 5/18/24, and 5/19/24 by Nursing Home Administrator (NHA), Director of Wellness, (DOW), and Health Information Manager (HIM), on the above. -The use of plastic cutlery will be discussed monthly during the Resident Council Meetings for second floor, on a monthly basis. Any concerns voiced by residents will be addressed on an individual basis. If no incidents occur, the community may consider having regular cutlery provided to residents. Visiting Hours -Visiting hours are twenty-four hours per day, seven days per week. -If there are concerns related to a visitor bringing in contraband items they will be requested to leave their items in a locker during their visit to prevent further concerns. This information is in the Resident Handbook. -The above was reviewed with all residents on 5/16/24, 5/17 /24, 5/18/24, 5/19/24, 5/21 /24, and 5/22/24. In addition, staff were educated on 5/17/24, 5/18/24, and 5/19/24 by Nursing Home Administrator (NHA}, Director of Wellness, (DOW), and Health Information Manager (HIM), on the above. -All responsible parties were notified of the above, by the NHA, on 5/17/24 and 5/21 /24. -Visiting hours will be discussed during the Resident Council Meetings, on each neighborhood, on a monthly basis. Elevator -The elevator operates 24 hours per day, 365 days per year, and residents have access to it at all times. Staff do not have the ability to manipulate the operation of the elevator in any way. -The above was reviewed with all residents on 5/16/24, 5/17 /24, 5/18/24, 5/19/24, 5/21 /24, and 5/22/24. In addition, staff were educated on 5/17/24, 5/18/24, and 5/19/24 by Nursing Home Administrator (NHA), Director of Wellness, (DOW), and Health Information Manager (HIM}, on the above. -Elevator availability will be discussed during the Resident Council Meetings, in each neighborhood, on a monthly basis. Smoking -(The facility will) continue to follow the CDPHE (Colorado Department of Public Health and Environment) directed plan regarding safe smoking from 2015. -The community reviews the Smoking Guidelines on an annual basis, and this information is in both the Resident Handbook and the Resident Agreement. -The Smoking Guidelines are reviewed with residents on an annual basis. -The above was reviewed with all residents on 5/16/24, 5/17 /24, 5/18/24, 5/19/24, 5/21 /24, and 5/22/24. In addition, staff were educated on 5/17/24, 5/18/24, and 5/19/24 by Nursing Home Administrator (NHA), Director of Wellness, (DOW), and Health Information Manager (HIM), on the above. A concern identified by residents was that they do not have funds to smoke more than 3 smoking times per day, and they do not want to run out of cigarettes. The residents voiced that they desire to smoke after each meal. -Resident's smoking abilities are assessed quarterly, and care plans are updated accordingly, based upon each resident's ability. -Resident smoking will be discussed during Resident Council Meetings, on each floor, on a monthly basis. -The community will hold a smoker's meeting on a quarterly basis. Mail Delivery on Saturdays -Mail is delivered Monday through Saturday, if/when the mail is received from the United States Postal Services and will be delivered by the Leader on Duty. -The above was reviewed with all residents on 5/16/24, 5/17 /24, 5/18/24, 5/19/24, 5/21 /24, and 5/22/24. In addition, staff were educated on 5/17/24, 5/18/24, and 5/19/24 by Nursing Home Administrator (NHA), Director of Wellness, (DOW), and Health Information Manager (HIM), on the above. -Mail delivery will be discussed during Resident Council Meetings, on each floor, on a monthly basis. Personal Needs Accounts -The community follows the following regulation regarding resident's personal needs accounts: -(The facility) will follow to regulation below. -All business office staff have been educated by the Administrator & dining service manager (DSM) on 5/17/2024 -Resident and staff have been notified by Administrator, DSM, on 5/17/2024, 5/18/2024. -Resident council was conducted on 5/18/2024- residents were also notified that (the facility) can issue a check for larger amounts of money upon resident request. -(The facility) will follow the amount allowed as of July 13, 2023, per our surety bond. -The law and regulations are intended to assure that residents have access to $100.00 ($50.00 for Medicaid residents) in cash within a reasonable period, when requested. Requests for less than $100.00 ($50.00 for Medicaid residents) should be honored within the same day. Requests for $100.00 ($50.00 for Medicaid residents) or more should be honored within three banking days. Although the facility need not maintain $100.00 ($50.00 for Medicaid residents) per resident on its premises, it is expected to maintain amounts of petty cash on hand that may be required by residents. -The above was reviewed with all residents on 5/16/24, 5/17 /24, 5/18/24, 5/19/24, 5/21 /24, and 5/22/24. In addition, staff were educated on 5/17/24, 5/18/24, and 5/19/24 by Nursing Home Administrator (NHA), Director of Wellness, (DOW), and Health Information Manager (HIM), on the above. -Personal Needs Accounts will be discussed during the Resident Council Meetings, on each floor, on a monthly basis. Care Plans -Assessments and behavior care plans are developed and created on a resident specific and individualized basis. Resident needs and preferences are included in each individual care plan. -Due to the nature of the population that is served at (the facility), the care plans must be specific, and in some cases, must include court orders, and/or specific resident-centered behavioral interventions. -The community does provide a culture that supports each individual resident's preferences, choices and values. A Resident Preferences Questionnaire has been completed, and residents have been interviewed, on 5/16/24, 5/17/24, 5/18/24, 5/19/24 and 5/22/24 regarding all of the above topics. All above items will be reviewed monthly in QAPI (quality assurance and performance improvement) and Safety Committee for three months and quarterly thereafter. C. Removal of immediate jeopardy The immediate jeopardy was removed on 5/22/24 at 5:39 p.m. based on the facility's removal plan (see above) that addressed restrictions that impacted the day-to-day lives of residents residing on the second and third floors of the facility. However, the deficient practice remained at an H level, actual harm at a pattern. II. Facility Policy The Resident Rights policy was provided by the NHA on 5/20/24 at 3:11 p.m. It read in pertinent part: The goal of (the facility) is to provide Residents with a holistic program that provides respect, dignity, and compassion. All Residents who live here are entitled to certain rights: -The right to be treated with respect and dignity. -The right to privacy. -The right not to be isolated or kept apart from other residents. -The right not to be sexually, verbally, physically or psychologically abused, humiliated, intimidated or punished. -The right to be free from neglect. -The right to live free from involuntary confinement, or financial exploitation and to be free from physical or chemical restraints. -The right to full use (of) the facility common areas, in compliance with the documented house rules. -The right to voice grievances and recommended changes in policies and services. The facility shall establish a written grievance procedure which shall be posted. It shall be posted in a Resident's record that he/she has read or had such policy for handling grievances explained upon admission. -The right to communicate privately including but not limited to communicating by mail or telephone with anyone. -The right to reasonable use of the telephone, including access to operator assistance for placing collect telephone calls. At least one telephone should have hearing amplification. -The right to have visitors, in accordance with house rules, including the right to privacy during these visits. -The right to make visits outside the facility in which case the administrator and the resident shall share responsibility for communicating with respect to scheduling. -The right to make decisions and choices in the management of personal affairs, funds, or property in accordance with their abilities. -The right to expect the cooperation of the provider in achieving the maximum degree of benefit from those services which are made available by the facility. -The right to exercise choice in attending and participating in religious activities. -The right to be reimbursed at an appropriate rate for work performed on the premises in accordance with the Resident's board and care plan; i.e. volunteer work program. -The right to 30 days written notice of changes in services provided by the facility, including but not limited to changes in charges foresident access to any floor other than the floor they resided on was by elevator?r any or all services. Exceptions to this notice are: -Changes in the resident's medical acuity that result in a documented decline in condition and that constitute an increase in care necessary to protect the health and safety of the resident. -Requests by the resident or family for additional services to be added to the care plan. -The right to have advocates, including members of community organizations, whose purposes include rendering assistance to the residents. -The right to wear clothing of choice unless otherwise indicated in the Resident's board and care plan in accordance with house rules. -The right to choose to participate in social activities, in accordance with resident's board and care plan. -The right to receive services in accordance with the resident agreement and the care plan. III. Residents' concerns with facility practices that impacted their dignity, self-worth, and sense of satisfaction and control over their lives. Forty-six residents resided in the secured unit on the facility's second floor and 84 residents resided on the third floor which was divided into two units, Pinon and Juniper. No residents resided on the first floor. Each floor had a dining room and the first and third floors had a soda machine. Resident access to any floor other than the floor they resided on was by elevator. A. A group interview was conducted with seven alert and oriented residents from the second and third floors of the facility. The group included the resident council presidents for the second and third floors. B. The group interview was conducted on 5/15/24 at 11:00 a.m. The residents (#76, #75, #115, #68, #7, #77, and #112) frequently attended the resident council. According to the residents, their concerns were brought up in previous resident council meetings, however, the concerns were not addressed. C. The group reported the following concerns: -Resident #115, who said she was the resident council president for the second floor, said the resident council was not permitted to meet without facility staff present and council members were fearful of punishment if they pushed the issue. Other residents agreed. -Residents said second floor residents were restricted to having only one soda per day and it was offered at 10:00 a.m. They were not told the reason. They were not allowed to buy soda from the soda machines on the third and first floors. Resident #115 said it made her mad that her sister buys her a 12-pack of soda and she was not allowed to drink it whenever she wanted. -Residents said they were only allowed to take out up to $5.00 a day from their personal needs accounts (PNAs); otherwise, they needed to get permission from the social worker. -Residents said mail is not delivered on Saturdays and, at times, not delivered during the week. -Residents said they were not able to eat in their rooms; they had to eat in the dining room. Two residents said that made them feel bad. -Residents said there was no privacy when they used the phone. The residents said there were no cordless phones and they had to use the phone at the nurses' station. -Residents confirmed the visiting hours were from 9:00 a.m. to 4:00 p.m., but they did not know why. They wanted the visiting hours to be longer. -Residents said they did not know how to file a grievance, know where to find survey results, or where to find information to contact outside support. -Residents said they were all supervised smokers and they were only allowed three smoke breaks and only got to have one cigarette, so only three cigarettes a day. Residents said they wanted the opportunity to have more than three smoke breaks. -Residents said call lights were not answered timely. The residents said the call lights blink all night long and it made them feel like no one cared. -One resident said he would have his chocolate milk taken away if he misbehaved. Another resident said they would have cigarette breaks taken away for misbehaving. The other residents agreed they had seen this happen. IV. Observations confirmed residents' reported concerns about limitations of their rights and the facility's failure to provide residents with an environment that supported and enhanced each resident's quality of life. A. Observations 5/14/24 regarding social activity, tableware, beverages, call lights On 5/14/24 at 10:15 a.m., residents sat at all of the tables in the second floor dining room. An unidentified activity assistant (AA) was observed to have cans of soda and coffee on a cart. The AA opened a can of soda and poured approximately four ounces of soda into a paper cup. There were approximately 20 residents in the dining room. None of the residents received the full can of soda. On 5/14/24 at 11:54 a.m., two call lights on the second floor were observed blinking. The two lights continued to blink until 12:18 p.m. when staff came up from the first floor to check on the first light. At the time, there were two certified nurse aides (CNA) in the dining area, a nurse at the medication cart near the nurses' station, and a nurse sitting at the nurses' station. There was not an audible tone or call light panel alerting staff of the blinking call lights. On 5/14/24 at noon, the second floor dining room was observed. The residents were served their meals with a plastic fork and spoon. The meal was baked chicken. An unidentified resident was observed to use his spoon to hold the chicken while he worked to scrape a piece of the meat off with the fork. On 5/14/24 at 5:32 p.m. the contact information sign for the state was observed on the first floor near the elevator. It did not include the phone number to reach the state office and was posted at the very top of the display case above the line of sight for residents in wheelchairs. On 5/14/24 at 5:34 p.m., the survey results binder was observed on the first floor. It held only the survey results from 2023. B. Observations 5/15/24 regarding call lights, privacy (phone calls), visitation On 5/15/24 at 9:37 a.m. the call light for room [ROOM NUMBER] was observed blinking. At 9:49 a.m., assistant director of nursing (ADON) #2 walked past room [ROOM NUMBER], entered her office, and did not check on the resident. At 9:56 a.m., ADON #2 left her office, walked past room [ROOM NUMBER] again, and did not check on the resident. At 10:03 a.m., ADON #2 passed room [ROOM NUMBER] to return to her office and did not check on the resident. At 10:15 a.m., a CNA entered room [ROOM NUMBER] and turned off the call light. There was no audible tone alerting staff that a call light had been activated. On 5/15/24 at 9:53 a.m. a corded telephone was observed on the desk at the third floor nurses' station. The phone was not in a private or quiet location; the nursing station was centrally located to a medication cart, staff offices, resident rooms, and the common area which also served as the main dining area. As such, conversations had on the phone would be audible to those in the common area and the nurses at the nursing station. On 5/15/24 at 11:56 a.m., the posting of visiting hours at the elevator on the first floor read, Visiting hours. As a courtesy to our resident who resides here at the (name of the facility) please visit your loved ones/friends during these hours: Monday- Sunday 9:00 a.m. -4:00 p.m. Thank you for your cooperation. On 5/15/24 at 2:31 p.m., Resident #118 was observed having an emotional, tearful conversation on the corded phone at the nurses' station on the second floor. The phone was not in a private or quiet location; the nursing station was centrally located to a medication cart, staff offices, resident rooms, and the common area which also served as the main dining area. D. Observations 5/16/24 regarding social activities and privacy (phone calls) On 5/16/24 at 2:25 p.m., Resident #8, who resided on the second floor, was observed crying. Per ADON #2, she was crying because she was not allowed to attend the resident activity on the first floor, celebrating birthdays for May. Observations revealed other residents from the second floor were allowed to attend the activity. On 5/16/24 at 3:20 p.m., four residents were observed crowded around the second floor nurses' station. One resident was speaking on the telephone and three residents were crowded next to him. The unit was noisy with residents singing and socializing. The resident on the phone was heard repeating his conversation and shouting into the telephone. E. Observations on 5/19/24 regarding call lights On 5/19/24 at 5:13 p.m., call lights were activated for rooms 200, 201 and 206. At the time, three employees were observed sitting behind the desk. One nurse was using her personal cell phone. At 5:29 p.m., the lights remained activated. V. Resident interviews Resident interviews confirmed residents' concerns about the limitations of their rights and the facility's failure to provide residents with an environment that supported and enhanced each resident's quality of life. A. Resident #1 was interviewed on 5/15/24 at 2:06 p.m. Resident #1 resided on the second floor. Resident #1 said she was not able to make private phone calls, and she could only make calls at the nurses' station. Resident #1 said this made her feel like she was trapped. B. Resident #182 was interviewed on 5/16/24 at 9:10 a.m. Resident #182 resided on the third floor and said he was new; he had resided in the facility for one to two weeks. He said he was told by staff not to go downstairs via the elevator after 6:00 p.m. each evening. Regarding visitation, he said visitors needed to call the facility to make an appointment. C. Resident #115 was interviewed on 5/16/24 at 9:48 a.m. Resident #115 resided on the second floor and said she did not want to live at the facility and felt trapped. She said she could not leave the second floor without an escort and did not know why. She reported her roommate had broken her cell phone charging cord the previous night and now her cell phone battery was dead so she was unable to call her kids or her sister. Resident #115 said she told staff and they told her she had not been at the facility long enough to be taken off facility property to get a new charger. D. Resident #74 was interviewed on 5/16/23 at 9:54 a.m. Resident #74 resided on the third floor. He said they closed down the elevator on the third floor at 6:00 p.m. because they closed the downstairs (first floor) down. Resident #74 said he had lived at the facility for six and a half years and he was okay with it because he was used to it. E. Resident #73 was interviewed on 05/16/24 at 1:31 p.m. Resident #73 resided on the third floor. He said he never went downstairs at night because the facility didn't let him. F. Resident #92 was interviewed on 05/16/24 at 1:35 p.m. Resident #92 resided on the third floor. Resident #92 said she only received $5 of her personal funds per day and wished it was more. Resident #92 said she only got to smoke three times per day because of facility rules. Resident #92 said she wanted more smoke breaks, and that it was a bummer. G. Resident #103 was interviewed on 5/16/24 at 1:36 p.m. Resident #103 resided on the third floor. Resident #103 said she was not allowed to go to a different floor to use the soda machines after 5:30 p.m. because staff would not let her. Resident #103 said she would rather go to the soda machines on the first floor during cold, rainy, or snowy weather because the soda machines on her floor were located outside on a patio. H. Resident #67 was interviewed on 5/16/24 at 01:43 p.m. Resident #67 resided on the third floor. Resident #67 said he only got $5 per day. Resident #67 said he didn't think that was right, and that he should be able to take out however much money he wanted. Resident #67 said the facility stopped him from going downstairs at night. Resident #67 said he felt like he was in jail because he could not go downstairs when he wanted to get a soda. I. Resident #87 was interviewed on 5/16/24 at 2:14 p.m. Resident #87 resided on the third floor. Resident #87 said he did not go downstairs, because the facility wanted him to stay upstairs. J. The representative for Resident #57 was interviewed on 5/16/24 at 2:14 p.m. Resident #57 resided on the third floor. The representative said she had to call the facility two days ahead whenever she wanted to take Resident #57 out of the facility. The representative said she was required by the facility to allow the facility to search her bag and keep it in a locker downstairs while she visited. K. Resident # 95 was interviewed on 5/16/24 at 4:50 p.m. Resident #95 resided on the third floor. She said she only used the facility telephone for incoming calls from her guardian. She said the facility telephone in the hallway was not adapted for her blindness. As a result, she was unable to dial telephone numbers for outgoing calls unless she requested staff assistance. She said she distrusted the facility staff and did not feel comfortable revealing the identity of the person she was calling. Resident #95 said she had concerns about staff members eavesdropping on her calls in the hallway. Resident #95 said an outside agency provided her with a smart telephone that allowed her to dial numbers through voice activation and now she could have private conversations in her room. <br[TRUNCATED]

Based on observations, record review, the facility failed to ensure menus were followed to meet the resident's nutritional needs. Specifically, the facility failed to ensure food items served during meals were consistent with the posted daily menu. Findings include: I. Resident group interview The resident group interview was conducted on 5/15/24 at 11:00 a.m. with seven residents (#76, #75, #115, #68, #7, #77 and #112) who were members of the resident council. The residents were identified as interviewable by the facility and assessments. The residents said the posted menu rarely matched what was served to residents during meals. The residents said they did not receive mashed potatoes and gravy very often. The residents said chicken was served a lot in the past but they complained about it, so now they were served a lot of pasta and rice dishes. II. Meal observations The 5/13/24 posted lunch menu revealed residents were to be served barbeque beef brisket, hot German potato salad, collard greens, vegetable soup and a dinner roll with butter. Dessert was listed as fruit gelatin with marshmallows and assorted beverages were to be served. During a continuous lunch observation of the third floor dining room on 5/13/24, beginning at 11:30 a.m. and ending at 1:30 p.m., the following was observed: -Butter was not provided for dinner rolls; -Soup was not offered or served; -The potatoes were mashed instead of a potato salad; and, -Dessert was an orange-colored fruit gelatin, however, there were no marshmallows in the dessert. Alternative selection for the main dish was pasta salad with protein (seafood) The 5/14/24 posted lunch menu revealed residents were to be served grilled chicken with onions, savory summer squash, cheesy potato casserole, poultry gravy, tomato florentine soup and a cornbread with butter. Dessert was listed as cheesecake with a cherry topping. During a continuous lunch observation of the third floor dining room on 5/14/24, beginning at 12:00 p.m. and ending at 2:00 p.m., the following was observed: -The chicken was baked instead of grilled and served without onions or gravy; -The potatoes were mashed instead of a cheesy potato casserole; -Butter was not served with the cornbread; -Soup was not offered or served; and, -Dessert was a squared piece of cake, brown in color, without frosting instead of cheesecake with a cherry topping. Alternative selection for the main dish was pasta salad with protein (seafood). -This was the second day in a row the alternative main dish option was pasta salad with seafood. The 5/15/24 lunch menu revealed residents were to be served rosemary pork loin with lemon dill sauce, rice pilaf, braised cabbage and carrots and a dinner roll with butter. Dessert was listed as coconut cream pie. Alternative selection for the main course was spaghetti with meat sauce on the second and third floor dining rooms. During a continuous lunch observation of the third floor dining room on 5/15/24, beginning at 12:00 p.m. and ending at 1:30 p.m., the following was observed: -The pork was served without the lemon dill sauce; -The rice was white rice instead of rice pilaf; -Butter was not served with the dinner roll; -Soup was not offered or served; and, -Dessert was pudding, off-white in color. Instead of coconut cream pie. III. Staff interview The dining services manager (DSM) was interviewed on 5/21/24 at 11:00 a.m. The DSM said the facilities corporate office created the menus and the DSM was responsible for implementing resident suggestions and/or requests. The DSM said there was a registered dietitian who reviewed the menus as well. The DSM said any changes made to the menu were authorized by her first. The DSM said the facility had a five week menu that had a main selection and alternative meal selections came from information received by the facilities food committee and resident requests. The DSM said she had not received any resident complaints regarding menu changes without prior notice. The DSM said menu changes only happened if a product was unavailable from a vendor.

Based on record review and interviews, the facility failed to provide services in accordance with currently accepted professional principles for one (#3) of five residents reviewed for catheter care management out of 11 sample residents. Resident #3 was admitted to the facility on [DATE] for long term care. He had a diagnosis of dementia with behaviors, Parkinson's disease and kidney disease. On 9/10/23 the resident developed signs of a urinary tract infection (UTI). He was sent to the emergency room (ER) for the evaluation and returned to the facility the next day (9/11/23) with an indwelling urinary catheter. Upon the resident's readmission from the ER, the facility failed to assess the resident for the need of the urinary catheter and did not document its presence and care. Subsequently, the resident developed an acute UTI with sepsis (a serious condition in which the body responds improperly to an infection) that resulted in two separate hospitalization s on 9/18/23 and 11/12/23. During the last hospitalization , the catheter was removed in the hospital due to the resident being able to void. In addition, the facility failed to schedule a urology follow up that was recommended by primary care physician (PCP) #1. Findings include: I. Facility policy and procedures The Resident with Indwelling Catheter policy, with no revision date, was provided by the nursing home administrator (NHA) on 12/22/23. It read in pertinent part: The purpose of this policy is to ensure that a resident who enters the community without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary. The community is responsible for the assessment of the resident at risk for urinary catheterization and/or ongoing assessment of the resident who currently has a catheter. This is followed by implementation of appropriate individualized interventions and monitoring for the effectiveness of the interventions. The clinician's decision to use an indwelling catheter in the elderly should be based on valid clinical indicators. II. Resident status Resident #3, age 78, was admitted on [DATE] and discharged on [DATE]. According to the November 2023 computerized physician orders (CPO), diagnoses included dementia with behaviors, Parkinson's disease, kidney disease stage one, history of urinary tract infection and sepsis was added on 9/25/23. The 9/18/23 minimum data set (MDS) assessment revealed the resident was cognitively impaired and a brief interview for mental status (BIMS) score was not conducted. He required substantial/maximal assistance with activities of daily living. He had an indwelling urinary catheter in place and was marked as frequently incontinent of bowel and bladder. III. Record review The initial nursing assessment on 6/16/23 documented that Resident #3 was admitted to the facility for long term care. He was independent with all daily activities and was oriented to person, place and time. The resident was continent of bowel and bladder and did not have an indwelling urinary catheter on admission. 1. hospitalization on [DATE] On 9/10/23 a nurse progress note documented the resident had blood in the urine and after the laboratory results were reviewed by the PCP #1, the decision was made to send the resident to the ER for the evaluation. Review of the progress notes between 9/10/23 and 9/18/23 revealed that the resident returned to the facility from theER on [DATE] with an indwelling urinary catheter. He continued to have blood in the urine and was treated with antibiotics for UTI. -PCP #1's evaluation was not located in the resident's electronic records and was not provided by the facility upon request by exit 12/19/23. It was unclear if the resident was evaluated by PCP #1 after his return from the hospital. -There was no supporting note clarifying the use of indwelling urinary catheter after resident was readmitted to the facility. The care plan for the indwelling urinary catheter, initiated on 9/26/23 (15 days after the catheter was inserted in the ER) and revised on 12/19/23 (a month after the resident was discharged from the facility), revealed the resident had a catheter. Interventions included to check the catheter tubing for knicks each shift and monitor for signs and symptoms of discomfort on urination and frequency. -The care plan did not specify the type of catheter the resident was using. -Resident #3's care plan did not mention the resident's predisposition for urinary tract infections and recent hospitalization s related to the catheter. -The medical administration record (MAR) and treatment administration record (TAR) for September 2023, October 2023 and November 2023 revealed no orders for the indwelling urinary catheter or care that was provided to the resident. -The review of medical diagnosis in the electronic medical record revealed no documentation of chronic use of indwelling urinary catheter or supporting diagnosis for its use. On 9/18/23, eight days after being readmitted to the facility from the previous hospitalization , Resident #3 was hospitalized again. 2. hospitalization on [DATE] Hospital admission note dated 9/18/23 revealed the resident was admitted [DATE] with altered mental status, he was tested positive for UTI. Admitting diagnosis was catheter associated UTI with sepsis. The admission note read: Patient presented with encephalopathy, most consistent with toxic metabolic etiology in the setting of likely UTI. Evidence of catheter associated UTI after replacement of Foley catheter and testing of urine. The hospital discharge summary on 9/25/23 documented the resident was treated with several antibiotics and required a one-on-one sitter due to consistently pulling on his catheter. -There were no documented progress notes in the facility's electronic medical records between 9/15/23 and 9/18/23, prior to Resident #3's hospitalization . On 9/25/23 a nurse progress note documented that Resident #3 returned to the facility from the hospital. PCP #1's note on 9/28/23 documented the resident was hospitalized and diagnosed with UTI and clostridium difficile (C-diff) colitis. He received a course of antibiotics in the hospital. PCP #1 recommended to schedule a urology consultation as soon as possible. -There were no additional notes regarding catheter care or follow up with urology in the electronic medical record. On 10/31/23 a nurse progress note documented: This morning on early rounds resident was found to have pulled foley catheter out. No bleeding noted bed was soaked. -There were no additional progress notes regarding what was done for the resident after he pulled his catheter. There was no evidence that it was communicated to PCP #1. 3. hospitalization on [DATE] The hospital admission note on 11/12/23 documented that Resident #3 was sent to the emergency room for evaluation after he developed lethargy, hypotension and positive UTI with concerns for sepsis. Patient required an indwelling urinary catheter at last admission to the hospital and needed intermittently, but did not arrive at the emergency department with the catheter. Admitting diagnoses included sepsis with urinary source, hypotension, acute kidney injury and toxic encephalopathy. The resident was started on antibiotics. After intravenous fluids and antibiotics, the resident's mental status returned to his baseline, he was able to recognize family members and made telephone calls. The indwelling urinary catheter was discontinued in the hospital. On 11/15/23, the resident was discharged back to the nursing facility. The admission note to the nursing facility on 11/15/23 read that the resident was alert and oriented to time and place, he was able to ambulate to bed. Resident #3 communicated the need to use a urinal and he was able to void about 200 milliliters of clear urine into the urinal. IV. Staff interviews Registered nurse (RN) #1 was interviewed on 12/19/23 at 11:15 a.m. She said she did not recall working with Resident #3. She said currently she had two residents who had indwelling urinary catheters. She said it was the nursing staff's responsibility to assess the catheter site for signs of infection every shift. She said catheter care was provided by certified nurse aides (CNAs) during incontinence care. She demonstrated the MAR for current residents which included catheter care every shift and supporting diagnosis for the catheter. CNA #4 was interviewed on 12/19/23 at 11:30 a.m. She said she had two residents on her unit who had indwelling urinary catheters. She said care was provided at least once during the shift and after every incontinence episode. She said the catheter bag was checked at the beginning and end of the shift and output was documented under tasks. She said if urine looked cloudy or bloody she would report it to the nurse. The director of nursing (DON) was interviewed on 12/19/23 at 1:45 p.m. He said Resident #3 was admitted to the facility for long term care. He said the resident was admitted without an indwelling urinary catheter, however, after he developed blood in his urine on 9/10/23, he was sent to the hospital where the catheter was placed. He said he was not sure about the actual diagnosis for the catheter as it was not listed on the resident's diagnosis list. He said since the resident spent only one night in the emergency room , from 9/10/23 to 9/11/23, a complete nursing assessment was not completed upon his arrival to the facility and catheter care was not added to the resident's MAR and TAR. He said the catheter care was still provided to the resident as it was documented in some progress notes. He said the catheter care was not consistently documented. Regarding the note on 10/31/23, when it was documented the resident pulled the catheter, he said he personally contacted PCP #1 and discussed it with her. He said the decision was made to use a condom catheter instead of an indwelling catheter since the resident was consistently pulling it out. He said the condom catheter was placed and monitored. He said he recognized the poor and inconsistent documentation regarding catheter care and he was not sure how that happened. PCP #1 was interviewed over the phone on 12/19/23 at approximately 3:00 p.m. She said the resident had chronic UTIs and she recommended follow up with urology back on 9/28/23. She said she had not heard back from the DON or other facility staff about the follow up and did not know if it was scheduled. She said she recalled multiple conversations with the DON regarding the treatment for Resident #3, the care for the indwelling catheter and ongoing infections. She said she did not recall the conversation about Resident #3 pulling the catheter. She said the proper follow up would be to do a bladder scan to check for residuals and evaluate the need for the catheter in light of the resident's mental and physical condition. She said she believed the resident had a urinary retention due to enlargement of the prostate and that was the reason for using the catheter. She said it was not documented among the listed diagnoses on the resident's electronic medical records, however the hospital records mentioned it. She said she did not believe Resident #3's hospitalization s were related to the care the resident received in the facility. She believed the appropriate care was provided based on the numerous discussions that she had with the facility staff. She said lack of documentation of the discussions of care was concerning, however not an indication for the lack of proper care. The NHA was interviewed on 12/19/23 at 4:30 p.m. She said the DON was not immediately available but would provide his comment regarding urology follow up by email. V. Facility follow-up On 12/21/23, the NHA submitted an email with the following comment regarding urology follow up. Transportation was attempting to get an appointment at the VA (Veterans Administration) for urology. I was notified that for new specialty referrals the request must be made through our SS (social services) contact. On 11/17 an email was sent to our SS contact to get his urology appointment request approved. -The note did not include why urology follow up was delayed by almost two months and was not scheduled in a more timely manner.

Based on observations, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, observations and interviews revealed the nursing staff lacked knowledge, training, and equipment to manage the residents' routine and emergency blood glucose monitoring needs. The facility's failure to monitor the blood glucose meters (glucometer) according to standard practice, coupled with the staff's lack of knowledge to ensure blood glucose meters were cleaned, sanitized, and stored properly in between each residents' use created the situation for serious harm likely to occur at a level of immediate jeopardy if the blood glucose meters continued to be shared among residents due to potential transmission of blood-borne pathogens. One resident who shared the glucometer with another had a diagnosis of chronic viral hepatitis C. In addition, the staff failed to perform hand hygiene when cleaning resident rooms. Findings include: I. Immediate Jeopardy A. Findings of Immediate Jeopardy Blood glucose meters The facility had two blood glucose meters, which were shared among three residents who required routine blood sugar checks. This included one resident who had a diagnosis of chronic viral hepatitis C. The Infection Control Program overview last updated 1/1/22 facility's policy and procedure documented to clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current standards of practice. Observation During an observation on 1/24/23 beginning at 3:50 p.m. and ending at 4:03 p.m. the following was observed: -At 3:50 p.m. registered nurse (RN) #1 took gloves out of her pocket and entered room [ROOM NUMBER] with the glucometer. -At 3:51 p.m. RN #1 left room [ROOM NUMBER] with the glucometer. She took more gloves out of her pocket and placed a pile of them on the medication cart. She put gloves on both hands without performing hand hygiene. She opened the container of test strips. She took the glove off her left hand and reached into her pocket to obtain her keys with her left hand. She then opened the medication cart. She then put on another glove that was sitting on top of the medication cart back on her left hand. She put her keys back in her pocket. She opened the cart and closed the cart again. She picked up the glucometer. She knocked on room [ROOM NUMBER]'s door and entered the room. She did not perform hand hygiene or take the gloves off prior to entering the room. -At 3:54 p.m. RN #1 came out of room [ROOM NUMBER] with gloves on and the glucometer in hand. She took her gloves off and disposed of them in the trash can. She did not perform hand hygiene. She opened her computer. -At 3:55 p.m. RN #1 crossed her arms across her body. -At 3:56 p.m. RN #1 reopened the cart and began looking in the cart. She put another pair of gloves on without performing hand hygiene. She obtained a bottle of insulin solution and a syringe put the needle into a bottle of insulin and filled it. She closed the cart and went into room [ROOM NUMBER]. -At 3:58 p.m. RN #1 exited room [ROOM NUMBER] and disposed of the used insulin syringe. She picked up the pile of gloves that remained on the medication cart and disposed of them in the trash can. She did not perform hand hygiene. She placed the glucometer in a black pouch without sanitizing it and entered room [ROOM NUMBER]. She exited room [ROOM NUMBER]. -At 4:00 p.m. RN #1 opened the cart and put the keys in her pocket. She obtained more glucometer test strips. -At 4:01 p.m. RN #1 put the test strip in the glucometer. -At 4:02 p.m. RN #1 assisted a resident move by touching their wheelchair. She then entered room [ROOM NUMBER]. Interviews Registered nurse (RN) #1 was interviewed on 1/24/23 at approximately 4:15 p.m. RN #1 who was working on the East cart said she had three residents who had to have their blood sugars checked. She said she only had two glucometers. She confirmed that she had tested two residents with one meter. She said she cleaned the meter with an alcohol swab after the first resident. She said she then cleaned it again with alcohol after the second blood check.The two glucometers were stored in their own bag, with a name on them. -However, observations of the blood glucose meters revealed they were not labeled. The assistant director of wellness (ADOW) was interviewed on 1/24/23 at approximately 4:15 p.m. The ADOW said the glucometers were not to be shared. She said the meters were meant to be individual and labeled with each resident name. She said when the meters were used they were to be cleaned with a purple top sani-wipe. She said then the glucometer needed to stay wet for two minutes since that was the surface disinfectant time. RN #2 was interviewed on 1/24/23 at 4:21 p.m. She stated there were three glucometers on the Pinion unit for three residents and she used alcohol wipes to clean the glucometers. She stated there was one glucometer that was specifically used for one resident but it was not labeled. All glucometers were observed stored together in the medication cart. They were not in individual bags or labeled with a resident's name and were touching each other in the cart. LPN #1 was interviewed on 1/24/23 at 4:28 p.m. She worked on unit 200. She stated she had two glucometers on her cart for two residents. She stated she was unsure what kind of cleaning wipes were used for the glucometers as she had used the last of the wipes and went to central supply for more. She returned with super sani cloth disinfecting wipes. LPN #5 was interviewed on 1/24/23 at approximately 4:30 p.m. She worked on the Juniper West cart. She said she had three residents who required blood sugar checks, but only had two meters. The meters were stored without individual bags, and were not labeled. The LPN said she used an alcohol pad to clean the meters in between residents. RN #1 was interviewed a second time on 1/24/23 at approximately 5:00 p.m. RN #1 said that when she took the resident's blood sugar with the glucometer, she did not pick and choose which one to use. She said that she just picked one of the glucometers. Facility policy and procedure The Infection Control Program Overview, revised on 1/1/22, was received on 1/24/23 from the assistant nursing home administrator. The policy read in pertinent part, Indirect transmission the transfer of an infectious agent through a contaminated inanimate object. The following are examples of opportunities for indirect contact. -Resident care devices (electronic thermometers or glucose monitoring devices) may transmit pathogens if devices contaminated with blood or body fluids are shared without cleaning and disinfecting between uses for different residents. Reducing and/or preventing infections through indirect contact requires the decontamination (cleaning, sanitizing, or disinfecting of an object to render it safe for handling) of resident equipment, medical devices, and the environment. B. Facility notice of immediate jeopardy On 1/25/23 at 12:15 p.m. the nursing home administrator (NHA) was notified of the immediate jeopardy. C. Facility plan to remove immediate jeopardy On 1/25/23 at 2:00 p.m., the NHA provided a plan to remove the immediate jeopardy. The plan read: Every resident requiring a glucometer has their own rather than sharing. This is a standard of practice to prevent exposure to bloodborne pathogens. No sharing of glucometers is permitted. After use of a glucometer, the device will be cleaned and disinfected after every use per manufacturer's instructions for cleaning and disinfecting are as follows: Glucometer Cleaning instructions Cleaning/Disinfecting equipment: -Perform hand hygiene before handling the meter, then don gloves. -Use Super Sani-Cloth Germicidal Disposable Wipes to wipe down Glucometer, then allow 2-minute wet (dwell) time (to allow for proper disinfection). -Make sure the meter is off and a test strip is not inserted. Wipe the outside of the meter thoroughly with a fresh Super Sani-Cloth wipe. Discard wipe. Using a new Super (sic) Sani-Cloth wipe, rub the entire outside of the meter using 3 circular wiping motions with (sic) moderate pressure on the front, back , left side, right side, top and bottom of the meter. Repeat as needed until all surfaces are visibly clean. Discard used wipes. Ensure that the outside of the meter stays wet for 2-minutes. NEVER put the meter in liquids or allow any liquids to enter the test port. Let meter air dry thoroughly before using it to test. Properly dispose of gloves and wipes after cleaning. Wash hands thoroughly after removing gloves. -This will be performed after each use of a glucometer. -Disinfection will also be performed and documented each night on the third shift along with the Quality Control check. (The two residents) will be tested on [DATE] for exposure to bloodborne pathogens, specifically Hepatitis C. A par level of ten (10) extra glucometers will be always maintained by central supply staff or designee in addition to the individual glucometers assigned to those residents with current physician orders. Every glucometer will be labeled with the resident's name clearly identified. Each glucometer will be placed in its own bag, also clearly identified with the resident's name. All nurses have been in service with repeat demonstration technique on 1/25/23 on proper cleaning and disinfecting procedures for glucometers. Agency nurses, new and/ or rehired nurses and vacation/absent nurses will be in service with repeat demonstration technique prior to working their shift. An extra glucometer will be retained in each nurse's cart in the event a resident's glucometer malfunctions. The nurse will notify central supply and/or designee for a replacement of the extra. Upon death and/or discharge, the resident's glucometer will be disposed of and not reassigned. The ADOW's assignee to (sic) the specific units will verify in writing every seven (7) days to ensure that every resident requiring a glucometer has their own. ADOW's will complete random visual performance checks on staff to ensure proper cleaning and disinfection of the glucometers. These checks will be documented on the glucometer cleaning form. These visual checks will be conducted daily for 30 calendar days then monthly thereafter. All findings of identification of concerns of witnessed cleaning procedure will be corrected and reported to the Quality Assurance Committee Meeting monthly for three (3) months then quarterly thereafter. D. Removal of immediate jeopardy The facility's plan to remove immediate jeopardy was accepted on 1/25/23 at 5:00 p.m. Record review and observations revealed the facility had not implemented their policy and procedure for blood glucose meter cleaning. They provided new blood glucose meters for each resident. The ADOW said they had to replace five meters. However, deficient practice remained at an E scope and severity, a pattern with the potential for more than minimal harm. II. Failure to ensure blood glucose meters were cleaned, stored, and sanitized in a manner consistent with standards of practice. A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Injection Safety, Infection Prevention during Blood Glucose Monitoring and Insulin Administration, retrieved from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html (2/5/23): The CDC has become increasingly concerned about the risks for transmitting hepatitis B virus (HBV) and other infectious diseases during assisted blood glucose monitoring and insulin administration. CDC is alerting all persons who assist others with blood glucose monitoring and/or insulin administration of the following infection control requirements: Finger stick devices should never be used for more than one person. Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. Meters requiring preloading of the test strip may come in direct or close contact with the resident's finger stick wound. Subsequent residents can be exposed when the meter is used on them. Staff hands can become contaminated with blood that is transferred to the meter when they obtain the reading. Blood remaining on the meter can be transferred to subsequent residents through staff hands when they perform the next procedure. According to the CDC Infection Prevention during Blood Glucose Monitoring and Insulin Administration, obtained from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html#anchor_1556215485 on 1/25/23, Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions to prevent carry-over of blood and infectious agents. B. Manufacturer instructions The [NAME] True Metrix blood glucose meter manufacturer cleaning recommendations were retrieved from: https://imgcdn.[NAME].com/CumulusWeb/Click_and_learn/TMX-Pro-CleaningGuide-v6.pdf on 1/25/23, read in pertinent part, Always wash hands and wear gloves when performing blood glucose testing, and when cleaning and disinfecting the meter; contact with blood presents a potential infection risk To Clean: Make sure the meter is off and a test strip is not inserted. Wipe the outside of the meter thoroughly with a fresh Super Sani-Cloth Wipe. Discard wipe. Using a new Super Sani-Cloth wipe, rub the entire outside of the meter using 3 circular wiping motions with moderate pressure on the front, back, left side, right side, top and bottom of the meter. Repeat as needed until all surfaces are visibly clean. Discard used wipes. To Disinfect: Using fresh wipes, ensure that the outside surfaces of the meter stays wet for 2 minutes. NEVER put meter in liquids or allow any liquids to enter the test port Let the meter thoroughly air dry before using it to test. Properly dispose of gloves and wipes after cleaning. Wash hands after removing gloves. B. Facility cleaning product after immediate jeopardy The facility used a product by PDI manufacturer, Super Sani-Cloth germicidal disposable wipes, to clean all blood glucose meter devices after the immediate jeopardy. The wipe required a two minute surface disinfectant time and was documented to be effective against non-enveloped viruses, bacteria, tuberculosis, fungi, multidrug resistant organisms and blood borne pathogens. The ADOW was interviewed on 1/24/23 at approximately 2:00 p.m The ADOW said new glucometers were replaced for five residents who required blood sugar monitoring. The glucometer would then be disposed of upon discharge. III. Additional interviews The medical director (MD) was interviewed on 1/25/23 at approximately 2:00 p.m. The MD said she was notified the facility received an immediate jeopardy for not cleaning the glucometers correctly. She said although the facility did not clean the glucometer correctly, she did not agree that it was an immediate jeopardy situation. She said the blood borne infection could not be transmitted through the glucometer unless there was a significant amount of blood. She said it could be transferred through the lancet. She said that alcohol was acceptable to clean the glucometer meter. She said hepatitis C was not an airborne disease. The MD said the building had issues acquiring the correct disinfecting wipes due to personal protective equipment shortages The nursing home administrator (NHA) was interviewed on 1/25/23 at 4:00 p.m The NHA said the building had no issues with any PPE shortages in the previous 90 days. IV. Hand hygiene failures while cleaning resident rooms A. Professional reference The Centers for Disease and Prevention (CDC) Hand Hygiene in Healthcare Settings, last reviewed 1/30/2020, retrieved on 2/2/23 from https://www.cdc.gov/handhygiene/providers/guideline.html included the following recommendations, in pertinent part for hand hygiene, Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. B. Facility policy and procedure The Infection Control Program Overview policy dated 1/1/22 was provided by the assistant nursing home administrator (ANHA) on 1/24/23 at 2:09 p.m. and read in pertinent parts, Associates will wash their hands before and after contact with a resident; after cleaning a room, after handling waste or linen, after using the bathroom, before and after serving in the dining room, any time hands have possibly become contaminated, before and after applying gloves. Waterless hand cleanser, ABHR, will be provided to associates when handwashing facilities are not readily available. The cleanser may not be used more than three times in a row without washing hands. C. Observation On 1/30/23 beginning at 10:02 a.m. a continuous observation of housekeeping services was made outside rooms #312 and #314. -At 9:53 a.m. in room [ROOM NUMBER], housekeeping associate (HA) #1 finished cleaning the resident room. She did remove her gloves and performed hand hygiene with ABHR, however it was for only six seconds, and put on new gloves. -At 10:05 a.m. HA#1 knocked on the room [ROOM NUMBER]'s door. HA#1 entered the room and picked up oxygen tubing off the floor and placed it on the resident's bed. -At 10:07 a.m. HA#1 wiped down the entire toilet in the bathroom, including the tank, seat and base. She did not perform hand hygiene and then changed the hand towels and soap over the hand sink. -At 10:09 a.m. HA#1 removed her gloves and performed hand hygiene with ABHR, however it was only for seven seconds, and then donned a new pair of gloves. D. Staff interviews HA #1 was interviewed on 1/30/23 at 10:35 a.m. She said she should change her gloves when they were contaminated. The NHA was interviewed on 1/30/23 at 4:00 p.m.The NHA said ABHR should be utilized after every resident interaction and when gloves were contaminated. The process was to use ABHR to cover their hands and wrists until it was dry, and the ABHR took 20 to 30 seconds to dry. She said she did hand hygiene audits to monitor if staff performed hand hygiene correctly. 46022 47151

Based on observations, record review and interviews the facility failed to prevent multiple falls with injury for two (#17 and #57) of two residents reviewed out of 41 sample residents. Resident #17 had a diagnosis of dementia, repeated falls, unsteadiness on feet, unspecified fracture of left arm. The facility failed to develop a person centered plan of care to promote safety and prevent repeated falls. Resident #17 had falls on 8/18/22, on 9/9/22 (had a 0.5 centimeter by 1 centimeter laceration was noted on the lower left leg), on 9/26/22; and on 11/11/22. Resident #17 had a laceration after she fell on [DATE] to her left front forearm, emergency medical services (EMS) were called and the resident was taken to the hospital. Hospital documentation revealed Resident #17 suffered a displaced fracture of the humerus (arm bone, see record review below). A person centered approach was not implemented until Resident #17 suffered a fracture on 11/11/22 (see record review below). A fall occurred on 11/21/22, a large bruise was noted to Resident #17's sacrum. A fall occurred on 11/22/22 and an abrasion was noted to Resident #17's sacrum. In addition, the facility failed to complete neurological checks for unwitnessed falls for Resident #17. Resident #57 was at high risk for falling related to confusion, deconditioning, poor communication and comprehension, and was unaware of safety needs. On 12/22/22 the resident was found on the floor. Subsequent to the fall, the resident was sent to the hospital on 12/23/22 and treated for a fractured hip and required surgery. The facility failed to implement effective interventions with his known fall risk and after the fall with injury on 12/22/22. Findings include: I. Facility policy The Fall policy, revised 11/12/10, was received from medical records (MR) on 1/30/23 at 5:00 p.m It read in pertinent part: Community residents will have a fall evaluation and prevention plan. Based on previous evaluations and current data along with the attending physician, therapy staff and others, the facility will seek to identify resident risk factors for falls and will document those risk factors in the residents medical record. Fall risk evaluations and a plan of care are completed upon admission. Approaches related to fall management are documented in the care plan and progress notes. Community staff are trained regarding fall prevention techniques. Education is provided to the resident, family, and staff regarding the fall risk and the fall care plan. When a resident falls complete the following documentation: -Incident report; -Wellness notes; -Post accident investigation; -Intervention; and, -24 hour report. II. Resident #17 A. Resident status Resident #17, age 62, was admitted on [DATE] and readmitted on [DATE]. According to the January 2023 computerized physicians orders (CPO), diagnoses included non traumatic subdural hemorrhage (head trauma), alcohol abuse, lack of coordination, repeated falls, and fracture of left arm. The 11/14/2022 minimum data set (MDS) assessment was reviewed and revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required supervision with bed mobility and transfers. She required supervision with toilet use, walking and was able to stabilize with human assistance and the use of her walker. B. Observations Resident #17 was observed on 1/24/23 at 3:15 p.m. She was walking around the unit with her walker and was unsteady on her feet. The tennis shoes she was wearing were flopping up and down as she walked as if they were too big for her feet. The resident was thin and frail and took small steps as she walked. She wore a protective helmet while walking outside of her room. C. Resident interview Resident #17 was interviewed on 1/24/23 at 10:00 a.m. The resident said she had fallen quite a few times since being admitted to the facility. She said the worst fall was when she fractured her left arm on 11/11/22. She said that was a very painful experience for her. Resident #17 said she should use her walker to help her stay safe, but she just could not remember to always use it. She said on 11/11/22 she got up from the bed and walked to the bathroom. She said she was walking barefoot in her room, she slipped on something in her room and fell to the floor. She said she complained of pain to her left arm when she tried to get up from the floor with assistance from the staff. She was assisted to a chair while staff called emergency services and was taken to the emergency room . She said she had surgery to repair the fracture to her left arm. D. Record review The resident had fallen on 8/18/22, 9/9/22, 9/26/22, 11/11/22, 11/21/22 and 11/22/22. The falls were not listed in the care plan. The care plan included the following interventions: call light within reach at all times (1/30/14) and staff to assist with transfers and mobility and frequent checks. The care plan, initiated 11/11/19 and revised on 10/11/22 revealed the resident was at a moderate risk for falls with gait and balance problems. Interventions listed for falls: -Follow facility fall protocol, date initiated 10/11/22; and, -Physical therapy to evaluate and treat as ordered, date initiated 11/11/22. Incidents The 8/18/22 incident report revealed the following: The certified nurse aide (CNA) notified the nurse that the resident fell on her side at 8:10 a.m. when she went to pick up a pen that had fallen on the floor of the smoking area.The resident's vital signs were normal, she did not have any wounds, and the resident denied any pain. The resident was advised to continue using her walker. -There were no post injury assessments for this fall or an interdisciplinary team (IDT) assessment/review. The 9/9/22 incident report revealed the following: The resident was found in the sitting position on the floor of her room at 9:50 a.m. The resident had a 0.5 centimeter by 1 centimeter laceration on her left leg. She said she was making her way to the restroom and lost her balance and fell . The resident did not use her walker. Resident #17 denied any pain. -There were no post injury interventions for this fall or an IDT assessment/review. The 9/26/22 incident report at 8:54 a.m. revealed the following: Licensed practical nurse (LPN) #1 said she saw the resident tip to the right in a chair and landed on her right side in the dining room. The resident said she tried to sit on the arm of the chair and it tipped over. No injuries were noted. The resident did not use her walker. The resident experienced three or more falls in the last three months.The resident had a balance problem with walking or standing. She experienced decreased muscle coordination. The post fall assessment for this fall 9/26/22 included: The resident was disoriented times three, had three or more falls in the past 30 days, balance problems with standing or walking, and was not incontinent. -There were no post injury interventions for this fall or an IDT assessment/review. The incident report on 11/11/22 at 9:50 a.m. revealed the following: A resident went to the front desk and told the nurse Resident #17 had fallen. Resident #17 was found in her room on the floor by her dresser. When attempting to stand the patient up her left arm was noted to be deformed and the resident was complaining of severe pain. The resident said she slipped and fell in her room. The resident refused to stand all the way up while complaining of pain in her left arm. The emergency medical services (EMS) were called and the resident was taken to the emergency room . Resident #17 experienced decreased safety awareness and did not use a walker as instructed. Hospital notes dated 11/11/22 indicated: Resident #17 was admitted to the emergency roiagnom on [DATE] at 6:00 p.m. The diagnosis was a displaced fracture of the left humerus (forearm) along with recommendation for surgery. No discharge instructions for the resident were given.The resident was recommended for physical and occupational therapy. Occupational therapy notes, dated 11/14/22 indicated the goals for the resident were bed mobility goals for modified independence, time frame one to three weeks. Toilet transfer goal given the time frame of two to three weeks. Physical therapy goal for the resident for modified independence in the time frame of two to three weeks. Upper and lower body dressing goal (modified) one to three weeks. The resident was discharged back to the facility on [DATE]. Progress notes 1/22/22 at 12:03 p.m. Resident #17 was moved to another room next to the nurse's station. Incident note: 1/22/22 at 2:30 p.m. Resident #17 self reported a fall. She said she was attempting to use the bathroom when she slid off the toilet and landed on her coccyx (sacrum). She said she scooted across the floor on her bare bottom to get to a call light to call for help. This fall occurred after the resident was moved next to the nurses station for her safety. Post fall assessment for 1/23/22: The fall was not witnessed. The resident was observed on the floor.The resident was not incontinent and the floor was not wet.The call light was not on and within reach.The resident hit her head when she fell .The neuro checks were not completed.The resident had four falls in the last 30 days. Interventions added were increased safety checks, and assigned to fall prevention programs.These interventions were not added to the resident's care plan. The neurological checks for Resident #17 were requested from the assistant director of nursing (ADON) on 1/26/23 at 2:00 p.m. they were not provided by the end of the survey on 1/30/23. E. Interviews The ADON was interviewed on 1/24/23 at 2:00 p.m. She said Resident #17 had multiple falls since admission. She said the following interventions were in the care plan: the call light was within reach, the resident should be using her walker when out of bed and wear the proper type of shoes that fit properly, with anti-skid protection on the bottom. She said any fall intervention should always be listed in the resident's care plan. The only intervention found from the list in the care plan was the call light within reach. LPN #1 was interviewed on 1/25/23 at 4:55 p.m. She said Resident #17 wore a helmet to protect her head if she had a seizure while she was walking. She said the resident was often unsafe when she walked and unsteady on her feet. CNA #3 was interviewed on 1/30/23 at 10:00 a.m. She said Resident #17 did not fall in the day time, but usually at night time. She said she thought there was not enough staff to care for the residents on the evening shifts so therefore the residents were not watched close enough to prevent accidents. She said one intervention put into place was to move the resident closer to the nurse station. She said one intervention was to have the call light within reach (2014). CNA #3 said although the call light was within reach (2014), the resident would hardly ever use it until after a fall had taken place. CNA #2 was interviewed on 1/30/23 at 10:30 a.m. She said she was not working the day that Resident #17 fell and broke her arm, but there were many times when the resident would not use her walker, especially in her room and that had caused accidents to happen. Resident #17 visited her husband on the first floor for lunch every day. She said the resident was escorted by the staff to the first floor because she was too weak and frail to walk by herself. LPN #4 was interviewed on 1/30/23 at 4:30 p.m. She said Resident #17 had multiple falls since she was admitted to the facility. She said the resident would not listen to any education that staff provided to her about safety when ambulating. She said most of her falls occurred in her room because she did not use her walker. She said the resident believed she could walk without the walker. LPN #4 said the resident was moved closer to the nurses station for safety, but she still kept falling. The IDT notes for these specific falls were asked for but not provided. 47151 III. Resident #57 A. Resident status Resident #57, age 72, was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO) the diagnoses included schizophrenia, diabetes mellitus type two, arthritis, high blood pressure and dementia. The 1/23/23 minimum data set (MDS) revealed the resident was unable to complete the brief interview for mental status (BIMS). He required assistance of one person for activities of daily living (ADLs) as well as locomotion on the unit, and was a two person assist for transfers. The MDS indicated walking in the resident's room or on the unit did not occur. B. Observations On 1/23/23 at 4:04 p.m. Resident #57 was observed lying in bed. His bed was not in a low position and there was no fall mat by his bed. The fall mat was folded in a small closet area in the resident's room. On 1/24/23 at 2:00 p.m. Resident #57 was observed lying in bed. His bed was not in a low position and there was no fall mat by his bed. The fall mat was folded in a small closet area in the resident's room. On 1/30/23 at 9:38 a.m. Resident #57 was observed lying in bed. His bed was not in a low position and there was no fall mat by his bed. The fall mat was folded in a small closet area in the resident's room. C. Record review The care plan focus initiated 10/31/22 revealed Resident #57 was at high risk for falls related to confusion, deconditioning, poor communication and comprehension, and was unaware of safety needs. The goal was for Resident #57 to be free of injury through the review date of 4/11/23. Interventions included family/caregivers about safety reminders and what to do if a fall occurs, and staff will anticipate and meet Resident #57's needs. The progress note dated 12/22/22 at 11:13 p.m. revealed Resident #57 was found on the floor unable to relate the events of his fall. No visible injury was observed at that time. The progress note dated 12/23/22 at 10:10 a.m. revealed the resident's right thigh appeared swollen and and the resident appeared to be in pain when right thigh was touched. The progress note dated 12/23/22 at 1:40 p.m. revealed the resident was sent to the hospital at 1:25 p.m. for further evaluation of his right hip. -The resident returned to the facility on [DATE] due to right hip fracture and surgery (see notes below). The post incident/accident investigation dated 12/24/22 revealed Resident #57 was found on the floor at his bedside. The resident was unable to relate events leading to the fall. No visible injury was observed. Vital signs and neurological assessment were within normal limits. No injuries were observed at the time of the incident. The corrective actions listed were an increase in safety checks, assigned to a fall prevention program and a physician consultation. The post incident and accident investigation also revealed the care plan was reviewed and updated and a significant change in the MDS assessment was required. The progress notes reviewed for Resident #57's post fall interventions revealed the following: 12/27/22 at 6:29 p.m. revealed Resident #57 was transported back to the facility at 4:45 p.m. on post right hip fracture and surgery. 12/29/22 at 11:44 a.m. risk management noted a fall mat should be placed at Resident #57's bedside and his bed in the lowest position; the resident should be on frequent rounding. 1/11/23 5:33 a.m. Resident #57 was trying to transfer out of bed unsafely and staff had to redirect the resident back to bed. -The fall mat and the bed in low position were not noted to be in place. 1/14/23 4:46 a.m. Resident #57 tried to get up from bed; the call light was in reach. The fall mat and bed in low position were not noted to be in place. 1/22/23 5:45 a.m. the bed was in a low position. -The fall mat was not noted to be in place. -The care plan focus for falls was not updated to include the recommended interventions written in the 12/29/22 risk management progress note. D. Interviews The assistant director of wellness (ADOW) #2 was interviewed on 1/30/23 at 9:40.a.m. She stated that Resident #57 should have a fall mat but only at night. She stated the resident was starting to ambulate more and walk without supervision as his strength increased and having a mat on the floor during the day was a trip hazard for him.

Based on record review and interviews the facility failed to provide services to a resident to avoid physical harm for one (#6) of three residents reviewed for falls out of nine sampled residents. Specifically, the facility failed to: -Provide oversight and safety measures to prevent Resident #6 from falling from a shower chair while bathing. Staff left Resident #6 unattended in the shower room while summoning assistance as the resident began sliding from the chair. The resident's fall was unwitnessed in the shower room. Due to the facility's failures, he was found on the floor sustaining a [MEDICAL CONDITION], pain and subsequently suffered a substantial amount of bruising from his knee to his hip. Additionally, the facility failed to: -Conduct ongoing, post-fall neurological assessments of the resident who experienced trauma to the head during the unwitnessed fall. -Sufficiently document the incident and investigate the circumstances contributing to the fall; -Failed to identify the elements of neglect contributing the the unwitnessed fall with injuries; and, -Investigate bruising of unknown origin once identified in subsequent skin evaluations. Findings include: A. Resident status Resident #6, age 68, was admitted to the facility on [DATE] and readmitted on [DATE]. According to the March 2021 computerized physician orders [REDACTED]. The 2/11/21 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The resident was totally dependent on physical assistance from others for bathing. He required extensive assistance from two persons for bed mobility, transfers, dressing, toileting, and personal hygiene. The resident required limited one-person physical assistance with locomotion on and off the unit, and eating. The resident required the use of a wheelchair for ambulation due to impairment to both lower extremities. B. Resident interview Resident #6 was interviewed on 3/29/21 at 12:00 p.m. The resident said he slipped one time a while ago but could not recall when. He did not remember being injured. C. Interview of the staff member involved in the incident Certified nurse aide (CNA) #1 was interviewed via phone on 3/29/21 at 4:25 p.m. She said Resident #6 fell in the shower room at the beginning of March 2021. The CNA said she could not recall the exact date. CNA #1 said she was working with CNA #4 that night and CNA #4 helped transfer Resident #6 into the shower chair. CNA #1 took the resident to the shower room and began his shower. She said she was the only staff in the shower room at the time. CNA #1 said she went to clean his bottom and he slid down the shower chair away from her because his bottom was raw due to bowel movement remnants on his skin. She said the resident continued to slide down in the shower chair. CNA #1 said she left the shower room to get help from the other CNA on shift. She said she left the door open in case he called for help. CNA #1 said after she left the shower room to get assistance to pull him back up into the shower chair, she heard a thud from the shower room. She said she rushed into the shower room and found the resident lying on the floor. She said the resident had a skin tear on his left arm and a bump on his head. She said she called for the nurse who came to assess the resident. She said after the assessment registered nurse (RN) #1 helped her get the resident back into the shower chair and got him back to his room and into bed. She said she notified the nurse but did not know who the nurse notified after the incident. D. Record review 1. Care plan The fall risk care plan, initiated 5/30/14, identified the resident was at risk for falls related to having a past fall history, and self transferring and repositioning. Interventions included encouraging the use of the call-light and offering frequent reminders, keeping the bed in the lowest position, keeping the room free of clutter, and reminding the resident to ask for help for all transfers as he forgets to do so sometimes. 2. Skin evaluations Skin integrity evaluations from 3/2/21, 3/9/21, 3/10/21, and 3/16/21 were reviewed on 3/29/21 and revealed: -On 3/2/21, the resident's skin was intact and no bruising was noted. -On 3/9/21 at 12:45 p.m., the resident had a hematoma on his left forehead. He was alert and verbal. This evaluation was categorized as a change of condition evaluation. The resident's left arm skin tear was not documented on this skin evaluation. -On 3/10/21 at 12:50 p.m., the resident had bruising to his left knee, left hip, and left thigh. Also documented was the resident's bruise to his left forehead, left knee, and left hip. This evaluation was categorized as a change of condition evaluation. The skin tear was not documented on the skin evaluation. -On 3/16/21 at 11:56 p.m., The resident had bruising to his left knee, left hip, and left thigh. Also noted was the resident's bruising to the left side was clearing, no description of the bruise was included on the skin evaluation. 3. Physician orders [REDACTED].>Physician ordered x-ray results dated 3/10/21 documented no acute fracture, dislocation, or destruction of the bone to the left side of the ribs, hip, or knee. However, there was no indication what prompted the x-ray order. A 3/10/21 physician note documented the presence of a new skin tear to the resident's left arm. The note revealed the wound as an early deep tissue injury that was to be dressed with border foam and changed three times a week. The March 2021 order summary documented a left-arm skin tear to be cleaned and border foam applied every Monday, Wednesday, and Friday, ordered 3/11/21. However, the skin tear was not identified on the weekly skin integrity evaluations, see above. -Review of the resident's health record for March 2021 and requests made to the facility for additional information failed to provide a description of the incident; a record of neurological checks following an unwitnessed fall involving head trauma; accurate post fall skin assessments; the reason for obtaining x-rays; evidence the incident had been identified and investigated as neglect; and/or, evidence that an investigation of bruising of unknown origin was completed. E. Staff interviews The interim director of wellness (IDOW) was interviewed on 3/29/21 at 3:34 p.m. He said he was the assistant nursing home administrator (ANHA). He said they did not have a fall investigation for Resident #6. He said he interviewed staff, Resident #6, and completed x-rays, and found no evidence of a fall. He said the staff he interviewed did not know about any injuries or falls sustained by the resident. He said Resident #6 had poor circulation and wound healing. He said his skin assessment from the previous week was clear and when he observed the bruising that it was dark and appeared fresh. He said if the CNAs observed any abnormalities they reported them to the nurse, who then comes to assess the resident. He said he did not know how he received the bruises to his left side at the beginning of March 2021. CNA #4 was interviewed on 3/29/21 at 4:12 p.m. She said she worked with Resident #6 frequently on the night shift. She said CNA #1 informed her that the resident had fallen and to be careful of his left leg when providing care. She said she remembered being told of his fall at the beginning of March 2021. She said she did not know any details of the fall. She said if she found a resident after a fall she reported it to the nurse on duty. Licensed practical nurse (LPN) #3 was interviewed on 3/29/21 at 3:50 p.m. She said if a resident suffered a fall, whoever found them needed to call for help and stay with the resident. She said, The nurse on duty assesses the resident for injuries, completes a risk assessment, notifies the physician, resident representative, and the director of wellness. If the resident hit their head or the fall was unwitnessed the resident was placed on 72-hour neurological observations and 15-minute checks. The incident should be placed on the 24-hour report and passed onto the next shift. All falls should be reported to the director of wellness. She said residents were transferred into the shower chair then covered and taken to the shower room. She said she saw the bruising on Resident #6's face at the beginning of March 2021. She said she approached the IDOW about it and he said he looked into it. She said he ordered x-rays because the resident was complaining of left side pain. She said nothing was found on the x-rays. She said Resident #6 complained of pain frequently and had medication he could request. Registered nurse (RN) #1 was contacted via telephone and voicemail left on 3/29/21 at 4:20 p.m. The voicemail was regarding her knowledge of Resident #6's fall. She did not return the call during the time of the survey. The IDOW was re-interviewed on 3/29/21 at 5:00 p.m. He said he was the unit manager on the unit when the incident occurred. He said, When a resident falls the physician, resident representative, hospice, unit manager, and the director of wellness should be notified. If the resident sustained [REDACTED]. Follow-up documentation for a fall should include a progress note and a risk management note. The CNAs reported incidents to the LPN who would report it to the RN on duty and the RN notifies everyone. The unit manager should be informed as soon as possible but they usually find out about incidents from the 24-hour report book. The 24-hour report book documents any changes or incidents from the previous 24 hours. Falls should be documented in the 24-hour report book. He said he did not know why he was not informed about the resident's fall or why it was not documented in the 24-hour report book. He said, The nurse on shift is supposed to update the book and is responsible for communicating falls to the oncoming shift. He said for unwitnessed falls the resident should be placed on 72-hour neurological checks with 15 safety checks during that time. He said the physician ordered the x-ray because of the observed bruising on the resident. He said he interviewed all the staff available to him including day, evening, and the next shift of night staff to see if they knew anything about the resident falling and none of them knew of a fall or injury to Resident #6. He said, The LPNs work the floors with the CNAs and there is an RN available in the building. Neurological checks and fall investigations were done on paper then scanned into the electronic record. When bruising was found and the origin was unknown an investigation was completed to try to determine when the incident happened and the cause. He said that he could not determine when and cause of Resident #6's bruises, skin tear and fall occurred through his investigation. However, he stated he did not document the investigation. He said skin tears were documented as injuries and were reported and tracked through skin assessments. He said he was not aware of the resident's skin tear to his left arm until today (3/29/21) when he saw the order for the treatment. He said he should have been notified of the resident's fall and how it happened. He said he kept track of all falls, witnessed and unwitnessed, to help maintain the highest level of wellbeing for the residents. He said if falls were not reported, injuries and changes in condition could be missed and the facility would not address interventions and care measures to help the residents. He said he expected to be notified of falls and incidents that happened in his unit. -Interviews with staff revealed a fall investigation for Resident #6 and subsequent follow-up was not documented; Resident #6 hit his head, had a laceration on his arm, suffered extensive bruising, and experienced pain as a result of the fall (warranting an x-ray to rule out structural damage); although the CNA admitted and facility leadership was aware the CNA left the sliding resident unattended, the incident was not identified or investigated as neglect; there was no evidence neurological checks were completed for the resident following an unwitnessed fall involving head trauma; skin assessments were inconsistent; and, bruising of unknown origin was not investigated. The resident was subject to neglect as the facility failed to provide the services and oversight needed to prevent bodily harm.

Based on record review and staff interview, the facility failed to ensure two residents (#4 and #5) reviewed for abuse were free from resident-to-resident altercations out of seven sample residents. Specifically, the facility failed to: - Protect Resident #4 from physical abuse from Resident #5 which resulted in Resident #4 sustaining a left [MEDICAL CONDITION] and laceration to her head. - Implement person-centered interventions for Residents #4 and #5 to protect other residents from being involved in resident-to-resident altercations. Findings include: I. Facility policy The Abuse policy, revised on 2/3/17, was provided by the assistant nursing home administrator (ANHA) on 2/25/2020 at 2:37 p.m. It read, in pertinent part, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish. Associates will identify events, such as suspicious bruising of residents occurrences, patterns and trends that may constitute abuse. The facility will assist in providing protection for the resident during the investigative process through an action that is least disruptive to the resident. The resident will be provided with an interview to determine how and what situations provide comfort and a feeling of well being. II. Physical altercation between Resident #4 and #5 which resulted in Resident #4 sustaining injuries. A. Resident #4's status Resident #4, age 86, was admitted on [DATE] and readmitted [DATE]. According to the February 2020 computerized physician orders [REDACTED]. The 11/22/19 minimum data set (MDS) assessment revealed the resident had severely impaired cognitive status and required assistance to make health care determinations. She required supervision with ambulation. B. Resident #5's status Resident #5, age 50, was admitted on [DATE] and readmitted on [DATE]. According to the February 2020 CPO, the [DIAGNOSES REDACTED]. The 11/11/19 MDS assessment revealed the resident had severely impaired cognitive status and required assistance to make health care determinations. He required extensive two-person assistance with transfer and locomotion off the unit. He required a wheelchair for mobility. He required supervision with setup only with locomotion on the unit and eating. C. Review of the facility's investigation into the physical altercation between Residents #4 and #5. The Facility Reported Incident (FRI) form dated 2/17/2020 read in part that the facility failed to prevent resident to resident physical abuse that resulted in harm. The nursing home administrator (NHA) was interviewed on 2/24/2020 at 1:30 p.m. She said the incident that happened between Residents #4 and #5 was reported to the State Agency. Shesaid both residents had severe cognitive deficits and Resident #4 had the tendency to go into other residents' spaces and touch their property. She said Resident #5 did not like others in his space. She said the staff reviewed the video tape and determined Resident #5 did not intend to hurt Resident #4. She said the staff moved Resident #5 to another unit and sent Resident #4 to the hospital for treatment. 1. Video review of the altercation On 2/24/2020 at 2:17 p.m. the video security tape was reviewed with the director of wellness (DOW). The visual field of the video included into the dining room and the nurses station. The dining room and nurses station were divided by a half wall and pillar. The video revealed that although the nurses station was located within line of sight of the altercation between Residents #4 and #5, the nurses were seated in chairs and did not maintain visual line of sight of residents. Resident #4 was observed having a shuffled gait while walking past the nurses sitting at the nurses station. Resident #4 walked over to the dining table where Resident #5 was sitting and eating. Resident #4 stood to the right of Resident #5 and faced him while saying something (no verbal recording on the video). Resident #4 was standing approximately three to four feet away from Resident #5. Resident #5 leaned forward began saying something to Resident #4 while gesturing in an aggressive manner. The staff did not look in the direction of the verbal altercation between Residents #4 and #5. Resident #5 reached out and grabbed Resident #4's left hand with his right hand and quickly pulled her toward him and to the right, then abruptly let Resident #4's hand go. Resident #4 stumbled and her feet slipped out from underneath her and she fell to the ground hitting her left hip then the left side of her face on the ground. Nurses stood up and attended to Resident #4. 2. Resident #4's hospitalization report The hospital discharge summary dated 2/19/2020 read Resident #4 sustained a left femoral neck fracture and a 0.5 centimeter laceration to the left side of her forehead. Resident #4 was taken to surgery and received a left hip replacement. 3. Resident #5's hospitalization report The hospital discharge summary dated 2/18/2020 read in part that Resident #5 was admitted to the hospital following a reported unprovoked assault on a fell ow long term care resident. It read Resident #5 was reported to have deliberately and unprovoked grabbed and pulled down an elderly woman, knocking her to the ground that resulted in the woman sustaining a [MEDICAL CONDITION]. It read the facility reviewed the footage of the incident and reported Resident #5 did not grab and pull down the elderly woman with dementia, but rather she was trying to steal his food and he gestured her away and she subsequently fell on her own. It read the facility initially felt unsafe with Resident #5 returning to their care until they reviewed the footage. After the facility reviewed the tape they decided they would take him back. D. Staff interviews The DOW and NHA were interviewed on 2/24/2020 at 1:54 p.m. The DOW said she was notified by the nurses of the incident between Residents #4 and #5. She said Resident #4 and #5 were immediately sent to the hospital. She said she reviewed the security video recording the morning after the incident as part of her investigation. She said Resident #5 was in his wheelchair at the dining room table when Resident #4 walked over to him. She said Resident #5 put his hands up to motion Resident #4 away. She said Resident #4 was walking around the unit and approached Resident #5 multiple times. She said Resident #5 grabbed Resident #4's hand and pulled her away from his food. She said Resident #4 was wearing socks and there were no spills on the floor. She said Resident #4's feet just came out from under her and she fell on her side. The DOW failed to recognize the Resident #5's involvement in Resident #4's loss of balance resulting in the fall. The NHA said the resident always wore non-skid socks that had the non-skid texture on the top and bottom of the sock. The NHA also failed to recognize Resident #5's involvement in Resident #4's loss of balance resulting in the fall with left [MEDICAL CONDITION]. The DOW said the nurses were at the nurses station with their backs turned away from the residents. She said the nurses could not see the residents because of the pillar blocking their view at the nurses station. She said the nurses did not witness the fall. She said another resident witnessed the fall and stated he did it, pointing at Resident #5. The DOW said her staff filed the FRI to the State Agency as abuse although, she felt that was incorrect since Resident #5 did not have malicious intent to hurt Resident #4. She said once she reviewed the tape she instructed her staff to not have emotion when reporting abuse incidents and to look at the facts. She said the FRI should have been reported as an accident and not filed as abuse since Resident #5 did not have intent to hurt Resident #4. The DOW failed to identify the physical altercation between Resident #4 and #5, which resulted in Resident #4 falling and sustaining a fracture, was an abuse altercation.

Based on observations, record review and interviews, the facility failed to ensure one (#9) of three out of 14 sampled residents maintained acceptable parameters of nutritional status. Specifically, the facility failed to: - Ensure resident appropriate interventions and assessments to prevent resident #9's significant weight loss; - Provide care based on the physician's orders [REDACTED]. - Maintain a normal protein range. The facility's failures resulted in resident #9 experiencing severe, 20% weight loss in six months. The facility's failures resulted in resident #9 not receiving appropriate assistance with meals as required. The findings included: 1. Professional standards According to the Center for Disease Control and Prevention (CDC), Division of Nutrition, Physical Activity, and Obesity http://www.cdc.gov/nccdphp/dnpao/index.html, About Adult BMI, 5/15/15, http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html (8/15). .BMI Below 18.5 .Weight Status Underweight .BMI 18.5-24.9 .Weight Status Normal or Healthy Weight .Formula: weight (kg) / (height (m))2 . According to the American Family Physician, Unintentional Weight Loss in Older Adults, http://www.aafp.org/afp/2014/0501/p718.html (8/15). .Unintentional weight loss (i.e., more than a 5 (five) % (percent) reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality. In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of [MEDICAL CONDITION] in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments . 2. Resident #9 Resident #9, age 67, was admitted on [DATE]. According to the 10/16 face sheet [DIAGNOSES REDACTED]. According to the 9/7/16 minimum data set (MDS) assessment, the resident was unable to participate in the brief interview for mental status (BIMS), and his cognitive skills were severly impaired for daily decision making. He required limited assistance with eating and drinking. His height was 65 inches and his weight was 116 pounds. He was not on a physician prescribed weight loss regimen and had experienced weight loss of more than five percent or more in the past month or 10 percent or more in the last six months. His vision was highly impaired and he did not utilize corrective lenses. He was not always able to make his needs known or understand others. He was able to respond adequately to simple, direct communication only. The care plan, initiated on 6/19/13 and updated on 6/10/16, identified that the resident was at-risk for altered nutrition related to depression, dementia, intracranial injury, and anxiety. Interventions included: - Monthly weights and weigh weekly as needed; - Diet as ordered; - Honor food likes and dislikes, and offer an alternative if intake under 50 percent; - Resident prefers finger foods for increased independence at meals; - Dislikes milk, but does not mind milk in foods; - Medication as ordered; - Laboratory testing as ordered; - Monitor and record intake at every meal; and - Supplements as ordered. The facility failed to honor resident #9's preference to consume finger foods during meal service in order to promote independence and to monitor and record intake at every meal. 3. Resident observations Resident #9 was observed on 10/5/16 at 5:55 p.m. He was sitting in his wheelchair at a table in the dining room with another resident. He was served the regular meal which consisted of taco casserole, rice, cool corn salad, and peach crisp. The dinner menu was not posted in the dining room. The resident picked up his fork and attempted to scoop the casserole and was unsuccessful. He became frustrated and began hitting the plate and throwing the food. The food was thrown on the table, floor, his lap and wheelchair. Certified nursing aide (CNA) #4 pulled him away from the dining room table, asked him if he would like to go to his room, he agreed and was transported to his bedroom. Further observation revealed the plate and silverware were not adapted to resident's needs and he was not assisted with consuming his meal. At 6:03 p.m. he was observed inside of his dark bedroom and on the floor, curled into the fetal position. At 6:05 p.m. the 10/5/16 Dinner diet card was observed on the table in the dining room. The card revealed he received a regular diet with thin liquids. He did not have any food allergies [REDACTED]. The Cuban sandwich was circled and crossed out on the ticket. At 7:06 p.m. the resident was observed in his dark bedroom and on the floor. His head was placed on the lower portion of the mattress on the floor and his body lying on the floor. A meal tray was not observed in the bedroom. On 10/6/16 at 7:16 a.m. resident #9 was observed in his dark bedroom, lying on the bed with his eyes opened. At 7:18 a.m. the dining room was observed. There were 13 residents sitting at the tables. The breakfast menu was not posted. Diet aide (DA) #4 was interviewed at 7:20 a.m. and said the breakfast meal was eggs, sausage, oatmeal, and a biscuit. The dining room was observed until 8:03 a.m. On 10/6/16 at 8:05 a.m. resident #9 was observed in his bedroom, awake and lying on his bed. The light was turned off and there was no breakfast food tray observed in his bedroom. At 8:10 a.m. CNA #6 was interviewed. She said resident #9 had behaviors during meal service and she had been instructed to leave him in his room and provide with meals later in the morning. She said he usually consumed his breakfast around 9:30 a.m. and 10:00 a.m. On 10/6/16 at 9:47 a.m. the resident was observed sitting in his wheelchair and waiting for the 10:00 a.m. activity to begin. He was not observed eating his breakfast meal. At 10:17 a.m. CNA #6 was interviewed. She said resident #9 did not receive the breakfast meal and would be served lunch at noon. 4. Record review The 10/16 physician's orders [REDACTED]. - Order date: 12/9/11, offer snacks at bedtime (HS), document A for accepted and R for refused; - Order date: 5/22/13, regular diet and thin liquid consistency; - Order date: 5/9/16, 206 cookies three times a day for weight loss; - Order date: 5/9/16, dietary evaluation due to weight loss; and - Order date: 7/18/16, carnation instant breakfast two times a day for weight loss with eight ounces of milk. A. Weight loss The Monthly Weight Report revealed the following weights: - 1/16, 145.2 pounds; - 2/16, 144.0 pounds; - 3/16, 142.3 pounds; - 4/16, 130.8 pounds; - 5/16, 125.0 pounds; - 6/16, 126.4 pounds; - 7/16, 123.0 pounds; - 8/16, 115.7 pounds; and - 9/16, 114.6 pounds. His BMI was 24.2 in 1/16 and 19.1 in 9/16. He lost 30.6 pounds between 1/16 and 9/16. Between 6/16 and 9/16 (three months' period) he lost 11.8 pounds or 9.3 percent of his body weight, and between 3/16 and 9/16 (six months' period) he lost 27.7 pounds or 19.46 percent of his body weight. B. Laboratory values The 5/9/16 (company) Medical Laboratory document revealed the total protein was 6.8 g/dl (normal range was 6.3-8.2 g/dl) and [MEDICATION NAME] was 3.8 g/dl (normal range was 3.5-5.0 g/dl). The 6/29/16 (company) Medical Laboratory document revealed the total protein was 6.0 g/dl (below the normal range) and [MEDICATION NAME] was 3.1 (below the normal range). The 8/21/16 (company) Medical Laboratory document revealed the total protein was 6.1 g/dl (below the normal range) and [MEDICATION NAME] was 3.0 (below the normal range). C. Nutritional assessments The 9/8/16 Dietary Profile revealed the following pertinent information: - Regular diet, regular texture, and regular consistency; - The portion sizes were regular; - His appetite was good; - He liked most foods and did not dislike any foods; - His hearing and sight were good; - He had his own teeth, no chewing or swallowing problems; - He utilized regular utensils and was independent with eating assistance; - He preferred to not eat alone; - [DIAGNOSES REDACTED]. - BMI was 19.3; - On 8/8 was 115.7 pounds which was minus 5.9% body weight and 7.3 pounds since 7/5; - Intake was 75%-100% at most meals; - He preferred finger foods related to independence at meals. The 9/8/16 Dining Services Note revealed he had a significant change related to weight loss. He was receiving a regular diet with thin liquids. He preferred finger foods related to independence at meals. D. Food assistance and intake The 9/7/16-10/5/16 Eating: Self Performance documents revealed the following pertinent information: - The assistance required for food intake was not documented as independent, supervision, limited assistance, extensive assistance, total dependence, resident not available, resident refused, or not applicable on 9/7 during breakfast and lunch, 9/8 during breakfast and lunch, 9/10 during breakfast, 9/12 during breakfast, 9/13 during breakfast and lunch, 9/14 during breakfast and lunch, 9/16 during breakfast and lunch, 9/17 and 9/18 during breakfast, lunch, and dinner, 9/19 during breakfast and lunch, 9/20 during breakfast and lunch, 9/21 during breakfast and lunch, 9/22 during breakfast and lunch, 9/23, 9/24, and 9/25 during breakfast, lunch, and dinner, 9/26 during breakfast and lunch, 9/27 during breakfast, lunch, and dinner, 9/28 during breakfast, 9/29 during breakfast and lunch, 9/30 during breakfast and lunch, 10/1 and 10/2 during breakfast, lunch, and dinner, 10/3 during breakfast and lunch, 10/4 during breakfast, lunch, and dinner, and 10/5 during breakfast and lunch. The 9/7/16-10/5/16 Amount Eaten documents revealed the following pertinent information: - The food intake was not documented as 0-25%, 26-50%, 51-75%, 76-100%, nothing by mouth (NPO), tube feeding, resident not available, resident refused, and not applicable on 9/7 during breakfast and lunch, 9/8 during breakfast and lunch, 9/10 during breakfast, 9/12 during breakfast, 9/13 during breakfast and lunch, 9/14 during breakfast and lunch, 9/16 during breakfast and lunch, 9/17 and 9/18 during breakfast, lunch, and dinner, 9/19 during breakfast and lunch, 9/20 during breakfast and lunch, 9/21 during breakfast and lunch, 9/22 during breakfast and lunch, 9/23, 9/24, and 9/25 during breakfast, lunch, and dinner, 9/26 during breakfast and lunch, 9/27 during breakfast, lunch, and dinner, 9/28 during breakfast, 9/29 during breakfast and lunch, 9/30 during breakfast and lunch, 10/1 and 10/2 during breakfast, lunch, and dinner, 10/3 during breakfast and lunch, 10/4 during breakfast, lunch, and dinner, and 10/5 during breakfast and lunch. E. Menu The Cycle 2, 2015-2016, Diet Spreadsheet revealed finger foods was an available diet. Some menu items included: banana bread, fruit, vegetables, hard cooked eggs, hamburger, cookie, sandwiches, potato chips, and breakfast and lunch meats. Review of the Week 5 Day 4 menu revealed the following pertinent information: - The dinner menu for the regular meal revealed taco casserole, cool corn salad, peach crisp, and beverage of choice. The alternative meal was Cuban sandwich; and - The dinner menu for the finger food meal revealed hamburger, tossed salad with dressing, cookie, and beverage of choice. The alternative meal was Cuban sandwich. The facility failed to offer resident the preferred finger food. Review of the Week 5 Day 5 menu revealed the following pertinent information: - The breakfast menu for the regular meal revealed fruit of choice, cereal of choice, egg of choice, and beverage of choice. The alternative meal was breakfast bread and breakfast meat; and - The breakfast menu for the finger food meal revealed fruit of choice, cereal of choice, hardboiled egg, and beverage of choice. The alternative meal was breakfast bread and breakfast meat. The facility failed to serve breakfast to the resident. 5. Staff interviews DA #1 was interviewed on 10/5/16 at 11:56 a.m. She said meal times were 7:00 a.m. for breakfast, 12:00 p.m. for lunch, and 5:00 p.m. for dinner. DA #2 was interviewed on 10/5/16 at 5:36 p.m. She said the dinner meal was taco casserole or shredded pork, Spanish rice, corn, and peach cobbler. The Cuban sandwich was not available. DA #3 was interviewed on 10/5/16 at 5:58 p.m. She said the sandwiches were provided on request. The request was made by the resident or staff prior to the meal service. She said resident #9's dining room did not have anyone receiving a finger food diet. DA #1 was interviewed on 10/5/16 at 6:02 p.m. She said the kitchen did not offer a finger food diet. In the past the kitchen had spoken about creating a finger food diet for residents, but it had not happened yet. Residents who would have benefited from a finger food diet were residents who cannot eat on their own or were unable to utilize utensils. DA #5 was interviewed on 10/6/16 at 8:03 a.m. She said room trays had been delivered and she was not asked to save a meal for resident #9. The activities assistant (AA) was interviewed on 10/6/16 at 9:25 a.m. She said resident #9 had experienced a decline in cognition. The activities department did not offer a lot of activities with food, but had a few. She said he required eating assistance from a CNA when food was offered during an activity. Restorative aide (RA) #1 was interviewed on 10/6/16 at 9:28 a.m. She said resident #9 was not receiving restorative nursing services. Feeding assistance required an evaluation by the speech therapist (ST), followed by a referral to the restorative nursing program with feeding instructions. She revealed the Restorative Dining Book with documented four residents ' names. Resident #9 was not included. Review of the Rehab to Facility Communication book revealed the current functional status, precautions, patient and caregiver goals, recommendations and approaches, and therapist review. She said eating assistance interventions included adaptive equipment (foam handles, curved spoons and forks, divided plates, and scoop plates), encouragement, guiding resident hands from their food to their mouth, and food items used to stimulate appetite. CNA #5 was interviewed on 10/6/16 at 10:04 a.m. She said residents with difficulty consuming food required a physical therapy (PT) or ST evaluation. Interventions from therapy for resident with dementia with behaviors included redirecting, allowing them more time to consume their meals, providing a quiet or private space to eat, and the restorative nursing feeding assistance program. Residents who had experienced weight loss or increased dementia were good candidates for the feeding assistance program. Food acceptance or decline was documented in the online charting system at every meal by the CNAs. CNA #6 was interviewed on 10/6/16 at 10:12 a.m. She said resident #9 would have benefited from a feeding assistance program. Concerns with his eating habits, vision, and the potential for the feeding assistance program was reported to several of the nurses. She said resident #9 had a decline in function and memory after moving to a different floor and a different room four to five months ago. He becomes frustrated and agitated with utensils and does not remember how to eat. He received a regular diet, but preferred finger foods. The occupational therapist (OT) was interviewed on 10/6/16 at 10:20 a.m. She said resident #9 would not benefit from therapy services because of his severe dementia and inability to retain instructions. She said he had not been evaluated by the ST for the restorative nursing feeding assistance programs, but would have been a good candidate for the program. The ST was not available for an interview. Licensed practical nurse (LPN) #2 was interviewed on 10/6/16 at 10:28 a.m. She said resident #9 was unable to utilize utensils properly. He had dementia and weakness, which created difficulty with eating. He would frequently sleep through breakfast and lunch, and daily intakes were required to be recorded. She said she had not reported resident #9's feeding difficulties to the therapy department. He would have benefited from a finger food diet or the restorative nursing feeding assistance program. The dietary manager (DM) was interviewed on 10/6/16 at 10:53 a.m. He said he was in the process of updating resident food preferences and meal cards. At 11:16 a.m. he said resident #9 was on the list to have his food preferences updated. He revealed once weight loss had been identified the resident's care was reviewed during the monthly weight loss meetings. The meetings included the DM, diet technician (DT), director of nursing (DON), social services director (SSD), and starting next month someone from the therapy department. He said he had not watched resident #9 consume any meal. Resident #9 was not on a feeding assistance program. At 11:31 a.m. the Eating: Self Performance and Amount Eaten documents were reviewed with the DM. He said he was unable to determine the amount of eating assistance required or the amount of food consumed. The documents were required to be completed at every shift. The DT was interviewed on 10/6/16 at 11:41 a.m. She said she worked with the nursing department to create interventions for residents who had experienced significant weight losses. Interventions may have included weekly weights, supplements, therapy referrals, and encouraging food intake at meals. She said residents with dementia were at high risk for weight loss and required monitoring. She revealed she had not witnessed resident #9 consuming a meal. The nurses were responsible for monitoring resident eating assistance and food intake. The facility had a restorative nursing program which provided feeding assistance at meals. Resident #9 was not receiving assistance with meals. Residents who would have benefited from feeding assistance were residents who had experienced weight loss, had dementia, low energy, required reminders and cuing assistance. Residents who had dementia with behaviors benefited from smaller groups and one on one assistance. She said resident #9 had a finger food preference and he was on the list to be reviewed for food preferences. He was not currently receiving a finger food diet. The DON was interviewed on 10/6/16 at 1:41 p.m. She said weight loss was determined by the nursing and dietary department, and discussed during the weight meetings. Interventions included supplements, adaptive equipment, and eating encouragement. She revealed resident #9 was not interviewable and had poor vision. He was not receiving a restorative nursing program for feeding assistance, but would have benefited from the assistance at meals and a finger food diet.

Based on record review and interview, the facility failed to ensure one of six residents identified for unnecessary medications (#58), out of 39 sample residents, was free of any significant medication errors. Specifically, resident #58 had an order for [REDACTED]. The findings include: A. Professional Reference According to Perry&Potter, Clinical Nursing Skills and Techniques, 8th Edition, (2014), page 480-481: Many medication errors are linked in some way to an inconsistency in adhering to the six rights: a. The right medication b. The right dose c. The right patient d. The right route e. The right time f. The right documentation Medication Orders . A medication order is required for every medication that you administer to a patient.Once you determine that information on the patient's MAR (medication administration record) to prepare and administer medication. When preparing medications from bottles or containers, compare the label or label of the medication container with the MAR indicated [REDACTED]. Finally, verify all medications at the patient's bedside with the patient's MAR . . The right dose: . When a medication is prepared from a larger volume or strength than needed or when the prescriber orders a system of measurement different from that which the pharmacist supplies, the chance of error increases. After calculating the doses of high-risk medications such as Insulin . compare the calculation with one done independently by a second nurse. B. Facility Failure On 1/19/16 in the evening, the resident experienced a hypoglycemic episode after receiving his evening dose of insulin. He was sent to the emergency department at midnight on 1/19/16, and was then admitted to the intensive care unit (ICU). The resident was treated in the ICU on 1/20/16, where his blood glucose levels returned to a normoglycemic state. The resident returned to the facility on [DATE]. The record indicated that on 1/19/16, the resident was sent to the hospital because of a hypoglycemic episode. The resident returned to the facility on [DATE]. The hospital discharge summary, dated 1/20/16, included the following documentation: .admitted after accidently given excess dose insulin at the SNF (skilled nursing facility). Was possibly 81 U(nits) rapid acting insulin .Sugars down to 40s in ED (emergency department) at the lowest and variable since so was admitted to the ICU .He has remained asymptomatic .Accidental excess insulin dosing with associated [DIAGNOSES REDACTED] .The patient, instead of getting his usual dose (18 units) insulin was given 81 units . The January 2016 Medication Administration Record [REDACTED]. There were no nurses' notes written during this three-hour time period regarding signs and symptoms, blood glucose levels, or actions taken by the facility for the resident prior to his transfer to the hospital. A note written by the assistant director of nursing (ADON) on 1/20/16 at 2:02 a.m. read, Resident was sent to (Hospital's) ED at approx. 0000 via (ambulance company name). Per report from previous nurse: resident's blood sugar had dropped to 47. Unknown time frame of resident's blood sugars per report, they were the following 47, 56, 44, 49. Resident received IM (intramuscular) [MEDICATION NAME], MD was called and order to send resident to ED. Report called to ED nurse. On 2/4/16, the resident was sent to the hospital due to a worsening wound to the finger, after which he did not return to the facility. C. Resident Status 1. Resident #58 Resident #58 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the minimum data set (MDS) assessment, dated 1/26/16, the resident had moderate cognitive impairment, as evidenced by a score of 12 out of 15 on the brief interview for mental status. He required extensive assistance for all activities of daily living, with the exception of eating and ambulating in a wheelchair, for which he required supervision. D. Record Review 1. Physician Orders The resident's insulin orders were as follows: -[MEDICATION NAME] (Humalog Solution 100 UNIT/ML (milliliters), Inject 14 units subcutaneously in the morning for IDDM ( insulin dependent diabetes mellitus), order date 11/12/15; - [MEDICATION NAME] (Humalog Solution 100 UNIT/ML), Inject 16 units subcutaneously in the morning for IDDM, order date 11/11/15; and -[MEDICATION NAME] (Insulin [MEDICATION NAME] Solution 100 UNIT/ML), Inject 18 units subcutaneously at bedtime - Document injection site, order date 11/25/12. 2. Care Plan The resident's Blood Glucose care plan (CP), initiated on 4/29/15, read the resident was at risk for unstable blood glucose level related to lack of adherence to dietary recommendations and lack of adherence to diabetes management. The facility's goal was that the resident not experience any hypoglycemic or hyperglycemic episodes through the next review period. The CP interventions included administer insulin as ordered by the physician, encourage compliance with dietary recommendations and encourage decreased intake of foods and fluids which are high in concentrated sugars. Additional interventions included finger stick blood sugars per physician order [REDACTED]. E. Staff Interviews The registered nurse (RN #1) was interviewed on 2/16/16 at 2:05 p.m. She said she frequently cared for the resident. She said she heard about the insulin administration error a couple days later. The assistant director of nursing (ADON) was interviewed on 2/17/16 at 11:10 a.m. She said the reason nurses' notes were not written between the time [MEDICATION NAME] was administered to the resident at 9:00 p.m. and midnight, when the resident was sent to the hospital, was because the nurse was so upset and not able to. I documented (at 2:02 a.m.) from the nurse. The director of nursing (DON) was interviewed on 2/17/16 at 11:18 a.m. The DON said an investigation conducted by the facility revealed that the nurse in question wasn't following the MAR per her interview .The computers were tied up and she wrote medications on paper. She found another computer on a different unit. The DON said that the nurse administered 81 units of insulin rather than 18 units. The DON stated that the pharmacist conducted an in-service for nurses on insulin administration.

Based on observations, record review, and interviews the facility failed to provide two (#2 and #3) of eight sampled residents proper indwelling catheter care. Specifically, the facility failed to: 1. Assess resident #2 when no urinary output was noted and resident was hospitalized 2. Obtain orders for an indwelling Foley catheter or care of the indwelling Foley catheter for resident #2 3. Provide indwelling Foley catheter care for resident #2 4. Develop a care plan for resident #3's suprapubic catheter 5. Provide care for the suprapubic catheter for resident #3 6. Obtain orders for the suprapubic catheter for resident #3 The Findings Include: A. Resident #2 a. Resident status Resident #2 was originally admitted to the facility on [DATE]. His/her pertinent [DIAGNOSES REDACTED]. According to the minimum data (MDS) assessment dated [DATE], the resident ' s cognitive status was not assessed. S/he required extensive to total assistance for his/her activities of daily living. S/he was noted to have an indwelling catheter and was frequently incontinent of his/her bowels. b. Record review admission orders [REDACTED] The admission orders [REDACTED]. Telephone orders A physician ' s telephone order (TO) dated 3/29/14 read to change the urinary catheter now and every month. Notify the physician for signs and symptoms of infection. The diagnosis/indication for the indwelling Foley catheter was for spinal cord injury. The order failed to indicate the size of the indwelling Foley catheter or any treatment orders for the indwelling Foley Catheter. A physician ' s TO dated 4/16/14 read, " Send to the hospital for a mental health hold. The diagnosis/indication was for possible pneumonia and [MEDICAL CONDITION] disorder. Care Plan The Foley catheter care plan initiated on 3/10/14 read in pertinent part, the resident required total assistance with B&B (bowel and bladder) management. The resident had a Foley Catheter for a [DIAGNOSES REDACTED]. The facility interventions listed included to notify the physician as needed and to follow the Foley catheter facility protocol and care as needed (prn). c. Hospital Discharge Summary According to the hospital discharge summary dated 4/18/14 the resident presented (4/16/14) with altered mental status (AMS) and gross pyuria (urine containing pus). His/her past medical history (PMH) included a chronic Foley catheter. His/her catheter was found to be grossly purulent (containing pus). His/her medications that could have contributed to the AMS were held. His/her Foley catheter was changed and the urine was cultured. The resident was treated with (name of antibiotics). The next morning s/he was found to be back at his/her baseline mental status ... d. Facility Failures 1. Failure to assess the resident or notify the physician regarding an absence of urinary output. Nursing note The nursing notes (NN) dated 4/14/14 through 4/16/14 revealed the following: " 4/14/14 at 6:30 a.m. the resident had no output (urine) on the shift (eight hours). 120 cubic centimeters (cc) of water was provided. The resident denied any retention, but at the end of the shift stated that s/he could feel it only when his/her lower abdomen was touched. Report was passed to the morning (a.m.) registered nurse (RN) to evaluate " . However, the NN failed to indicate that staff had assessed the resident or that the physician had been notified regarding the change of condition. " 4/15/14 at 9:50 p.m. the resident had 650 milliliters (ml) of urine output " . (Note: this was the only recorded output since staff noted no urinary output on 4/14/14). " 4/16/14 at 6:44 p.m. the resident was lethargic and hard to wake up. S/he had increased weakness and lacked the ability to more his/her wheelchair (w/c). His/her vital signs were out of normal limits. Per the physician the resident would be sent to the hospital " (see above). 2. Failure to provide Indwelling Foley catheter care Physician orders The admission orders [REDACTED]. Nursing notes Nursing notes dated 3/5/14 through 8/5/14 failed to reveal that staff was providing the resident with indwelling catheter care. TARs The treatment administration records (TARs) dated 3/2014 through 8/2014 failed to reveal that staff was providing the resident with indwelling Foley catheter care as indicated in his/her care plan (see above), since his/her admission to the facility on [DATE]. e. Interviews The Unit Manager (UM #7) was interviewed on 8/20/14 at 2:00 p.m. and stated that a nurse should have assessed the resident when there was no urinary output noted. The nurse should have documented the change in the resident ' s condition on the 24 hour report and notified the physician. The UM stated that s/he would have also expected to have been notified as well as the director of wellness (DOW). The director of wellness (DOW) was interviewed on 8/21/14 at 12:08 p.m. The DOW stated that s/he would have expected the resident to have been assessed for having no urinary output and for the physician to have been notified. The DOW stated that the change in the resident's condition should have also been documented on the 24 hour report. The DOW stated that documenting resident output was not a requirement; however s/he would have expected the urine output to have been tracked since the resident did not have any urinary output on 4/14/14. The DOW stated that s/he would expect catheter care to have been completed every shift, as the resident would allow and to have been documented as being completed. The DOW stated that going forward all catheter care would be documented on the residents TAR. B. Resident #3 a. Resident status Resident #3, age 29, was admitted to the facility on [DATE]. His/her pertinent admission [DIAGNOSES REDACTED]. According to the minimum data set (MDS) assessment dated [DATE]; the resident had no cognitive (memory) problems. S/he had clear speech, was able to make his/her needs known, and was able to understand others. S/he required limited assistance with transfers and toileting and supervision with personal hygiene and dressing. S/he was noted to have an indwelling catheter and was always incontinent of his/her bowels. b. Observations On 8/18/14 at 10:22 a.m. and 11:03 a.m. the resident was noted to be sitting in an electric wheelchair (w/c) participating in a group activity. His/her catheter tubing was noted to be wrapped around to the back of the w/c. Urine was noted in the catheter tubing and the catheter bag was located in a pouch on the back of the w/c, above the level of the resident's bladder. On 8/18/14 at 2:25 p.m. the catheter tubing was noted to be dragging on the floor and the catheter bag remained in the pouch on the back of the w/c, above the level of the resident's bladder. On 8/19/14 at 9:58 a.m. the resident was noted to be sitting up in his/her electric wheelchair (w/c) the catheter tubing was wrapped around to the back of the w/c. There was urine noted in the catheter tubing and the catheter bag was placed in a pouch on the back of the w/c; above the level of the resident ' s bladder. On 8/20/14 at 10:16 a.m. an observation with CNA #2 revealed the resident's catheter tubing was wrapped around the w/c and the catheter bag was located in the pouch on the back of the w/c, above the level of the resident's bladder. CNA #2 stated that this was where the resident preferred his/her catheter bag to be placed. CNA #2 stated that the resident was worried about running over it with the electric w/c and had already pulled the catheter out and was sent to the hospital to have it replaced. On 8/20/14 at 10:37 a.m. an observation with LPN #6 revealed the resident's catheter tubing wrapped around the w/c and the catheter bag was placed in the pouch on the back of the w/c, above the level of the resident ' s bladder. c. Record review Physician orders The admission orders [REDACTED]. Telephone orders The physician ' s telephone orders (TO ' s) dated 7/17/14 through 8/19/14 revealed that on 8/5/14 the resident was discharged to the hospital to have his/her suprapubic catheter replaced. However the TO ' s failed to reveal any orders for the indwelling suprapubic catheter, the type and size of the indwelling suprapubic catheter, or any treatment orders for the indwelling suprapubic catheter. Care plan The resident's care plans initiated on 7/19/14 failed to reveal a comprehensive care plan for the resident's suprapubic catheter. Catheter Evaluation According to a catheter evaluation dated 8/7/14, the resident was paraplegic and had a suprapubic catheter related to retention, which could not be treated medically or surgically. There were no plans to remove the catheter at the time and the benefit outweighed the risk. Nursing notes The nursing notes dated 7/17/14 through 8/18/14, revealed that on 8/5/14 the resident was transferring him/herself into bed, causing the suprapubic catheter to come out and disconnect. The physician was notified and orders were obtained to send the resident to the emergency room to have the suprapubic catheter replaced. The nursing notes failed to reveal that the staff was providing care to the resident's suprapubic catheter. d. Facility Failures 1. Failure to obtain orders for the indwelling suprapubic catheter. According to the admission orders [REDACTED]. According to the physicians telephone orders dated 7/17/14 through 8/19/14 there were no orders for the resident's suprapubic catheter or treatments. Furthermore, when the resident returned from the hospital on [DATE], after having his/her suprapubic catheter replaced, there were no orders obtained for the use or care of the suprapubic catheter. 2. Failure to complete comprehensive care plan The facility failed to complete a comprehensive care plan for the resident's suprapubic catheter. 3. Failure to provide indwelling suprapubic catheter care The admission orders [REDACTED]. Nursing notes Nursing notes dated 7/17/14 through 8/19/14 failed to reveal that staff was providing the resident with indwelling suprapubic catheter care. TARs The treatment administration records (TARs) dated 7/2014 through 8/2014 failed to reveal that staff was providing the resident with indwelling suprapubic catheter care. 4. Interviews The resident was interviewed on 8/21/14 at 8:44 a.m. and stated that s/he did not have any concerns with his/her indwelling catheter. S/he stated that every time a nurse came into the room they provided catheter care. The resident also stated that staff had educated him/her on the placement of his/her catheter bag; however, s/he could not state those risks. The resident ' s licensed practical nurse (LPN #6) was interviewed on 8/20/14 at 10:37 a.m. and stated that catheter care was provided to the residents on every shift. The nurses ' were responsible for suprapubic catheter care, if the resident would allow. The LPN stated that there should be orders for the catheter and the care and treatment of [REDACTED]. The LPN reviewed the residents clinical record and acknowledged that there were no orders or care plan in place for the suprapubic catheter. The LPN immediately called the physician ' s office to obtain orders. UM #7 was interviewed on 8/20/14 at 4:07 p.m. The UM reviewed the resident's clinical record and acknowledged that there was no care plan or physician orders [REDACTED]. The UM stated that there should be orders in place for the use and care of the suprapubic catheter and there should also be a care plan in place. The UM acknowledged that the resident's catheter bag should be placed below the level of the bladder, so gravity would promote the flow of urine away from the bladder. The UM stated that if the resident preferred a particular placement of the catheter tubing and bag it should be reflected in the resident's care plan. Facility Action On 8/20/14 the facility contacted the resident's physician and obtained orders for the suprapubic catheter. The facility also completed a comprehensive care plan for the resident's suprapubic catheter.

Based on record review and interviews the facility failed to provide one (#1) of eight sampled residents specialized rehabilitative services such as, but not limited to physical therapy, speech-language pathology, occupational therapy, and mental health rehabilitative services for mental illness and intellectual disabilities. Specifically, the facility failed to provide resident #1 with mental health services as outlined in the resident's pre-admission screening and resident review (PASRR) level II. Ultimately the resident was discharged and admitted to the hospital for mental health issues. The findings include: A. Professional reference: According to Medicaid.Gov. at <http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Institutional-Care/Preadmission-Screening-and-Resident-Review-PASRR.html>, retrieved on 8/29/14, stated in pertinent part that: Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for mental illness and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care settings); and 3) receive the services they need in those settings. PASRR is an important tool for states to use in rebalancing services away from institutions and towards supporting people in their homes, and to comply with the Supreme Court decision, Olmstead vs. L.C. (1999), which held that that all individuals have the right to live in the "least restrictive setting" possible. PASRR can also advance person-centered care planning by assuring that psychological, psychiatric, and functional needs are considered along with personal goals and preferences in planning long term care. In brief, the PASRR process requires that all applicants to Medicaid-certified Nursing Facilities be given a preliminary assessment to determine whether they might have MI or MR. This is called a "Level I screen." Those individuals who test positive at Level I are then evaluated in depth, called "Level II" PASRR. The results of this evaluation result in a determination of need, determination of appropriate setting, and a set of recommendations for services to inform the individual ' s plan of care. B. Resident Status: Resident #1, age 66, was readmitted to the facility on [DATE]. His/her admission [DIAGNOSES REDACTED]. According to the minimum data set (MDS) assessment dated [DATE], the resident had severe cognitive (memory) deficits. S/he had clear speech, was able to make his/her needs known, and was able to understand others. S/he was noted to have verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) daily, and s/he had other behavioral symptoms not directed toward others (e.g., 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, disruptive sounds) less than daily. S/he was noted to reject care on a daily basis and was independent with all of her activities of daily living (ADL ' s). C. Clinical record review PASSR level II According to the PASRR level II dated 9/12/2000, the resident had a mental illness (MI) [DIAGNOSES REDACTED]. S/he required other mental health interventions and the following recommendations were made: Mental health services ? Requires regular one to ones, assess his/her compliance with mental health certification; compliance with care and psychiatric stability Medication Management ? Monthly certification and medication reviews by a psychiatrist. "Follow up on medication compliance, effectiveness of medications. Assist staff regarding ESTC? And court ordered medications" Case Management: * "The resident will require further monitoring of medication, sleep, appetite patterns, and any increased irritability, which may be due to medication non compliance. Seek a psychiatric evaluation (27-10) peer any verbally threatening behaviors as the resident has a history of assaults when s/he would decompensate." Other (behavioral) interventions ? Monitor cigarette smoking and utilize for a positive reinforcement. Will require close monitoring related to a history of fire setting. Also monitor medications; suggest 5 minute observation after medication administration ? Encourage participation with activities for increased structure and support ? Low level redirecting was suggested. PASRR progress note The PASRR progress notes failed to reveal any PASRR level II updates since 9/16/11 Notice to staff An important notice located in the resident's clinical record (not dated or on letter head) read: important: please do not alter, add, or discontinue any psychiatric medications for this resident without consulting with his/her mental health provider. Computerized Physician order [REDACTED]. According to the 8/2014 CPO ' s the resident was to receive the following medications ? [MEDICATION NAME] 325 mg (milligrams) 1-2 tabs orally every 4 hours as needed for pain or fever ? [MEDICATION NAME] suppository 10 mg per rectum q day as needed for constipation ... ? Milk of magnesia suspension 400 mg/5 milliliters (ml) give 30 ml orally as needed for constipation ... ? [MEDICATION NAME] 200 mcg orally every day for [MEDICAL CONDITION] TO's A physician's telephone order (TO) dated 6/9/14 read; send the resident to (name of hospital) via ambulance transport with a police escort for full psychiatric evaluation and court certification for medications and treatment. D. Facility Failure: Failure to provide mentally ill resident with required mental health services According to the social services notes (SSN) dated 1/19/13 through 4/12/13, the resident was receiving mental health services through an outside mental health care provider until 4/12/13. Further review of the SSN revealed the following: -4/12/13 - the resident remained stable and comfortable at the (name of facility). The resident was independent with ADL's, had a [DIAGNOSES REDACTED]. This quarter the resident discontinued services after not wanting to communicate with the case worker. The resident usually kept to herself and could become agitated when others attempted to make conversation with him/her ... -5/7/13 - the resident's antipsychotic medication was discontinued related to resident refusals and no call to OBRA (omnibus budget reconciliation act) was needed. -4/12/13 through 6/8/14 - failed to reveal that the resident's mental health needs were being met, that the facility made attempts to determine the cause for refusals, or that the facility attempted to provide the resident with any outside mental health services; as outlined in his/her PASRR level II. Furthermore there was not any PASRR level II updates made (see above) regarding the resident's continued refusals of therapy, discontinuation of mental health services, or refusals and discontinuation of [MEDICAL CONDITION] medications. -6/9/14 at 8:49 a.m. - (discharge to hospital) the resident had an altercation with another resident with the resident being aggressive toward another resident due to entering his/her room and leaving the door open (note: resident was discharged to the hospital at 1:30 p.m.) (see below). E. emergency room Report According to the emergency department report dated 6/9/14, the resident was sent to the hospital due to increasing agitation, depression, psychotic behaviors, aggressive, responding to external stimuli, and refusing to take any medications. Based on the resident's presentation and his/her threatening nature to staff, s/he was placed in behavior restraints in the ambulance and kept in behavior restraints in the emergency department. S/he was chemically restrained with (name of drug) in the emergency department and (name of drug) and was resting comfortably the remainder of the physician ' s shift. The physical restraints were removed two hours after placement in the emergency room . The physical exam read; the resident was agitated, shouting obscenities, threatening staff, refusing evaluation and refusing to be examined ... the patient was responding to external stimuli while in the room. F. Interviews. The Social Services Director (SSD) was interviewed on 8/2/14 at 10:06 a.m. and stated that when a resident was admitted to the facility a PASRR level one would be completed. If the PASRR level one triggered for a PASRR level II, she (SSD) would receive the determination letter and she (SSD) would review the letter with the interdisciplinary team (IDT) to discuss and plan the resident's care/needs. However some residents would require a pre-admission care plan to be completed prior to being admitted to the facility. The SSD further stated the resident was originally admitted to the facility on court ordered medications and treatments; however s/he (SSD) had been with the facility since 2012 and the resident had not been on any court ordered medications or treatments since then. The SSD went on to say when the resident was receiving mental health services from (name of provider) and taking his/her [MEDICAL CONDITION] medications she was being seen and reviewed, sometimes staff would meet with her daily if needed, however, more times than not she would refuse to meet with staff. The SSD stated that she believed the facility attempted to get the resident the services she needed, but the resident would refuse (note: this is the resident ' s base line to refuse). The SSD reviewed the resident's clinical record and noted that the resident ' s mental health provider discontinued the resident's services (4/2013) related to his/her refusing to talk with the case worker. The SSD acknowledged that a month later the resident's antipsychotic medications were also discontinued due to the resident's refusals to take his/her medications (note: resident's base line, reason she was on court ordered meds and treatment when she originally was admitted to the facility). The SSD stated that when there were changes in the resident ' s medications, she (SSD) would receive and review the telephone orders, previous medications or treatments noted on the PASSR. The SSD stated s/he would then document the changes and determine if a status change or depression diversion screen was required. The SSD reported that the resident was discharged to the hospital on [DATE] for a full psychiatric evaluation and was expected to readmit to the facility on court ordered medications and treatments The SSD stated that the facility had already talked with the mental health care provider who has picked the resident back up for mental health services. The Director of Wellness (DOW) was interviewed on 8/21/14 at 11:50 a.m. and stated that prior to being admitted to the facility a PASSR level one would need to be completed. If the resident had a mental illness or mental disability a PASSR level II would be required. The DOW stated that the SSD would then review the PASSR level II in detail and update the IDT regarding the plan of care. While the DOW was not exactly sure when a PASSR level II update would be required, s/he stated that s/he would expect progress notes to be completed if there were changes in the resident ' s medications or treatments. The DOW stated that there was never a question of the resident being readmitted to the facility, the resident just needed to be " certified " , on court ordered medications, and treatments prior to his/her return.

Based on record review, observations and staff interviews, the facility failed to provide adequate care and services to promote healing and to prevent new pressure ulcers from developing for one (#23) of 24 sample residents. Specifically: -The facility failed to consistently identify, assess, monitor and implement timely interventions to address facility acquired shearing, failed to document wound progression, and failed to prevent further skin breakdown. These failures culminated in the worsening of resident #23's stage I pressure ulcers (shearing) to stage II pressure ulcers and in the development of a new stage I area to the buttocks, which the facility was unaware of until it brought to the facility ' s attention during survey. The findings included: A. Professional Reference The National Pressure Ulcer Advisory Panel's (NPUAP) February 2007 guidelines, found at the website: http//www. npuap.org. provided the following definitions: Pressure Ulcer Definition: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction... B. Facility Form A facility form entitled "WOUND/SKIN HEALING RECORD" (WSHR) identified the following Pressure Ulcer Stages -"Stage I: An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters...A defined area of persistent redness in lightly pigmented skin... -Stage II: partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater." C. Resident #23 Resident #23's medical record was reviewed on 3/29/11 through 3/31/11. 1. Resident #23, a [AGE] year-old male, was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented that the resident made himself understood and could understand others. The resident had no short-term or long-term memory problems and was independent with daily decision making. -The resident needed limited assistance of one staff with bed mobility, transfers, toileting, and personal hygiene. -The resident needed extensive assistance of one staff with dressing and bathing. The resident was non-ambulatory and was independent with locomotion via wheelchair. -The resident was on a toileting program, was frequently incontinent of bowel and bladder. -The resident was at risk for pressure sores and had no unhealed pressure sores. 2. Skin breakdown Review of the resident's skin breakdown care plan revealed the resident was identified at risk for breakdown 7/10 and developed actual skin breakdown 3/11. Specifically: A skin breakdown care plan was initiated on 7/26/10, and then updated on 1/19/11, 3/19/11 and 3/21/11. The care plan read in pertinent part "7/26/2010 Skin - (resident #23) is at risk for skin breakdown r/t (related to)...3/21/11...incontinent of B&B (bowel and bladder) @ times...3/19/11...Shearing to right & left buttocks." -The goals read in pertinent part: "skin will remain intact X90 days." Approaches to the care plan read in pertinent part: "Provide repositioning upon q (every) 2 hours rounds and as needed (PRN). Pressure relieving mattress and w/c (wheelchair) cushion...barrier cream as needed...Brief check and change program. Check...Q 2 hours rounds and change after each incontinence episode. Complete weekly skin assessment and report abnormalities to MD (physician)...Prompt + void program required." Another skin breakdown care plan was initiated on 3/19/11 and read in pertinent part: "Non-Pressure Skin Care Plan...3/19/11...Open area shearing...right inner buttock....Short Term Goal...will be treated according to... (physician) orders over the next 90 days...Approaches...3/19/11 cleanse...(with) NS (normal saline) apply Siva Sorb gel to wound bed cover...(with) foam dsg (dressing)...(change) QD (everyday). Monitor on wound rounds weekly." Nurses notes dated 3/19/11, read in pertinent part: "...checked skin. Noted 2 open areas on inner buttocks from shearing. Resident slides in bed/in & out of wheelchair also. Right inner buttock 1 X 1 cm 0.2cm depth, left inner buttocks 1cm X 0.5cm...(less than) 0.1cm beds red in color 0 drainage noted...MD in facility obtained orders...monitor open areas to buttocks on wound rounds and weekly." Although the open areas presented in pressure areas with depth (see nurses' note above), the wounds were documented and identified as "non-pressure wounds" on the skin breakdown care plan 3/19/11. Physician telephone Orders and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Cleanse open areas on Right & left inner buttock...(with) NS, apply Silva Sorb gel to wound bed, cover...(with) foam dsg(dressing)...(change) QD (everyday). 2) Monitor areas on wound rounds weekly." IDT (interdisciplinary team) notes dated 3/21/11 read in pertinent part, "IDT REVIEWED PASS PRIVILEGES CONT (continue) FREQUENT OBSERVATIONS." There were no IDT notes regarding the skin breakdown. A weekly form entitled "WOUND/SKIN HEALING RECORD" (WSHR) initially dated 3/22/11, with the resident's name was reviewed. -The WSHR dated 3/22/11 documented resident #23 with two open areas and read in pertinent part, "Non-pressure buttocks shearing." -The WSHR documented no staging of the wounds and indicated "N/A" (non-applicable) under the subtitle "Stage." (But see nurse's note above documenting 2 open areas on inner buttocks from shearing with size and depth, consistent with a Stage II pressure ulcer per facility WSHR. The wounds were identified and documented on the WSHR as: -Right buttock - "NA" for "Stage" superficial shearing that was round and measured 1cm. No drainage or odor. The surrounding skin was normal. -Left buttock - "N/A" for "Stage" superficial shearing measured 1.2cmX0.3cm. No drainage or odor. The surrounding skin was normal. Review of the WSHR revealed no weekly skin assessment on 3/29/11 (day 7) as indicated. 3. Additional skin breakdown On 3/30/11 at about 1:30 p.m., the Director of Nursing (DON) stated the 3/29/11 weekly wound rounds were missed as the surveyors were in the building. No wound rounds had been completed for resident #23 by 3/30/11 at 11:30 a.m. The Wound Care Licensed Practical Nurse (WCLPN) was informed of a request to observe wound care. The WCLPN confirmed she had not yet done the dressing change. The WCLPN further stated the resident preferred wound care after lunch at about 1:00 p.m., and the surveyor would be called for observations. On 3/30/11 at 1:30 p.m., with the resident's permission, wound care provided by the DON and WCLPN was observed. The resident was assisted from the wheelchair to bed and his incontinence brief was removed. -Observations revealed no dressings on the resident's buttocks, as ordered by the physician. The WCLPN stated, "...The dressing(s) must have fallen off after the shower this morning...I don't know when it fell off...I put one on yesterday (3/29/11) at 1:30 p.m." -Instead of the documented "shearing superficial", observations at that time revealed: Right buttock stage II measured 0.7 cm X 0.6 cm X 0.1 cm crater. The surveyor pointed out a reddened area to the right buttock and requested assessment and measurement of the area. Right buttock stage I that measured 6.4 cm X 1.5 cm, non-blanchable red area. Left buttock stage II, measured 0.4 cm X 0.1 cm X 0.1cm crater. The DON stated, "They are pressure sores...I did not see those wounds last week...It was shearing." The WCLPN stated, "He did not have redness yesterday...it (redness) is not blanchable in the middle." After the dressing change was completed, the DON, WCLPN and certified nurse aide (CNA) were interviewed together outside of the resident's room. -The CNA stated, "He had a dressing on this morning...I gave him a shower this morning (3/30/11) at about 8:30 a.m. I told the nurse (WCLPN) at about 8:30 a.m., that it fell off...He had no dressing on (after the shower)...It got off in the shower." -The WCLPN denied she was made aware of the resident's dressing condition. The DON stated, "My expectation is that the CNA should have told the WCLPN that there was no dressing after the shower...there was no good communication between the WCLPN and CNA." After the dressing change on 3/30/11, the resident's care plan was updated to indicate actual pressure sores to his buttocks. Furthermore, follow-up for pressure sores instead of non-pressure wounds was initiated on 3/30/11. Review of the WSHR after the 3/30/11 dressing change revealed the WSHR was documented with stage II wounds to the right and left buttocks. Although that WSHR was documented with a new 6.4 cm X 1.5 cm red area, the facility failed to indicate the area was a stage I, as indicated. Finally, after the dressing change 3/30/11, the WCLPN notes dated 3/30/11 at 1:40 p.m. read, in pertinent part, "DON and I (WCLPN) were present...Left buttock inner area size 0.4 X 0.1 cm...0.1 depth, right buttock inner area open area 0.7 cm X 0.6 cm...0.1 depth. New area noted red mark on right buttock 6.4 cm X 1.5 cm. redness blanchable on end sections but remains Red in center. Will call physician...to report changes." Nurses' notes dated 3/30/11 at 2:55 p.m. revealed the Nurse Practitioner (NP) called the facility with new orders. Nurses' notes read in pertinent part, "Call received from...NP. Requested (ordered) wound nurse eval (evaluation), encourage (resident) repositioning q 2...(hours)." Nurses' notes dated 3/31/11, indicated the physician ordered for a Registered Dietitian evaluation for the resident on that date. 4. Staff interview On 3/31/11 at 3:35 p.m., the DON was interviewed again. -The DON stated, "There was a progression in the wounds, it did not happen overnight...There was a slow progression...we kept calling it shearing, when we looked yesterday it was stage II (a total of two stage II pressure sores) pressure...The WCLPN went through special wound care training...I expected documentation on that wound(s) as it progressed (from shearing) to stage IIs...It should have been reflected in notes instead of calling it shearing when it had actually progressed to the next step of stage IIs." -The DON stated the wounds were observed daily by the WCLPN and the progression was not documented as indicated. -The DON further stated, "When the CNA completed the shower (on 3/30/11), the WCLPN should have put a dressing on the resident's wounds immediately...five hours later was not timely."