Every finding on record at Kalispell Rehabilitation and Nursing LLC

Based on interview and record review, the facility failed to provide necessary care and services to maintain the highest practicable physical well-being for 1 (#1) of 8 sampled residents. The facility failed to administer an anticoagulant medication as ordered, resulting in the omission of 27 doses of Eliquis (Apixaban), increasing the risk for complications including stroke and blood clots; and failed to implement physician-ordered medication hold instructions before a scheduled vascular procedure, resulting in the cancellation and rescheduling of the resident's fistula surgery on two separate occasions and causing the resident frustration. These failures delayed medically necessary treatment. Findings include:1. During an interview on 6/15/26 at 2:28 p.m., NF1 stated she was contacted by the nursing home staff and they informed her they had made an error and had mistakenly taken resident #1 off his blood thinner for a period of time.Review of resident #1's physician's office visit showed resident #1 was to be seen by the vascular physician on 3/5/26 at 1:00 p.m. The physician notes and physician orders showed, will need to stop/hold Eliquis 48 before surgery - 4/28/26 . The physician orders and notes were acknowledged by staff members on 3/5/26 and again on 3/9/26.Review of resident #1's Medication Administration Record (MAR) for March 2026 showed:-Eliquis Oral Tablet 5 MG (Apixaban), Give 1 tablet by mouth two times a day, related to unspecified Atrial Fibrillation (I48.91) until 3/25/26 23:59 (11:59 p.m.), order dated 3/9/26 at 0036 (12:36 a.m.).-The Eliquis 5 mg, po BID was put on hold 48 hours before the resident's surgery on 4/28/26. The MAR showed, Check with vascular after surgery to see if this should be restarted, one time only for follow-up for 2 days, ordered dated 3/9/26 at 0038 (12:38 a.m.).Review of resident #1's MAR for April 2026 showed:-Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day related to Long Term (Current) Use of Anticoagulants (Z79.01), order dated 4/8/26 1759 (5:59 p.m.).Resident #1 did not receive Eliquis, a blood thinner, from 3/26/26 to 4/8/26, resulting in the omission of 27 prescribed doses.During an interview on 6/17/26 at 11:36 a.m., staff member B said resident #1's Eliquis was discontinued rather than placed on hold, which caused the resident to miss multiple doses of his Eliquis in March and April 2026.Review of the facility's Medication Error Reported, date and time of the error 4/8/26, identified that a nurse had discontinued the Eliquis order instead of placing the medication on hold. The report classified the error as a dose omission and documented the reason for the error as D/C instead of hold.Review of resident #1's progress notes showed an event note template on 4/16/26 at 9:17 a.m. that showed event description: Eliquis 5 mg order was discontinued by [Staff Member's Name] instead of it being held. She wrote to hold it but it appears that she discontinued on accident. Notified patient, MD and DON. Notified [family member] about incident. MD stated there is no concern for harm. Requested to restart it and hold 48 hours before surgery.2. During an interview on 6/15/26 at 2:28 p.m., NF1 stated resident #1's fistula surgery had been scheduled on two occasions and was cancelled both times due to the facility's medication errors. NF1 stated that during the first scheduled procedure, hospital staff discovered resident #1 had received Ozempic despite physician orders requiring the medication to be held before surgery, resulting in the cancellation and rescheduling of the procedure. NF1 further stated that when the procedure was rescheduled for 6/9/26, the facility staff administered resident #1's anticoagulant despite orders to hold the medication, resulting in cancellation of the procedure for a second time. NF1 stated that resident #1 was already on the procedure table when the surgeries were cancelled. NF1 reported that the repeated cancellations caused him fear and frustration.During an interview on 6/16/26 at 2:26 p.m., resident #1 reported the fistula procedure had been cancelled twice because medications that were ordered to be held had been administered. Resident #1 stated the repeated postponements were frustrating.During an interview on 6/17/26 at 11:36 a.m., staff member B said resident #1's procedure scheduled for 4/28/26 was put on hold because the medication Ozempic was given in error.Review of resident #1's electronic health record showed the following:- Nurse's Note, dated 4/8/26 at 17:47 (5:47 p.m.), Note Text: Orders received from pre-anesthesia appt.Other: Eliquis 5 mg BID do not take after 4/25, Ozempic do not inject after 4/20. Held and edited orders. [sic]- Nurse's Note, dated 4/28/26 at 16:48 (4:48 p.m.), Note Text: Resident's procedure for a fistula will have to be rescheduled, nurse call [Physician's Name] office and the procedure will be on June 9th at 0830am (8:30 a.m.), all previous hold orders and insulin order will remain the same. [sic]- A communication with Family/NOK/POA, dated 4/29/26 at 3:32 p.m., showed, Note Text: Spoke with [family member's Name], she was upset about residents procedure needing to be rescheduled. Try to explain that once the Ozempic dose was increased, that hold medication order changed into a new order and the system did not catch the hold order. Updated [family member's Name], letting her know that I will be putting in TARS and MAR orders for 2 weeks so all staff is notified about med hold orders that will need to be flagged/important for his procedure. [sic]- The physician orders, Administration Note, dated 6/9/26 at 11:25 a.m., showed, Note Text: Resident to have a fistula procedure on June 9th with [Physician Name] (vascular) at 0830 (8:30 a.m.). one time only for Fistula procedure June 9th 0830 (8:30 a.m.) related to DEPENDENCE ON RENAL DIALYSIS (Z99.2) for 1 Day Resident unable to have procedure d/t eliquis administration. [sic]Review of resident #1's preoperative note from [Hospital Name] dated 4/28/26 at 13:24 (1:24 p.m.) showed, .Pt surgery cancelled for Hight potassium and had taken Ozempic prior to surg.Review of resident #1's preoperative note from [Hospital Name], dated 6/9/26 at 8:41 a.m., showed, .procedure canceled. [Facility Name] failed to hold Eliquis 48 hours prior to procedure.Review of the facility's Medication Error Report Form for resident #1 showed the date and time of the error were on 4/16/26 and showed the Ozempic was given in error. The root cause was determined to be that the medication was placed on hold, but the physician's order changed, and it didn't get pulled over.Review of the facility's Medication Error Report Form for resident #1, showed the date and time of the error, which was on 6/9/26. The staff documented Eliquis 5mg twice daily was not placed on hold due to surgical procedure, and the outcome to the resident showed the surgery was cancelled.

Based on interview and record review, the facility failed to effectively and systematically identify, assess, implement, monitor, and modify interventions timely after the identification of facility-acquired pressure injuries, which resulted in the progression of bilateral heel pressure injuries, including the development of an additional pressure injury to the plantar aspect of the left heel for 1 (#2) of 3 sampled residents for pressure injuries. The facility actions being taken for the wound(s) were not sufficient to meet the resident's needs related to wound care and the prevention of wounds. Findings include:During an interview on [DATE] at 11:26 a.m., NF2 reported that resident #2 had developed wounds on her feet during her stay at the facility.During an interview on [DATE] at 11:55 a.m., NF3 stated that resident #2 had two heel wounds when she assessed the resident on the day of discharge when she was admitted to hospice. NF3 said the wound on the right heel had eschar and odor present, and the left heel was open with granulation tissue and surrounding callus formations.Review of resident #2's Braden Scale for Predicting Pressure Sore Risk dated [DATE] showed resident #2 scored 13, reflecting the resident was at moderate risk of developing pressure injuries. Review of resident #2's Braden Scale for Predicting Pressure Sore Risk, dated [DATE], again showed resident #2 scored a 13, at moderate risk for developing pressure injuries. Review of resident #2's Admit/Readmit Screener, dated [DATE], showed, . Section C: .10. Integrity Skin Assessment . Site and Description:53) Sacrum Open wound covered with meplex,55) Right gluteal fold yellow slough25) Right trochanter (hip) Sutures. Nothing was documented for the resident having heel pressure injuries. Review of resident #2's Occupational Therapy treatment encounter progress note, dated [DATE], showed, . Patient did not have socks on and therapist (noted) what appeared to be large blood blisters (one on the back of each heel). Notified the nurse immediately.Review of resident #2's weekly wound observation tool showed: Left Heel:- [DATE]: The left heel wound was facility-acquired, with a wound onset date of [DATE], although it was noted by the therapist on [DATE]. The notes showed the wound type as pressure, and it was a deep-tissue injury. The comments showed it was a fluid-filled blister. The measurement was 5 cm in length x 4 cm in width, with no depth documented. The wound treatment consisted of wiping it with sure prep twice daily. The notes did not show if the pressure wound was avoidable. -[DATE]: The left heel wound still measured 5 cm x 4 cm, no depth measurement was documented. The current treatment plan was to cleanse with wound cleanser and cover with a silicone foam border dressing and change daily. No debridement was performed (medical process of removing dead, damaged, or infected tissue to promote wound healing and prevent infection).-[DATE]: No measurements for the left heel wound were documented, and the current treatment plan showed the wound on the left heel was resolved. -[DATE]: Left heel - the plantar aspect was facility-acquired, and the date of onset was [DATE]. This was a new pressure area on the resident's left heel. The type of wound was identified as a pressure wound. The severity was a Stage II, with granulation (beefy red) tissue present. The plantar aspect wound of the left heel measured 1 cm x .5 cm. There was no depth measurement documented. The treatment plan was to cleanse the wound with wound cleanser, to apply collagen, and cover the wound with a silicone foam border dressing, and to change the dressing daily. No debridement was performed. The progress notes did not show if the pressure wound was avoidable. Right Heel:-[DATE]: The deep tissue injury was facility-acquired, and the date of onset was [DATE], although the therapist identified it and reported it to the nurse on [DATE]. The type of injury was classified as a pressure wound, but the notes did not show if it was avoidable. The wound measured 2 cm x 2 cm, and no depth measurement was documented. The treatment consisted of sure prep twice daily.-[DATE]: The right heel wound size in increased and it measured 3 cm x 4 cm, with no depth measurement documented. The treatment plan showed nursing staff was to continue with the sure prep treatment and float the resident's heels (offload pressure to heels).-[DATE]: The right heel wound was measured as 4.5 cm x 5 cm, and no depth measurement was documented. The treatment remained unchanged from the prior treatment of the sure prep and floating the heels. No debridement was performed throughout the documented wound progression.Review of resident #2's progress notes showed:- [DATE]: Nursing documented that resident #2 was seen during wound rounds for the bilateral heel wounds consisting of fluid-filled blisters.- [DATE]: The physician documented that the left heel blister had opened and was leaking serosanguineous drainage.- [DATE]: A physician's order was requested for an air mattress (for pressure relief), and the nursing staff requested a physician's order to float the resident's heels.- [DATE]: The nurse documented new treatment orders for the left heel, and there were no changes to the right heel treatment.- [DATE]: The physician documented the right heel pressure wound was a 3 cm x 4 cm dark hard discoloration. The left heel blister had ruptured and now measured 5 cm x 4 cm, with moderate serous drainage.- [DATE]: The physician documented the right heel measured 3 cm x 6 cm, with dark, hard skin discoloration, while the left heel remained soft and boggy. - [DATE]: The physician documented information for both heel wounds, but there were no measurements recorded. The physician referenced the wound note rather than personally documenting the wound details, even though the nursing assessments/notes were incomplete for the wounds. - [DATE]: The physician orders included documentation that the original left heel deep tissue injury had resolved; however, a new pressure sore had developed on the plantar aspect of the resident's heel. This showed that preventative measures identified and carried out by the facility prior to [DATE] did not prevent wound development from occurring on the resident's heel. - [DATE]: The physician documented the right heel deep tissue injury measured 4.5 cm x 5.5 cm with dark hard discoloration, while the plantar wound on the left heel measured 1 cm x 0.5 cm with 100% granulation tissue and moderate sanguineous drainage.- [DATE]: The interdisciplinary team met, and the registered dietitian going to discuss options with the resident and recommend Arginaid (nutritional support for individuals with pressure ulcers, diabetic foot ulcers, etc., which are not healing), and assess the resident's protein needs.Review of resident #2's comprehensive care plan, last reviewed on [DATE], and cancelled on [DATE] showed:Focus: [Resident Name] has limited physical mobility r/t delirium, dementia, Alzheimer's disease, physical behavioral symptoms directed toward others, long-standing mental health problem associated with behavioral symptoms, and pain. The focus was initiated on [DATE].Goal: The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date. The date this was initiated was [DATE].Interventions: Wound care to L (left) heel and Wound care to R heel were interventions initiated on [DATE].Focus: Resident has a pressure injury (location). This was initiated on [DATE] and revised on [DATE].Goal: The pressure injury will show sign/symptoms of health with decease risk of infection through next review. The goal was initiated [DATE], and it was revised on [DATE].Interventions:a. Monitor Dressing QS to ensure it is intact and adhering. Report concerns to nurse. Nurse to change dressing as needed/ordered. This was initiated on [DATE] and revised on [DATE].b. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length X width X depth) stage. c. Measure wounds weekly and report non-healing and worsening wounds to provider. Date initiated [DATE], revision on [DATE]. No other interventions for wound prevention and/or care were added. The care plan did not reflect ongoing attempts to add, modify, or show that the interventions were assessed and found to be beneficial for wound prevention. Review of resident #2's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for [DATE] showed the required weekly skin assessment scheduled for [DATE] was not completed. The TAR included documentation showing changes in wound care orders; however, the resident's record showed the continued progression and worsening of both heel wounds, despite ongoing treatments and documented interventions. Review of resident #2's diagnoses listing lacked any diagnoses related to pressure injuries to the resident's bilateral heels.Review of the facility's policy, Pressure Injury Prevention and Management, reviewed on [DATE], showed: Policy: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection, and the development of additional pressure ulcer/injuries.Policy Explanation and Compliance Guidelines: .2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate.3. Assessment of Pressure Injury [NAME]. Licensed nurses will conduct a pressure injury risk assessment, using the Braden Scale, on all residents upon admission, then quarterly or whenever the resident's condition changes significantly.4. Interventions for Prevention and to Promote Healing.C. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: .iii. Provide appropriate, pressure-redistributing, support surfaces; .6. Modifications of Interventionsa. Any changes to the facility's pressure injury prevention and management processes will be communicated to relevant staff in a timely manner.b. Interventions on a resident's plan of care will be modified as needed. Consideration for needed modifications include:i. Changes in resident's degree of risk for developing a pressure injury.ii. New onset or recurrent pressure injury development.iii. Lack of progression towards healing.iv. Resident non-compliance.v. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights.The National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP), and Pan Pacific Pressure Injury Alliance (PPPIA) Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline shows: Category/Stage III: Full Thickness Skin Loss, Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is 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 III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.Unstageable pressure ulcer: Full thickness tissue loss in which actual depth of the ulcer is completely obscured 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 cannot be determined, but it will be either a Category III or IV pressure ulcer. Stable (dry, adherent, intact, without erythema or fluctuance) eschar on the heels serves as a natural (biological) cover and should not be removed.

Based on observation, interviews and record reviews, the facility failed to promptly identify, evaluate, and implement interventions to address clinically significant weight loss and nutritional declines for 3 (#s 2, 7, and 5) of 3 sampled for weight loss; and failed to timely notify the resident representative of severe weight loss for 1 (#2) resulting in delayed intervention for a resident who experienced the severe 19.2 pound weight loss (14.0%) within approximately 30 days and met criteria for severe malnutrition for #2. This failure also resulted in delayed implementation and evaluation of nutritional interventions after resident #7 experienced progressive, clinically significant weight loss, which was severe, and subsequently met criteria for severe malnutrition; and the failure delayed evaluation and modification of nutritional interventions after resident #5 experienced an approximately 11% unplanned severe weight loss within 35 days despite multiple identified nutritional risk factors and meeting criteria for malnutrition for resident #5. Findings include:1. During an interview on 6/16/26 at 11:26 a.m., NF2 said resident #2 had lost 20 pounds during her stay at the facility and stated he was not notified of the weight loss until three weeks into her stay at the facility.Review of resident #2's electronic health record showed she was admitted to the facility on [DATE] following surgical repair of a right hip fracture.During an interview on 6/16/26 at 1:20 p.m., staff member B said residents with a weight variance of five pounds (more or less) were reviewed during weekly Nutrition at Risk (NAR) meetings.During an interview on 6/17/26 at 10:54 a.m., staff member G stated weekly weights were reviewed to monitor newly admitted residents and to recognize missed weekly weights or delayed identification of weight changes. Staff member G stated that when weights were not obtained, the process of identifying and addressing weight loss was delayed.During an interview on 6/17/26 at 11:55 a.m., NF3 stated resident #2 had experienced a weight loss of approximately 19.8 pounds within one month when admitted to hospice on 5/28/26.Review of resident #2's weights showed a 19.2 lb severe weight loss within approximately 30 days. The weights documented included:4/27/26 - 136.8 lbs.4/28/26 - 137.0 lbs.4/29/26 - 134.0 lbs.4/30/26 - 135.4 lbs.5/12/26 - 122.2 lbs.5/19/26 - 117.8 lbs.5/20/26 - 117.0 lbs.5/26/26 - 117.6 lbs.Review of resident #2's physician orders showed weekly weights were ordered beginning 4/27/26.Review of resident #2's May 2026 Medication Administration Record showed no weekly weight was obtained during the week of 5/3/26, as ordered.Review of resident #2's Mini Nutritional Assessment, completed shortly after admission, dated 4/29/26, showed resident #2 scored a 6, reflecting malnourishment. The assessment also included an inaccurate weight entry of 184.2 pounds, when the resident's actual weight was 134 pounds, creating an inaccurate baseline for nutritional monitoring.Review of resident #2's nutritional assessment dated [DATE] showed the identification of multiple nutritional risk factors, including declining meal intake with frequent refusals, medication-induced sedation limiting oral intake, increased nutritional needs related to wound healing, and recommendations for nutritional supplementation and interdisciplinary review.Review of meal documentation showed:- Five meals were documented as refused;- Nine meals were documented as 0% consumed;- Eight meals were documented as 1-25% consumed; and,- Twenty-four meal entries contained no intake documentation. Despite identified risks, poor oral intake, and documented weight decline, review of NAR meeting documentation dated 5/20/26 showed a 13.1-pound weight loss had been identified; however, the sections designated for current and new interventions were left blank. Resident #2 had not been reviewed during prior NAR meetings despite identified nutritional risk factors. It was unclear if the loss was avoidable, although the resident had multiple contributing factors for it. Review of resident #2's Medication Administration Record for May 2026 showed interventions addressing the resident's nutritional decline were not initiated until 5/10/26 and not revised with the order to offer high-protein snacks, Med Pass 2.0, and enhanced fluids until 5/21/26. Medication changes intended to address possible sedation affecting intake were not implemented until 5/23/26.Review of resident #2's progress notes showed the following:- Weight Change Note, effective 5/21/26, documented resident #2 had experienced a severe 14.5% weight loss since admission and met criteria for severe malnutrition. The note identified poor oral intake, increased nutritional needs related to wound healing, and possible medication-induced sedation as contributing factors.- MD Progress Note, effective 5/21/26, documented that dietary staff had identified the weight loss associated with poor oral intake and frequent tray refusals. This documentation showed that physician review occurred after the resident's severe weight loss had already occurred.- Nurses Note, effective 5/24/26, referenced a severe 14.5% weight loss and documented the resident's POA was notified on 5/23/26.Review of resident #2's physical and occupational therapy documentation for her stay lacked goals with a focus on nutrition and/or weight loss.Review of resident #2's comprehensive care plan, last reviewed on 5/4/26, showed: .Focus: [Resident #2] meets AND/ASPEN diagnostic criteria for Severe Malnutrition in the context of an acute injury (post-op right hip ORIF), evidenced by severe non-volitional weight loss (-14.5% over 30 days) and severe energy restriction (75% EEN for >7days). Her nutritional decline is heavily compounded by advanced dementia, severe expressive aphasia, and a profound behavioral component. She frequently exhibits a clamped mouth defense mechanism, refusing both meal trays and oral medications. She has active bilateral heel Deep Tissue Injuries (DTIs) requiring elevated metabolic support. Date Initiated: 04/27/2026.Goal: Resident will meet >75% of her Estimated Energy Needs and elevated protein goals (71-88 g/day) to facilitate tissue synthesis and heal her bilateral heel DTIs. Date Initiated: 4/27/2026.Interventions: Administer Med Pass 2.0 (60cc TID) between meals to provide concentrated calories and protein to support intensive wound healing, particularly during periods of decreased PO meal intake. Date Initiated: 05/11/2026.Monitor for profound daytime sedation and somnolence (particularly following 12:00 PM scheduled psychotropic doses) that severely limits her ability to safely eat or drink. Report continued meal refusals related to sedation to the MD/Pharmacy for medication review. Date Initiated 5/11/26.Obtain weekly weights to monitor for significant fluctuations. Monitor and record meal intake percentages and total fluid consumed daily. Date Initiated 5/11/26.Provide and serve diet as ordered: Regular diet, regular texture, thin liquids. Date Initiated: 5/11/2026.Provide setup assistance, cueing, and 1:1 supervision during all meals to promote safety, address impulsivity/dementia, and encourage intake. Date Initiated: 05/11/2026.The resident needs assistance to eat at mealtimes and will be encouraged to eat in the dining room to facilitate assistance/supervision at meals as needed. Date Initiated: 04/27/2026.These findings demonstrated that although the facility identified and attempted to address the severe weight loss for resident #2, the medical record failed to show that the facility monitored, evaluated, and implemented effective, timely interventions to address resident #2's nutritional decline, resulting in delayed interventions for the weight loss. 2. During an observation on 6/16/26 at 2:59 p.m., resident #7 was observed seated in the day room at a table. Resident #7 was calm and was not exhibiting anxiety, pacing, or other behaviors that would interfere with activities of daily living, such as when eating a meal. During an interview on 6/16/26 at 9:22 a.m., staff member G stated that resident weight changes are identified during the facility's weekly Nutrition at Risk (NAR) meetings. Staff member G said implementation of weekly weights resulted in more weight-loss triggers being identified and reported, and she was notified of residents with weight loss during the weekly meeting.During an interview on 6/17/26 at 9:15 a.m., staff member B stated she was absent from the facility beginning on 5/11/26 for approximately two weeks. Staff member B stated that the Nutrition at Risk meeting documentation was not prepared for physician review during her absence, and she was unable to produce the missing NAR meeting documentation requested during the survey.During an interview on 6/17/26 at 10:54 a.m., staff member G stated that staff member B was the lead staff member for the Nutrition at Risk meetings. Staff member G said the task of completing the tracking was not delegated during staff member B's absence. Staff member G stated that weight variances were identified when she reviewed charts and through the NAR meetings, when staff member B reviewed weights before the meetings occurred.Review of resident #7's weight documentation showed a 10.2% weight loss within approximately 60 days and an 8.5% weight loss within less than 90 days, which is a severe loss. The resident's weight decreased by 15.2 pounds from 4/12/26 to 5/19/26, per the weights documented in resident #7's medical records, which showed: 2/19/2026 - 130.6 Lbs.2/24/2026 - 127.8 Lbs.3/4/2026 - 131.6 Lbs.3/11/2026 - 130.8 Lbs.3/12/2026 - 128.0 Lbs.3/17/2026 - 131.2 Lbs.3/26/2026 - 132.4 Lbs.4/2/2026 - 131.2 Lbs.4/7/2026 - 133.0 Lbs.4/12/2026 - 133.0 Lbs.4/12/2026 - 133.0 Lbs.4/21/2026 - 128.8 Lbs.4/29/2026 - 128.7 Lbs.5/7/2026 - 127.2 Lbs.5/19/2026 - 117.8 Lbs.5/27/2026 - 118.0 Lbs.6/2/2026 - 116.2 Lbs.6/10/2026 - 118.8 Lbs.6/12/2026 - 120.0 Lbs.Review of resident #7's Speech Therapy documentation showed the speech therapy evaluation was completed on 4/16/26, and the swallow evaluation was completed the same day. The evaluation showed the identified goals for treatment of swallowing dysfunction and/or oral function for feeding. The resident was seen again on 4/23/26 for diet tolerance. Resident #7 was discharged from speech therapy services on 4/23/26.Review of resident #7's Occupational Therapy documentation showed that the goals for care for resident #7 were to increase the ability to feed herself and transfer to and from the commode as established in the evaluation completed on 4/27/26. The occupational therapy evaluation revealed a short-term goal: the resident will feed herself with encouragement from CNAs, set up so that she can fully reach her food, and complete at least 50% of her present food and drink, with a target date of 5/11/26. The documented long-term goal was that the resident would be set up at the table and be able to obtain food and consume over 50% with supplements if needed, with a target date of 6/22/26. However, treatment records showed occupational therapy did not address the resident's feeding or nutritional goals until 6/3/26, despite the goals being established on 4/27/26, and the resident had a severe weight loss.Review of resident #7's Medication Administration Records from January 2026 to June 2026 showed:- Mirtazapine 7.5 MG ordered on 11/12/25 for Major Depressive Disorder, but it was discontinued on 1/6/26.- Haldol orders were discontinued on 4/23/26 and 4/29/26.- Behavior monitoring documented eleven intervention episodes during May.Review of resident #7's behaviors from 5/19/26 to 6/16/26 showed the behaviors were consistently documented as None of the above observed, with one documented refusal. Review of psychiatric progress notes dated 5/21/26 and 6/4/26 described the resident as behaviorally stable without recurrence of previous severe aggression, paranoia, or psychotic behaviors.Review of resident #7's progress notes for May 2026 showed:- Orders-Administration Note, effective 5/5/26, included documentation that the resident was compulsive about staff care with other residents and required a back rub, redirection, to be spoken to gently, repositioning, food, and drinks.- Behavior Note, effective 5/7/26, showed, Resident is having some anxiety this evening but is easily redirected by having a conversation with staff and reassurance she does have a bed to sleep in for the night and a room here.Review of resident #7's Mini Nutritional assessment dated [DATE] showed a score of 10, reflecting the resident was at risk for malnutrition. However, the assessment contained inaccurate documentation of the resident losing 2.2 to 6.6 pounds during the previous three months. A review of documented weights showed the resident had actually lost approximately 12.8 pounds during those 3 months. Therefore, the assessment underestimated the resident's weight loss.Review of resident #7's quarterly nutritional assessment dated [DATE] showed, .Resident has experienced significant, unintentional weight loss. Current weight represents an 8.3% loss over 1 month (from 128.7), a 10.3% over 3 months (from 31.6 lbs) and 10.1% loss over 6 months (from 131.2). Resident now meets GLIM Criteria for Severe Malnutrition. The assessment also contained documentation of contributing factors such as discontinuation of Haldol, increased anxiety and agitation, and the prior removal of Mirtazapine.Review of the Nutrition at Risk meeting notes showed resident #7 was not discussed until the NAR meeting held on 5/27/26, despite the resident's ongoing documented weight loss.Review of the facility's document titled Clinical Diagnosis of Malnutrition (GLIM Criteria) dated 5/27/26 included documentation that resident #7 met the criteria for a formal diagnosis of Severe Malnutrition. Nutritional supplementation with Med Pass 2.0, three times daily, was initiated on the same date.Review of resident #7's comprehensive care plan, last reviewed on 5/6/26 showed the facility identified severe malnutrition, significant unintentional weight loss, increased caloric expenditure, medication changes, dementia, and previous dysphagia as contributors to nutritional decline. The care plan included interventions to:- obtain weights per facility protocol;- provide increased encouragement and supervision during meals;- monitor meal intake each meal;- provide calorically dense supplementation; recommended psychiatric medication review; and- monitor weights according to facility protocol and NAR recommendations.Despite these identified risks and planned interventions, the record showed resident #7 continued to experience progressive weight loss before severe malnutrition was formally identified on 5/27/26. Nutrition at Risk (NAR) review implementation of Med Pass supplements, and recommendations for psychiatric medication review did not occur until after the resident met criteria for severe malnutrition. 3. During an interview on 6/17/26 at 10:54 a.m., staff member G said when a weekly weight was missed, she would request a reweight; however, the reweight was often not obtained until the following week. Staff member G said by the time weights were obtained and entered into the resident's medical record, identification and response to weight changes occurred later than preferred. Staff member G stated she obtained resident #5's weight of 107.6 pounds on 6/10/26.Review of resident #5's weights since admission reflected an 11% severe weight loss in approximately 35 days. Weights documented included: 5/8/2026 - 120.2 Lbs.5/9/2026 - 121.5 Lbs.5/10/2026 - 121.0 Lbs.5/11/2026 - 121.0 Lbs.5/14/2026 - 120.2 Lbs.5/22/2026 - 121.0 Lbs.6/5/2026 - 105.8 Lbs.6/10/2026 - 107.6 Lbs.6/12/2026 - 106.8 Lbs.Review of resident #5's Mini Nutritional Assessment, dated 5/12/26, was completed with a score of 6, categorized as malnourished, establishing that nutritional risk had been identified early in the resident's stay. Review of the facility's Nutrition at Risk (NAR) meeting notes showed resident #5 was not discussed until 5/27/26. The notes revealed no data in the columns for weight loss/gain, current weight versus prior eight weeks, and the notes showed the interventions to be Med Plus three times daily and Vitamin C and Zinc for two weeks.Review of resident #5's progress notes showed the resident consistently had no clinically significant edema documented throughout the period preceding the substantial weight decline, including Skilled Evaluation Notes dated 5/18/26 through 6/5/26, and physician progress notes dated 5/19/26, 5/26/26, and 6/2/26. A review of resident #5's Weight Change Note, effective: 6/16/26, showed the Resident triggered for significant weight loss, with an 11.7% decline (14.2 lbs.) from her 121.0 lbs. facility admit weight over the past 30 days. The initial rapid weight loss occurred following a traumatic fall at home, resulting in hospitalization for acute pelvic obturator fractures and subsequent transition to the facility. The weight decline from her 121 lbs. admit weight is also related to fluid shifts and fluid losses following her hospitalization. While this weight loss is multifactorial, it does indicate that true weight loss from her baseline has occurred.Review of resident #5's comprehensive care plan, last reviewed on 5/14/26, showed:Focus: NUTRITIONAL STATUS: [Resident #5] is at high nutritional risk related to the presence of severe pressure injuries (Left Ischium Stage 3, Right Proximal Hip Unstageable) and high metabolic demands following a recent pelvic fracture. Her nutritional status is heavily complicated by a history of Adult Failure to Thrive, severe dementia, acute agitation, and a German language barrier resulting in highly erratic meal and snack intake (ranging from 0% to 100%). Date Initiated: 05/08/2026, Revision on: 05/19/2026.[Resident #5] has nutritional problem or potential nutritional problem r/t difficulty making self understood, difficulty understanding others, arthritis, cardiovascular disease, pain, pressure injury, contractures, arthritis, functional limitation in ROM, hemiplegia/hemiparesis, cognitive loss and dementia. Date Initiated: 05/08/2026Revised Focus: NUTRITIONAL STATUS: Ute triggers for Severe Malnutrition (GLIM criteria) evidenced by severe significant weight loss (11.7% / 14.2 lbs. over 30 days) following a traumatic fall, acute pelvic fractures, hospitalization, and subsequent fluid shifts. Her weight has recently stabilized. She has high metabolic and nutritional demands to support healing of an active Stage 3 pressure injury to the proximal right hip. Nutritional status is heavily complicated by severe dementia, acute fracture pain, and a German language barrier, which historically results in erratic meal and snack intakes. Date Initiated: 05/08/2026, Revision on: 06/16/2026.Goal: Resident will consume adequate food and fluid intakes to support stable weights and signs of healing/progression of wounds through next review date. Date Initiated: 5/14/2026, Revision on: 05/19/2026.The resident will maintain adequate nutritional status as evidenced by no unplanned/undesired significant weight changes, no s/sx of malnutrition, and adequate nutritional intake at meals through review date. Date Initiated: 05/14/2026.Revised Goal: Resident will maintain her recently stabilized weight and consume adequate food, fluids, and supplements to support the healing and progression of her Stage 3 pressure injury through the next review date. Date Initiated: 05/14/2026, Revision on: 06/16/2026.Interventions: Offer/Encourage fluids of choice. Date Initiated: 05/19/2026.Administer Med Plus 2.0 at 60cc TID between meals to provide concentrated protein and calories to support wound healing during periods of poor meal compliance. Date Initiated: 05/19/2026.Monitor intake at all meals, offer alternate choices as needed, alert Dietitian and Physician to any decline in intakes. Date Initiated: 05/14/2026, Revision on: 05/19/2026.Provide and serve diet as ordered: Regular diet, regular texture, thin liquids. Date Initiated: 05/19/2026.Provide assistance, visual cueing, and consistent, gentle verbal encouragement at all meals to maximize tray intake and safely navigate her cognitive and language barriers. Date Initiated: 05/19/2026.Revised Interventions: Actively offer and encourage 4-8 oz of preferred fluids between meals and with all medication passes to counteract diuretic use (Spironolactone) and support adequate tissue perfusion for wound healing. Date Initiated: 05/19/2026, Revision on: 06/16/2026.Administer Med Plus 2.0 at 60cc TID between meals to provide concentrated protein and calories to provide concentrated protein and calories to support weight stabilization and wound healing. Date Initiated: 05/19/2026, Revision on: 06/16/2026.Provide and serve diet as ordered: Regular diet, regular texture, thin liquids. Fortify foods. Date Initiated: 05/19/2026, Revision on: 06/16/2026.The documented records showed Resident #5 was identified as malnourished on 5/12/26 and experienced significant weight loss thereafter; however, review through the Nutrition at Risk process, recognition of severe malnutrition, and revision of the care plan did not occur until after the clinically significant weight loss had already occurred.Review of the facility's policy, Weight Monitoring, reviewed on 5/7/26, showed, .Compliance Guidelines: Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem.1. The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes:a. Identifying and assessing each resident's nutritional status and risk factorb. Evaluating/analyzing the assessment informationc. Developing and consistently implementing pertinent approachesd. Monitoring the effectiveness of interventions and revising them as necessary2. A comprehensive nutritional assessment will be completed upon admission on a residents to identify those at risk for unplanned weight loss/gain or compromised nutritional status.3. Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns and preferences. The care plan should address the following, to the extent possible:a. Identified causes of impaired nutritional statusb. Reflect the resident's goals and preferencesc. Identify resident-specific interventionsd. Time frame and parameter for monitoringe. Updated as needed such as when the resident's condition changes, goals are met, interventions are determined to be ineffective or a new causes of nutrition-related problems are identified.f. If nutritional goals are not achieved, care planned interventions will be reevaluated for effectiveness and modified as appropriate.g. The resident and/or resident representative will be involved in the development of the care plan to ensure it is individualized and meets personal goals and preferences.4. Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status.5. A weight monitoring schedule will be developed upon admission for all residents:a. Weights should be recorded at the time obtained. Mathematical rounding should be utilized (i.e., if weight is X.5 pounds [lbs] or more, round weight upward to the nearest whole pound. If weight is X.1 to X.4 [lbs] round down to the nearest whole pound).b. Newly admitted residents - monitor weight weekly for 4 weeksc. Resident with weight loss - monitor weight weekly.6. Weight Analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as:a. 5% change in weight in 1 month (30 days)b. 7.5% change in weight in 3 months (90 days)c. 10% change in weight in 6 months (180 days).7. Any weight change of 5% or more since the last weight will be retaken within 24 hours for confirmation. If the weight is verified, the RD will be notified by the DON or designee of the significant weight change. [sic]

Based on observation, interview, and record review, the facility failed to failed to ensure proper PPE was worn, clean technique was followed, a catheter bag was emptied timely, and catheter perineal care was completed correctly for an indwelling Foley catheter for 1 (#2), and the resident had multiple urinary tract infections in the prior year; and the facility failed to provide a physician ordered catheter change(s), failed to provide proper daily site assessments and a dressing change(s), and failed to empty the catheter drainage bag timely for a resident with a Suprapubic indwelling catheter, for 1 (#15). These deficient practices increased the risk of negative urinary outcomes for all residents receiving catheter services, out of 5 sampled residents for catheter use and care. Findings include:1. During an interview on 3/11/26 at 9:48 a.m., resident #2 stated he did not get catheter care often enough and suffered from facility acquired UTIs often. He stated he was lucky to get clean (catheter care) once a day, and nothing gets done unless you ask for it. Resident #2 stated he had gone septic from a few of his UTIs, and this had almost killed him. A request was made for all documentation for resident #2 regarding Foley care, appointments, and UTIs. The documentation provided showed resident #2 had the following UTIs in the past year: 4/16/25, 4/29/25, 5/11/25, 7/2/25, and 8/13/25. During an interview and observation on 3/11/26 at 9:55 a.m., staff member V stated a catheter bag should not be this full, but a staff member had called off this morning, and no one had emptied the catheter for #2. Staff member V stated call offs would happen four times a week. Resident #2's catheter bag was full, and the urine was backing up into the catheter tubing a few inches. During an observation on 3/11/26 at 10:12 a.m., staff member V did perineal care on resident #2, but it was incomplete as the penis was retracted into the surrounding tissue. The glans was not exposed for cleaning during the perineal care. When asked, staff member V stated they always retracted the surrounding tissue and then completed the task, which revealed a whitish buildup around the glans. 2. During an observation and interview on 3/10/26 at 10:56 a.m., resident #15 was lying in his bed in his room. He had a urinary drainage bag attached to his bedside. The catheter drainage bag had over 2000 ml of urine in the bag. Resident #15 stated he recently had a Suprapubic catheter placed by the urologist because he kept getting UTI's when he had a Foley catheter. He stated he thought the insertion site was healing fine, except he still had some pain at the insertion site when the staff cleaned the site or changed the dressing. He stated he could not remember when the catheter was last changed, when they last changed his dressing, and the resident could not remember when they last emptied his catheter drainage bag. He stated the staff only provided his care when they could get around to it. The resident then lifted his nightgown to show his suprapubic catheter site. The site was covered with a white gauze dressing, which was dated 3/9/26, with the initials of the staff member who last changed the dressing. a. Suprapubic Catheter Change Review of resident #15's Physician Orders, dated 12/13/25, showed, Change SP Catheter PRN or as indicated by MD. Change SP [every] month and prn, use 16 [French]/10cc per Urology. One time a day every 1 month(s) starting on the 1st for 1 day(s) for urinary retention related to Obstructive and Reflux uropathy. Review of resident #15's Treatment Administration Record (TAR) for March 2026, showed the Suprapubic catheter was to be changed on 3/1/26. The TAR did not show the catheter change was completed on 3/1/26. A review of resident #15's EHR did not show documentation of the catheter change or a refusal for the catheter change on 3/1/26. Review of resident #15's Progress Note, dated 3/5/26, showed, [Complaints of] pain at Supra pubic site - Cath changed / sterile tech / orders (16f with 10cc balloon). (Less than) 400cc out – [tolerated] well - draining / gravity - call bell within reach. [sic] Review of resident #15's Progress Note, dated, 3/12/26, showed, Catheter not changed on 3/1/26 6pm-6am shift second to this LN involved in continuous close monitoring and care of another resident. Resident aware. Reported to AM nurse for follow up. [sic] During an interview on 3/11/26 at 11:12 a.m., staff member I stated resident #15's Suprapubic catheter should be changed monthly, but sometimes it needed to be changed more often since the resident had a lot of sediment in his urine, and it would often block the drainage tube. Staff member I stated he was not sure when the last time resident #15's Suprapubic catheter was changed or why it was not changed on 3/1/26. b. Missed Assessment and Dressing Change During an observation and interview on 3/11/26 at 11:00 a.m., staff member I performed site care for resident #15's Suprapubic insertion site. Staff member I removed the white gauze covering the resident's site. The gauze was dated 3/9/26, with the initials of the staff member who last changed the dressing. The resident's Suprapubic site was dimpled into his lower abdomen. The dimple where the catheter tube entered the resident's abdomen was pooled with a thick and chunky appearing drainage that was yellow and greenish in color. There was dried drainage on the tubing. Staff member I cleansed the site and attempted to remove some of the dried drainage from the tubing. Resident #15 started to raise his voice at the nurse stating, ouch, that hurts and used some expletives. Once staff member I finished cleansing the site, resident #15 quit yelling about the site hurting. Staff member I then placed a clean gauze over the site and left the resident's room. During an interview on 3/11/26 at 11:12 a.m., resident #15 stated he was having discomfort at the insertion site when staff member I was changing the dressing. He stated the site did not usually hurt, only when someone applied pressure or pushed on the area. During an interview on 3/11/26 at 11:15 a.m., staff member I could not explain why resident #15's catheter site was not assessed, or the dressing was not changed on 3/10/26. He stated if the resident had refused, there should be a note in his chart documenting the refusal. Review of resident #15's Physician Orders, dated 12/15/25, showed, Assess suprapubic catheter site [every] shift related to Obstructive and Reflux Uropathy. c. Emptying Catheter Drainage Bag During an observation and interview on 3/10/26 at 10:56 a.m., resident #15 was lying in his bed in his room. He had a urinary drainage bag attached to his bedside. The catheter drainage bag had over 2000 ml of urine in the bag. During an observation on 3/10/26 at 11:28 a.m., resident #15's urinary catheter drainage bag was full of urine above the measurement line of 2000 ml on the bag. The urinary catheter bag showed to hold a maximum amount at 2000 ml of urine. Note: The average normal range for 24-hour urine volume is 800 to 2,000 milliliters per day.¹ During an observation on 3/10/26 at 3:27 p.m., resident #15's catheter drainage bag was completely full to the top of the bag and starting to regurgitate into the catheter tubing. Note: Failure to empty a catheter bag (which should be done when it is full) can lead to serious physical complications due to back pressure on the bladder and kidneys, as well as an increased risk of infection.² During an interview on 3/11/26 at 10:36 a.m., staff member J stated she would empty resident #15's catheter bag several times a day, or at least once during her shift. She stated she would usually empty the drainage bag at the end of her shift. She stated she documented the urinary output of the bag in the resident's chart. Staff member J stated she did not feel there were any barriers to emptying resident #15's catheter bag during her shift. During an interview on 3/11/26 at 10:36 a.m., staff member I stated the aides usually emptied a resident's urinary catheter bag at least once a shift. He stated they were to report any changes they observed to the nurse. Staff member I stated it could lead to infection and other urinary tract complications if the urinary drainage bag was completely full and not emptied regularly. Staff member I stated he was not aware of any concerns with emptying resident #15's urinary drainage bag. During an interview on 3/11/26 at 11:20 a.m., staff member B stated it was the expectation for staff to follow the provider's orders for catheter changes and site care. Staff should notify the provider if there is any concern regarding the catheter or the insertion site, such as swelling, pain, and drainage. She stated she was not sure why resident #15's catheter was not changed on 3/1/26, since there was no documentation in his chart for why it was not completed. Staff member B stated she also could not explain why resident #15's Suprapubic site care was not completed on 3/10/26. She stated there was nothing documented in the resident's chart regarding a refusal or rationale for why it was not changed. Staff member B stated staff were expected to empty catheter drainage bags when the bag was half to one third full, or as needed, and at least once a shift, and document the output in the resident's chart. Staff member B stated she was not aware of any concerns regarding resident #15 refusing care or any concerns regarding the management of his Suprapubic catheter. A review of the facility's policy and procedure titled, Catheter Care, with an initiation date of 4/11/25, showed: 1. Catheter care will be performed every shift and as needed by nursing personnel . 8. Empty drainage bags when bag is half-full or every 3 to 6 hours. For Suprapubic Catheters: 2. Inspect insertion site for redness, swelling, discharge, or signs of infection. 3. Using a clean cloth or gauze moistened with mild soap and water or facility-approved cleanser (or per orders), gently clean around the insertion site in a circular motion, starting closest to the catheter and moving outward. 4. Use a clean section of cloth or new gauze for each pass. 5. Rinse the area with a separate clean, moistened cloth or gauze to remove any soap residue. 6. Pat the site dry with a clean towel or sterile gauze. 9.and document care provided, including any abnormalities. ¹The normal range for 24-hour urine volume is 800 to 2,000 milliliters per day (with a normal fluid intake of about 2 liters per day) Citation from online source National Institute for Health (NIH): [NAME] Foen [NAME] JW, van Mastrigt R. Age and volume dependent normal frequency volume charts for healthy males. J Urol. 2009 Jul;182(1):210-4. doi: 10.1016/j.juro.2009.02.113. Epub 2009 May 17. PMID: 19447412. ² Failure to empty a catheter bag (which should be done when it is full) can lead to serious physical complications due to back pressure on the bladder and kidneys, as well as an increased risk of infection. Citation from online source AORN Journal: [NAME], J. L. (2017). Indwelling Urinary Catheters: A Pathway to Health Care Associated Infections. Aorn Journal, 105(5), 446-452. https://doi.org/10.1016/j.aorn.2017.02.013

Based on observation, interview, and record review, the facility failed to frequently encourage and facilitate ambulation for 1 (#98) of 38 sampled residents, and this contributed to resident #98 losing mobility and becoming bed-bound and developing a Stage III pressure wound. Findings include:During an interview on 3/10/26 at 10:19 a.m., NF3 stated his father was not taken care of at the facility. NF3 stated his father ambulated independently with a walker prior to a fall at home and being admitted to the hospital. NF3 stated the plan for resident #98 was to go to the facility and gain strength in order to go to an assisted living facility. While resident #98 was at the facility, NF3 stated staff would not ambulate resident #98 because he was a high fall risk and sometimes combative. NF3 stated he watched his father ambulate at the facility one time and most of the time they left him in his chair or in bed. NF3 stated resident #98 lost all mobility due to the facility not encouraging him to ambulate. NF3 stated the facility staff members had a very poor dementia approach and would not complete any cares if resident #98 showed behaviors. NF3 stated, I felt like my dad was angry about what was going on. NF3 stated the facility in return stated they could not force him to participate in cares and this was why the care was not being done. NF3 continued to explain a medication, Haldol, was given in error for at least five days, and friends that had visited during that time said he was like a zombie. NF3 also stated resident #98 developed pneumonia and a pressure ulcer that was almost to the bone while at the facility due to not moving or being repositioned. Refer to F686 Treatment/Services to Prevent Pressure Ulcers for more detail related to the pressure ulcer. During an interview on 3/10/26 at 2:34 p.m., NF4 stated she had visited resident #98 a few times a week. NF4 stated the resident had only been at the facility two months, deteriorated, and then passed away. She said she asked the staff why he was not walking, and the staff told her, We had no idea he could even walk. NF4 stated that when the resident was at home, he did not break anything, and he only stayed at the hospital because he did not have a caretaker at home and had dementia. Resident #98's wife needed surgery after they had both fallen at home, and she was his caretaker. NF4 stated that after a month had gone by at the facility, resident #98 could not get up on his own. NF4 stated they talked to the administrator about rehab services, about three weeks after the resident was admitted , but were told by the administrator that they would have to pay more because they were private pay.Review of resident #98's physician order, dated 9/26/25, showed: PT/OT evaluation and treatment for deconditioning.During an observation and interview on 3/11/26 at 11:38 a.m., staff member W showed a blank document on their computer screen showing that resident #98 never received PT or OT services. Staff member W stated, Looks like the orders never got to him. Staff member W stated there were orders for resident #98 to have PT and OT, but due to the resident being private pay, they had approached the family and offered rehab services instead. Staff member W stated the rehab department made an error and should have documented the conversation with the family, but they did not.During an interview on 3/11/26 at 12:40 p.m., staff member U stated resident #98 was agitated sometimes, but they were usually able to work with him with no combativeness or behaviors. Staff member U stated he only had a couple of days where he was agitated, and this was usually due to being really tired. Staff member U stated the family had found out about the restorative program, so that was when they had started working with resident #98. Staff member U stated they felt staff had a good dementia care approach, but that Everyone is in a rush in the morning. Staff member U stated it looked like it was a mix of disciplines that missed the PT/OT, including admissions telling the correct parties of the order, nursing assessing and realizing the order was needed, and PT/OT responding to the order.

Based on interview and record review, the facility failed to reposition and facilitate ambulation for 1 (#98) and this deficient practice resulted in the development of an avoidable Stage III pressure ulcer; and the facility failed to provide necessary positioning and repositioning for skin protection and the prevention of wound development, for 3 (#s 2, 71, and 73) of 38 sampled residents. Findings include:1. A review of resident #98's skin and wound care documentation showed the nursing staff identified a reddened area on the resident's coccyx due to pressure on 9/5/25. This reddened area then developed into a Stage III pressure ulcer. During the interview on 3/10/26 at 10:19 a.m., NF3 stated resident #98 had developed wounds while residing at the facility. NF3 stated resident #98 had walked before going into the facility and then was never taken for walks with staff or repositioned, so the resident developed a pressure ulcer on his coccyx. NF3 asked the facility to print papers to remind the staff to turn (reposition) resident #98, but those only stayed up for a week. NF3 stated the wound care nurse was doing care, but because the wound continued to worsen, he personally doubted the treatments were being done correctly or consistently. NF3 stated they made an appointment with the wound care specialist for resident #98, who later said the staging (severity) of the wound was almost to the bone. NF3 stated the family made an appointment with resident #98's primary care provider as they were concerned about him and his care. Review of resident #98's Weekly Skin Check Assessment, dated 8/29/25, showed resident #98's skin is intact, at that time. Review of resident #98's primary care physician's note from [external facility], showed: a pressure ulcer of sacral region, Stage III. During this appointment, a referral for physical therapy, occupational therapy, and the wound care clinic was made. The physician notes also showed: . (Resident #98) has developed decubitus ulceration impacting his right and left buttocks . is at least stage III. He has had some wound care at [the facility] however with the worsening of the wound, A formal wound care evaluation has been requested in our wound care clinic. Frequent moving and repositioning are recommended to prevent further deterioration. [sic] During an interview on 3/12/26 at 2:34 p.m., NF4 stated they had been with resident #98 during the primary care appointment, and it had taken two of the office nurses to stand him up. NF4 stated this was the first time they had seen the wound and had known of a wound on his coccyx. NF4 stated they had gone into the facility multiple times and tried to encourage the staff that they needed to turn him every two hours. NF4 stated they had a nurse print off two papers saying turn every two hours, but those were only up for a couple of weeks. NF4 stated they then printed off two papers from home and put them up above the resident's head (on wall) and on his door. NF4 stated that during the wound care appointments, the facility would forget to pack the resident's lift sling, so he could never have his appointment. NF4 stated this happened with two of the three appts. Review of resident #98's EHR showed a Wound Care Visit note, dated 10/13/25, and the appointment was rescheduled because resident #98 was not sent with his lift sling under him. Review of resident #98's Wound Care Visit notes, dated 9/29/25, showed: an Unstageable pressure ulcer of the sacral region. The physician also noted: Provider Comments: This is a sad case of an [AGE] year-old man who was fairly independent at home with his wife when both had a fall. This was about 5 or 6 weeks ago. He has gone into a skilled nursing facility but was somewhat combative and confused and when sedated became more bedbound. This resulted in a sacral pressure injury of mixed depth across the injury. At this current level activity will be impossible to keep him from either having this injury or a different pressure injury. The Pressure Ulcer measures 13 cm x 11 cm x 0.1 cm . [sic] During an interview on 3/12/26 at 11:00 a.m., staff member T stated Haldol was contraindicated for a resident with dementia and stated there were other medications that could be used to help with behaviors. Staff member T stated the wound that developed on resident #98's coccyx was due to pressure. Staff member T stated they had only staged the wound as a deep tissue injury and that it was not measurable. Review of resident #98's progress note, dated 10/20/25, showed: . Please clarify treatment orders for coccyx wound. The wound is severe, with depth and tunneling. Review of resident #98's progress note, dated 10/19/25, showed: Coccyx wound is fleshy, black, deep with tunneling. 2. During an interview and observation on 3/10/26 at 9:36 a.m., resident #73 stated he had been in his motorized wheelchair a dozen times since being at the facility. Resident #73 stated, They don't get me in it, and he stated he had asked staff members about getting in the motorized wheelchair, but nothing changed. Resident #73 stated he also was not turned while he was in bed. He stated his buttock area hurt pretty often. He stated he would not refuse any staff members rotating him side to side or positioning him with any pillows. Resident #73 was lying on his back with no pillows used for positioning at the time of the observation. Review of resident #73's EHR showed an admission date of 8/11/25. During an observation and interview on 3/10/26 at 1:26 p.m., resident #73 stated he had gotten up for a few hours with physical therapy, but was back in bed since noon, and he had eaten his lunch. His shirt was covered with crumbs, and chocolate spread across his shirt from a muffin he had eaten. Resident #73 was on his back with no pillows used for positioning during the observation. During an observation on 3/10/26 at 5:02 p.m., resident #73 was lying in bed on his back with no pillows for positioning. During an observation on 3/11/26 at 7:33 a.m., resident #73 was lying in bed on his back with no pillows for positioning. During an observation on 3/11/26 at 9:39 a.m., resident #73 was lying in bed on his back with no pillows for positioning. During an observation on 3/11/26 at 10:39 a.m., resident #73 was in his motorized wheelchair with physical therapy. During an interview on 3/11/26 at 11:38 a.m., staff member W stated resident #73 never moved. Staff member W stated they recently put him back on rehab services because staff member W felt bad for resident #73, and he would just sit in bed all day. During an observation on 3/11/26 at 1:00 p.m., resident #73 was lying directly on his back. 3. During an observation on 3/10/26 at 7:41 a.m., resident #2 was in bed and lying on his back. tilted slightly to his left side. He had an ace bandage on his left forearm, and his left elbow was directly on the bed. Resident #2 had an open wound on his left elbow. During an observation on 3/11/26 at 7:35 a.m., resident #2 was lying on his back while lying on his left elbow. During an observation on 3/11/26 at 9:55 a.m., resident #2 was positioned on his back with his left elbow directly on the bed. His left elbow wound was undressed, and the wound dressing was stuck below on the catheter bag that was on the floor. See F880 for infection control concerns regarding catheters. During an observation on 3/11/26 at 1:01 p.m., resident #2 was lying directly on his back, and his left elbow was resting directly on the bed. Resident #2's elbow wound was undressed. 4. During an observation and interview on 3/10/26 at 5:14 p.m., resident #71 was lying directly on his back. He stated that facility staff did not rotate him in bed and stated his buttock area would hurt from sitting for a long time. During an observation on 3/11/26 at 7:34 a.m., resident #71 was lying on his back with no positioning pillows in place. During an interview on 3/11/26 at 2:50 p.m., staff member A stated there was documentation for residents being rotated. Staff member A stated that if a physician stressed a concern for rotating, the documentation would show specifically to rotate a resident every two hours, either towards the window or the door. Staff member A stated that this documentation would then be scanned into the EHR. A request was made for the repositioning documentation for residents #s 2, 71, 73, and 98. No documentation was provided by the end of the survey for the repositioning documentation. Review of a facility policy, titled Turning and Repositioning, dated 11/11/25, showed: . 1. All residents at risk of, or with existing pressure injuries, will be turned and repositioned, unless it is contraindicated due to a medical condition. In this case, small shifts in repositioning will be employed. 3. A routine turn schedule includes using both side-lying and back positions, alternating from the right, back, and left side. e. Avoid positioning the resident on surfaces with existing pressure injuries, including persistent redness.

Based on interview and record review, the facility failed to employ a certified dietary manager or a full-time dietician to serve as the director of food and nutrition services. The deficient practice had the potential to affect all residents who received meals and nutritional services from the facility. The deficient practice increased the risk for food quality/safety concerns; resulted in inadequate oversight of food service operations; increased the potential for weight loss; resulted in residents eating less and feeling hungry (see F804.) Findings include:A request for the Dietary Managers Certification was submitted to the facility on 3/10/26 at 8:08 a.m. The facility was unable to provide appropriate certification for staff member M. The facility provided a copy of a ServSafe Certification dated 12/7/23 for staff member M.During an interview on 3/11/26 at 10:28 a.m., staff member M stated she did not have a current Certified Dietary Manager Certification. Staff member M stated she was currently enrolled in the training. Staff member M stated she was enrolled after the request for her certification was made the day before.During an interview on 3/11/26 at 11:45 a.m., staff member K stated she was employed by the facility full time. Staff member K stated she worked 35 to 40 hours a week in the facility. Staff member K stated she had worked for the facility for two weeks.During an interview on 3/11/26 at 12:20 p.m., staff member A stated staff member K is a full time employee. Staff member A stated the previous dietician was not employed full time. Staff member A stated he was not previously aware that a ServSafe Certification did not meet the requirement for a Certified Dietary Manager. Staff member A stated staff member M had been enrolled in the Certified Dietary Manager course as a result.

Based on observation, interview, and record review, the facility failed to provide palatable food (including appetizing food visually, taste wise, and with preferences) for 10 (#s 2, 8, 26, 27, 36, 50, 73, 74, 79 and 101) of 38 sampled residents. This deficient practice resulted in residents eating less, feeling hungry, a potential in weight loss, and resident #74 requesting to be discharged . Findings include:During an interview on 3/9/26 at 2:40 p.m., resident #36 stated the food is passable, but was sometimes cold by the time it was delivered to her in her room.During an interview on 3/9/26 at 2:47 p.m., resident #26 stated the food sucks. He stated the food had no good flavor, They don't cook it right, and they're not good cooks.During an interview with resident #2 and #79 on 3/9/26 at 3:12 p.m., resident #2 stated the food was terrible, and It's so bad. He stated many times he was unable to identify the food on his plate. He stated the food was unappetizing visually, but also after eating it as well. He stated one time he was served a burger with just the bun, no condiments or toppings. Resident #79 also stated he was served a burger with just the bun. Resident #79 stated he ate cereal often because he disliked the food so much. Resident #79 stated, You don't know what it is (when looking at it or after eating it). He stated he loved biscuits and gravy but by the time it was served to him the biscuits were soggy, and the food was cold. He said most food felt like the temperature of ice to him. He stated he had never seen any staff member take the temperature of his or his roommate's food before. Resident #79 stated the eggs served at the facility were also terrible. He stated he had personally asked the cook to make him over-easy eggs for breakfast, and they are hard by the time they are served or just burnt. Resident #79 stated, I'm always hungry here. Resident #79 stated he either was not served enough food or he would not eat what was served. Both resident #2 and #79 stated the food was always cold.During an interview on 3/9/26 at 3:59 p.m., resident #73 stated the food is pathetic at the facility. Resident #73 stated he never ate breakfast because he disliked the food so much.During an interview on 3/9/26 at 4:02 p.m., resident #74 stated the facility could improve with . better food. Man, the food is terrible. Resident #74 stated she could never eat the eggs at the facility. She stated the eggs were served as two big scoops of ice cream and had no taste. She stated she was served a pork chop and had to eat it with her fingers because it was too hard to cut. Resident #74 stated that one time she was served a plate full of cooked carrots, and stated, I thought, what in the world. I was just so shocked. She stated that day, the CNA had told her she was going to be surprised by what was served. Resident #74 stated she often was hungry (including the day she was only served cooked carrots). Resident #74 stated she was not served enough calorie-dense or filling foods, which contributed to her feeling hungry.During a return phone call with NF5 on 3/16/26 at 10:52 a.m., NF5 stated resident #74 was crying because she was served a plate full of cooked carrots and soup with tofu or ham and water. During an interview on 3/9/26 at 4:11 p.m., resident #50 stated the food that was served one night . was bad. Resident #50 stated it was onion and ham soup that was unappetizing visually and taste-wise.During an interview and observation on 3/10/26 at 9:32 a.m., resident #2 stated his eggs were super hard, and he was unable to dunk his bread in the yolk. When taking a fork, one yolk had a small bit of yolk left, but the majority of the three eggs were closer to a poached egg than an over-easy egg. Resident #79's eggs were burnt on the bottom. Both residents ate some of their breakfast but left the eggs. During an interview and observation on 3/10/26 at 9:36 a.m., resident #73 stated he disliked the scrambled eggs as they were a scoop of eggs, and he had not been served a piece of toast since he had been at the facility. He stated he was constantly served potatoes with gross gravy.During an observation and interview on 3/10/26 at 5:41 p.m., resident #11 was served a spinach salad with honey mustard dressing over the top of it. Resident #11 stated the facility always served salads with this same type of dressing, which no one seemed to like. Resident #11 stated he wished the facility would get more variety in the salad dressings instead of serving the same one over and over.During an interview and observation on 3/10/26 at 5:42 p.m., resident #27 held up a whole piece of spinach and stated, This looks like a weed in my garden. Resident #27 had placed some of the large pieces of spinach on the side of her plate. The salad only consisted of whole pieces of spinach and no other greens. And the salad was topped with tomatoes and hard-boiled eggs.During an interview and observation on 3/10/26 at 5:43 p.m., resident #101 stated the salad dressing was too sweet and gross. Resident #101 stated blue cheese salad dressing would taste really good on the salad served, but that was not an option. Resident #101's salad was barely touched, and he also had large pieces of spinach.During an interview on 3/11/26 at 9:28 a.m., resident #8 stated the food could be way better, and the food isn't even worth eating.Review of a facility policy, titled Food Preparation Guidelines, dated 4/11/25, showed: . 3. Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature. Strategies to ensure resident satisfaction include: . d. Addressing resident complaints about foods/drinks.

Based on observation and interview, the facility failed to store food in a safe, sanitary manner; failed to maintain cooler temperatures within a safe range; and failed to maintain cleanliness of the kitchen and food preparation/storage areas. The deficient practices caused increased risk for foodborne illness for all residents receiving food from the dietary department. Findings include:During an observation on 3/9/26 at 1:19 p.m., the following concerns were observed:- Ground [NAME] with an expiration date of 3/21/25- Ground Sage with an expiration date of 8/17/24- A box of foam containers was sitting directly on the floor- Two paper towels were noted on the floor beside a garbage can to the right of the handwashing station in the kitchen. The garbage can was full and overflowing- Stovetop burners had a thick black buildup on them- A slice of white bread was observed on the kitchen floor- Crumbs, particles of food, dirt and grease were observed on the shelves and boxes where pan liners and foil were stored- Food and garbage was observed on the floor in the walk-in-freezerDuring an observation on 3/12/26 at 9:12 a.m., the following concerns were observed:- Two mayonnaise packets on the floor in the dry storage area- Dirt and food particles on the floor of the walk-in-freezer- Dirt and food particles were observed on the floor outside the door to the walk-in-freezer- A wrapper, paper, and food particles were observed on the floor inside the walk-in-cooler- A pitcher containing an orange liquid was on a cart inside the walk-in-cooler. There was no date on the pitcherDuring an interview on 3/9/26 at 1:56 p.m., staff member M stated the counters and floors in the kitchen were cleaned daily. Staff member M stated the burners on the stove were cleaned every Saturday. Staff member M stated the shelves where pan liners and foil were kept were obviously not cleaned often enough. Staff member M stated temperatures were recorded twice a day every day. Staff member M stated cold food should be stored at or below 41 degrees Fahrenheit. Staff member M stated the walk-in-cooler was getting old and sometimes temperatures were noted above 41 degrees Fahrenheit. Staff member M stated when this occurred staff should wait 15 minutes and if the temperature was still out of range, maintenance should be notified to adjust the cooler setting. Staff member M stated there were no follow-up temperatures recorded to show adjustments.A review of temperature logs for the facilities walk-in-cooler showed:- March 2026: Temperatures were recorded above 41 degrees Fahrenheit nine times with no documented follow up. Temperatures were not recorded four times- February 2026: Temperatures were recorded above 41 degrees Fahrenheit nine times with no documented follow up. Temperatures were not recorded seven times- January 2026: Temperatures were recorded above 41 degrees Fahrenheit 18 times with no documented follow up. Temperatures were not recorded 21 timesDuring an interview on 3/12/26 at 8:59 a.m., staff member A stated he would try to do rounds to ensure the cleanliness of the kitchen, check food temperature logs weekly. He stated he would point out areas which needed to be cleaned and would try to follow back later to ensure the area was cleaned. A review of a facility policy titled, Food Safety Requirements, implemented on 4/11/25, showed: Policy:. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety.A review of a facility policy titled Sanitation Inspection, last reviewed on 2/27/26, showed: Policy Explanation and Compliance Guidelines:1. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. 4. Sanitation inspections will be conducted in the following manner:a. Daily: Food service staff shall inspect refrigerators/coolers, freezers, storage area temperatures, and dishwasher temperatures daily. [sic]

Based on observation, interview, and record review, the facility failed to have the required enhanced barrier precaution (EBP) signage posted for residents who required EBP for cares for 2 (#s 15 and 82); failed to ensure staff adhered to EBP protocols for personal protective equipment (PPE) while providing catheter care for a Suprapubic catheter for 1 (#15); failed to ensure proper perineal care was completed, clean technique used, and enhanced barrier precautions were followed when emptying a foley catheter bag for 1 (#2); and failed to ensure hand sanitizer was available to prevent the spread of infection for 4 (#s 54, 71, 73, and 74) of 38 sampled residents. These deficient practices increased the risk of facility acquired UTI's, and the transmission of microorganisms from resident to resident. Findings include: 1. No EBP Signage a. During an observation and interview on 3/10/26 at 9:35 a.m., on the outside of the door for resident #82's room was a hanging PPE caddy. There was no signage on the door to show what type of precautions were to be taken. Staff member I stated resident #82 was on EBP because he had an upper right chest port for dialysis. Staff member I stated he would need to get a sign to place on the resident's door. b. During an observation and interview on 3/10/26 at 11:36 a.m., on the outside of the door of resident #15's room was a hanging PPE caddy. There was no signage on the door to show what type of precautions were to be taken. Staff member I stated resident #15 was on EBP related to his indwelling catheter. Staff member I then left to get a sign to place on the door. 2. No EBP Used During an observation and interview on 3/11/26 at 11:00 a.m., staff member I performed catheter care for resident #15's Suprapubic catheter. Staff member I did not don the appropriate PPE for EBP prior to performing the catheter site care. Staff member I stated he knew he needed to put on the PPE for the EBP while providing the catheter care but did not expect to be changing the dressing for the resident at that time. He stated he could have stopped and put on the appropriate PPE. Review of resident #15's Order Summary, dated 12/8/24, showed, Nursing Order Enhanced Barrier Precautions: PPE required for high or direct care resident contact activities [due to] indwelling catheter. During an interview on 3/11/26 at 11:20 a.m., staff member B stated it was the expectation for the proper signage to be placed on the door next to the PPE caddy so staff and visitors would know what PPE to put on before entering a residents' room or providing care if they had infecton control precautions in place. Staff member B stated staff were expected to put on and use the appropriate PPE for EBP when providing catheter care for residents with any type of indwelling device. 3. During an interview and observation on 3/9/26 at 2:35 p.m., the hand sanitizer located inside of resident #54's room did not work when pushed, even though the hand sanitizer was in the container. Resident #54 stated, It's been a while since the hand sanitizer worked in her room. During an observation and interview on 3/9/26 at 3:48 p.m., the hand sanitizer located in resident #71's room was out of hand sanitizer. During an observation on 3/9/26 at 4:02 p.m., resident #74's hand sanitizer did not work. During an observation on 3/10/26 at 1:28 p.m., resident #73's hand sanitizer did not work. During an observation on 3/10/26 at 5:02 p.m., resident #73's hand sanitizer did not work. During an observation on 3/11/26 at 7:33 a.m., resident #73's hand sanitizer did not work. During an observation on 3/11/26 9:39 a.m., resident #73's hand sanitizer did not work. During an observation on 3/11/26 2:03 p.m., resident #73's hand sanitizer did not work. During an observation and interview on 3/11/26 at 5:21 p.m., staff member V tried to use the hand sanitizers in residents #s 54, 71, and 73 rooms. Staff member V stated they did not know these were empty as they always washed their hands every time when entering and when leaving a resident's room. Staff member V stated they felt three rooms without working hand sanitizer was a large number. During the catheter care and catheter emptying observations, staff member V failed to wash her hands or use hand sanitizer prior to and after the tasks (on 3/11/26 at 9:55 a.m. and 10:12 a.m.). 4. During an interview on 3/11/26 at 9:48 a.m., resident #2 stated he did not get catheter care often enough and suffered from facility-acquired UTIs often. He stated he was lucky to get clean (catheter care) once a day, and nothing gets done unless you ask for it. Resident #2 stated he had gone septic from a few of his UTIs and this had almost killed him. A request was made for resident #2's Foley care, appointments, and UTI documentation. The documentation provided showed resident #2 had the following UTIs in the past year: 4/16/25, 4/29/25, 5/11/25, 7/2/25, and 8/13/25. During an interview and observation on 3/11/26 at 9:55 a.m., staff member V stated resident #2's catheter bag should not be located on the ground because it was not sanitary. Staff member V moved the catheter bag from the ground and into the basin that was located far underneath the bed. Resident #2's catheter bag was completely full, and the urine was backing up into the catheter tubing a few inches. Staff member V stated a catheter bag should not be this full, but a staff member had called off this morning, and no one had emptied the catheter. Staff member V stated call offs would happen four times a week. Staff member V grabbed an empty basin and bent down to drain the urine from resident #2's catheter bag (with only gloves on). When asked about the PPE hanging on the door, staff member V stood back up and put a gown on (while using the same gloves). Staff member V stated they felt the PPE on the door was only good for collecting dust and other junk in the facility. Staff member V emptied 825 ml then 650 ml, then used an alcohol pad to clean the drainage valve. During an observation on 3/11/26 at 10:12 a.m., staff member V did perineal care on resident #2, but it was incomplete as the penis was retracted into the surrounding tissue. The glans was not exposed for cleaning during the perineal care. When asked, staff member V stated they always retracted the surrounding tissue and then completed the task. When staff member V retracted the surrounding tissue, there had been a whitish buildup around the glans. Review of resident #2's physician order, dated 8/15/25, showed: Enhanced barrier precautions: PPE required for high-contact direct care activities r/t indwelling catheter. During an interview on 3/12/26 at 9:16 a.m., staff member D stated staff were educated on Enhanced Barrier Precautions upon hire, and annually thereafter. Staff member D stated gloves and gowns should be worn with high contact cares, such as catheter care. Staff member D further stated that when staff were providing care to a resident who was on EBP, staff should change gloves after removing a dirty dressing and put new gloves on before applying a clean dressing.

Based on observation, interview, and record review, the facility failed to maintain a sanitary environment, by not maintaining clean resident rooms and resident bathrooms, for 6 (#s 3, 7, 24, 35, 57, and 80) of 41 sampled residents; and failed to keep the community bathing/shower room on the A and B hall clean. Findings include:During an interview on 3/9/26 at 3:42 p.m., NF2 stated the resident rooms, resident bathrooms, and the community bath/shower rooms had been dirty.During an observation on 3/10/26 at 8:07 a.m., the bathroom floor in resident room B10 had dried, light black spots on various places on the floor.During an observation on 3/10/26 at 8:08 a.m., the bathroom floor in resident room B7 had a dried, light brownish/black stain covering over half of the one-foot square tile under the toilet and when wiped with a wet, white paper towel, the paper towel became stained with a brownish/yellow stain with black specks and hair.During an observation on 3/10/26 at 8:12 a.m., the community bath/shower room for the A and B halls contained two showers and was noted to have a light gray/black stain about 18 inches in diameter around the drain just outside the shower closest to the entrance door. The shower drain, for that shower, had a brownish stain around one side of the drain and the drain was partially occluded with hair. The second shower was noted to have the hand-held shower head lying on the floor of the shower next to the shower stool.During an observation on 3/10/26 at 10:36 a.m., the floor in room B9 had multiple dried drip stains running from the bathroom to the bed on the left side of the room as viewed from the door.During an observation on 3/11/26 at 8:31 a.m., the community bath/shower room for the A and B halls was noted to have brownish/black staining randomly across the linoleum floor just outside the showers. When the floor was wiped with a wet, white tissue, the tissue became stained brownish/black.During an observation on 3/11/26 at 8:34 a.m., the floor in room B9 still had multiple dried drip stains running from the bathroom to the bed on the left side of the room as viewed from the door.During an observation on 3/11/26 at 8:35 a.m., the bathroom floor in resident room B7 still had a dried, light brownish/black stain covering over half of the one-foot square tile under the toilet.During an interview on 3/11/26 at 8:37 a.m., staff member O stated that when the memory care unit got a housekeeper, the memory care unit would be relatively clean. Staff member O stated the memory care unit had gone up to a week sometimes without any housekeepers. Staff member O further stated the aides and herself had tried to keep up with the cleaning when there were no housekeepers. During an interview on 3/11/26 at 8:50 a.m., staff member H stated there was a housekeeper assigned to clean resident rooms on each hall every day, Monday through Friday. Staff member H further stated the CNA's that gave showers would clean up after each resident shower and housekeeping staff would do a deeper clean of the shower rooms two times a week.During an observation and interview on 3/11/26 at 8:53 a.m., while observing the bathing/shower room for the A and B halls, staff member H stated the shower room doesn't look like it had been cleaned.During an observation and interview on 3/11/26 at 8:55 a.m., while observing the bathroom for resident room B7, and the floor in resident room B9, staff member H stated that it had not met her expectation. During an interview on 3/12/26 at 7:54 a.m., staff member B stated staff member A oversees the housekeeping and the shower rooms should have been cleaned by the CNA after each resident was showered.During an interview on 3/12/26 at 8:59 a.m., staff member A stated he completed Guardian Angel Rounds where he would look in rooms and if they needed to be cleaned he would notify housekeeping. He stated all managers in general were looking at certain rooms to ensure the cleanliness of those rooms. He stated there were Swiffer Sweepers available at all the nurses' stations so staff could clean up any messes or spills they seen if housekeeping was not immediately available. He stated If there were areas which needed to be cleaned more readily there was a WhatsApp group chat nurses could utilize to notify if there was a dirty area which needed to be cleaned as well as the paging system if needed.A review of a facility policy titled, Routine Cleaning and Disinfection, with an implemented date of 4/11/25, showed: Policy:It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible.Definitions:'Cleaning' refers to the removal of visible soil from objects and surfaces and is normally accomplished manually or mechanically using water and detergents or enzymatic products.Policy Explanation and GuidanceI. Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge.

Based on interview and record review, the facility failed to honor a POA's (Power of Attorney) wishes with regard to treatment for 1 (#84) of 41 sampled residents. This deficient practice resulted in the POA not being informed of resident #84's condition or treatment, the resident continuing to receive a psychotropic medication without the POA's knowledge for approximately six months, and the resident receiving the psychotropic medication for approximately two months after the POA requested it to be stopped. Findings include: During an interview on 3/9/26 at 4:02 p.m., NF1 stated that the facility had not contacted her for a care conference for resident #84, since the last care conference in August 2025, and she had not heard from the facility since then. NF1 stated during the care conference, in August 2025, the facility had informed her that due to resident #84's depression, Ativan had been prescribed and was being administered to resident #84 since February 2025. NF1 further stated that she never gave consent for the Ativan and she informed them during the August care conference, she wanted the facility to stop administering Ativan to resident #84. A review of resident #84's Clinical Resident Profile in the facility's EHR showed [NF1] was the Responsible Party, POA, Care Conference Person, Emergency Contact #1, . Responsible Care. [sic]A review of a medication order for resident #84 in the facility's EHR, dated 2/12/25, showed, Ativan Oral Tablet 0.5 MG (Lorazepam) *Controlled Drug* Give 1 tablet by mouth every 24 hours as needed for Aggression Give 1 hour prior to bath/shower. [sic]A review of a medication order for resident #84 in the facility's EHR, dated 2/16/25, showed, Ativan Oral Tablet 0.5 MG (Lorazepam) *Controlled Drug* Give 1 tablet by mouth every 24 hours as needed for Aggression with showering. Give 1 hour prior to bath/shower only 1-2x/week. [sic]A review of a medication order for resident #84 in the facility's EHR, dated 2/26/25, showed, Ativan Oral Tablet 0.5 MG (Lorazepam) *Controlled Drug* Give 1 mg by mouth as needed for Aggression with showering. Give 1 hour prior to bath/shower only 1-2 times per week, 1 hour prior to bath or shower. [sic]A review of a medication order for resident #84 in the facility's EHR, dated 5/21/25, showed, Ativan Oral Tablet 0.5 MG (Lorazepam) *Controlled Drug* Give 0.5 mg by mouth two times a day for Anxiety, agitation. [sic]A review of a medication order for resident #84 in the facility's EHR, dated 6/22/25, showed, Ativan Oral Tablet 0.5 MG (Lorazepam) *Controlled Drug* Give 1 mg by mouth as needed for Aggression with showering. Give 1 hour prior to bath/shower for 90 days 1-2 times per week, 1 hour prior to bath or shower. [sic]A review of resident #84's MAR for the months of February to April 2025, showed, Ativan was administered seven times PRN from 2/12/25 through 4/3/25.A review of resident #84's MAR's for months of June to October 2025, showed, Ativan was administered to resident #84 two times a day, every day from 6/1/25 to 10/29/25.A review of a facility document titled, Care Conference Summary Form, dated 8/8/25, showed, List of names and titles (as applicable) of the people who participated in the meeting: . [NF1] via phone. Medication Review, . Went over medications. [NF1] wasn't aware of Ativan.During an interview on 3/11/26 at 9:17 a.m., staff member E stated the facility never informed NF1 that resident #84 was taking Ativan. NF1 found out that resident #84 was taking Ativan during the care conference in August, and she hung up before the care conference was completed.During an interview on 3/11/26 at 10:45 a.m., NF1 stated she was contacted by a nurse in October 2025 for an updated consent for Ativan, That's when I found out they were still giving [Resident #84] Ativan after I told them to stop in August 2025.A review of a facility document titled, Resident Rights, with a date of 7/7/23, showed: (b) Exercise of rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.(3) In the case of a resident who has not been adjudged incompetent by the state court, the resident has the right to designate a representative, in accordance with State law .(i) The resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the resident representative.(4) The facility must treat the decisions of a resident representative as the decisions of the resident to the extent required by the court or delegated by the resident, in accordance with applicable law.(c) Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment, including:(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.(iii) The right to be informed, in advance, of changes to the plan of care.(6) The right to request, refuse, and/or discontinue treatment, . [sic]

Based on observation, interview, and record review, the facility failed to provide a resident with necessary respiratory care and services in accordance with professional standards of practice and physician orders and failed to ensure a portable oxygen tank was replaced when the metered volume was empty for 1 (#6) of 4 residents sampled for oxygen therapy. This deficient practice increased the risk of negative outcomes related to hypercapnia (a condition characterized by abnormally high levels of carbon dioxide in the blood, typically caused by hypoventilation, chronic lung diseases, like COPD, or breathing issues resulting in confusion, fatigue, and shortness of breath). Findings include:During an observation and interview on 3/9/26 at 3:49 p.m., resident #6 was laying on her back turned slightly on her right side. The head of the bed was in the lowest position and was not elevated. There was an oxygen concentrator next to her bed. The oxygen concentrator was turned off, and there was no oxygen tubing attached to the oxygen concentrator. Resident #6 was not wearing any oxygen while in bed. When asked questions, the resident would respond with simple short answers but ended her answers with I am afraid. Resident #6 was not able to elaborate about what she was afraid of.During an observation on 3/9/26 at 5:00 p.m., resident #6 was laying in bed, with the head of the bed in the lowest position. The oxygen concentrator was off and there was no oxygen tubing connected to the concentrator. The resident was not wearing oxygen. Review of resident #6's Physician Hospital Discharge Summary and Order, dated 12/6/25, showed, Orders.Assessment and Plan:(1) Encephalopathy: Status: Acute resolved. Patient back to baseline mental status, level of function. Suspect metabolic encephalopathy in the setting of acute infection and hypoxia - was found without her oxygen on at SNF prior to admission and O2 sats in the 70s the morning of admission. Head CT negative for acute findings. She has had several previous admissions with similar presentation. ABG with mild hypercapnia to 53, though this appears chronic for her.(3) Chronic hypoxic respiratory failure: Status: Chronic Patient remains stable on baseline 1.5 L NC. Told patient she needs to keep her oxygen on at all times and if she feels short of breath needs to let nurse know at skilled nursing facility.(4) COPD (chronic obstructive pulmonary disease): No current evidence of exacerbation, remains stable on baseline O2.Review of resident #6's Facility Documented Physician Orders, with a start date of 12/29/24, showed, Continuous Oxygen at 2 LPM per nasal cannula. May titrate prn supplemental Oxygen from 1-4 L/min via nasal cannula prn for dyspnea to keep O2 saturations [greater than] 88 [percent]. May use portable tank or concentrator. Every shift related to Chronic Obstructive Pulmonary Disease and as needed for Hypoxia.Review of resident #6's Care Plan, with a revision date of 6/26/25, showed, [Resident #6] has oxygen therapy. The resident will have no signs or symptoms of poor oxygen absorption through the review date. Interventions:- Continuous Oxygen at 2 LPM per nasal cannula. May titrate prn supplemental.- Oxygen from 1-4 [liters per minute] via nasal cannula prn for dyspnea to keep O2 saturations [greater than] 88 [percent] May use portable tank or concentrator.- Head of Bed Elevation is needed due to shortness of breath.During an observation on 3/10/26 at 3:27p.m., resident #6 was sitting in her wheelchair in the day room next to the E-Hall nurses' station. She was wearing oxygen via a nasal canula that was attached to a portable oxygen tank on the back of her wheelchair. The oxygen was set at 1.5 liters of oxygen, but the metered volume on the oxygen tank showed the oxygen was empty.During an observation on 3/11/26 at 9:10 a.m., resident #6 was asleep in her wheelchair which was positioned in front of the E-Hall nurses' station. The resident was wearing oxygen via a nasal canula which was attached to an oxygen tank on the back of her wheelchair. The oxygen was set at 1.5 liters continuously.During an interview on 3/11/26 at 10:36 a.m., staff member J stated the resident should be on two liters of continuous oxygen via a nasal canula. Staff member J stated resident #6 could go a little while without the oxygen, but her oxygen levels would begin to drop without having the oxygen. She stated when the resident was in bed she should be wearing oxygen from the oxygen concentrator that was next to her bed and when she was up in the wheelchair she would use the oxygen from the tank on the back of her wheelchair. Staff member J stated she was not aware if resident #6 needed to be positioned in bed with the head of the bed raised.During an interview and observation on 3/11/26 at 10:36 a.m., staff member I stated resident #6 could go for a little while without oxygen, but her oxygen levels would drop into the low 70's without continual oxygen. Staff member I stated he usually set resident #6's oxygen setting at two liters continuous. Staff member I stated if he set her oxygen at two liters, that would usually keep the resident above 88 percent oxygen saturation. He stated if the resident did not have her oxygen on, and you were to check her oxygen levels after approximately 30 minutes, her oxygen saturations would be in the 70's or 80's. Staff member I stated if resident #6's oxygen was low; she usually became tired and would start having increased confusion and some behaviors. Staff member I stated he usually elevated the resident's head of her bed but stated she did not need it to be elevated. Staff member I checked resident #6's oxygen setting, stating it was currently set at 1.5 liters of oxygen. He then obtained a pulse oximetry reading of resident #6's oxygen saturation level, which showed the resident was at 94 percent blood oxygen. Staff member I then turned resident #6's oxygen dose down to one liter of oxygen.During an interview on 3/11/26 at 11:20 a.m., staff member B stated it was the expectation for staff to follow the orders for oxygen administration. She stated when a resident was on continuous oxygen, they should have an oxygen concentrator at bedside to administer oxygen while the resident was in their room or in bed. She stated staff should be monitoring residents oxygen tanks while rounding to ensure the oxygen was set to the correct amount and to ensure the oxygen canister was not empty.During an observation and interview on 3/12/26 at 9:39 a.m., resident #6 was asleep in her wheelchair in the day room across from the E-Hall nurses' station. The resident's nasal canula and tubing were out of her nose and resting over her shoulder behind the wheelchair. The oxygen was set at one liter of oxygen. The metered volume on the oxygen gauge showed the oxygen canister was empty. Resident #6 awoke when asked how she was feeling. The resident responded, tired, and closed her eyes again. There were no staff in the immediate vicinity.During an observation and interview on 3/12/26 at 9:50 a.m., staff member L replaced resident #6's oxygen. She stated she was not sure if the resident was on scheduled or PRN oxygen, then checked the resident's oxygen order in the medical record. Staff member L read resident #6's oxygen order out loud and stated the order was confusing but thought she would set resident #6's oxygen administration to two liters of continuous oxygen. Staff member L stated it was difficult to determine what should be done for resident #6.A review of the facility's policy and procedure titled, Oxygen Administration, with an implementation date of 4/11/25, showed, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.1. Oxygen is administered under orders of a physician, except in the case of an emergency.4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to:a. The type of oxygen delivery system.b. When to administer, such as continuous or intermittent and/or when to discontinue.c. Equipment setting for the prescribed flow rates.d. Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered.e. Monitoring for complications associated with the use of oxygen.

Based on interview and record review, the facility failed to provide the necessary care and services (including preferences, goals, and standards of care) to meet the resident's physical, mental, and psychosocial needs for 1 (#74) of 38 sampled residents. This deficient practice resulted in resident #74 feeling uncared for, crying about the food (or lack of) served to her, NF5 upset about the care provided to resident #74, and resident #74 requesting to be discharged from the facility. Findings include:During an interview on 3/9/26 at 4:02 p.m., resident #74 stated the facility could improve the food as it was . terrible. Resident #74 stated she could never eat the eggs at the facility. She stated the eggs were served as two big scoops of ice cream and had no taste. She stated she was served a pork chop that she had to eat with her fingers, and was once served a plate full of cooked carrots and no other items on the tray other than soup. Resident #74 stated she was often hungry at the facility, and she was not served enough calorie-dense or filling foods. She stated she did not like being at the facility, and NF5 had talked to staff members about their concerns many times.During an interview on 3/11/26 at 8:54 a.m., staff member E stated, I didn't know why she was discharging. Staff member E stated they now knew the reason why resident #74 wanted to discharge, but staff member E did not want to put in a progress note because it was going to sound bad. Staff member E stated the floor staff had been aware of resident #74 and the family's concerns, but stated nothing had been done. Staff member E stated her coworker needed more education as they had never told staff member E that resident #74 wanted to be discharged from the facility. Staff member E stated NF5 had called Monday morning (3/9/26) and had said she wanted to be discharged , but did not tell staff member E why she was being discharged . Staff member E stated NF5 stated, She said over the weekend, she was done, because resident #74 had been served a plate full of carrots and watery soup that consisted of either pieces of ham or tofu. Staff member E stated resident #74 had been crying because of what she was served. Staff member E showed the survey team a picture of this meal and stated, That looks wretched. Staff member E stated we get a lot of dietary complaints, and the administration just keeps doing PIPs (Performance Improvement Plan) or POCs (Plan of Correction). Staff member E stated resident #74's feet were swollen; her blood sugar was over 400 for three days because the therapeutic diets were not followed. Staff member E stated the facility was supposed to be their home.During a return phone call with NF5 on 3/16/26 at 10:52 a.m., NF5 stated resident #74 was crying because of the poor care she received, and the plate full of carrots was the last straw. Please see F804 for more dietary details.Review of resident #74's Care Plan, initiated 3/4/26, showed: . is at risk for alteration in nutritional status r/t inadequate protein intake and inconsistent carbohydrate distribution with increased demands for wound healing . chronic non-healing LLE wound and reports confusion regarding DM lifestyle management .

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to independently carry out activities of daily living (ADL) for self-grooming and showering was provided a regular shower and the removal of female facial hair for 1 (#6) of 4 sampled residents for ADL services. Findings include:During an observation and interview on 3/9/26 at 3:49 p.m., resident #6 was lying in her bed on her back, with a sheet covering her lower body. She had numerous sporadic gray chin and neck hairs, which were approximately 1 to 1.5 inches long. When asked if the resident preferred to have her facial hair removed, the resident nodded her head yes, as she stated, Yes. When asked if she needed help with shaving her face, the resident nodded and said, Yes, please. The resident had a moderate amount of dried white scaly and moist yellow eye rheum in both eyes. She had a slight musty odor emanating from her person. During an observation on 3/10/26 at 11:20 a.m., resident #6 was sitting in the common day room across from the E-Hall nurses' station. She continued to have numerous sporadic gray chin and neck hairs, which were approximately 1 to 1.5 inches long. During an observation on 3/10/26 at 5:01 p.m., resident #6 was sitting in her wheelchair and was at a table in a full communal dining hall with other residents and visitors. The resident continued to have the same numerous sporadic gray chin and neck hairs as observed previously. During an observation on 3/11/26 at 10:36 a.m., resident #6 was sitting in her wheelchair in front of the E-Hall nurses' station. Staff member I was assessing the resident's oxygen level. While waiting for the oxygen meter to register, staff member I leaned towards resident #6 and ran his finger across the resident's chin and neck hair, stating, We need to cut back your chin hairs.During an interview on 3/11/26 at 10:36 a.m., staff member J stated resident #6 usually had a shower once a week, and facial hair would be removed during the shower. Staff member J stated the resident did not typically refuse her showers, but if she did, they would reapproach her later and try again, or try again on another day. She stated if a resident refused a shower, they completed a shower refusal form. During an interview on 3/11/26 at 11:20 a.m., staff member B stated resident showers were provided weekly, and/or per the resident's preference. Preferences would be documented in the resident's care plan. She stated if a resident refused a shower, the staff were to attempt to reapproach the resident at a different time and try again. If the resident did not wish to reschedule the shower, the staff were to complete a shower refusal form and chart the refusal in the resident's medical chart. Staff member B stated that female chin hair removal would be dependent upon the resident's wishes.Review of resident #6's Care Plan, with a revision date of 4/1/24, showed a Focus of: Needs assistance with my ADL's for completion and hygiene. Ability limited by decreased shoulder ROM and fatigue. My care, and acceptance of care, may be affected by my diseases including psychosis and borderline personality disorder. With interventions to include: - Personal Hygiene/Grooming: requires partial/moderate to substantial/dependent assist of one staff. Encourage hair care by staff every morning. When I refuse, remind me of potential risk and positive outcome if I follow through with the task.- I prefer to shower weekly. I need assist of two for my showers.- If I refuse bath/bathing, report to charge nurse. Charge nurse to offer me alternative bathing, for example: bed bath, tub bath, shower. If I continue to refuse after attempt by charge nurse, report to DON and/or Administrator.Review of resident #6's shower/bathing log showed the resident was provided a bath on 3/1/26 at 5:59 p.m., and 3/11/26 at 5:59 p.m. A review of refusals for resident #6 did not show that any refusals were documented for March 2026.Review of resident #6's Nurse Progress Note, dated 3/11/26 at 6:31 p.m., showed, Resident had assistance to complete showering and personal hygiene, including the removal of her facial hair per her request. Resident expressed gratitude for the completion and tolerated process well. A review of the facility's policy and procedure titled, Activities of Daily Living, with an implementation date of 4/11/25, showed, The facility will. ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable.3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to implement safe interventions for swallowing medications and food for 1 (#73) of 38 sampled residents. This deficient practice resulted in resident #73 feeling rushed when taking his medications, coughing on the medications, and potentially vomiting. Findings include:During an interview and observation on 3/10/26 at 9:36 a.m., resident #73 stated only the physical therapist helped him sit up in the day to eat, but they would not visit him until early afternoon. He stated he had already eaten breakfast. Resident #73 was lying flat on his back with his head kinked forward. He stated he would often choke or throw up from taking the medications if a nurse rushed him, but had no problem swallowing food. He stated he swallowed the medications better at home because he had been sitting up in a chair before taking the pills.During an interview and observation on 3/10/26 at 9:51 a.m., resident #73 was about to be given his morning medications, and he asked staff member X, Can you adjust my head, so I don't choke? Resident #73 had been lying down with his head kinked forward. Staff member X had pushed the button to move the head of the bed of resident #73 up, but the movement was too quick, and resident #73 winced and asked to be moved back down to his original position. Staff member X asked if the new position was adequate, and resident #73 stated, I guess. Staff member X never tried to reposition resident #73 again or offer any education about swallowing with his head of the bed at a 30-degree angle. Staff member X gave a medication with a lot of pudding. Resident #73 chewed on the pudding for some time, swallowed, then coughed and spat out a bit of the pudding, which landed on his chest. Resident #73 stated he was able to swallow the medication. Resident #73 stated he never had a problem taking all of his medications altogether at home when sitting up.Review of resident #73's Care Plan, with an initiation date of 12/18/25, failed to show resident #73's need to be sat up during meals and during medication administration to prevent the risk of choking. This failure increased the resident's risk for choking on meals or medications each day or opportunity to consume them.Review of a speech therapy note, dated 2/12/26, showed: . Position during eval . posture impacts function, is modifiable with intervention .

Based on interview and record review, the facility failed to identify and investigate an allegation of potential neglect of care for 1 (#11) of 38 sampled residents. The allegation was later found to be an accident, but the reporting timeline was not met for an allegation of neglect, and the investigation was not immediately initiated for neglect of care, in an attempt to rule out neglect of care. Findings include:A review of resident #11's progress note, created on 2/23/26 at 4:46 p.m., showed: Secure Message:[DATE]Rachael Garrey. The tube is out 5 inches from the stitches; no urine output. resident stated tube was pulled out by a CNA on Wed or Thur. and stopped draining urine today. [sic]During an interview on 3/11/26 at 3:15 p.m., Staff member A stated the facility had not investigated the allegation to rule out neglect because the IDT did not feel that it was a reportable incident.A review of resident #11's progress note, with an effective date of 3/11/26 at 3:29 p.m., showed: NHA spoke with resident on the incident with CAN where his nephrostomy tube had come out. He did not feel it was an abusive or neglectful act.During an interview on 3/11/26 at 4:30 p.m., staff member A stated his conversation with resident #11 about the nephrostomy tube being dislodged, occurred on 3/11/26, not at the time of the allegation.A review of a facility policy titled, Abuse, Neglect and Exploitation, implemented 4/11/25, showed: . Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The components of the facility abuse prohibition plan are discussed herein:. V. Investigation of Alleged Abuse, Neglect and Exploitation. A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. [sic]

Based on interview and record review, the facility failed to submit an initial incident report for an allegation of neglect to the State Survey Agency, for 1 (#11) of 38 sampled residents. The resident did not receive the necessary care and services related to a nephrostomy tube and the tube being dislodged during care, which was later identified to be an accident. Findings include:Review of resident #11's progress note, created on 2/23/26 at 4:46 p.m., showed: Secure Message:[DATE] . The tube is out 5 inches from the stitches; no urine output. resident stated tube was pulled out by a CNA on Wed or Thur. and stopped draining urine today. [sic]During an interview on 3/11/26 at 3:09 p.m., staff member C stated he was aware of the allegation that a CNA had caused resident #11's nephrostomy tube to become dislodged. Staff member C stated he did not report this to staff member A. Staff member C stated it should have been reported to staff member A. Staff member C stated that's not my job.During an interview on 3/11/26 at 3:15 p.m., staff member A and staff member B stated the facility did not report the allegation that a CNA had caused resident #11's nephrostomy tube to become dislodged to the State Survey Agency. Staff member A stated the Interdisciplinary Team had reviewed it at the time and did not feel it was neglect.A review of resident #11's progress note, with an effective date of 3/11/26 at 3:29 p.m., showed: NHA spoke with resident on the incident with CNA where his nephrostomy tube had come out. He did not feel it was an abusive or neglectful act.During an interview on 3/11/26 at 4:30 p.m., staff member A stated his conversation with resident #11 about the nephrostomy tube being dislodged, occurred on 3/11/26, not at the time of the allegation.A review of a facility policy titled, Abuse, Neglect and Exploitation, implemented 4/11/25, showed: . Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The components of the facility abuse prohibition plan are discussed herein:. VII. Reporting/Response. A. The facility will have written procedures that include:1. Reporting of all alleged violations to the administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, orb. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. [sic]

Based on interview and record review the facility failed to schedule timely care conferences with the POA (Power of Attorney) for a resident who resides on the memory care unit, for 1 (#84) of 41 sampled residents. Findings include:During an interview on 3/9/26 at 4:02 p.m., NF1 stated she had not been notified or involved in a care conference for [Resident #84] since August 2025.During an interview on 3/10/26 at 2:22 p.m., staff member E stated she scheduled care conferences within 48 hours of admission and then annually. Staff member E further stated there was no documentation of invitations to care conferences for NF1.During an interview on 3/11/26 at 9:05 a.m., staff member E stated she was unaware that care conferences for residents was supposed to be conducted quarterly and had only been having them annually. Staff member E stated she was unaware she was supposed to invite the POA to the care conference. Staff member E further stated she did not know a care conference should have been held if a resident had a change of condition.During an interview on 3/11/26 at 10:45 a.m., NF1 stated the prior management of the facility before it was [Facility name] had conducted care conferences with her for [Resident #84] on a quarterly basis.During an interview on 3/12/26 at 7:54 a.m., staff member B stated care conferences for residents should have been done on admission, then quarterly and when there was a change in the resident's condition. A review of resident #84's medical record showed, two care conferences in the last 12 months, one on 3/12/25 and the other on 8/8/25.A review of a facility policy titled, Care Planning-Resident Participation, with an implemented date of 5/13/25, showed: Policy:This facility supports the resident's right to be informed of, and participate in, his or her care planning and treatment (implementation of care).Policy Explanation and Compliance Guidelines: .8. The facility will honor requests for care plan meetings and acknowledge requests for revisions to the person-centered plan of care.9. The facility will honor the resident's right to participate in establishing the expected goals and outcome of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.10. The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility will make an effort to schedule the conference at the best time of the day for the resident/resident's representative. The facility will obtain a signature from the resident and/or resident representative after discussion or viewing of the care plan.

Based on interview and record review, the facility failed to consult and receive a representative's permission to order and administer a psychotropic medication for a resident on the memory care unit, for 1 (#84) of 41 residents. This deficient practice resulted in the resident representative not being informed in advance or being allowed to make treatment decisions for the resident's care. Findings include:A review of resident #84's Clinical Resident Profile in the facility's EHR showed [NF1] was the Responsible Party, POA, Care Conference Person, Emergency Contact #1, . Responsible Care. [sic]During an interview on 3/9/26 at 4:02 p.m., NF1 stated she found out the facility was administering Ativan to [Resident #84] for six months, without her consent.During an interview on 3/11/26 at 9:17 a.m., staff member E stated NF1 had not been informed that [Resident #84] was receiving Ativan. Staff member E further stated that NF1 was on the phone during the care conference for [Resident #84] in August 2025 and hung up when she was told [Resident #84] was prescribed Ativan without her knowledge.During an interview on 3/11/26 at 10:45 a.m., NF1 stated she received a phone call from a nurse at the facility, sometime in October 2025, asking for a verbal consent to continue administering Ativan to resident #84. NF1 further stated that's when I found out they were still giving her Ativan, after I told them to stop in August 2025.A review of a facility document titled, Resident Rights, with a date of 7/7/23, showed: . (4) The facility must treat the decisions of a resident representative as the decisions of the resident to the extent required by the court or delegated by the resident, in accordance with applicable law.(6) The right to request, refuse, and/or discontinue treatment, . [sic]A review of a facility policy titled, Care Planning-Resident Participation, with a date implemented of 5/13/25, showed: Policy:This facility supports the resident's right to be informed of, and participate in, his or her care planning and treatment (implementation of care).Policy Explanation and Compliance Guidelines: .3. The facility will notify the resident and/or resident representative, in advance, of the care to be furnished and the type of caregiver or professional that will furnish care, as well as changes to the plan of care.4. The facility will encourage and assist the resident and/or resident representative to participate in choosing care and treatment options including:a. Initial decisions about treatmentb. Decisions about changesc. The right to refuse treatment .

Based on interviews and record reviews, the facility and staff failed to provide the supervision and oversight for a resident residing on the memory care unit, who had dementia, poor safety awareness, displayed aggressive behavior towards others, and would wander continuously. On one occasion, the resident went into a room of a fellow resident, was pushed, had a fall, and fractured her hip, as staff were not available and present to stop her from going into the room, for 1 (#15) of 3 residents sampled on the memory care unit; and, this affected 1 (#20) when resident #15 went into her room and punched her in the chest while sleeping, which made the resident afraid. Although the facility did attempt to identify and implement interventions for the resident and her behaviors, they were not adequate to meet the resident's needs. Findings include: A review of resident #15's admission Minimum Data Set assessment, with an Assessment Reference Date of 8/13/25, showed the Brief Interview of Mental Status (BIMS) assessment was coded with a score of 00 which was for severe cognitive impairment. The resident displayed inattention and disorganized thinking, which was continuous. She was coded as being down, depressed, or feeling hopeless, 2 to 6 days of the assessment period. The resident was always incontinent of bowel and bladder, but did not have a program for bowel or bladder training. The resident was unable to state if she had pain, but the staff stated she had, Non-verbal sounds (e.g., crying, whining, gasping, moaning, or groaning) of pain signs or symptoms, and this was for the frequency with which resident complains or shows evidence of pain or possible pain which was 1 to 2 days of the assessment period. Section J showed the resident was at risk for falls, and she had prior elopements from home prior to her admission. A review of resident #15's interdisciplinary (IDT) progress notes showed the resident was admitted to the facility on [DATE], and began displaying behaviors the following day. Her IDT notes included: -8/14/25, the resident tried to hit the staff three times, was wandering, up and out of bed consistently, and went into other resident rooms. -8/16/25, resident #15 was combative with care, displayed anxiety and agitation, was restless, and was going into the rooms of other residents. -8/17/25 to 8/24/25, the resident's behaviors continued. On 8/26/25, she attempted to bite a person but was unsuccessful. As of 8/31/25, she complained of hip pain, but did not have any falls. Resident #15 was ordered Tylenol as needed. It was unclear if her pain was a contributing factor to her behaviors and wandering prior to this. -9/5/25, the resident was documented to be going in and out of all the rooms on the memory care unit. She was stealing items from other residents who were complaining about her. Staff noted she usually left her room to toilet, but per review of the MDS, and progress notes, the resident was not on a toileting plan. -9/7/25, resident #15 went into a resident's room, and resident #15 swung at the other resident. She continued her exit seeking, and the progress notes showed she was constantly on the move, I mean constantly. The family member was contacted, and the nurse requested the family member come in to stay with the resident. On 9/8/25, the physician documented the resident had lost weight, which was also documented in the nutrition note dated 9/20/25. One contributing factor to the loss was resident #15's inability to sit still and eat a meal. On 9/27/25, the resident had a fall, trying to sit down in an unlocked wheelchair. She had poor safety awareness per the progress note entries. -10/1/25, resident #15 had another fall, she was brought to the day room by a CNA. It was unclear what she was doing or how the resident got on the floor, due to the lack of staff oversight. On 10/2/25, the progress notes showed the resident needed close monitoring, which was essential, and she was scaring other residents. On 10/4/25, she was again found on the floor, her mattress and blankets half off the bed, and urine was on the floor. It is unclear if the resident's needs were met prior to being found on the floor, or if staff oversight was in place as required. Refer to F689 - Accidents and Hazards for more fall information. -10/8/25, resident #15 went into resident #20's, and while she was in bed, resident #15 punched her in the chest. This caused resident #20 to be afraid of #15. She was also going through the drawers in the room. Per the progress notes, resident #15 was put on 15-minute checks and 1 to 1 observation.-10/9/25, the interdisciplinary team documented the resident willfully places herself on the floor, which was to address the 10/4/25 fall, where she was found on the floor. The facility IDT notes do not show that this behavior occurred. On 10/9/25, it was noted in the nursing progress notes that resident #15 was sitting at the same dining table as resident #20, although #20 previously mentioned fear of #15. Staff did not ensure the two were kept separate. On 10/12/25, 15-minute checks were implemented for behavior monitoring. A review of the monitoring showed it was attempted to be completed on 10/8/25, 10/9/25, and 10/10/25. Of the three pages of 15-minute checks for resident #15, completed for the Threat/Danger to others, the documentation showed: 10/8/25 - The checks started at 7:30 p.m., and showed the resident was ambulating until 11:45 p.m. She also displayed exit seeking and had other (unknown) behaviors, or none. A line was drawn down through the staff initials section. 10/9/25, documentation of the 15-minute checks occurred from 12:00 midnight until 6:30 a.m., then stopped. There were lines drawn down through the remaining opportunities to document the resident's behaviors. Initials above the lines showed TG. For the times documented, the resident was in her room, ambulating, sleeping, or had no behavior. The 15-minute checks did not reflect that they were completed properly. 10/10/25, the 15-minute monitoring documentation form showed four columns/sections, each included the 15-minute checks in that specific time period. Each check was to include the location, the activity, and the behavior displayed by the resident. Column/section one was from 12 midnight to 5:45 a.m., column/section two was from 6:00 a.m. to 11:45 a.m., column/section three was from 12:00 noon to 5:45 p.m., and the 4th column/section was for the times from 6:00 p.m. to 11:45 p.m. Of the four columns and sections documented, one column/section had a line drawn down through the checks, with the initials SC at the top of the line. The second column had a line drawn through the first three rows, again with the initials SC at the top of the line. All other opportunities were blank. The 15-minute checks were not completed as identified necessary. -10/16/25, resident #15 went into another resident's room and urinated in a cup she took off the table, and for the days following this, she continued behaviors of shooing staff away, refusing care, yelling, agitation, anxiousness, wandering, or would become aggressive and push at staff if they attempted to redirect her.-On 10/23/25, a psychological evaluation showed the resident had poor impulse control, fragmented sleep, and her behavior appeared to be driven by her disorientation and restlessness. She had poor impulse control and would need ongoing staff support, a strict routine, and behavior monitoring was essential. It was noted that supervised walking was recommended to help channel her restlessness and to provide a path to redirect her so she would not intrude on others. Toward the end of the evaluation, it showed that close observation was needed in the evenings and at night. Resident #15's behaviors continued, but her supervision and oversight by staff failed to meet her behavioral needs per the progress notes. On 11/12/25, it was noted a CNA was parked outside her door, sitting in a wheelchair, but the resident was not redirectable. Depakote Sprinkles were added to her medication regimen to assist with her behavior. On 11/13/25, she again had pain in her back, which appeared to have increased around that time. By 11/18/25, she was screaming in pain, and it was questioned if she had hurt her back during a fall the prior week, but the resident didn't have a fall the prior week, per the progress notes. The CNA reported the resident was also walking differently, and she would yelp when sitting or rolling in bed. The resident was sent out for further evaluation, and it was found she had an L1 Compression Fracture; the cause was unknown. It was unclear if the resident's pain was a contributor to her behaviors from her prior fall(s), or her behaviors before the falls began. -On 11/28/25, the resident went into a room with two other residents residing on the memory care unit, and this upset them. A verbal argument ensued, and they attempted to get resident #15 to leave. Staff did not stop resident #15 from entering the room, showing that supervision and oversight were not sufficient. The resident was pushed, had a fall, and sustained a right hip fracture, which required surgical repair. -When the resident returned from the hospital, she was ordered pain medication to treat her pain. Resident #15's behaviors continued, to include yelling out, screaming, refusing care, slapping at staff when care was provided, and she would get agitated and bite or scratch. In review of the resident's provider notes related to managing the resident's pain, documentation showed the licensed staff were not providing the resident with the pain medication available, as ordered. The provider noted this concern in the progress notes, and the note reflected that this needed to be done before another change in her pain medication would be considered. The failure of the staff to provide the available pain medications as ordered or needed contributed to the resident's ongoing behaviors, although some interventions and medications were attempted by staff, it was not adequate to ensure her comfort. A review of resident #15's comprehensive care plan showed the plan was not individualized and tailored to the resident's specific needs during her stay as related to her behaviors and dementia care needs, and showed: -A problem was initiated on 8/18/25 related to a cognitive decline. The goal included that the resident will develop skills to cope with cognitive decline and maintain safety by the review date. This goal, due to the resident's level of cognitive impairment, was not realistic. The interventions showed staff were to cue and reorient her as needed, but it did not show how they were to do that specifically. The staff were to ask the resident yes and no questions, to determine her needs, and present one thought, idea, or question at a time. There were no other interventions noted on the cognitive decline care plan related to how she was to develop skills to cope with the cognitive decline, considering her diagnosis of dementia and cognitive deficits. - On 8/18/25, a PAIN care plan was initiated but the plan did not show how resident #15's pain could disrupt the resident, did not identify or show information about her normal level of pain, the location(s), severity or type, how that pain could specifically be relieved, or how her level or type of pain contributed to her ongoing behaviors.-The elopement care plan was initiated on 8/12/25, showing she was identified as an elopement risk on admission. The interventions showed staff were to offer the activities, and it was identified during the survey that there was a lack of activities in the memory care unit. (Refer to F679 Activities of Interest) On the care plan, it showed staff were to identify her patterns of wandering, if it was purposeful, aimless, or escapist, whether she was looking for something, or she was trying to indicate a need. These patterns were not developed or identified per the medical record or care plan. -The behavior care plan showed the resident was aggressive to another resident, which was initiated on 9/8/25. The goal was for her to demonstrate effective coping skills, although she had severe cognitive deficits and an inability to understand her safety risks. Staff were to provide verbal cues, provide positive feedback, encourage her to seek out a staff member when agitated, and assist her in setting goals for more pleasant behavior. On 10/9/25, frequent checks were added for agitated behavior, but the frequency was not measurable or specified. The last intervention, dated 9/8/25, showed she wandered into other resident rooms, but there were no specifics for contributing factors or specific interventions to prevent it. During an interview on 12/15/25 at 2:55 p.m., staff member I stated, We were always redirecting, she crawled into bed with another resident one time, or she would go in (get into) their (dresser) drawers and take things. Staff member I stated, She (resident #15) was placed on 1:1 observation for two weeks after one of the altercations. I don't know why they stopped (the 1:1 monitoring) because it helped us keep an eye on her. Staff member I stated, We never knew where she was sometimes, and we're so busy with all the residents here, and We didn't know what else to do. The resident had passed away before the survey.During an interview on 12/15/25 at 3:26 p.m., NF3 stated (resident #15) was healthy when she was admitted to the facility . I think she fell through the cracks because they didn't have enough help to watch her (#15).During an interview on 12/16/25 at 10:52 a.m., staff member H stated resident #15 would wander into all the rooms on the secure memory care unit anytime she was out of bed, then stated, All she did was walk and wander any time she was not sleeping. Staff member H stated resident #15 did not know where her room was, she even urinated in another resident's room, and I almost called a Code Pink because we couldn't find her. Staff member H stated resident #15's behaviors started on the first day of her admission to the secure unit, and stated, We never tried using visual cues on her door or other interventions; We just always redirected her to her room, or I would give her a snack in the common room. Staff member H stated, We only got to do 1:1 observation (with resident #15) to monitor her behaviors for two weeks, then it just fell away. I wish they had given us more staff to help supervise her (resident #15), she needed 1:1, she was super-fast too. During an interview on 12/16/25 at 11:17 a.m., staff member L stated, . Resident #15 was safer when she had 1:1 observation, so they could keep an eye on her, then stated, It was safer for everyone when we did that. I don't know why it stopped.During an interview on 12/16/25 at 2:06 p.m., NF3 stated, Several times when I would visit her on the weekends, I went to her room, most times she wasn't there, and I would ask is [Resident 15] here, sometimes they didn't know where she was. We would usually find her in someone else's bed. NF3 stated, They never knew where she was because they were busy. During an interview on 12/16/25 at 11:31 a.m., staff member C stated he was involved regularly with the interdisciplinary team meetings and risk management meetings. Staff member C stated, I knew of resident #15's aggressions towards other residents and falls, but (he) did not know she constantly wandered. Staff member C stated that if he knew of all of resident #15's dementia related behaviors, he would have added more interventions to the resident's care plan, other than just redirecting her as needed.During an interview on 12/16/25 at 12:11 p.m., staff member B stated, I think we just redirected her (resident #15) and tried everything we could, she (resident #15) chose rooms to wander into that didn't like visitors. I don't think there was anything else we could have done, maybe more education. Staff member B stated the 1:1 observation for two weeks started after resident #15 hit resident #20.During an interview on 12/16/25 at 12:42 p.m., staff member A stated resident #15 was on a 1:1 observation at one point after an altercation with another resident, then stated But we felt she was in a safe place to be taken off. Staff member A stated other things could have been done. The 1:1 observations of resident #15 were not a long-term solution.During an interview on 12/17/25 at 9:59 a.m., NF4 stated, I'm so frustrated with the care (in the memory care unit), they don't have enough help to watch everyone with memory issues. I used to see one person wandering around into other rooms (resident #15), getting into their things or their beds.During an interview on 12/17/25 at 3:33 p.m., staff member B stated the nurses were mistaken when discussing the monitoring and oversight of resident #15, because the 1:1 observation for resident #15 was only supposed to be for three days, after the incident that occurred with resident #20, stating it was . just to get her (resident #15) through the weekend.A review of the resident's physician orders, showed medications to treat the resident's behaviors and pain were attempted, but were not successful, which is why the staff supervision and oversight were important to meet her behavioral, safety, and cognitive needs. These medications included:-Donepezil HCI 10 mg for dementia with agitation. -Melatonin 5 mg for her disturbed sleep cycle. -Tylenol 325 mg for pain (different orders)-Hydrocodone 5/325 scheduled and as needed for pain (different orders).-Oxycodone 5 mg every 6 hours as needed for post-surgical pain. -QUEtiapine Fumerate, which was an antipsychotic medication, 25 mg every 6 hours as needed for agitation. Review of a facility policy, titled, Elopements and Wandering Residents, with an initiation date of 2/25/25, reflected the following: . This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision .3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, . d. Adequate supervision will be provided to help prevent accidents.

Based on interviews and record reviews, the facility failed to provide enough supervision and monitoring of a resident who had a history of falls with injury. The resident resided on the memory care unit, had dementia, and significant cognitive deficits, which hindered her ability to comprehend safety awareness. The resident wandered consistently and had altercations with other residents, and although supervision was in place, it did not meet the resident's safety needs related to her behavior and falls. The resident sustained two major injuries, one was from a known fall, and one was an unknown injury, suspected to be from a fall. The resident's care plan, although it had interventions in place, was not adequate to meet her safety, supervision, and oversight needs related to accidents and hazards, for 1 (#15) of 24 sampled residents. The two major injuries included a compression fracture and a fractured hip, which required surgical repair. Findings include:A review of resident #15's admission Minimum Data Set assessment, with an Assessment Reference Date of 8/13/25, showed the Brief Interview of Mental Status (BIMS) assessment was coded with a score of 00 which was for severe cognitive impairment. The resident displayed inattention and disorganized thinking, which was continuous. The staff stated she had Non-verbal sounds of pain signs or symptoms, for possible pain which was 1 to 2 days of the assessment period. Section J for Falls, showed the coding for falls that occurred before the resident's admission, which included: -Did the resident have a fall at any time in the last month prior to admission/entry or reentry? (J1700A) 1 - Yes, was marked. -Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry? (J1700B) 1- Yes, was marked. -Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry? (J1700C) 1- Yes, was marked. Due to the resident's fall history, a thorough fall care plan for fall prevention on admission, and after, would be beneficial for the resident's safety. A review of resident #15's comprehensive care plan showed: -A problem was initiated on 8/18/25 related to a cognitive decline. The goal included the resident will develop skills to cope with cognitive decline and maintain safety by the review date. This goal, due to the resident's level of cognitive impairment, was not realistic. The interventions showed staff were to cue and reorient her as needed, determine her needs, and ask one question at a time. - A problem was implemented for an ADL decline on 8/12/25, which included the wording, pain in right knee. None of the interventions addressed the pain in the knee; they all pertained to her personal care and or activities of daily living. It was unclear if the pain in the resident's knee hindered her ability to ambulate or move safely. - On 8/18/25, a PAIN care plan was initiated for a surgical incision, arthritis, hip fracture, sleep concerns, agitation, delirium, and day-to-day activities. The goal was not to have an interruption of normal activities due to pain. The goal did not show how pain could disrupt the resident and her daily routine(s), mobility, or safety related to accidents and hazards. -A problem for the resident showed she was having limited physical mobility r/t dementia and (was) forgetful which included a goal that showed the resident would demonstrate the appropriate use of non-skid shoes for ambulation, even though she had severe cognitive deficits. The resident's inability to understand safety risks was documented in several areas of her medical record. -The elopement care plan was initiated on 8/12/25, showing she was identified as an elopement risk on admission. The interventions showed staff were to offer the activities she preferred, but none were listed. It was also identified during the survey that there was a lack of activities in the memory care unit. (Refer to F679 Activities of Interest) On the care plan, it showed staff were to identify her patterns of wandering, if it was purposeful, aimless, or escapist, whether she was looking for something, or she was trying to indicate a need. These patterns were not found to have been developed or identified per the medical record, in an attempt to prevent accidents or hazards. -The behavior care plan showed the resident was aggressive and the first intervention showed staff were to anticipate her needs, such as food, thirst, toileting, comfort, body position, or pain, but the facility did not identify specifics related to these areas, such as when she frequented the bathroom, where her pain was typically located, or how staff could alter it using non medicinal or medicinal interventions. The last intervention, dated 9/8/25, showed she wandered into other resident rooms, which increased her risk of conflicts and or accidents/hazards, but there were no specific interventions added for safety related to this. -On 8/12/25, the facility implemented a FALLS care plan, which showed resident #15 was at risk for falls related to her medications and health conditions, behavior, cognition, and poor hearing. The fall care plan did not address her weakness, confusion, intruding on others' spaces, or poor safety awareness. The care plan did not address the psychological evaluation interventions, such as creating a path for her to wander safely without intruding on others. The goal showed the resident would be free of falls with injury. The interventions showed staff were to anticipate her needs, but did not identify what specific needs needed to be anticipated. Staff were to keep frequently used items in reach, but the plan did not show what her frequently used items were. Staff were to educate the resident/family about safety reminder if a fall occurs, encourage her to wear proper footwear, follow the fall protocol, orient the resident to the call light and keep it in reach, redirect her if using a wheelchair, refer to therapy, and an intervention showed she . sometimes goes on the floor to pickup things she can or can't really see. This behavior was not identified as having actually occurred in the progress notes, but it was created as an intervention after she was found on the floor. During an interview on 12/15/25 at 2:55 p.m., staff member I stated resident #15 wandered all the time when she was awake, and she would frequently upset the other residents. Staff member I stated, I think she fell a few weeks ago, and no one knew her back was hurting, turns out she fractured her back. Staff member I stated, We never knew where she was sometimes, and we're so busy with all the residents here. Staff member I stated that the only interventions on the care plan for resident #15 were to redirect her to her room. Staff member I stated, We didn't know what else to do. Staff member I explained resident #15 also had another altercation where a resident pushed her, and She ended up having hip surgery, and went downhill afterwards.During an interview on 12/15/25 at 3:26 p.m., NF3 stated (resident #15) was healthy when she was admitted to the facility. They called me all the time about incidents with other residents, falls . I think she fell through the cracks because they didn't have enough help to watch her (#15).A review of resident #25's interdisciplinary progress notes, showed:- The resident had a fall on 9/27/25, which was considered a witnessed fall. The witness reported the resident did not hit her head. The nursing note did not show interventions for the direct cause of the fall, such as if it was related to mobility, weakness, or other contributing factors. Nothing was noted about a wheelchair being involved in the progress notes for that fall. It was unclear if the resident had the necessary oversight in place for fall prevention at the time of that fall, as nothing was documented related to her supervision. On 9/28/25, a progress note showed the resident tried to sit in an unlocked wheelchair the day prior and had a fall. -The resident was found on the floor on 10/1/25, as reported by a CNA. The CNA assisted resident #15 up off the floor and brought the resident to the dining room. This occurred prior to the nursing assessment to identify any injuries sustained in the fall. There were no interventions noted for fall prevention in the progress notes. On 10/2/25, the resident was found to have a lump on her right temple of her head, suspected to be from the fall on 10/1/25, which was not identified after she was found on the floor by the CNA. The progress notes showed the close monitoring of the resident was essential as she scared other residents. It was unclear if she had the necessary oversight in place at the time she was found on the floor, as there was nothing in the progress notes related to her activities and oversight prior to the fall.- On 10/4/25, the resident was found on the floor, she had voided a small amount of urine on the floor. Her blanket and mattress were half off the bed. She was picking the nonskid strips off the floor. There were no interventions noted for future fall prevention or identified direct root causes to the resident's actions or why the mattress/blankets were almost off the bed. It was unclear if she had the necessary oversight for fall prevention or if all fall interventions were in place at the time of the fall. Due to the urine being on the floor, it was unclear if the resident had been toileted as needed, or if a toileting plan was considered.- On 10/9/25, five days after the fall on 10/4/25, the interdisciplinary progress note showed the resident willfully places self on the floor, which was documented to address the fall on 10/4/25, but it was an unwitnessed event, and it was unknown how she got on the floor. Due to the resident's cognition she was considered an unreliable reporter. The reasoning and implementation of this intervention was unclear, per the medical record. -On 10/23/25, a psychological evaluation showed the resident had poor impulse control, fragmented sleep, had disorientation, was restless, and needed ongoing staff support. It was noted staff should supervise her walking to channel restlessness and provide a path for her to wander safely as not to interfere with others. It was not evident in the medical record if the facility implemented a supervised walking program for her.-On 11/13/25, the resident voiced pain in her back, this was a newer complaint per the review of the progress notes. Tylenol was given for the pain.On 11/15/25, the resident was wincing while standing, saying, Oh my back, while holding her back, showing it hurt her when she moved. Tylenol was given with good to moderate relief. -On 11/18/25, the CNA reported the resident had pain in her back again, and the notes showed staff questioned if #15 fell and injured her back the week prior. The resident had not had a fall since 10/4/25, per the IDT progress notes. The CNA stated the resident had not been walking as well either. On 11/19/25, the resident was yelping when sitting. The resident was sent for an evaluation and testing of her pain, and an L1 Compression Fracture was identified. The injury was not identified before this or known to be from a fall. As of 11/20/25, the facility was still questioning if the resident had a fall that caused the injury. - On 11/28/25, the resident wandered into a room where two other residents resided. The residents in the room became upset with #15 and a verbal altercation occurred. The resident was coming out the door and was pushed by the resident in the room. She fell and landed on her left hip and back, instantly screaming, I hurt, I hurt. The resident was sent to the emergency room for further evaluation. It was found the resident had a right hip fracture, which required surgical repair. The resident did not have the necessary supervision and oversight of staff to prevent her from going into the room of the other two residents. The nursing note showed the resident was pushed, but the facility's incident report showed the other resident was guiding her out of the room, which was a contradiction of the nursing note. Additional supervision and monitoring were documented as being initiated. The information reported to the State Survey Agency, for the fall and injury, showed, Moments later, both residents attempted to physically guide/push [Resident] out of the room. During this interaction, [Resident] was pushed into the hallway and subsequently lost her balance, falling onto her left side. This again contradicted the event's investigative findings of her being guided out of the room. During an interview on 12/16/25 at 10:52 a.m., staff member H stated resident #15 would wander into all the rooms on the secure memory care unit anytime she was out of bed, then stated, All she did was walk and wander any time she was not sleeping. Staff member H stated, I almost called a Code Pink because we couldn't find her . We never tried using visual cues on her door or other interventions; We just always redirected her to her room, or I would give her a snack in the common room. Staff member H stated, We only got to do 1:1 observation (with resident #15) to monitor her behaviors for two weeks, then it just fell away. Staff member H did not state the 1:1 observations were related to fall prevention, but said, I wish they had given us more staff to help supervise her (resident #15), she needed 1:1, she was super-fast too. During an interview on 12/16/25 at 11:17 a.m., staff member L stated, She (resident #15) wandered constantly from day one. Staff member L stated resident #15 was safer when she had 1:1 observation, so they could keep an eye on her, then stated, It was safer for everyone when we did that. I don't know why it stopped.During an interview on 12/16/25 at 2:06 p.m., NF3 stated, They never knew where she was because they were busy. I didn't know they had her on 1:1 observation after one of the incidents. I think it might have helped them watch her better.During an interview on 12/16/25 at 11:31 a.m., staff member C stated I knew of resident #15's aggressions towards other residents and falls, but (he) did not know she constantly wandered, as he would have added more interventions to the resident's care plan.During an interview on 12/16/25 at 12:11 p.m., staff member B stated, I think we just redirected her . she (resident #15) chose rooms to wander into that didn't like visitors. During an interview on 12/16/25 at 12:42 p.m., staff member A stated resident #15 was on a 1:1 observation at one point after an altercation with another resident, then stated But we felt she was in a safe place to be taken off. Staff member A stated other things could have been done. The 1:1 observations of resident #15 were not a long-term solution. Staff member A stated a wall caddie (not initiated until 11/4/25) and stop signs (not initiated until 12/2/25) were added as interventions to help keep resident #15 safe.During an interview on 12/17/25 at 9:52 a.m., NF1 stated most of the time when visiting, There are only two people working (in the memory care unit), and one is always behind the desk, I don't know how they can keep track of all the dementia residents. I know they had one resident who wandered a lot and would go through everyone's drawers.During an interview on 12/17/25 at 9:59 a.m., NF4 stated, I'm so frustrated with the care (in the memory care unit), they don't have enough help to watch everyone with memory issues. Review of a facility policy, titled, Elopements and Wandering Residents, with an initiation date of 2/25/25, reflected the following: . This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents.3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. d. Adequate supervision will be provided to help prevent accidents.Review of a facility policy, titled Accidents and Supervision, with an implementation date of 4/11/25, reflected the following: . Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents.

Based on observation, interview, and record review, the facility licensed staff member failed to provide necessary services, medically neglecting a resident's care needs, after a significant medication error occurred due to the staff member failing to follow the facility procedures for medication administration, resulting in an Immediate Jeopardy level significant medication error, for 1 (#1) resident of 3 sampled residents for medication errors. The resident had a significant decline in health, was unresponsive, had to be given Narcan, and was sent to the ER and had a hospital stay due to the failures identified. Findings include: On [DATE] at 12:37 p.m., the facility Regional Director of Operations, Administrator, and Director of Nursing was notified an Immediate Jeopardy situation existed for 1 resident (#1) for F726, Competent Nursing Staff. An acceptable plan for the removal of immediacy was provided on [DATE] at 7:32 p.m. The immediacy was removed on [DATE] at 7:45 p.m. The severity and scope of the Immediate Jeopardy was identified at the J level, immediate jeopardy to resident health and safety. Upon removal of the immediacy, the scope and severity is lowered to the level of G, actual harm that is not immediate jeopardy. 1. During an interview on [DATE] at 1:59 p.m., staff member H said she was passing medications on [DATE]. She said she had two residents left, so she decided to put all their medications into cups, prior to going down the hall to give the medications to the residents. She said this allowed her to save time (prepouring the medications). She was getting ready to give one of the residents his medication when resident #1 came up to her and asked for a Tylenol. She said she retrieved the Tylenol from the cart and placed it in the wrong resident's medication cup, and then handed it to resident #1. Resident #1 swallowed the medications. Staff member H said when she turned to the cart to give the other resident his medications, she realized what she had done. She said she gave resident #1 a 10 mg Vicodin and 60 mg OxyContin (both high dose opioids that cause sedation, decreased respiration, and may cause death). Staff member H said she called the provider on call and was told to take the residents vital signs every four hours and to report to the provider if the resident had any changes. Staff member H said she did not look up the side effects of the medication, she did not take baseline vital signs, and she did not put the resident on a continuous oxygen saturation monitor (a monitor to show the effectiveness of respirations). Staff member H said resident #1 was found approximately two hours after she had taken the medications. She took resident #1's vital signs and found the resident was hypotensive (low blood pressure), had a low oxygen saturation level, and was not responsive. Staff member H said she gave resident #1 Narcan, to reverse the effects of the opioid medication, and called 911. She said the ambulance came and took resident #1 to the hospital. Staff member H did not adhere to the facility medication administration policies and procedures, and used a process for administering medications, which was not an acceptable standard of practice. Staff member H did not implement health monitoring for the resident immediately following the significant medication error, and within two hours, the resident was found to have had a significant decline in health status. During a telephone interview on [DATE] at 11:06 a.m., staff member I said she was the provider on call on [DATE]. She said she received a phone call from staff member H stating she accidentally gave resident #1 the wrong medication. Staff member I said she told staff member H to monitor resident #1 for any changes and to send her to the Emergency Department if she showed any changes. Staff member I said she did not tell staff member H to check vital signs every four hours. Staff member I said it would be dangerous not to monitor a resident after being given such a large dose of opioid pain medications. Staff member I said the protocol for monitoring a resident after taking those medications should be vitals every 15 minutes, and she would expect medication action within 30 minutes. She said waiting two hours to take vital signs could have been serious and dangerous for the resident. During an interview and observation on [DATE] at 4:58 p.m., staff member B said she could not find any documented vital signs between 9:38 a.m., when the significant medication error was made, to 11:33 a.m., when resident #1 was taken to the hospital by paramedics. She stated staff member H should have known the resident required continuous monitoring after the significant medication error was made and 4-hour vital signs were not adequate. Staff member B showed a document, titled Nursing Competency Checklist and explained all licensed nursing staff were required to have all of the skills checked off during orientation. She stated staff member B was required to complete the checklist. The checklist showed staff member H was trained that the facility did not allow pre-pouring medications. Review of resident #1's electronic medical record, showed resident #1 was given Vicodin ,d+[DATE] mg and OxyContin 60 mg ER at 9:38 a.m., and resident #1 was found unable to open her eyes, her blood pressure was ,d+[DATE], and her oxygen saturation was 80%. There was no time documented for the resident's vital signs. Narcan 0.4 mg was given at 11:30 a.m. The EMR failed to include documentation of the resident's vital signs, or documentation of her state of consciousness, between 9:38 a.m. and 11:30 a.m., on the morning of [DATE], after the significant medication error occurred. Review of resident #1's ambulance report, dated [DATE], showed the ambulance was notified by dispatch of an unresponsive resident who had been given an unintentional overdose of medication at 9:38 a.m. The unit arrived at the facility at 11:36 a.m. The report showed medications had been given approx. two hours prior to 911 activation . Patient was found in her room unconscious and initial oxygen saturation of 79%. Staff then administered 0.4 mg naloxone into a vein on the patient's right hand . Review of resident #1's hospital EMR, showed resident #1 arrived at the emergency department on [DATE] at 11:58 a.m. Resident #1 was treated for an opioid overdose including continuous oxygen saturation monitoring, and a continuous intravenous Narcan drip. She had one episode of vomiting while wearing her oxygen mask. She was discharged on [DATE] with antibiotics and prednisone for aspiration pneumonia. Review of the OxyContin package insert showed, OxyContin 60 mg, 80 mg, and 160 mg tablets, or single dose greater that 40 mg, ARE FOR USE IN OPIOD-TOLERANT PATIENTS ONLY. A single dose greater than 40 mg, or total daily doses greater than 80 mg, may cause fatal respiratory depression when administered to patients who are not tolerant to the respiratory depressant effects of opioids. Patients should be instructed against use by individuals other than the patient for whom it was prescribed, as such inappropriate use may have severe medical consequences, including death. Review of a file provided by the facility, included documentation for the [DATE] significant medication error, which contained a corrective action form for disciplinary action given to staff member H for giving the wrong resident MS ER 60 mg and Norco ,d+[DATE] mg. Review of a facility policy titled Administering Medications, dated [DATE], showed: Policy Interpretation and Implementation .9. The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: a. checking identification band; b. checking photograph attached to medical record; and c. If necessary, verifying resident identification with other facility personnel. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . Review of a facility document titled Nursing Competency Checklist, not dated, showed No pre-pouring medications. Review of a facility policy titled, Adverse Consequences and Medication Errors, Revised February 2023, showed, .4. Monitor the resident for medication-related adverse consequences when there is a (an): . f. Medication error, e.g., wrong or expired medication. 5. In the event of a significant medication - related error or adverse consequence, take action, as necessary, to protect the resident's safety and welfare .

Based on interview and record review the facility failed to keep 2 (#s 1 and 3) residents free from significant medication errors, of 3 sampled residents for medication errors. This deficiency resulted in an Immediate Jeopardy level deficiency for 1 (#1) resident, and interventions included medication, emergency medical care, and hospitalization , and the deficiency had the potential to cause life threatening side effects for resident #3. Findings include: On [DATE] at 12:37 p.m., the facility Regional Director of Operations, Administrator, and Director of Nursing was notified an Immediate Jeopardy situation existed for 1 (#1) resident for F726 - Residents Free from Significant Medication Errors. An acceptable plan for the removal of immediacy was provided on [DATE] at 7:32 p.m. The Immediacy was removed on [DATE] at 7:45 p.m. The scope and severity of the Immediate Jeopardy was identified to be at the level of J, Immediate Jeopardy to Health and Safety, and upon removal of the immediacy, the scope and severity was lowered to the level of G, Actual Harm that is not Immediate Jeopardy. 1. During an interview on [DATE] at 1:59 p.m., staff member H said she was passing medications on [DATE]. She said she had two residents left so she decided to put all their medications into cups prior to going down the hall to give the medications to the residents (this was pre-pouring the medications). She said this allowed her to save time. She was getting ready to give one of the residents his medication when resident #1 came up to her and asked for a Tylenol. She said she retrieved the Tylenol from the cart, placed it (unknowingly) in the wrong resident's medication cup, and handed it to resident #1, who then swallowed the medications. Staff member H said when she turned to the cart to give the other resident his medications, she realized what she had done. She said she gave resident #1 a 10 mg Vicodin and 60 mg OxyContin (high dose opioid medications that cause sedation, decreased respiration, and may cause death). Staff member H said she called the provider on call and was told to take the residents vital signs every four hours and to report to the provider if the resident had any changes. Staff member H said she did not look up the side effects of the medication, she did not take baseline vital signs, and she did not put the resident on a continuous oxygen saturation monitor (a monitor to show the effectiveness of respirations). Staff member H said resident #1 was found, approximately two hours after she had taken the medications and took resident #1's vital signs and found the resident was hypotensive (had low blood pressure), had low oxygen saturation levels and was not responsive. Staff member H said she gave resident #1 Narcan to reverse the effects of the opioid medication, and called 911. She said the ambulance came and took resident #1 to the hospital. During a telephone interview on [DATE] at 11:06 a.m., staff member I said she was the provider on call on [DATE]. She said she received a phone call from staff member H stating she accidentally gave resident #1 the wrong medication. Staff member I said she told staff member H to monitor resident #1 for any changes and to send her to the Emergency Department if she showed any changes. Staff member I said she did not tell staff member H to check vital signs every four hours. Staff member I said it would be dangerous not to monitor a resident after being given such a large dose of opioid pain medications. Staff member I said the protocol for monitoring a resident after taking those medications should be to check vitals every 15 minutes. Staff member I said for those medications she would expect medication action within 30 minutes. She said waiting two hours to take vital signs could have been very serious and a danger to the resident. Review of resident #1's electronic medical record, showed resident #1 was given Vicodin ,d+[DATE] mg and OxyContin 60 mg ER at 9:38 a.m. Resident #1 was found unable to open her eyes, her blood pressure was ,d+[DATE] and her oxygen saturations were 80%, and there was no time documented for the vital signs taken. Narcan 0.4 mg was given at 11:30 a.m. The EMR failed to show documentation of vital signs, or documentation of her state of consciousness for resident #1, between 9:38 a.m. and 11:30 a.m., on the morning of [DATE]. Review of resident #1's ambulance report from [DATE] showed, the ambulance was notified by dispatch of an unresponsive resident who had been given an unintentional overdose of medication at 9:38 a.m., the unit arrived at the facility at 11:36 a.m. The report showed, on arrival we are met at the door by staff member and directed to the patient's room. Find the patient seated in a wheelchair in the room. Staff members have placed her on oxygen at 15 liter per minute via nasal canula. Patient is barely conscious but is arousable . Medications had been given approx. 2 hours prior to 911 activation. Patient was found in her room unconscious and initial oxygen saturation of 79%. Staff then administered 0.4 mg naloxone into a vein on the patient's right hand . Review of resident #1's hospital EMR, showed resident #1 arrived at the emergency department on [DATE] at 11:58 a.m. Resident #1 was treated for opioid overdose including continuous oxygen saturation monitoring and a continuous intravenous Narcan drip. She had one episode of vomiting while wearing her oxygen mask. She was discharged on [DATE] with antibiotics and prednisone for aspiration pneumonia. Review of the OxyContin package insert showed, OxyContin 60 mg, 80 mg, and 160 mg tablets, or single dose greater that 40 mg, ARE FOR USE IN OPIOD-TOLERANT PATIENTS ONLY. A single dose greater than 40 mg, or total daily doses greater than 80 mg, may cause fatal respiratory depression when administered to patients who are not tolerant to the respiratory depressant effects of opioids. Patients should be instructed against use by individuals other than the patient for whom it was prescribed, as such inappropriate use may have severe medical consequences, including death. Review of a facility policy titled Administering Medications, dated [DATE], showed: Policy Interpretation and Implementation .9. The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: a. checking identification band; b. checking photograph attached to medical record; and c. If necessary, verifying resident identification with other facility personnel. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . Review of a facility document titled Nursing Competency Checklist, not dated, showed, No pre-pouring medications. Review of a facility policy titled, Adverse Consequences and Medication Errors, Revised February 2023, showed: . 4. Monitor the resident for medication-related adverse consequences when there is a (an): . f. Medication error, e.g., wrong or expired medication. 5. In the event of a significant medication-related error or adverse consequence, take action, as necessary, to protect the resident's safety and welfare . 2. Review of resident #3's EMR revealed an Incident Note dated [DATE], which showed, Order dated ,d+[DATE] from Urology appt was entered incorrectly and resident received incorrect dose of Trospium. Provider notified, Contact [name] notified, and resident notified. No ill effects noted, and resident denies any side effects. Nurse educated. Review of Resident #3's medication administration record, showed on [DATE], a physician's order was placed for Trospium Chloride 20 mg BID (twice a day), then on [DATE] that order was discontinued, and a new order was placed for Trospium Chloride 20 mg, give 60 mg four times a day. On [DATE], that order was discontinued, and a new order was placed for Trospium Chloride ER 60 mg once daily. Resident #3 was given 80 mg of Trospium Chloride for 7 days, and 80 mg is double the recommended dose for Trospium. During a telephone interview on [DATE] at 3:37 p.m., staff member J said she was aware of a medication error for resident #3. She said two nurses are required for putting orders into the electronic medical record. She said the first nurse puts the order into the electronic medical record, and another nurse is required to double check the order was put in the system correctly. She said staff member O put an order in the EMR for Trospium for resident #3, on [DATE]. Staff member J said she was the nurse who double checked the order in the EMR. She said she was going through a lot of orders that night, and she said she misread the order. She stated, I should have been more careful. She said the order was hard to read, and so she thought QD (every day) was written QID (four times a day). She said that was how it was ordered in the computer, so she completed the order in the system. She said the pharmacy discovered the mistake several days later. Staff member O was not available for interview during the survey. Review of a medication error report for resident #3, dated [DATE], showed, resident #3 was given the wrong dosage of Trospium. The form showed the wrong dosage was entered into the EMR for resident #3, on [DATE]. Review of a Physician Office Visit note for resident #3, dated [DATE], showed, Physician Notes/Orders: Please continue Trospium, will increase to 60 mg QD if not on formulary may use 20 mg BID.

Based on observation, interview, and record review, the facility failed to protect 1 (#1) resident from neglect of medical care by a staff member, when the licensed staff member provided incorrect medications, which was a significant medication error, then failed to properly monitor the resident after the error, and the resident then had a decrease in cognition and change in vital signs. When the decline was identified, the resident had to be given additional medication and was sent to the emergency room and had a hospital stay; the facility also failed to protect two (#s 5 and 7) residents on the memory care unit from having sexual contact without having prior assessment for their ability to consent to sexual contact; and, failed to protect 1 (#10) resident from a resident to resident abuse event which resulted in a resident fall. There were 11 residents in the sample for this investigation. Findings include: 1. During an interview on 8/27/24 at 1:59 p.m., staff member H said she gave resident #1 a 10 mg Vicodin and 60 mg OxyContin (High dose of opioid medications that cause sedation, decreased respirations, and may cause death). This was a significant medication error, as she gave the medication to resident #1, and the resident did not have an order for the medication. Staff member H said she called the provider (physician) on call; and was told to take the resident's (#1) vital signs every 4 hours, and then report to the provider if the resident had any changes. Staff member H said she did not take baseline vital signs on the resident, and she did not put the resident on a continuous oxygen saturation monitor (a monitor to show the effectiveness of respirations) after the error. Staff member H said approximately two hours after she had given the medications to the resident she took resident #1's vital signs and found the resident was hypotensive (low blood pressure), had low oxygen saturation levels, and was not responsive. Staff member H said she gave resident #1 Narcan to reverse the effects of the opioid medication, and then called 911. During a telephone interview on 8/28/24 at 11:06 a.m., staff member I said she received a phone call from staff member H stating she accidentally gave resident #1 the wrong medication. Staff member I said she told staff member H to monitor resident #1 for any changes and to send her (#1) to the Emergency Department if she showed any changes. She said waiting two hours to take vital signs could have been very serious, and a danger for the resident. Review of resident #1's electronic medical record, showed resident #1 was given Vicodin 10/325 mg and OxyContin 60 mg ER at 9:38 a.m. Resident #1 was found unable to open her eyes, her blood pressure was 84/54, and her oxygen saturation 80%. There was no time documented for the vital signs, then Narcan 0.4 mg was given at 11:30 a.m. The EMR failed to show documentation of her vital signs, or documentation of her state of consciousness, between 9:38 a.m. and 11:30 a.m., on the morning of 7/27/24. Review of resident #1's ambulance report, dated 7/27/24, showed the ambulance was notified by dispatch of an unresponsive resident who had been given an unintentional overdose of medication at 9:38 a.m. The unit arrived at the facility at 11:36 a.m. The report showed, . Patient is barely conscious but is arousable . Medications had been given approx. 2 hours prior to 911 activation. Patient was found in her room unconscious and initial oxygen saturation of 79%. Staff then administered 0.4 mg naloxone into a vein on the patient's right hand . [sic]. Review of resident #1's hospital EMR, showed resident #1 arrived at the emergency department on 7/27/24 at 11:58 a.m. Resident #1 was treated for opioid overdose including continuous oxygen saturation monitoring, and a continuous intravenous Narcan drip. She had one episode of vomiting while wearing her oxygen mask. She was discharged from the hospital on 7/29/24, with antibiotics and prednisone, for aspiration pneumonia. Review of a facility policy titled, Adverse Consequences and Medication Errors, Revised February 2023, showed: 5. In the event of a significant medication-related error or adverse consequence, take action, as necessary, to protect the resident's safety and welfare . Review of a facility policy titled, Abuse Prevention Plan-Montana Policy, not dated, showed: Abuse Prohibition 1. All residents have the right to be free of abuse, neglect . .7. Neglect . d. The absence of or likelihood of absence of care or services necessary to maintain the physical and mental health of the resident and which a reasonable person would deem essential to obtain or maintain the Resident's health, safety and comfort . e. Neglect of goods or services may occur when staff are aware, or should be aware, of a resident's care needs . .h. Not providing supervision and/or monitoring of the delivery and implementation of care and/or environment . Further Examples of Abuse .2. Medical Neglect .d. Failure to monitor for adverse drug reactions . 2. During an interview on 8/27/24 at 1:12 p.m., staff member F said he was working on the memory care unit on 8/19/24. He and another staff member noticed residents #5 and #7 were getting pretty close. He said they (staff) were watching them more closely because the residents would go into each other's rooms. He said he became concerned when he noticed resident #5 went into resident #7's room, and they had not been seen for a while. He said he went to check on them, and he found resident #7's door was closed. He said he knocked on the door, opened it, and found resident #5 and resident #7 naked in the bed. Staff member F said it looked like they were having sex. He said he didn't know what to do at first. He said he and another staff member separated the residents, and as he was getting resident #5 dressed, the resident told he would sure like to do that again, and that it made him feel like a man. Staff member F said he did not ask resident #5 what that meant because he felt it was pretty clear. Staff member F said resident #5 seems to be more interested in the female residents since the incident on 8/19/24. Staff member F said he did not know if either resident was assessed for their ability to consent to sexual contact. During an interview on 8/27/24 at 1:28 p.m., staff member B said resident #5 and resident #7 were found naked in resident #7's bed. She said they moved resident #5 out of memory care and onto a different hall because she felt the female residents in that hall have more capability to make a decision. Staff member B said she did not know if anyone had done an assessment on either resident to determine if they were capable of consenting to sexual behavior, but she said it was the responsibility of the Social Service Department to fill those out. During a telephone interview on 8/28/24 at 5:23 p.m., staff member M said she was with staff member F when they found residents #5 and #7 in bed naked together. She said she knew the residents were in the room together, so she had staff member F go with her to check on them. She said after they saw the two residents were naked, and it looked like they were having sex, they shut to door and notified the nurse. She said the nurse called the manager on call, and they were told to separate the residents. She said they went back in, got the two residents out of bed, and separated them. She said she did not ask either resident what was happening or what occurred between them. Staff member M said resident #7 was in memory care because she was an exit seeker. She said resident #7 could carry on a conversation and was confused sometimes, but she did not know if resident #7 was capable of consenting to sexual contact. Staff member M said resident #5 was frequently confused, and he would forget he had difficulty standing, he would forget he was married, and she did not know if he had been assessed for his ability to consent to sexual contact. During an interview on 8/27/24 at 12:59 p.m., staff member L said she heard about resident #5 and #7 being found in bed naked together. She said she did not know if either resident had been assessed for their ability to consent to sexual contact. She said she thought that would be a nursing duty. She said it was possible it was her responsibility, but she had not been instructed to do that type of assessment on resident #5 or resident #7. Staff member L said she did speak with resident #5's significant other, and she was told the significant other did not think resident #5 could have sex. During an observation and interview on 8/27/24 at 2:25 p.m., resident #7 was sitting at a table with a male resident. She was telling him about a family with a child, and she was repeating herself frequently. The story she was telling did not seem to follow a timeline, and it was difficult to understand if what she was talking about was something that happened, or if it was fictional. The male resident was looking down and not participating in the conversation. Staff member N said resident #7 was in memory care because she couldn't remember anything and because she would frequently try to escape from the facility. Staff member N said resident #7 would frequently share stories about her past, but she was unsure if what resident #7 was talking about during the observation, was something from resident #7's past. Review of resident #5's EMR, showed resident #5 had a diagnosis of unspecified dementia. He had a BIMS (Brief Interview for Mental Status) on 7/9/24 of 9 reflecting moderate impairment, and a previous BIMS of 4, reflecting severe impairment. Resident #5's care plan showed his wife (who is the POA) aids with all decision-making. A Care Plan note, dated 8/19/24, showed, Resident has now moved from memory care unit to C-hall due to inappropriate sexual conduct with another resident on 8/19/24. However, today after lunch this nurse overheard another resident talk about how this resident was expressing his interest with her in having a sexual relationship. Will continue to monitor resident's location. The EMR lacked an assessment for ability to consent to sexual contact, and lacked documentation in the chart describing the incident of sexual contact,with resident #7, on 8/19/24. Review of resident #7's EMR, showed resident #7 had a diagnosis of Frontotemporal Neurocognitive Disorder, Oppositional Defiant Disorder, and Unspecified Dementia. Resident #7 had a BIMS of 12, reflecting moderate cognitive impairment, on 7/25/24. An admission progress note, dated 8/1/24, showed [Resident Name] has been living with family; however her dementia has progressed to the point where she is a danger to herself and family caregivers. The EMR lacked an assessment for the resident's ability to consent to sexual contact, and lacked documentation in the chart describing the incident of sexual contact with the other resident on 8/19/24. Review of a facility policy, titled, Abuse Prevention Plan-Montana Policy, not dated, showed: Abuse Prohibition 1. All residents have the right to be free of abuse, neglect, involuntary seclusion, exploitation, misappropriation of funds/property and mistreatment/maltreatment. 2. The intent of this policy is to provide a safe living environment to all residents of the facility ad to provide guidelines for investigating and reporting of suspected maltreatment. Definitions 1. Vulnerable Adult a. A vulnerable adult means any resident receiving services from this facility who may be unable to report maltreatment without assistance due to physical or mental impairment . 12. Criminal Sexual Abuse a. Per Affordable Care Act: Serious bodily injury/harm shall be considered to have occurred if the conduct causing the injury is relating to aggravated sexual abuse or any similar offense under State law. . c. Serious bodily injury also includes sexual intercourse with a resident who is incapable of declining to participate in the sexual act or lacks the ability to understand the nature of the sexual act . 17. Abuse .b. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary obtain or maintain physical, mental and psychosocial well-being . . 2. Sexual Abuse . b. Generally, sexual contact is nonconsensual if the resident either: . i. Appears to want the contact to occur but lacks the cognitive ability to consent . c. Other examples of nonconsensual sexual contact may include, but are not limited to: .vii. Anytime the facility has reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility will ensure the resident is evaluated/assessed for capacity to consent by the Clinician, legal representative and/or appropriate family members, resident, facility staff, and if needed, a psychologist/psychiatric representative. viii. The review will include an evaluation of the resident's DX, BIMs, observations of past and present behaviors/actions, and fluctuations in lucidity. ix. Results of this evaluation will be kept in the resident's chart. Residents without the capacity to consent to sexual activity may not engage in sexual activity. 3. During an interview on 8/27/24 at 12:55 p.m., staff member K said she was not working the day resident #10 was found in resident #11's room on the floor. Staff member K said the memory care unit was a locked unit, and the staff tried to keep residents that wandered from going into other resident's rooms, but she said it still happened frequently. Staff member K said resident #11 was moved out of the memory care unit because she does not like it when residents wander into her room. During an interview on 8/27/24 at 1:22 p.m., staff member F said he works in the memory care unit, sometimes. He stated resident #10 only speaks Russian, so he uses Google Translate to help him communicate with her. He said she frequently wanders and will go into other resident's rooms. Staff member F said the staff try to keep residents out of other resident's rooms because some of the residents will get upset. He stated it is hard to keep residents out of other rooms when the residents on the memory care unit tend to wander without purpose. Review of resident #10's EMR, included an incident note dated 6/29/24, which showed resident #10 was found on the floor in resident #11's room. Resident #11 stated she was trying to get resident #10 out of her room, so she pushed her and resident #10 fell . The EMR showed resident #10 had diagnoses of Repeated Falls, Muscle Weakness, Altered Mental Status, Alzheimer's disease, and Dementia. Review of resident #11's Care Plan, showed on 7/1/24, an intervention was placed reflecting, Please redirect wandering residents away from her personal space. Move off memory care for less interaction with wandering residents. Review of an incident report provided by the facility, showed on 6/29/24, resident #10 wandered into resident #11's room. The Nursing description of the event included, [Resident #11 name] attempted to get resident (#10) out of room causing the other resident (#10) to fall to the floor. The Resident description of the event included, Stated she (#11) was trying to her (#10) out of her (#11) room and pushed her (#10). Review of a facility policy titled, Abuse Prevention Plan-Montana Policy, not dated, showed: Abuse Prohibition 1. All residents have the right to be free of abuse, neglect, involuntary seclusion, exploitation, misappropriation of funds/property and mistreatment/maltreatment. 2. The intent of this policy is to provide a safe living environment to all residents of the facility ad to provide guidelines for investigating and reporting of suspected maltreatment. .6. Abuse .c. Hitting, slapping, kicking, biting, scratching, pushing, pinching or any other corporal punishment .

Based on interview and record review, the facility failed to protect 2 (#s 9 and 10) residents from accidents and hazards. Resident #9 sustained eight falls within 17 days, she was sent to the hospital for five of the falls, and had significant injuries for two of the falls. Resident #10 was pushed by another resident and fell to the floor, putting her at risk for injury, due to her wandering, of 11 sampled residents. Findings include: 1. Review of resident #9's EMR, showed resident #9 was admitted to the facility on [DATE]. Resident #9's medical record showed: - An alert note documented on 6/23/24 at 12:42 p.m., showed resident #9 was impulsive, forgetful, and was a fall risk. - An Incident note on 6/23/24 at 7:47 p.m., showed resident #9 was found on the floor of her room at 2:00 p.m. - An incident report on 6/23/24 at 7:49 p.m. showed resident #9 was found in her room on the floor, the note showed resident #9 was confused, she was returned to her bed, and given pain medication for low back pain. Resident #9 said she may have hit her head. - An alert note written on 6/26/24 at 7:00 p.m., showed resident #9 was sent to the emergency department for a head laceration after she fell . - An incident note on 6/27/24 at 7:22 a.m. showed resident #9 was found on the floor in her room, bleeding from her head. The note showed resident #9 had a history of falls, was encouraged to call for assistance, and had a sign posted in her room reminding her to call for assistance, at the time of her fall. Resident #9 was transported to the ER. - An event note dated 6/27/24 at 11:01 a.m., showed resident #9 had an unwitnessed fall. The note showed her care plan was updated, and the new intervention included putting resident #9 at the assisted table in the dining room. - An incident note on 7/7/24 at 4:33 a.m. resident #9 was found on the floor in her wheelchair with blood on the ground. She had a laceration on the back of her head. Resident #9 was sent to the hospital. - An event note documented on 7/9/24 at 11:45 a.m., showed resident #9 fell in the dining room. Her table-mates said she was sitting in her wheelchair, she got up and started to walk, and fell on the floor. The note showed her care plan was updated. - An event note written on 7/9/24 at 12:22 p.m. showed resident #9 had an unwitnessed fall in her room. The note showed her care plan was updated and the resident would have a fall mat and seat belt for her wheelchair. Resident #9's care plan showed, The resident is at risk for falls r/t diagnosis of dementia, history of repeated falls, diagnosis of muscle weakness, unsteadiness, confusion, and underlying dementia; initiated on 6/20/24. The interventions were updated on 6/27/24, 7/1/24, 7/9/24, and 7/10/24. Review of #9's emergency department notes showed: - On 7/6/24, resident #9 was seen for a traumatic subarachnoid hemorrhage after she fell . - A CT of resident #9's thoracic spine, dated 7/6/24, showed an acute compression fracture of L1, and a probable acute compression fracture of T9. - An ER note dated 7/9/24 showed her head CT showed a new small subarachnoid hemorrhage, new intraventricular hemorrhage, chronic subdural hematoma from three days prior, and a new frontotemporal scalp hematoma. - The EMR lacked an ER note from 6/26/24, 6/27/24, and 7/7/24. Review of a facility document, titled Read and Sign Education, dated 7/10/24, showed resident #9 was an extreme fall risk. Resident #9 had L1 and T9 compression fractures, and the document included ten interventions to decrease falls for resident #9. The instructions showed staff were to sign the form after reading it. There were no staff signatures on the document. During an interview on 8/27/24 at 1:25 p.m. staff member F said resident #9 . wasn't even supposed to be walking and sometimes she would just stand up and down she would go. You know, people don't want their independence taken away. Staff member F said residents fall when staffing is good, and they fall when staffing is low. Staff member F said he had been a CNA for a long time, so he could just tell when people where a high fall risk, which was by the way they move. Staff member F said staff would get a report when someone is a high fall risk and administration would put notes on the resident's charts, and he said fall risk was put on the report sheets. He said he did not know how to look at the resident's care plan or where to find it. Staff member F said he did not know when there were changes to the care plan, or how fall risk would be communicated unless it was on the report sheets. During an interview on 8/28/24 at 4:47 p.m., staff member B said resident #9's falls where not listed on the fall log provided to surveyor because she only included residents currently in the facility, and resident #9 had been discharged . 2. During an interview on 8/27/24 at 12:55 p.m., staff member K said she was not working the day resident #10 was found in resident #11's room, on the floor. Staff member K said the memory care unit was a locked unit, and the staff try to keep residents that wander from going into other resident's rooms, but she said it still happens frequently. Staff member K said resident #11 was moved out of the memory care unit because she does not like it when residents wander into her room. During an interview on 8/27/24 at 1:22 p.m., staff member F said he works on the memory care unit sometimes. He stated resident #10 only speaks Russian, so he uses Google Translate to help him communicate with her. He said she frequently wanders and will go into other resident's rooms. Staff member F said the staff try to keep residents out of other resident's rooms because some of the residents will get upset. He stated it is hard to keep residents out of other rooms when the residents on the memory care unit tend to wander without purpose. Review of resident #10's EMR included an incident note, dated 6/29/24, which showed resident #10 was found on the floor in resident #11's room. Resident #11 stated she was trying to get resident #10 out of her room, so she pushed her and resident #10 fell . It was noted resident #10 was wearing fuzzy socks. The EMR showed, resident #10 had diagnoses of Repeated Falls, Muscle Weakness, Altered Mental Status, Alzheimer's disease, and Dementia. Resident #10's care plan showed a focus area for risk of falls related to Alzheimer's, inability to communicate her needs, weakness, decreased mobility, unsteadiness on feet, previous fall history, psychotropic medication use, and history of wandering behaviors, initiated on 5/23/24. Interventions included the resident wearing appropriate footwear, initiated on 6/29/24, and staff to attempt to redirect resident #10 if she wanders into another residents room, was initiated on 7/1/24. Review of resident #11's Care Plan showed, on 7/1/24, an intervention was placed reflecting, Please redirect wandering residents away from her personal space. Move off memory care for less interaction with wandering residents. Review of an incident report provided by the facility, showed on 6/29/24, resident #10 wandered into resident #11's room. The Nursing description of the event included, [Resident #11 name] attempted to get resident (#10) out of room causing the other resident (#10) to fall to the floor. The Resident description of the event included, Stated she (#11) was trying to her (#10) out of her (#11s) room and pushed her (#10).

Based on interview and record review the facility failed to provide an environment safe from accidents and hazards, and anticipate and assess the residents needs related to fall prevention, for 1 (#4) of 4 sampled residents, and the resident had a history of falls with significant injury. This deficiency resulted in resident #4 having an unwitnessed fall, with a significant injury, resulting in the resident requiring an additional hospital visit and surgery. Findings include: Review of resident #4's EMR progress notes, as of 10/2/23, showed: - 8/23/23 at 7:07 p.m., the resident was being admitted to the facility after having sustained a fall at home that caused a right femur fracture. The resident needed assistance getting to the bathroom but was continent of bowel and bladder. The resident was too weak to ambulate independently. The resident was in stable condition at the time of admission. - An unwitnessed fall report, dated 8/24/23 at 3:00 a.m., showed the nurse was at the nursing station and heard someone yell out for help. The resident was found sitting on the floor at the end of his bed. - An SBAR note, dated 8/24/23 at 6:35 a.m., showed the resident had an unwitnessed fall. He had a history of falls at home, and the resident was unable to walk unassisted. - A progress note, dated 8/24/23 at 7:05 p.m., showed the resident was sent to the emergency department via ambulance. - A progress note, dated 8/24/23 at 11:23 p.m., showed the resident was admitted to a local hospital for a hip fracture. The EMR did not show the resident was oriented to the call light, did not show a baseline care plan had been initiated/entered, and there was no fall assessment entered into the EHR. Review of resident #4's Hospitalist History and Physical, from the local hospital, dated 8/24/23, showed, Patient is an [AGE] year-old male . who presents to the emergency room for evaluation of a fall and subsequent left hip pain . Patient was discharged yesterday to [facility name] where he suffered an unwitnessed fall. Patient is unable unfortunately to provide any significant history . of events, though patient's wife and son were present at bedside report they were called at approximately 2:30 (a.m.) in the morning state that he was found on the ground out of bed presumably fell out of bed unwitnessed. Since that time, he has been complaining of ongoing left hip pain. Review of a facility provided document, titled 5 Why's Root Cause Analysis Tool Template, not dated, showed, resident #4 had an unwitnessed fall. Resident #4 was in the facility less than 24 hours, he was 50% weight bearing after having a right femur surgery, he was reaching for his shoes, and he had to go to the bathroom. Review of a facility provided document, titled Reportable Incident, dated 8/30/23, showed, Resident (#4) found on floor sitting on the floor at the end of the bed. Resident stated he was trying to get to his shoes to go to the bathroom. Resident was unable to understand that he is unable to walk unassisted. Resident was oriented to self only at the time of the fall . Resident was a new admit, under 24 hours, prior to fall. At time of fall resident did not complain of any pain or discomfort. Resident was sent to the hospital the next day for other medical reasons and at that time discovered the fracture and was surgically repaired. Resident was discharged from the to home on hospice due to other medical issues. During an interview on 10/12/23 at 10:52 a.m., staff member B said the facility MDS coordinator usually does the initial care plans. She said the facility needs something to go by so the nurses and CNAs know the resident's needs, and a fall risk would be important to enter in the care plan. During an interview on 10/12/23 at 10:53 a.m., staff member B said resident #4 eventually passed away but she did not know when. During an interview on 10/12/23 at 10:59 a.m. staff member F said the initial care plan should be done within the first 48 hours. When the resident comes in from the hospital, the floor nurse would do the first assessments. Staff member F stated, We have 12 hours to do the initial assessments, and then 48 for the care plan. Usually, we have an idea of what their transfer status is from getting report from the hospital. We can gauge their needs a little bit then. Part of the admission assessment is range of motion, and the fall risk assessment is done then as well. The expectation would be that the night shift nurse would complete the assessments the day shift nurse couldn't get to. The nurse would be expected to pass on any transfer needs to the CNAs. We generally orient the resident to the call light right away. It should be documented in the admission progress note, but it isn't required. During an interview on 10/11/23 at 12:30 p.m., staff member A stated, We don't even look at Care Plans anymore, we only make them for you guys (surveyors). We use other ways of passing on the information that would be on the care plan for taking care of the residents now.

Based on observations, interview, and record review, the facility staff member failed to follow accepted standards of safety when using a mechanical lift for a resident transfer, for 1 (#12) of 5 sampled residents. The deficient practice resulted in a left hip fracture for resident #12. Findings include: 1. Review of a Facility Reported Incident, submitted to the State Survey Agency, dated 2/10/23, showed resident #12, . fell out of lift and sustained a left hip fracture that required surgical repair. [sic] During an interview on 6/7/23 at 2:37 p.m., staff member J stated she was in the process of getting resident #12 from the bed to her wheelchair. Staff member J stated she had been trained on the use of mechanical lifts, and knew she was supposed to have another staff member assist her when using the mechanical sling lift for resident transfers. The staff member stated, she did not try to find someone to help her, and made a foolish decision when she attempted to transfer resident #12 from her bed to her wheelchair, when the lift accident occurred, and resident #12 was injured. Review of the facility's policy titled, Mechanical Lift Policy Including Sit-to-Stand and Full Lifts, dated 12/22, showed, Mechanical lifts must be operated by at least two trained staff members (certified nursing assistants, licensed nurses, or other approved team members). One designated as the lift operator and one designated to maintain physical contact with the resident during the transfer process. Refer to F689 - Free of Accident Hazards for additional information regarding resident #12's fall.

Based on observation, interview, and record review, the facility failed to ensure safe operation of a mechanical lift resulting in a fall with major injury for 1 (#10) of 1 sampled resident; failed to prevent a fall out of bed with a fracture for 1 (#1) of 2 sampled residents; and failed to ensure door alarms were armed and outside gates were locked adjacent to the secure memory care unit, resulting in a resident elopement for 1 (#9) of 1 sampled resident. Findings include: 1. Review of a Facility Reported Incident, dated 2/10/23, showed resident #10 experienced a fall from a mechanical lift, resulting in a left hip fracture requiring surgical repair. Review of the investigative file for resident #10's fall, which occurred on 2/10/23, showed staff member J was attempting to transfer resident #10 from her bed to her wheelchair. Staff member J's handwritten statement, dated 2/13/23, showed she was trying to get the resident lined up over her wheelchair when the mechanical lift began to tip over. Staff member J was positioned on one side of resident #10's wheelchair, and the mechanical lift was positioned on the other side of the resident's wheelchair. While pulling the sling, with resident #10 in it, the mechanical lift tipped over, and staff member J was not able to prevent the resident from landing on the floor. During an interview on 6/7/23 at 2:37 p.m., staff member J stated she had been trained on the use of mechanical lifts, and knew she was supposed to have another staff member assist her when using the mechanical sling lift for resident transfers. Staff member J confirmed she had acted as documented on her handwritten statement. The staff member stated she was in a time crunch and did not try to find someone to help her with the transfer. Staff member J stated she made a foolish decision when she attempted to transfer resident #10 from her bed to her wheelchair. 2. Review of a facility reported incident, submitted to the State Survey Agency, dated 5/23/23, showed resident #1 fell out of bed during care, and sustained a femur fracture. NF2 stated she was providing care, and resident #1 was too close to the edge of the bed. NF2 blamed the resident for falling out of bed. The report showed social services was to monitor the resident for anxiety after the fall. During an observation and interview on 6/6/23 at 9:23 a.m., resident #1 was not able to participate in her bed mobility. Staff member H stated resident #1 had really gone down hill (declined in health) since her fall. The resident was wearing a right knee immobilizer and voicing pain. Review of resident #1's Fall Scene Investigation report, dated 5/20/23, showed the root cause was the amount of assistance in effect, and CNA did not get assistance. Review of resident #1's social service note, dated 5/21/23, showed resident #1 was refusing to be turned and refusing cares. The resident voiced she was afraid she would fall out of bed with turning. No other social service visits for monitoring resident #1's mood were documented. During an interview on 6/7/23 at 2:50 p.m., staff member D stated her monitoring for resident #1 consisted of implementing two person care, and a fall mat for the resident. 3. Review of a Facility Reported Incident, dated 3/26/23, showed resident #9, a resident residing on the secure memory care unit, was found outside of the facility by a staff member. The findings, submitted to the State Survey Agency, on 3/31/23, showed the alarm on the facility's exit door, located in the day room of the memory care unit, which led to the outside patio, was not on and alarmed as it should have been. The findings showed while staff were away from the day room, resident #9 went out the exit door and through a gate which led to a back parking lot. During an interview on 6/7/23 at 8:11 a.m., staff member M stated the alarm on the exit door to the patio should be on at all times. Staff member M stated the only time the alarm was off was when staff were supervising residents, from the memory care unit, outside on the patio. During an interview on 6/7/23 at 1:45 p.m., staff member C stated she was responsible for investigating the incident involving resident #9's elopement. Staff member C stated she believed the back gate may have been damaged during winter snow removal. Staff member C stated she believed the damaged gate was the reason resident #9 was able to get to the back parking lot. Review of a work order, dated 3/27/23, showed the gate outside the memory care unit was found to be broken and was unable to lock on 3/24/23 (the elopement occurred on 3/26/23). The gate was documented as fixed on 3/27/23.

Based on interview and record review, the facility failed to ensure a physician was available to supervise the medical care of a resident when their attending physician was unavailable for 1 (#5) of 1 sampled resident. This deficient practice resulted in a delay in treatment for the resident's urinary tract infection. Findings include: Review of the facility report titled, Admission/Discharge To/From Report, dated from 1/1/23 to 6/6/23, showed resident #5 was admitted to the local acute care facility on 3/21/23, and readmitted back to the long-term care facility on 4/5/23. Review of resident #5's nursing progress notes, dated from 3/18/23 to 3/21/23, showed the following: - 3/18/23 at 6:40 a.m., urine dipstick was positive for a urinary tract infection, - 3/18/23 at 6:20 p.m., the nurse documented she called the provider who was on call for the resident's attending physician. The note showed the provider was not familiar with the resident and directed the nurse to call the facility's in-house physician. The note showed the Medical Director (in-house) was not familiar with the resident. No recommendations or orders were documented in the note; - 3/19/23 showed resident #5 was agitated and was placed on oxygen. - 3/22/23 showed the resident had been admitted to the local acute care hospital on 3/21/23. No nursing progress notes were found for 3/20/23 or 3/21/23. Review of resident #5's physician orders, dated from 3/18/23 to 3/21/23, showed no orders were received for the resident. Review of resident #5's Primary Care Visit note, dated 3/21/23, showed the resident went to her primary care provider's office for a scheduled 60-day compliance visit. The note showed the provider was concerned about the resident's condition and sent her directly to the ER via private vehicle accompanied by staff from the facility. The note also showed the provider received a message which showed the on-call physician recommended the facility's in-house physician manage the resident's care. The noted showed the resident reported she never received any antibiotics. During an interview on 6/8/23 at 9:35 a.m., staff member C stated the nursing staff was allowed to do a urine dipstick to check for any abnormalities, but a provider order was required to send the urine specimen to the laboratory for additional analysis and culture. Staff member C also stated a provider order was required to send a resident to the emergency department. The nurses who cared for resident #5 on 3/18/23 and 3/19/23 were no longer employed by the facility, and not available to interview. Review of resident #5's EHR, dated 3/18/23 to 3/21/23, failed to show orders for a urinalysis, urine culture, antibiotics, or transfer to the emergency department for evaluation. Other than the nursing progress notes shown above, the EHR failed to show any other attempts to obtain physician guidance regarding resident #5's condition, assessments of the resident's status, or vital signs between 3/18/23 and 3/21/23. Review of the facility's policy titled, Change of Condition or Status, dated 3/2019, showed, In the event of a change in status, use the following criteria to discern immediate versus next day contact of the physician . resident's condition is assessed and reported to the MD immediately . 6. A need to alter the resident's medical treatment significantly . The policy also showed the nurse was to record information relative to changes in the resident's condition or status in the medical record.

Based on observation, interview and record review, the facility failed to provide ongoing monitoring and interventions to prevent a severe weight loss for 2 (#s 20, and 180) of 4 sampled residents; and, failed to evaluate a residents feeding ability leading to significant weight loss for 1 (#5) of 1 sampled resident. Findings include: 1. Record review of the weight documentation for resident #20 showed her weight on 6/21/22 was 110.5 pounds and on 12/21/22 was 90.2 pounds, representing a severe weight loss of 18.37% in 180 days. Resident #20's weight on 11/29/22 was 96.0 pounds, representing a weight loss of 6.04% in less than 30 days. No weights were documented for the period between 11/29/22 and 12/20/22. During an interview on 12/21/22 at 2:38 p.m., staff member D stated the facility registered dietician was not available for interview. During an interview on 12/21/22 at 2:46 p.m., staff member E stated resident #20 was not on comfort care or palliative care. During an interview on 12/21/22 at 3:24 p.m., staff member D said the physician was notified of resident #20's weight loss after she weighed the resident on 12/20/22. Staff member D said the physician said the resident was not on comfort/palliative care at this time, and he did not see a reason to place the resident on comfort/palliative care. Staff member D said the physician said the resident's weight loss was an issue. Record review of a progress note for resident #20, dated 8/11/22, showed: .Resident is triggering for a 7.5% wt loss.Any recommendations? .[Dietician]: Her weight loss trigger is 9.5% x 90 days .I believe she is comfort care, so overall goal is likely comfort to maintain QOL at EOL - if decline is anticipated r/t disease progression. Record review of a physician order for resident #20, dated 8/17/22, showed: House supplement shake with lunch. One time a day for health maintenance. Record review of a progress note for resident #20, dated 10/24/22, showed: .Resident with weight loss of 4 lb in past month. She is down 13 lbs in 120 days. She did turn [AGE] year this September. Weight appears stable. Do you have any orders? .[Physician]: No changes at this time, continue to follow trends. Record review of an IDT progress note for resident #20, dated 11/18/22, showed resident #20 triggered for a 10% weight loss since 6/21/22 (110.5 pounds). The nutritional goal was to maintain the current regime with a house shake at the lunch meal. Evaluation for effectiveness of the intervention showed it was effective and resident weight was stabilizing. Record review of resident #20's Nutritional Evaluation, dated 11/21/22, showed resident #20 was on a regular diet with dysphagia advanced and thin liquids. The evaluation showed resident #20 had a severe weight loss of 13% over 180 days, no difficulty swallowing, no difficulties chewing, no edema present, and no constipation or diarrhea. Record review of resident #20's quarterly Multidisciplinary Care Conference Summary, dated 11/21/22, showed: .2. Evaluations/Goals Comfort care - r/t QOL d/t age No s/s dehydration Tolerance to current diet textures Weight stability Record review of a progress note for resident #20, dated 12/21/22, showed: .Resident with weight loss of 6 lbs in past month. She is down 13.8 lbs in 120 days. She is triggering for >10% wt. loss. She did turn [AGE] year in September. She has been sleeping more, and currently has some respiratory issues. Her cognition is baseline. Do you have any orders? [Physician]: We can obtain 2 view CXR and evaluate for any acute pulmonary changes. She does not take any sedatives or hypnotics, we can encourage improving PO nutritional intake by waking her up for meals. [Dietitian]: Per discussion PCP ordered COVID swab, influenza screen, RSV screen and CMP and CBC 2. Record review of the weight documentation for resident #180 showed her weight on 12/14/22 was 115 pounds and her weight on 12/20/22 was 108.6 pounds, representing a severe weight loss of 5.57% in 6 days. During an interview on 12/21/22 at 3:24 p.m., staff member D said she contacted the physician after she weighed resident #180 on 12/20/22. Staff member D said, He felt he needed to talk to the dietician because the weight loss is significant, and refusal of tube feedings is an issue. He would make suggestions after talking with the dietician. Record review of physician orders for resident #180, dated 12/12/22, showed: 1. Enteral Feed four times a day for weight loss related to dysphagia 2. Diet: Regular diet, mechanical soft, regular consistency, related to dysphagia. Oral diet: semi soft foods for pleasure. Record review of a progress note for resident #180, dated 12/21/22, showed: .Resident with weight loss of 6.4 lbs since admission. Factors to consider, type of scale variation, we used mechanical lift vs standing scale. Resident at home with more liberty in diet? Do you have any orders? .[Physician]: I will defer to dietary on minimal caloric requirements to maintain body weight. Oral snacks or food is strictly for pleasure and not to be considered for nutritional requirements. Record review of resident #180's MAR, dated 12/12/22 through 12/21/22, showed 36 opportunities for enteral feeding. Resident #180 declined feeding 14 times, amount administered was not documented 7 times, and no documentation was provided 3 times. Resident #180's MAR showed the resident received her enteral feeding 12 times out of 36 opportunities. Record review of resident # 180's care plan, dated 12/19/22 did not include interventions for resident refusal of tube feedings or the risk of lack of tube feedings to the resident. 46400 3. Review of resident #5's care plan, initiated 10/12/22, showed, I want to maintain my weight within a 3% range over the next 90 days. Review of resident #5's weight chart showed, on 10/22/22 she weighed 189 lbs. On 12/8/22 resident #5 weighed 176 lbs, a 6.88% weight loss in 1.5 months. Review of resident #5's medical record showed a lack of dietary assessment or acknowledgement about the weight loss. A request was made for resident #5's, most recent dietary eval. A document titled, Nutritional Evaluation, with a date of 10/12/22, was all that was provided. During an observation on 12/20/22 at 10:14 a.m., resident #5 was lying in bed with her breakfast tray untouched at her bedside. During an observation on 12/21/22 at 1:39 p.m., resident #5 was lying in bed. Her lunch tray was in front of her, and she was confused and pushing food around the plate with a fork. There did not appear to be any food consumed. Review of resident #5's charted food intakes, dated 12/1/22 - 12/22/22, showed: Breakfast amount eaten: 0-25% on three days, 26-50% on five days, 51-75% on one day, 76-100% on one day, Resident refused one day, and there was no documentation for the task on 11 days. Lunch amount eaten: 0-25% on two days, 26-50% on five days, 51-75% on two days, 76-100% on one day, Resident refused one day, and there was no documentation for the task on 10 days. Dinner amount eaten: 26-50% on one day, Refused on one day, Not applicable for six days, and there was no documentation for the task for 12 days. During an interview on 12/22/22 at 8:55 a.m., staff member H stated resident #5 had some recent medication changes due to cycling (resident has diagnosis of schizophrenia with documented periods of difficulty). She stated resident #5 might need more help with tasks. Review of a facility policy Nutrition Unplanned Weight Loss Clinical Policy, revision date March 2019, showed: .Monitoring 1. The Physician and staff will closely monitor residents who have been identified as having impaired nutrition or risk factors for developing impaired nutrition. Such monitoring may include: a. Evaluating the care plan to determine if the interventions are being implemented and whether they are effective in attaining the established nutritional and weight goals; b. Evaluating the resident's response to interventions should be based on defined criteria for improvement/worsening of nutritional status . .2. The physician, with input from the staff, will determine the most appropriate intervals for weight assessments. b. Recognizing the emergence of complications associated with certain interventions; for example, aspiration pneumonia secondary to nasogastric tube or further weight loss due to diet restrictions; and c. Recognizing the emergence of new risk factors; for example, pressure ulcers, fever, or acute illness.

Based on observation, record review, and interview, the facility failed to provide adequate interventions to prevent significant or severe weight loss for 2 (#s 15 and 75) of 22 sampled residents. Findings include: 1. During an observation on 11/26/18 at 1:05 p.m., resident #75 was lying in bed, asleep. Her lunch tray was on a bedside table, untouched. Review of resident #75's weight records, showed her weight was 98.6 pounds on 3/1/18 and down to 85.8 pounds on 4/20/18, after developing an unstageable pressure sore on 4/5/18. She was placed on hospice in (MONTH) (YEAR) secondary to her decline in status. The facility stopped weighing the resident related to her enrollment in hospice care. Review of resident #75's weight records showed no weights were obtained from 10/3/17 through 3/1/18. The reason for the lack of weights was requested but not answered. Review of resident #75's current diet order showed she was on a pureed diet with regular liquids. During an interview and observation on 11/27/18 at 9:36 a.m., staff member X was feeding resident #75. Breakfast service started at 8:00 a.m. Staff member X stated resident #75 did not like the meat or eggs, but would eat her hot cereal and drink her boost. Review of resident #75's food likes and dislikes showed no breakfast dislikes, and the document was not dated or signed. Review of resident #75's Care Plan showed she was at nutritional risk due to increased nutritional needs related to an unhealed pressure ulcer. Interventions included honor food preferences/intolerance's as they become known. (Resident) is have a difficult time making food likes/dislikes known. We are honoring past food preferences, and family will let dietary know if they are in facility what to serve at meals. This was initiated on 9/28/15 and revised on 2/27/17. No evidence of preferences on the diet card were noted. During an observation on 11/29/18, the room trays were delivered to the nurses station at 9:13 a.m. Breakfast service started at 8:00 a.m. Staff member O stated the room trays should arrive by 8:30 or 8:40 a.m. Resident #75 was assisted with her meal at 9:24 a.m. The cereal and eggs were 92 degrees. The resident was unable to verbalize if the food was unpalatable for her to consume. Review of resident #75's Nutrition at Risk IDT Committed Notes, dated 5/4/18, showed Weight review for weight loss of 11.7 percent in 30 days (severe weight loss). Resident has been admitted to Hospice. Continues with high-calorie Boost 4 times a day, meeting 46 percent of estimated needs. Appetite varies, MD ordered unavoidable weight loss. Continues with unstageable pressure injury to right (sic) ischial tuberosity. Review of resident #75's Nutrition at Risk IDT Committee Notes, dated 9/27/18, showed Review of weight with stage II (sic) pressure injury to right heel and pressure injury to right ischial tuberosity. Wound nurse is following. Expected weight loss related due to decline. Diet; Regular, mechanical soft texture. Receives Boost four times a day. Meal intakes 26-50 percent. Consumes roughly one supplement per day. No diuretic therapy. On hospice care. Will continue to monitor. No interventions were implemented for weight loss. Review of resident #75's Nutrition at Risk IDT Committee Notes, dated 10/19/18, showed review of weight, wound to right ischial tuberosity and left heel. Currently on hospice. No weight as hospice has discontinued weights. Weight decline expected. No changes at this time. Will continue to monitor. No interventions were addressed by the Committee for the prevention of resident's ongoing weight loss. 2. During an observation and interview on 11/29/18, at 8:40 a.m., resident #15 received a large bowl of yogurt for breakfast, which she refused. She stated she did not feel well, and had very little appetite. The resident stated I doubt I'll dwindle away. I'm not ready to go yet. She stated the quality of the food had gone down. Review of resident #15's Quarterly MDS, with the ARD of 9/3/18, showed a current weight of 268 pounds, and a significant non-physician prescribed weight loss. Review of resident #15's Quarterly MDS, with the ARD of 6/19/18, showed a weight of 305 pounds. Review of resident #15's Nutrition at Risk IDT Committee Notes, dated 6/9/18, showed Review of weight. Weight is 305 pounds. Weight is trending upwards. BMI qualifies as obesity grade III. Diet: NAS. Good meal intake. Receives eggs for protein needs for breakfast. Educated daughter for resident's increased protein needs. Daughter brings in meals for resident. Currently on diuretic therapy. RD meets weekly regarding healthy eating and decreasing processed food intake. Will continue to monitor. Review of resident #15's Nutrition at Risk IDT Notes, dated 9/20/18, showed Review of weight: weight: 274.6 pounds. Diet: Cardiac. Meal intake: 75-100 percent. Supplement: Boost each day. Current diuretic therapy. Skin issues to BLE. Per RD no changes at this time. Will continue to monitor until weight stable x 4 weeks. The review did not include the 30 pound, 10 percent weight loss in the past three months. No interventions were implemented to prevent further weight loss. Review of resident #75's Nutrition at Risk IDT Committee Notes, dated 11/15/18, showed reviewed weight loss: weight 261 pounds. Diet: Cardiac, high protein. Meal intake: 50-75 percent. Supplement: Boost every day. Skin issues BLE. Currently on diuretic therapy. Weight fluctuates related to [MEDICAL CONDITION]. RD to discuss diet preference. Will continue to monitor until weight stable x 4 weeks. The note did not include the five percent weight loss from 9/20/18, or the decrease in the percent eaten by the resident, and interventions implemented. Review of resident #75's Nutrition at Risk IDT Committee Notes, dated 11/23/18, showed Review of weight: weight 264.2 pounds. Diet: Cardiac high protein. Meal intake: 25-50 percent. Boost each day. Diuretic therapy. Skin issues to BLE. Weight fluctuates related to [MEDICAL CONDITION]. Will continue to monitor until weight stable x 4 weeks. The note did not address the further decline in appetite, and no interventions were implemented to prevent further weight loss. During an interview on 11/27/18 at 5:06 p.m., staff member L stated resident #15's current weight was down to 257 pounds. She said the continued weight loss was related to the resident's declining appetite. She stated the resident would only drink one Boost per day, and she thought the resident was ready to move on, and no other interventions had been implemented. Resident #15 had lost 45 pounds in six months, with no preventative interventions implemented, to include interventions to assist with pressure ulcer healing.

Based on observation, record review, and interview, the facility and staff failed to prevent the development of a pressure ulcer, document the interventions attempted to heal the pressure ulcer, and the ongoing status of the wound, and the wound continued to worsen over time, turning into an unstageable pressure ulcer, for 1 (#75) of 22 sampled residents. Findings include: During an observation on 11/27/18 at 10:26 a.m., staff member Z changed the dressing for resident #75's unstageable pressure ulcer. The wound, as stated by the staff member, was the size of a half dollar, measuring 3 cm x 3 cm. Review of a wound assessment dated [DATE], showed the wound bed contained approximately 24 percent slough and had undermining around the edges. There was no odor, and the resident stated she was not in pain. Serosanguineous drainage was noted on the dressing. Staff member Z stated the ulcer had not improved, and would probably never heal. Staff member Z changed gloves during the treatment, but did not wash her hands before or after the procedure. Review of resident #75's Nursing Progress Notes, dated 4/5/18, showed pressure injury was found on residents right buttock/bony prominence of sacrum. Wound is a stage II with eschar present in the wound bed. Wound measure 2 cm x 1 cm. No drainage at this time. Wound was cleansed with wound cleaner and covered with an [MEDICATION NAME]. Review of resident #75's Nursing Progress Notes, dated 4/12/18, showed Has a full thickness, unstageable pressure injury to left ischial tuberosity. Measure 4 cm x 2.5 cm, depth unknown related to area of firmly adherent yellow/brown slough to center of wound bed. Resident is on low air loss mattress, prefers to lie on left side. Will ensure regular repositioning to aid in wound healing. The wound had worsened since the discovery on 4/5/18. Review of resident #75's Nutrition at Risk IDT Committee Notes, dated 4/25/18, showed Review of weight related to wound to left ischial tuberosity. weight 85.8 pounds. Diet: Regular mechanical soft. Meal intake 0-25 percent. Family aware and spoke with RD. Hi cal supplement with meals and PM hydration pass. Hospice consult regarding noted decline. Will continue to monitor until wound healed or changed in therapy. Review of resident #75's Weekly Wound Documentation Form showed documentation for 4/12/18 to 4/25/18 and 10/4/18 to 11/21/18. No documentation on the wound was provided from (MONTH) (YEAR) through (MONTH) (YEAR). Staff member A stated the facility had significant staffing concerns through the summer, for why documentation was not completed. Review of resident #75's Treatment Administration Record for the month of (MONTH) (YEAR) showed missing treatments for 6 out of 20 days. The dressing was ordered to be changed daily. Review of resident #75's Quarterly MDS, with the ARD of 11/11/18, showed she was totally dependent on staff for positioning in bed, toileting, and eating. Review of resident #75's Quarterly MDS, with the ARD of 8/11/18, showed she experienced a significant weight loss of five percent. Review of resident #75's weight records showed no weights were provided from 10/3/17 through 3/1/18. The reason for the lack of weight documentation was requested, but a response was not received from the facility on the question. During an interview on 11/26/18 at 2:40 p.m., staff member S stated she did not know much about resident #75's pressure ulcer, but she kept her clean, although the wound had been present for many months. During an interview on 11/29/18 at 12:40 p.m., staff member R stated she did not know why the pressure area was not discovered until it was unstageable. She stated if she had been notified in a timely way, the area would not have developed to a full thickness loss. She stated resident #75 was bed bound but she did not know why. She stated the resident used to get up for a whirlpool bath, which helped with the healing of the pressure ulcer.

Based on interview and record review, the facility failed to ensure the protection of a resident and ensure the resident was free from ongoing abuse from a facility staff member for 1 (#21) of 22 sampled residents. Resident #21 had ongoing anxiety and anger due to staff member F's hostile behavior. Findings include: During a resident council meeting on 11/27/18 at 1:30 p.m., resident #21 and her daughter, NF1, stated they had filed grievances for verbal abuse by staff members to the facility. NF1 stated, No one ever got back to us once the grievances were filed. Resident #21 stated, I wrote a letter and everything. She stated she signed and dated the letter and gave it to a staff member. During an interview on 11/27/18 at 4:45 p.m., resident #21 stated she had been subjected to verbal abuse by staff member F the previous month. She stated staff member F was angry, Because I had to use the bathroom so much. Resident #21 stated staff member F called her, Wicked. She stated she reported the incident via a hand-written letter and she dated and timed the letter when she signed it. Resident #21 stated she gave the letter to a staff member. She stated she was, Very angry, and the incident caused her anxiety. During an interview on 11/28/18 at 12:17 p.m., staff member A stated she had no knowledge of an allegation of verbal abuse to resident #21 by staff member F. She stated, There was an allegation of verbal abuse made in late September, but I don't have anything for October. Staff member A stated, I think (resident #21) and her daughter are confused. Staff member A stated staff member F was an employee of the facility but was not currently working and on leave. During an interview on 11/28/18 at 1:52 p.m., staff member B stated resident #21 gave a letter to staff member D which alleged verbal abuse by a staff member F on 10/31/18 at 8:00 p.m. She stated the letter was placed inside of a sealed envelope and staff member D gave the sealed envelope to staff member C. Staff member B stated staff member F was not currently working at the facility. She stated her last day of work was 11/4/18. During an interview on 11/28/18 at 2:20 p.m., staff member D stated resident #21 gave her a letter around the 7th or 8th of November. She stated that she gave the letter to a facility nurse the day that she received it. Staff member D stated the letter was placed in a sealed envelope. She stated she did not read the letter, but she engaged in a conversation with resident #21 about the contents of the letter. Staff member D stated resident #21 shared with her several concerns about staff member F and she mentioned, Abuse once or twice, during their conversation. She stated resident #21 told her that the tone used by staff member F, Wasn't what she expected to hear, from a staff member. Staff member D stated she reported the abuse and turned in the letter to a facility nurse. She stated she did not report the allegation of the abuse to the medical director of the facility and stated, In retrospect, the medical director should have been notified. Staff member D stated it was her understanding that if she reported the allegation of verbal abuse to the facility, the facility would take the necessary steps to investigate the incident. She stated she was not sure if she included the allegation of verbal abuse in resident #21's physician progress notes [REDACTED].#21) does not make false accusations. She stated, (Resident #21) has a sense of relief because (staff member F) is no longer here. During an interview on 11/29/18 at 9:41 a.m., staff member C stated, So the letter was received by me and at that time, the nurse was not here. She stated, staff member D gave her a sealed envelope, which contained a letter from resident #21, alleging verbal abuse by staff member F. Staff member C stated she could not recall the exact date she received the letter, or if she had informed the Administrator about the allegation, and stated, There was a lot going on. Review of the letter written by resident #21, signed and dated on 11/1/18 at 11:00 p.m. showed on 10/17/18, (Staff member F) . complained about me having to go to the bathroom so many times during the night. On 10/31/18, resident #21 wrote, Verbal abuse, she complained about me getting up at 8 p.m.; when she gave me my night time pill said I was being wicked having to go so often. The letter further read, I should not have to go thru (sic) that kind of abuse. Review of resident #21's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of resident #21's (MONTH) (YEAR) Medication Administration Record [REDACTED]. The facility failed to protect resident #21 and ensure that the resident did not experience harm nor was subjected to ongoing abuse by staff member F.

Based on observation, interview, and record review, the facility failed to report and investigate an injury of unknown origin which resulted in a right hip dislocation which required surgery for [REDACTED]. The facility failed to report a repeat in injury of unknown origin to the State Agency for 1 (#1) of 11 sampled and supplemental residents. This deficient practice had the potential to affect all vulnerable residents receiving care provided by the agency. Findings include: The facility failed to document the incident which resulted in the re-hospitalization of the resident for a left [MEDICAL CONDITION] on 11/10/17, and a right hip dislocation on 11/19/17. Review of resident #1's clinical record, showed the resident had an injury of unknown origin which resulted in the hospitalization and surgical repair of a right [MEDICAL CONDITION] which occurred on 10/31/17. The first injury, which occurred on 10/31/17, was reported and investigated by the facility. A second injury of unknown origin occurred on 11/10/17 which resulted in a second hospitalization for surgical repair of a right [MEDICAL CONDITION]. The facility failed to report the incident to the state agency, but an investigation was completed on 11/10/17 (see section B). The third incident which occurred on 11/19/17 resulted in injury of unknown origin which required a third hospitalization in less than one month, and a third surgical intervention to repair a dislocated right hip, this incident was not documented, reported or investigated (see section A). 1. Resident #1 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of resident #1's Quarterly MDS with 9/29/17, showed the resident had a BIMS of 9, severely cognitively impaired. During an observation on 11/22/17 at 10:00 a.m., resident was asleep, laying on his back in bed. He had a wedge between his legs, which was strapped to keep the wedge in place. During an interview on 11/20/17 at 9:30 a.m., resident #1's wife stated the resident had been admitted to the facility due to his advanced dementia, and she could no longer care for him at home. She stated the resident had been hospitalized three separate times since 10/31/17 for two [MEDICAL CONDITION] and most recently, a hip dislocation. She stated the resident required surgery on all three of these incidents. She stated the facility had notified her of all three occurrences, but she was worried about her husband, and could not understand why he had had so many injuries. A. Right Hip Dislocation Review of resident #1's clinical record failed to reflect documentation which would explain the events which occurred on 11/19/17, to reflect why the resident was sent to the emergency department for evaluation of his right hip pain. Review of resident #1's Emergency Department Note, dated 11/19/17, showed, [AGE] year-old male sent over from (facility) via EMS with report of patient was found moaning in bed. He has a history of underlying dementia, and per EMS report he has had recent bilateral hip surgeries and has a spacer between his legs. Nursing notes .there is no report of recent falls. Review of resident #1's Pelvic X-Ray, dated 11/19/17, showed, dislocated right hip hemiarthroplasty with skin staples again noted laterally. There is an oblique latency overlying the femur at the tip of the femoral stem such that a fracture cannot be excluded and dedicate right femur radiographs should be obtained to follow-up to exclude fracture. Review of resident #1's Pelvic X-Ray, dated 11/19/17, showed, the current study demonstrates persistent dislocation of the right femoral prosthetic component in relation to the bony acetabulum. No fracture. The visualized right prosthetic component is well positioned. A review of resident #1's Physician Consultation Note, dated 11/19/17, showed, Dislocated right hip. (Physician) will under anesthesia attempt to reduce the hip. A review of resident #1's facility progress note, dated 11/20/17, showed, at KRMC. A review of resident #1's facility progress note, dated 11/21/17, showed, Resident at hospital. A review of resident #1's facility progress note, dated 11/21/17, showed, Resident back from hospital via ambulance at 1210 pm. Resident has abductor pillow between legs with Velcro straps keeping in place .Resident not to have head higher than 30 degrees per KMRC. Resident denies any pain at present . A review of the facility's incident log, failed to identify the third injury of unknown origin for resident #1, which occurred on 11/19/17. The incident was not reported or investigated for root cause. The injury was a dislocation and not a pathologic fracture, no investigation was conducted to investigate why resident #1's hip became dislocated. A request for documentation of the reporting and investigation for third injury of unknown injury for resident #1 provided to the facility on [DATE] at 12:00 p.m., the facility failed to provide documentation of reporting and investigation for the third injury of unknown origin for resident #1. Review of the facility reported incidents to the SA from 11/1/17 to 11/22/17, failed to reflect the facility reported the injury of unknown origin and the resulted investigation to the state for the incident which occurred on 11/19/17. During an interview on 11/22/17 at 10:00 a.m., staff member A stated the agency did not report or investigate the injury which occurred on 11/19/17 for resident #1. He stated the agency had already known the resident had a pathological reason for the fractures and therefore, the incident did not need to be investigated. Staff member A stated he could not explain the reason for the resident's dislocation since it was not investigated. The staff member stated the facility discussed the incident on 11/19/17 in their daily stand-up meeting the next day, but no investigation was completed or provided. He stated the incident was not discussed at the weekly IDT meetings. B. Left [MEDICAL CONDITION]: Review of resident #1's SBAR, dated 11/10/17, showed, Situation: resident holding his left hip and crying out in obvious pain this morning. CNA reports resident cried out in pain as soon as toes on left foot touch the floor. Background: Resident was reported to have required a Hoyer lift to transfer during the night, but no reported fall or apparent injury that would cause his left hip to hurt. Also told by CNA that evening shift had reported resident having hallucinations and strange behavior last evening including talking about dying and resident was overheard talking to someone invisible to them saying, No, I can't get to heaven that way, there must be another way. Assessment: Resident having severe acute left hip pain. Spoke with (NF1) and got order for mobile x-rays of left hip to rule out fracture. Response: Medicated for pain and x-ray contacted. Review of resident #1's SBAR Progress Note, dated 11/10/17, showed, resident was x-rayed by mobile imaging and found to have an acute left [MEDICAL CONDITION]. Background: Resident exhibiting severe pain in left hip this morning with no recent fall history or reported potential cause of hip injury. (NF1) reports it is possible resident may have suffered a spontaneous pathological fracture due to advanced [MEDICAL CONDITION] and recent stress on left lower extremity bearing most of resident's weight after he had right [MEDICAL CONDITION] and surgery. Response: Phoned (NF1) who looked at x-rays and gave order to transfer to ER at KMRC. Phoned resident's wife and notified her of the situation and transfer to ER. Review of resident #1's physician progress notes [REDACTED]. Sent to ED for evaluation. I reviewed the images from portable x-ray myself and my interpretation is a displaced left femur fracture. I suspect that he will require surgical correction for his hip as well. No report of fall, but if not as a result for fall, then I would suspect a pathologic fracture. He is not on bisphosphonate, but he isn't on a calcium supplement either. It is conceivable that as he is recovering and healing from his previous [MEDICAL CONDITION], that his body has been reabsorbing calcium from his other bones to use as raw material to heal his fracture. Review of resident #1's Skilled Nursing Progress Note, dated 11/12/17, showed: resident was transferred back to (facility) from KRMC where he underwent a left hip ORIF with IM nail for a displaced left hip intertrochanteric fracture on 11/10/17. Transported back to the facility by ambulance due to bilateral [MEDICAL CONDITION] with surgical repair. status [REDACTED]. Wife called shortly after return from hospital and spoke with ADON regarding her concerns for safety and fall prevention. Discussed why side rails are not used in facility and bed alarms are discouraged; Fall matts considered a tripping hazard for people that try to stand up and get out of bed and are not advised, but a scoop mattress might be beneficial. Hoyer lift for all transfers; wound care; log roll in bed for turning/changing, PT/OT to evaluate for additional recommendations. A review of the facility Internal Investigation Form, dated 11/10/17, showed the facility investigated the incident related to the left [MEDICAL CONDITION] for resident #1. Review of the facility reported incidents to the SA from 11/1/17 to 11/22/17, failed to show the facility reported the injury of unknown origin and the resulted investigation for the incident on 11/10/17. During an interview on 11/20/17 at 6:10 p.m., staff member E stated it was the expectation of staff to report all incidences which result in serious bodily injury to the state. She stated she would report to the incident to the Administrator, DON, or ADON, immediately. During an interview on 11/21/17 at 8:00 a.m., staff member H stated it was the expectation to report all injuries of unknown source to the Administration, immediately. During an interview on 11/22/17 at 10:00 a.m., staff member A stated it was the expectation of the facility to report to the state and complete a follow up investigation for suspicious injuries of unknown origin. He stated he did not feel either of resident #1's injuries which occurred on 11/10/17 and 11/19/17 were suspicious and required the need to report to the SA. Staff member A stated the facility did an investigation into the left [MEDICAL CONDITION], but did not feel it needed to be reported since it was determined to be a pathological fracture. He stated the resident having a pathological fracture would be the same if the resident had an appendicitis, he stated it would not need to be investigated or reported. The staff member stated the facility did not discuss resident #1's incident and fracture from 11/10/17, at the IDT meetings. He stated the facility did not need to report or investigate the third incident which resulted in a right hip dislocation for resident #1 because the cause was pathological and was not an injury of unknown origin. Staff member A stated he did not feel it was possible to report all injuries of unknown origin which occurred in the facility. During an interview on 11/22/17 at 10:30 a.m., staff member B stated it was the expectation the facility would report and investigate all injuries of unknown source, especially if the injury resulted in major bodily injury, and because of the number of incidences which occurred for the same resident in such a small window of time. A review of the facility's policy and procedure titled, Abuse Prevention Plan (MT), showed, In accordance with the Vulnerable Adult Law of the State and Centers for Medicare and Medicaid, (CMS), it is our policy that all residents residing in the facility will be protected from abuse, neglect, misappropriation of funds/property, exploitation or involuntary seclusion, mistreatment and that interventions are implemented to provide ether vulnerable adult with a safe living environment. 5. Injuries of Unknown Source: the source of the injury was not observed by any person or the source of the injury could not be explained by the resident; AND the injury is suspicious because of the extent of the injury or the location of the injury (i.e.: the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. Reporting: The facility requires that all suspected maltreatment will be reported to the Administrator and the State promptly. All staff are required to report suspected maltreatment of [REDACTED]. If the Administrator is not in the building, direct care staff will report to the Nursing Supervisor, at the time of suspicion. The Administrator, DNS, or Nursing Supervisor will make sure that a report is filed, that the internal investigation begins immediately and the appropriate reporting takes place. All alleged violations involving abuse, neglect, exploitation, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials. Serious bodily injury is an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization , or physical rehabilitation. Investigation: Faculty will investigate all incidences such as falls, bruises, medication errors, resident complaints etc. Monday thru Friday, normal business hours, all incidents will be reviewed with the following disciplines: nursing, social services, Administrator, activities, and therapies .The facility will conduct its own internal investigation to the extent possible.

Based on interview, record review, and observation, the facility failed to ensure adequate supervision, assessment, monitoring, and interventions, were implemented to prevent resident falls, which caused fractures, and in an attempt to reduce the number of falls for 5 (#s 6, 9, 14, 16 and 18); failed to provide timely evaluation and follow up for a resident who had a major injury after a fall, for 1 (#18), and failed to evaluate incidents of elopement and the risk for elopement, for 1 (#13) of 21 sampled residents. Findings include: On 8/23/17 at 2:04 p.m., staff members A, B, C, and U were notified of an Immediate Jeopardy situation in the area of F323, Accidents/Supervision, cited at a severity and scope of K for three residents with falls who had fractures. 1. Review of resident #18's progress notes, dated 7/2/17 through 8/9/17 showed the following: -On 7/2/17, resident #18 had an unwitnessed fall, without injuries. The resident was found on the floor next to her bed. The resident's nursing notes did not show ongoing neurological assessments, monitoring, or the implementation of interventions for future fall prevention. Review of the resident's care plan did not show interventions related to fall prevention. -On 7/15/17, resident #18 had an unwitnessed fall in which the resident sustained [REDACTED]. The fall scene investigation, not dated, showed the resident was sent to the ER for evaluation. Wound care was provided for the skin tear. Review of the resident's nursing note, dated 7/15/17, did not show ongoing neurological assessments, monitoring or interventions for future fall prevention. -On 8/9/17, resident #18 had an unwitnessed fall in which the resident sustained [REDACTED]. Review of nurse's notes, dated 8/9/17, showed the resident was assessed and complained of left hip pain with ambulation. Review of the resident's progress note, dated 8/10/17, showed the resident was transferred to the ER for evaluation. There was a 12-hour delay in the transfer, for the resident to receive a higher level of care, in an acute setting. Review of the resident's care plan did not show interventions for fall prevention. Review of the resident's clinical record did not show ongoing neurological assessments. The resident's fall scene investigation report, dated 8/9/17, showed the resident had difficulty pushing the call light. -On 8/10/17, the resident was sent to the emergency room for evaluation of left hip pain. The resident returned to the facility with a [DIAGNOSES REDACTED]. Review of the resident's care plan did not show updated information and interventions related to falls as of 8/10/17. Review of resident #18's clinical record did not show neurological assessments for the three unwitnessed falls. Review of the resident's care plan did not show interventions for fall prevention. Review of the CAA (care area assessment), dated 7/3/17, showed falls were triggered as a problem, due to the resident's unsteadiness and the need for staff assistance. Review of resident #18's Admission MDS, with an ARD of 6/28/17, showed a BIMS (brief interview for mental status) score of 13, cognitively intact. Review of the resident's MDS, with an ARD 8/16/17, showed a BIMS score of 6, severe cognitive impairment, a significant change from the previous assessment. Review of resident #18's nursing notes, for 7/2/17 through 8/17/17, showed the IDT met one time, on 7/12/17, to review the resident's fall. The one intervention put into place, was for staff to remind the resident not to wear slippery pajamas, although her cognition was impaired. During an interview on 8/23/17 at 10:09 a.m., staff member M stated the resident did not complain of hip pain. Staff member M stated the fall protocol was to assess the resident, check vital signs, check ROM (range of motion), check for injuries, and use a lift to move the resident. Staff member M stated neurological checks were started for resident #18, for the fall on 8/9/17, and were left for the next shift. During an interview on 8/23/17 at 3:17 p.m., staff member H stated the protocol for falls was to check for injuries, complete neurological checks if the resident hit their head, complete a fall report and fall assessment, and notify the resident's physician and family. During an interview on 8/24/17 at 10:20 a.m., staff member B stated the expectation for falls was for the nursing staff to follow the facility policy and procedure. 2. Review of resident #6's falls from 5/11/17 through 7/5/17 showed the following: -The resident had five falls, which were on 5/11/17, 6/4/17, 6/9/17, 6/13/17, and 7/5/17. -One out of five falls resulted in rib fractures. -Two out of five falls were related to toileting needs. -All five falls were during self transfers by the resident. Review of resident #6's care plan did not show interventions related to toileting needs, although two falls occurred related to toileting. Review of resident #6's Quarterly MDS, with an ARD of 6/15/17, showed the resident needed extensive assist by one staff for toileting needs. Review of the facility's Fall Prevention policy showed the following: 1. A fall risk assessment will be completed at the following times: a. upon admission/readmission to the facility b. quarterly - can complete a quarterly review instead of full assessment if no change since previous assessment c. prior to annual MDS d. change of condition 2. Fall precautions will be reviewed and appropriate precautions will be implemented after a fall occurs. 3. An incident report and a fall scene investigation form are to be completed after each fall. 4. Fall will automatically be logged through completion of incident report in PCC. 5. Initiate Neuro checks if the resident hit their head or if the fall was unwitnessed. 6. The resident's physician and family were to be notified of the resident's fall. 7. Once per week, the IDT (interdisciplinary team) fall committee will meet and complete a fall review on each resident who had fallen during the preceding week. The care plan will be updated with any new or decided interventions. This will continue for 3 weeks post-fall or until the resident has had no further falls for 30 days. 8. The Quality Assurance Committee will discuss all residents, who have fallen that month and the status of each resident and their current interventions. 3. Resident #14 was a long-term resident in the facility, and was re-admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. During an interview on 8/23/17 at 3:00 p.m., resident #14 said, I just lose my balance. He said, once or twice he transferred himself because he, Couldn't get to the call button. Resident #14 said he couldn't remember how he broke his hip, and felt maybe he had been in a car accident. Review of resident #14's Progress Note, dated 7/23/17 at 7:35 p.m., showed resident #14 fell in the dining room and the resident was sent to the ER. At 10:43 p.m., a progress note showed resident #14 had been admitted to the hospital with [REDACTED]. Review of resident #14's (hospital) History and Physical Report, dated 7/23/17, showed, . was walking today when his leg caught on the leg of a coffee table. He fell on the left side and immediately had pain in the left hip. Review of resident #14's (hospital) Discharge Summary, dated 7/27/17, showed, He was walking today (at the nursing home) when his leg got caught on the leg of a coffee table. He landed on his left side and had exquisite pain, and, He went to the Emergency Department and was found to have a left-sided hip fracture . Review of resident #14's Fall report, for 7/23/17, revised on 7/31/17, showed the report had only been partially completed, and showed, No injuries observed post incident. Review of resident #14's late Progress Note, dated 7/28/17 at 5:29 p.m., showed resident #14 had returned to the facility on [DATE], .early in the day. The facility staff had not documented resident #14's return until the evening of the following day. Review of resident #14's Fall risk assessment, dated 6/2/17, showed the resident fall risk had not been completed. Review of resident #14's Fall Risk Assessment, upon return to the facility on [DATE], was requested, but one was not provided. Review of resident #14's Progress Note, dated 8/2/17 at 12:37 p.m., showed resident #14 had Slipped off of the edge of his bed while trying to dress himself. Resident #14 had reported that he didn't think he needed any help. Review of resident #14's Progress Note, dated 8/2/17 at 5:18 p.m., showed. Resident was trying to put his pants on and slipped off bed onto the floor. Denied any new pain. No skin issues noted. Assisted resident with dressing and put into w/c. MD Notified. Review of resident #14's Significant Change MDS, dated [DATE], after re-entry to the facility, showed, resident #14 needed limited assist with transfers, he had not walked between locations in his room or in the corridor, and he required extensive assist with dressing, toilet use, and personal hygiene, and had not been bathed. The MDS showed resident #14 was, Not steady, only able to stabilize with staff assistance, for moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer. Resident #14 had a functional limitation in range of motion for his lower extremities, on one side. Section GG of the MDS showed resident #14 required partial/moderate assistance with sit to stand, chair/bed-to-chair transfer, toilet transfer, wheel 50 (and 150) feet with two turns, and refused to perform sit-to-lying, and lying-to-sitting, on the side of the bed. The MDS showed the resident had only experienced one non-injury fall since admission of 7/27/17. Based on documented falls dated 8/2/17, this data did not accurately reflect the number of falls. Review of resident #14's Progress Note, dated 8/5/17 at 8:48 p.m., showed, Resident did not follow instructions and did not use the call light as instructed to call for assistance with transferring. Resident slid off his bed and ended up on the floor. At 4:35 resident was found sitting on the floor by the CNA, (name). Resident stated that he was trying to get up and slid off his bed. Resident said that he did not suffer any injuries and did not hit his head. Resident was assessed. Review of a fax to the provider regarding resident #14, dated 8/10/17, showed, Resid (sic) slid out of bed this evening. Moving all extremities without diff. 0 (zero) obvious inj. Review of resident #14's Progress Note, dated 8/11/17 at 1:06 a.m., showed on 8/10/17 resident #14, Was found sitting on the floor by his bed and w/c. 'I was trying to take my socks off.' Moving all extremities. No obvious injury. Review of resident #14's Physician/Prescriber orders, dated 7/16/17, showed, #3. Head CT without contrast (unreadable) r/t 8/7 fall was ordered. This order was not followed by nursing staff. Review of resident #14's Physician/Prescriber orders, dated 7/21/17 showed, #2 Head CT without contrast r/t fall tomorrow. During an interview on 8/22/17 at 10:00 a.m., staff member BB, expressed concerns that orders were not being carried out in a timely manner, and for resident #14 a CT scan had not been secured when ordered, on 7/16/17. She said, I don't know that I can trust that my orders are going to be carried out. During an interview on 8/22/17 at 2:30 p.m., staff member DD said, I wasn't aware of the need for the CT scan until the (physician) reminded me yesterday. I've been wearing a lot of hats lately. (Staff member EE) and I have been sharing the ward clerk duties since (named staff) has been on vacation. (Staff EE) has been working the floor. Review of resident #14's progress note, dated 8/19/17, showed resident #14 had been found lying supine on the floor next to his bed at 7:00 a.m., and showed a basic physical assessment had been performed and no injuries were noted. No neuro checks were conducted. No root cause analysis of the fall was conducted. The writer noted the resident had received two units of packed red blood cells on 8/18/17. Review of resident #14's Fall Risk Assessment, dated 8/19/17, showed the resident scored a 23, with a score of 10 or above considered a fall risk. During an interview on 7/22/17 at 10:30 a.m., staff member FF, said, I worked the E-Wing unit on 8/19/17, it was my first day. I wasn't oriented to this unit when I arrived. There was supposed to be a second CNA on that unit, but they never showed up. At about 11:00 a.m. another CNA arrived at the unit to help. The day nurse was also late showing up. When she did show up she wouldn't help me, and went to the dining room to pass medications. Every time I would come out of a room there would be eight lights going off, and no one came to help me. On the second day (8/20/17) there was a second aide, but they came and got her and took her to a different wing. Staff member FF said, When I arrived in the morning (8/19/17) there was a guy on the floor (resident #14.) He fell twice on that date. Staff member FF said, When he fell I didn't even know where to find the vitals equipment. I think he had been there long enough, because he had pulled down a pillow and blanket. They had only had one night aide. She said, The second slide out of bed was at the end of the shift. Review of resident #14's Progress Notes and Fall reports for 7/19/17, showed no evidence or documentation of a second fall for the resident. During an interview on 8/23/17 at 8:30 a.m., staff member GG said, I changed to the 6:00 a.m. to 2:00 p.m. shift to be a bath aide the 1st of this month. The baths are not getting done. I have been pulled to the floor all but about two days. I was on this hall (E-Wing) last Monday by myself, just one aide. The nurses won't help because they are overwhelmed themselves. The nurses never help with ADL's, they will tell you to ask a CNA from another wing. The call lights just go off for over thirty minutes. There are a lot of fall risks. There are two person transfers that I usually just use a sit-to-stand for because I don't have help, and don't have time to go to another hall to find help. During an interview on 8/23/17 at 3:15 p.m., staff member AA said resident #14, Is forgetful and probably doesn't always use his call light. He said resident #14 had been independent prior to falling and breaking his hip. Staff member AA said, Staff is working to ensure the call-light and chair are placed where they should be in resident #14's room. He said resident #14 had been moved to the rehab wing earlier today (8/23/17), and the nurses on the rehab wing were more attuned to resident #14's type of acuity. Staff member AA said, I have worked at the facility for some time, and I know what a normal staffing ratio looks like. He said, Lately we have been very short staffed. During an interview on 8/24/17 at 8:45 a.m., staff member B said, We have not been able to locate any neuro checks for resident #14, and there has been nothing specific about resident #14's falls discussed in the fall committee. A review of the facility's policy, Sufficient Staffing, showed, 4. Nursing direct care staffing ratios will be figured with changes in census and level of care needs. A review of the facility's policy, Fall Prevention, showed, Initiate Neuro checks if resident hit head or unwitnessed fall. Documentation showed the resident had fallen at least five times since returning to the facility on [DATE]. No neuro checks were provided by the facility for any of the falls. Review of resident #14's Risk of Falls Care Plan, provided by the facility, showed, PT/OT eval and treat, w/c for locomotion, and weight bearing as tolerated were added to the interventions on 7/27/17, after returning from the hospital. On 8/5/17, I am very passionate to direct my own care. Often refusing therapy. They continue to work with me in strengthening. The care plan, dated 7/27/17, did not address call lights or frequent monitoring. 4. Resident #13 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of resident #13's 5-day PPS, dated 7/23/17, showed she had wandered 1-3 days during the look back period. Review of resident #13's Admit Progress Note, dated 7/8/17, with no documented time, showed, Stated she was falling bc (sic) her ex husband took away her Norco and then made her come on this vacation. Spoke with (hospital staff) stated the patient is not here on vacation, she moved here. Review of resident #13's Progress Note, dated 7/9/17, showed. Patient is confused and thinks she is here working as the DON. Patient has been trying to leave the facility and is considered an elopement risk. She also wrote a personal check and gave it to staff . Patient has been placed on watch and staff is locating and documenting Q 15 min as to where the patient is at. Review of resident #13's Progress Note, dated 7/18/17 at 1:38 p.m., showed, found (sic) resident pushing another resident in w/c (resident also from locked wing) down D wing hall, redirected and amb (sic) with both residents back to locked wing and alerted staff of prior departure. Progress notes do not hold evidence of documentation of a prior departure. Review of resident #13's Progress Note, dated 7/19/17 at 6:00 p.m., showed, Resident has escaped off locked unit three times this morning when other staff have opened the secured doors. She swats (sic) down against the wall hidden from view then sneaks out behind linen or housekeeping carts unobserved until caught by staff by the main nurses station and escorted back to unit; DON brought a wander-guard down and resident was very agreeable to wearing it when I explained it was a safety device to help us from loosing rack (sic) of her; She informed me she looses herself all the time and was tankful for all the safety she could get. Review of resident #13's Care Plan, dated 7/25/17, showed no care plan was developed in regards to elopement, the risk of elopement, or the use of a Wander Guard. A review of the facility's policy, Elopement, reflected, the facility did not consider escaping the secured unit an elopement. The threshold for elopement was escaping the building. During an interview on 8/23/17 at 1:30 p.m., staff member's A and C, stated that unless a resident elopes out of the building it was not considered an elopement. Because she had only left the secure unit, the incidents were not reported to the State Survey Agency. Surveyor: Latham, Lori

Based on record review and interview, the facility failed to utilize resources available and administer the facility adequately to ensure resident supervision, relating to care and services, and to protect residents from abuse, and to prevent and reduce falls with and without fractures for 9 (#s 6, 7, 8, 9, 14, 18, 22, 23, and 24) of 30 sampled and supplemental residents. Findings include: On 8/23/17 at 2:04 p.m., staff members A, B, C, and U were notified of an Immediate Jeopardy situation in the area of F226-J, Abuse, F323 Accidents - K, and F490 Administration - K. 1. Review of the State Survey Agency, facility event report, dated 6/4/17, showed the facility moved a resident with an identified behavior (resident #7) of unwanted sexual contact into a unit with 28 demented residents, to include resident #s 8, 22, 23, and 24. Record review of resident #7's progress note, dated 6/28/16, showed three female residents were identified as having their breasts fondled. Record review of resident #7's care plan and progress notes, for June and July, 2017, showed the facility did not implement interventions after this incident on 6/28/17, to protect the residents from further abuse. Review of a Progress Noted, dated 6/9/17, four days after placement on the secured unit, resident #7 was observed kissing a female resident; he was told to go to his room, but no further action was taken. During an interview on 8/21/17 at 1:45 p.m., staff member B stated the facility had not reassessed the appropriateness of the resident's placement of the secured unit, which was meant to be a temporary move. Resident #7's Quarterly MDS, with the ARD of 6/2/17, showed he had a higher level of cognition than the residents who he fondled, or who he made unwanted advanced toward. Review of #7's Progress Note, dated 7/22/17, showed the resident was observed 'persuading' a female resident to come into a room. The facility implemented an increase in supervision on 8/22/17, after the survey team identified the concern. Refer to F226 for more information relating to this deficiency. 2. Review of the facility Incident By Incident Type report showed 13 unwitnessed falls in May, 2017, which had doubled to 26 unwitnessed falls in August, 2017. Three of the falls resulted in significant injuries, which were fractures, for residents #s 6, 14 and 18. Resident #9 fell 11 times in four months. During an interview on 8/23/17 at 10:15 a.m., staff member B stated falls had been identified as a concern for the facility, and the facility had just began implementing a fall prevention program. A 'Performance Improvement Project for falls had not been implemented. During an interview on 8/23/17 at 10:09 a.m., staff member A stated a large exodus of staff was noted in June. The Quality Assurance Program had not formally identified a staffing shortage but had started a recruitment plan, and a retention plan to address staff satisfaction, on 8/19/17. She stated the facility began using Agency staff on 7/31/17, related to the lack of adequate staff for the facility. Refer to F353 for staffing details, and deficient practices.

Based on record review and interview, the facility failed to operationalize the abuse policies and procedures for the protection of residents, specifically when a resident (#7) was moved to the dementia secure unit, after the resident had exhibited sexual predatory behavior towards residents of the opposite sex, which continued after the move. Staff failed to ensure the residents were protected, and the needs of resident #7 were addressed adequately, to ensure a safe environment, free of sexual abuse. This deficient practice had the potential to affect the 28 residents on the unit who had contact with resident #7, and specifically females, and was identified to have affected four female residents (#s 8, 22, 23, and 24) of 30 sampled and supplemental residents. Findings include: On 8/23/17 at 2:04 p.m., staff members A, B, C, and U, were notified of an Immediate Jeopardy situation in the area of F226, Abuse, Policies and Procedures, cited at a severity and scope of J. This included four residents. 1. Review of the State Survey Agency, facility event report, dated 6/4/17, showed resident #7 was observed groping resident #24's breast. Review of resident #7's Quarterly MDS, with the ARD of 6/2/17, showed the resident had a BIMS of 14, meaning he was cognitively intact. Review of resident #7's Progress note, dated 6/4/17, showed resident #24 cried loudly after the incident with resident #7. The documentation showed, The patient was distraught, the male was smiling. Review of resident #24's Annual MDS, with the ARD of 6/2/17, showed the resident had a BIMS of 10, meaning she had moderately impaired cognition. Review of the State Survey Agency, event report, dated 6/4/17, showed resident #7 was moved to another hall, and the sexual abuse was substantiated relating to resident #7. 2. Review of resident #7's Progress Note, dated 6/25/17, showed (the resident) was knocking on female resident door, opened door and was entering room. Staff stepped into door and told (resident #7) the other resident was asleep, and he was not to be in her room. (The resident) became angry and swung at staff member hitting them in the neck. Staff told him this was not appropriate behavior and he was escorted to his room. The Progress Note did not show future interventions to protect the resident in the room resident #7 was entering. 3. Review of resident #7's Progress Note, dated 6/28/17, showed staff intervened on 4 separate occasions this morning whenever (resident #7) was caught squeezing and fondling 3 different female residents' breasts. (Resident #7) was redirected away, and was reminded again that this is inappropriate behavior. Review of the State Survey Agency, facility event report, dated 6/28/17, showed the plan to prevent further abuse was to monitor (resident's) movements. The doctor had been contacted to assess (resident) who appears to be delusional, thinking the women are his lady friends. During an interview on 8/22/17 at 10:20 p.m., staff member BB stated she had not been made aware resident #7 had been touching females on the memory care unit, although the staff member provided medical oversight. Review of resident #7's Progress Note, written by staff member W, dated 7/5/17, showed Noc nurse reports increase in (resident #7's) inappropriate touching of female residents and resident's fixation on resident #22. Nurse also reported (resident #7) urinating in drinking glass and placing used toilet paper in sink. Day shift CNA reports staff need to monitor (resident #7) to avoid having female residents in his room. 'He will lure them in.' Also, same CNA reported (resident) consistently making sexual comments, inappropriate touching of multiple residents, exposing himself in the dining room, urinating in common areas, and demonstrating increased aggression when staff attempt to redirect. The administrator was contacted to discuss re: safety of residents on unit in relation to (resident #7's) behavior, with planned follow-up with MD. Review of resident #22's Quarterly MDS, with the ARD of 7/14/17, showed the resident had a BIMS of 4, meaning she had severely impaired cognition. The facility was unable to provide follow-up regarding the 7/5/17 note, to show steps taken to protect the residents on the unit. During an interview on 8/22/17 at 2:40 p.m., staff member A stated staff member V and W were on vacation, and could not provide further information. During an interview on 8/21/17 at 1:45 p.m., staff member B stated resident #7 was moved to the memory care locked unit, because there was more supervision. She stated the facility had not reassessed the resident, or the situation relating to the sexual behavior, since the room move on 6/5/17. She did not know what interventions were in place to protect the residents living in the locked memory care unit. 4. Review of resident #23's progress note, dated 6/28/17, showed resident #8 said hi to resident #7, in the dining room. Resident #7 grabbed and squeezed resident #8's breasts. The residents were separated. Resident #8 did not show any reaction. Resident #7 was reminded again that the behavior was inappropriate, although this has been unsuccessful prior. Review of resident #8's Quarterly MDS, with the ARD of 7/18/17, showed the resident had a BIMS of 2, meaning she had severely impaired cognition. 5. Review of resident #23's Progress Note, dated 7/22/17, showed resident #7 had attempted to persuade the resident to enter a room with him. Staff redirected male resident but (resident #23) was upset by interaction for brief time. Review of resident #23's Annual MDS, with the ARD of 6/2/17, showed the resident had a BIMS of 9, meaning moderately impaired cognition. During an interview on 8/21/17 at 2:20 p.m., staff member P stated the facility continued to monitor resident #7, and he had a psychiatry evaluation on 8/17/17. The results of the evaluation were not available. She stated the resident now had a dementia diagnosis, so she thought abuse was not substantiated. She stated the sexual contact by resident #7 did not bother resident #22, and resident #8 and #23 did not remember the incident with resident #7. She thought the move was a temporary change. During an interview on 8/21/17 at 1:30 p.m., staff member K stated she had witnessed episodes of resident #7 touching females, and the staff were to watch him closely when he was up walking through the hall. During an interview on 8/21/17 at 3:00 p.m., staff member J stated she had witnessed the resident touching other female residents, and the staff were told to redirect and separate resident #7 from the female residents. During an interview on 8/22/17 at 7:35 a.m., staff member L stated resident #7 was very sexual, even with the CNAs. She stated she was concerned about his placement on the memory care unit, and was told the move was only temporary. She also stated she had been the only CNA on the memory care unit on several occasions, and could not provide the expected supervision of the 28 residents.

Based on interview and record review, the facility failed to provide sufficient staff for resident safety, and the provision of care and services, to include: the failure to provide restorative services for 2 (#s 3 and 20); for the failure to assess, supervise, monitor, and implement interventions to prevent and reduce accidents and hazards for 7 (#s 3, 6, 9, 14, 15, 16, and 18); for the failure to identify risk factors, and implement interventions, in an attempt to adequately protect the residents and prevent future occurrences of abuse, for 6 (#s 7, 8, 9, 22, 23, and 24); for the failure to provide timely and adequate service for the provision of answering call lights, for 1 (#26), hydration for 1 (#15), and psychosocial well being and safety, for 1 (#30); and failed to provide timely and adequate bathing and shower services to meet the residents individualized needs, for 4 (#s 3, 4, 15, and 20) out of 30 sampled and supplemental residents. Findings include: STAFFING During a private meeting on 8/22/17 at 10:00 a.m., residents stated staffing was bad, especially on weekends. Often one CNA was on the halls. Mail was not always delivered timely or received by residents, especially during the weekends. Medications were late, bathing was not getting done, restorative not being offered, and answering call lights could be up to an hour and a half before a staff member answered. The residents stated they were only receiving one to two showers/baths a month. The consensus was that the facility had a problem with not having enough staff. During an interview on 8/22/17 at 11:24 a.m., NF1 stated the facility was constantly short of staff. NF1 stated only one CNA was on E Hall, 8/19/17, until 11:00 a.m. NF1 stated the nurses did not help the CNAs if the facility was short of CNAs. Three weeks ago, NF1 stated giving a grievance to the administrator, about staffing, and stated being worried her husband would not receive the care he required, if she was not there. I have seen many, many times when there was only one CNA to 33 residents. During an interview on 8/21/17 at 1:49 p.m., resident #15 stated there was a shortage of CNAs for three months. Resident #15 stated knowing CNAs were working short when she did not received water one to two times a day, in her room, from the water wagon. During an interview on 8/22/17 at 2:35 p.m., resident #3 and NF2 stated staff were to use a hoyer lift for resident #3. Both stated when nursing staff was low, only one staff member would work the hoyer lift. Review of resident #3's Plan of Care, with a revision date of 2/19/16, showed resident #3 required a hoyer lift to transfer with two person assist. Review of resident #3's physician progress notes [REDACTED]. Resident #3 was to be primarily in bed, but sometimes a challenge with getting to bed due to staffing issues. During an interview on 8/24/17 at 11:55 a.m., staff member E stated she was new at the job, and had no previous orientation on the floor. Staff member E was placed with another staff member, for training. There was an altercation with a resident and the staff member who was training staff member E. Staff member E ended up working the floor by self and one CNA. The next day, staff member E was to orientate with a staff member but there was not enough staff. Staff member E worked the floor again with no training. Two days prior to the interview, staff member E stated there was her and another nursing staff member, with three to four weeks experience, and two CNAs, on the night shift, for six halls, for care of approximately 102 residents. During an interview on 8/23/17 at 10:09 a.m., staff member A stated a large exodus of staff was noted in June, 2017. The Quality Assurance Program had not formally identified a staffing shortage, but had started a recruitment plan, and a retention plan, to address staff satisfaction, four days prior to the interview date. During an interview on 8/23/17 at 2:25 p.m., resident #26 stated he has had a hard time getting his call light answered and had to wait for as long as two and one half hours. Resident #26 stated there was usually one CNA on his hall. During an interview on 8/23/17 at 3:17 p.m., staff member H stated she didn't have time to answer call lights because of short staffing. During an interview on 8/21/17 at 3:50 p.m., NF3 stated the last three Mondays, the memory care unit had one CNA on day shift. The nurse on duty told him she could not watch all the residents, because she did not have two CNAs on shift. During an interview on 8/22/17 at 1:40 p.m., NF4 stated the facility did not have enough staff. She stated she was receiving lots of concerned phone calls from family members, and families were moving their loved ones because of care needs not being met. During an interview on 8/22/17 at 5:10 p.m., staff member II stated the facility was completely understaffed and it had gotten worse and worse since April (2017). During an interview on 8/23/17 at 2:05 p.m., resident #30 stated her stay at the facility had been horrible and that there were too many residents for the CNAs. I feel abused here. They have problems here, big problems. During an interview on 8/22/17 at 10:30 a.m., staff member FF, said, I worked the E-Wing unit on 8/19/17, it was my first day. I wasn't oriented to this unit when I arrived. There was supposed to be a second CNA on that unit but they never showed up. At about 11:00 a.m. another CNA arrived at the unit to help. The day nurse was also late showing up. When she did show up she wouldn't help me, and went to the dining room to pass medications. Every time I would come out of a room there would be eight lights going off, and no one came to help me. On the second day (8/20/17) there was another aide, but they came and got her and took her to a different wing. Staff member FF said, When I arrived in the morning (8/19/17) there was a guy on the floor (resident #14.) He fell twice on that date. Staff member FF said, When he fell I didn't even know where to find the vitals equipment. I think he had been there a long enough, because he had pulled down a pillow and blanket. They had only had one night aide. She said, The second slide out of bed was at the end of the shift. During an interview on 8/23/17 at 8:30 a.m., staff member GG said, I changed to the 6:00 a.m. to 2:00 p.m. shift to be a bath aide the 1st of this month. The baths are not getting done. I have been pulled to the floor all but about two days. I was on this hall (E-Wing) last Monday by myself, just one aide. The nurse won't help because they are overwhelmed themselves. The nurse never helps with ADL's, they will tell you to ask a CNA from another wing. The call lights just go off for over thirty minutes. There are a lot of fall risks, there are two person transfers that I usually just use a sit to stand for because I don't have help, and don't have time to go to another a hall to find help. Staff member GG said the facility had been using a Companion Aide as a CNA, she said the Companion Aide was not CNA certified. During an interview on 8/23/17 at 1:30 p.m., staff member O said, I have worked as a Companion Aide for two months. She was to be trained as a CNA at the facility. She said she did not have a skills check list and was not a CNA. Staff member O said mostly she has worked doing hydration, linen, answering lights, and shadowing another CNA on the floor. She said she had not received any class room training. Staff member O said, There has been a few times that we used the lift to get someone off the toilet, who had been there a while. I worked as a CNA about a week ago; combing hair, changing shirts, brushing teeth. I did not do peri care. I have done feeding in the dining room. Staff member O said, (Staff member K) told her to be a CNA when they were shorthanded. I never got trained to be a Companion Aide. During an interview on 8/24/17 at 9:50 a.m., staff member KK said, I used to do the staffing schedule. I was always asking for more staff and corporate would turn me down. The Administrator would try to get travel personnel, but he would not get any. In May, 2017, they said they would change to twelve hour shifts. This was mandatory. Some of the CNAs quit because they said they have nowhere to go for help and are working alone. BATHING Review of the Resident Council minutes, for June 7, 2017, showed residents had concerns with nursing staff. Review of the Resident Council minutes, for July 5, 2017, showed seven out eleven residents identified bathing as a concern. Review of the Grievance/Concern Report Form, dated 7/5/17, showed staff member B addressed the grievance by scheduling designated bath attendants. Review of the Resident Council minutes, dated August 2, 2017, showed the residents at the meeting still had bathing concerns. A resident had identified staffing issues on the weekends. The resident had said in the meeting that she required a two person lift. Relating to the staffing shortage the weekend of 7/30/17, the resident remained in bed because of the staff shortage. Review of the Grievance/Concern Report Form, dated 8/2/17, showed staff member B had not addressed the concerns with the bathing issues, and the issue continued to cause stress for those residents who attended the resident council, on 8/2/17. During an interview on 8/21/17 at 1:49 p.m., resident #15 stated receiving one shower every 10 days. Resident #15 stated she used a wash cloth to bath herself, when there were no baths/showers provided. Review of the facility bathing sheets, with dates from the last bath/shower given until present, showed resident #15 received four showers from 5/13/17 until 8/21/17. Resident #15 had four showers in 101 days documented as provided. During an interview, on 8/22/17 at 11:24 a.m., NF1 stated resident #20 had not received a shower from 8/9/17 until 8/21/17. If no bath aides are on the schedule, no baths are given. During an interview on 8/22/17 at 2:35 p.m., resident #3 stated he received only one shower every two weeks. Resident #3 stated that was not enough showers. Review of the bathing sheets, with dates from the last bath/shower given until present, showed resident #3 received three showers from 5/16/17 until 8/21/17. Resident #3 had three showers in 98 days documented. During an interview on 8/22/17 at 9:00 a.m., resident #4 stated she would routinely go 15 days without a shower. Resident #4 stated there is not always enough staff to meet her needs. Review of resident #4's bathing sheets showed four showers in the last 11 weeks. During an interview on 8/21/17 at 2:28 p.m., staff member T stated residents were not receiving showers/baths timely related to the call offs and short nursing staff. During an interview on 8/21/17 at 4:30 p.m., staff member BB stated baths/showers did not get done because of short staffing due to call offs and no shows. During an interview on 8/22/17 at 10:09 a.m. staff member A stated the Quality Assurance Committee had identified residents not receiving baths, in the March 2017 meeting. A bath aide was hired and quit, shortly after. A CNA was recently put into the bath aide position. During an interview on 8/22/17, at 5:00 p.m. staff member B stated the facility had instituted, a couple weeks before, two bath aides per day. Yes, they have been pulled to the floor. The restorative aides have been pulled to the floor. During an interview on 8/23/17 at 3:17 p.m., staff member H stated it had been hard to get baths/showers completed because of short staffing and some residents had not had a bath/shower for six weeks. Review of the most current MDSs for the 21 sampled residents showed 'no shower was completed' in section G, during the 7-day look-back period, for 14 out of 21 residents. RESTORATIVE During an interview, on 8/22/17 at 2:35 p.m., resident #3 and NF2 stated resident #3 was to receive restorative therapy three times a week. Resident #3 and NF2 stated the resident wasn't receiving restorative therapy as ordered. Review of resident #3's care plan, with a review completion date of 5/2/17, showed the resident had leg spasms with pain. Interventions were to complete range of motion on the resident's lower left extremity Review of the restorative aide's worksheets, dated 6/10/17 through 8/11/17, showed resident #3 received restorative 14 times out of 9 weeks. During an interview on 8/24/17 at 9:16 a.m., staff member R stated trying to work with resident #3 daily, but could not if the staff member was pulled to the floor, I can't do two jobs. Review of a Nursing restorative progress note, dated 6/1/17, showed resident #20 was to receive restorative, 3-5 times a week. Review of the restorative aide's worksheets, dated 6/10/17 through 8/11/17, showed resident #20 received restorative sessions 14 out of 27 required sessions. During an interview on 8/22/17 at 7:56 a.m., staff member R stated, when pulled to the floor to be a CNA, she was unable to work with the residents who required restorative services. Staff member R stated residents, on the restorative program, were not receiving what was specifically ordered. Staff member R identified that the CNA staffing shortage made it difficult to offer restorative services, as ordered. During an interview on 8/22/17 at 5:00 p.m., staff member B stated The restorative aides have been pulled to the floor, when there was CNA staff shortage. FALLS Review of the Incidents By Incident Type report for May, 2017, showed resident #9 had five unwitnessed falls. Review of the Incidents By Incident Type report for June, 2017, showed resident #6 had three unwitnessed falls, and resident #9 had two unwitnessed falls. Review of the Incidents By Incident Type report for July, 2017, showed resident #9 had two unwitnessed falls, resident #6 had one unwitnessed fall, and resident #15 had one unwitnessed fall. Review of the Incidents By Incident Type report for August, 2017, showed resident #14 had four unwitnessed falls, and resident #9 had two unwitnessed falls. Review of the Incidents By Incident Type reports showed the number of unwitnessed falls doubled from May to August, 2017. During an interview on 8/23/17 at 4:30 p.m., staff member C stated the facility had no documentation regarding a fall for resident #16, that resulted in a dislocated hip. Review of resident #18's Progress Note, dated 8/9/17, showed resident #18 had an unwitnessed fall in which the resident sustained [REDACTED]. On 8/10/17, the resident was sent to the emergency room for evaluation of left hip pain. The resident returned to the facility with a [DIAGNOSES REDACTED]. During an interview on 8/23/17 at 3:15 p.m., regarding resident #14's falls in the facility, staff member AA, said, I have worked at the facility for some time, and I know what a normal staffing ratio looks like. He said, Lately we have been very short staffed. Refer to F323, Accidents and Hazards, relating to fall information. ABUSE Review of the State Survey Agency, facility event report, dated 6/4/17 and 6/28/17, showed resident #7 fondled the breasts of resident #s 8, 22, 23, and 24. Review of the State Survey Agency, facility event report, dated 7/25/17 showed physical and verbal abuse were substantiated against staff member Z toward resident #9. During an interview on 8/21/17 at 3:50 p.m., NF3 stated the last three Mondays, the memory care unit had one CNA on day shift. The nurse on duty told him she could not watch all the residents, because she did not have two CNAs on shift. During an interview on 8/23/17 at 3:00 p.m., staff member LL stated she could confirm a day where there was one CNA in the unit, during the month of August, 2017. During an interview on 8/22/17 at 7:35 a.m., staff member L stated she had been the only CNA on the memory care unit on several occasions, and could not provide the expected supervision for the 28 residents. Refer to F225 and F226 relating to abuse.

Based on interview and record review, the facility failed to report physical and verbal abuse when they were observed by staff, which allowed continued abuse for 1 (#9), and failed to protect a resident by failing to recognize a resident's risk for elopements, assess the risk, and address an elopement thoroughly, for 1 (#13) of 21 sampled residents. Findings include: 1. Review of the State Survey Agency, facility event report, dated 7/25/17, showed physical and verbal abuse were substantiated, in which staff member Z was the aggressor, and resident #9 was the victim. Review of the Summary/Outcome of Investigation Findings, dated 7/19/17, showed Seven witness statements named staff member Z as being verbally aggressive/inappropriate with resident #9, and others. Two eye witness accounts of physical abuse with bruises consistent (sic) match with accounts. Both accounts reported late. The facility addressed staff member Z, who was no longer employed at the facility. Review of resident #9's Progress Note, dated 6/20/17, showed Has been awake most of the night yelling out. Had only slept about an hour. Continually yelling out 'help . why don't you like me .' Review of resident #9's Progress Note, dated 7/19/17, showed Bruising on each side of chest is hand-shaped with largest bruised area on each side measuring 6 cm x 6 cm. Review of staff member Y's witness statement, dated 7/20/17, showed she observed staff member Z walk past resident #9, who was exhibiting repetitive vocalizations, and said in a loud stern voice, with her hand raised in stop sign, You need to stop, stop. She also stated the week before, resident #13 had told her that staff member Z did not like any of the residents on the unit. During an interview on 8/22/17 at 9:20 a.m., staff member Y stated she did not follow-up with why the resident stated staff member Z did not like the residents, and she did not report the statement to management, because she did not believe it was abuse. Review of staff member J's witness statement, dated 7/19/17, showed staff member Z yells at (resident #9) when she is calling out for help, telling her to quit, saying help and to sit back in the recliner and be quiet. She will not let resident #9 get out of the recliner even when the resident says she has to go pee. Review of staff member X's witness statement dated 7/20/17, showed (staff member Z) called a resident pathetic, and moved her aggressively against the table. When assisting (resident #9) staff member Z is aggressive. I have witnessed (staff member Z) grabbing (resident #9's) hands and slamming them into her lap. I was uncomfortable saying anything and thought the nurse would report it forward. Review of staff member L's witness statement, dated 7/19/17, showed she had on many occasions seen (staff member Z) blatantly abuse (resident #9). She stood against the wheelchair and pinned (resident #9) against the table. (Resident #9) stated she could not breath (sic), and staff member Z told her to shut up. (Resident #9) has bruises on her chest and arms from (staff member Z) pushing her back so hard. Review of staff member JJ's witness statement, dated 7/19/17, showed On several occasions I have witnessed staff member Z's short temper and inability to control it with residents. She often tells them to 'shush' or 'shut up.' Residents with behaviors cause her to get highly agitated, and she has repeatedly pushed them back or held them in place while they are in their wheelchairs. During an interview on 8/24/17 at 9:10 a.m., staff member JJ stated the residents were 'riled up' when staff member Z was on shift. She stated she would report suspected abuse immediately to her supervisor. During an interview on 8/23/17 at 8:05 a.m., staff member L and K, staff member L stated she had reported the abuse in May, 2017, through a written document. She stated she told staff member K, and they went to staff member B together. Staff member K stated she thought this had occurred more recently than May 2017. The facility showed no documentation of this report or abuse, until July 19, 2017. Staff member L stated she did not know there was a State Survey Agency hotline she could call for suspected abuse. 2. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #13's 5-day PPS, MDS assessment, dated 7/23/17, showed she had wandered 1-3 days during the look back period. Review of resident #13's Progress Note, dated 7/9/17, showed. Patient is confused and thinks she is here working as the DON. Patient has been trying to leave the facility and is considered an elopement risk. She also wrote a personal check and gave it to staff ., Patient has been placed on watch and staff is locating and documenting Q 15 min as to where the patient is at. Review of resident #13's Progress Note, dated 7/18/17, at 1:38 p.m., showed, found (sic) resident pushing another resident in w/c (resident also from locked wing) down D wing hall Review of resident #13's Progress Note, dated 7/19/17, at 6:00 p.m., showed, Resident has escaped off locked unit three times this morning A review of the facility's policy, Elopement, reflected, the facility staff did not consider the resident eloping from the secured unit an actual elopement, but rather the threshold for elopement was a resident had to escape the building. During an interview on 8/23/17 at 1:30 p.m., staff member A and C stated they agreed with the facility policy, and unless a resident eloped out of the building, it was not considered an elopement.

Based on observations, record reviews, staff and resident interviews and policy reviews, it was identified the facility was not managed effectively, utilizing it's resources, while providing care for 15 residents (#'s 1, 2, 3, 4, 6, 8, 11, 12, 13, 14, 18, 20, 21, 24 and 26) out of 26 sampled and supplemental residents. Immediate jeopardy was identified pertaining to Resident Behavior and Facility Practices for neglect of care, and Quality of Care for not maintaining the resident's highest well being. A resident experienced repetitive injury; the facility failed to provide interventions to prevent future occurrences of harm. During the recertification survey, completed on 5/23/14, the survey team identified deficient practice in six regulatory areas with 14 deficiencies being cited. Findings include: 1. Resident Rights a. F157-Notification of physician and family was cited. The facility failed to ensure proper and timely notification was made to the physician and/or family/responsible party for resident's #1 and 24. The scope and severity was a pattern due to the repetitive lack of notifications for resident #1, with no actual harm, but potential for more than minimal harm (see F224 for detailed information). b. F176-Self administration of drugs, was cited. The facility failed to identify residents # 2 and 26, who maintained over the counter medications, with warning labels, in their room unsecured. Several observations of the over the counter medications were made over several shifts/days. The scope and severity of this deficiency was isolated with no actual harm, but potential for more than minimal harm. 2. Resident Behavior and Facility Practices a. F224 Prohibition of neglect, mistreatment, and misappropriation of property was cited. The facility failed to provide medically related services for a disabled resident, #1, who was dependent on care. The resident received repetitive injuries over the last year. The facility failed to implement preventative measures to prevent future injuries for her (see F224 for details). Resident #14 was found to have an injury of unknown origin, which the facility failed to provide intervention for future recurrences or investigate the injury. Resident #24 experienced a deterioration in her symptoms of depression over a 6 month period, with lack of intervention by the facility. This deficiency was cited at an immediate jeopardy to resident health or safety for resident #1, due to the repetitive injuries and lack of intervention by the facility. b. F226 Development of abuse and neglect policies was cited. The facility failed to identify and investigate allegations of unknown injuries for residents' #1 and 14. This deficiency was cited as a pattern at no actual harm with potential for more than minimum harm due to the repetitive nature of injuries resident #1 received (see F224 for detailed information). 3. Quality of Life F253 Housekeeping and maintenance services was cited. This was for the failure to correct uncleanable surfaces. This was isolated with no actual harm with potential for minimal harm. 4. Resident Assessment a. F278 Assessment accuracy/coordination and certification was cited. The facility failed to complete a comprehensive wound assessment or monitoring for resident #13. This deficiency was isolated with no actual harm, with potential for more than minimal harm. b. F279 Developing a comprehensive care plan was cited. The facility failed to develop and review comprehensive individualized care plans, to reflect the residents' current status, for residents' #'s 1, 2, 3, 6, 8, 12, 20, 21, 24 and 26. This was cited as a pattern, with no actual harm with potential for more than minimal harm. c. F281 Services provided meet professional standards was cited. The facility failed to complete documentation for the assessment and monitoring of skin, completion of wound care, physician ordered treatments, supplement administration, monitoring for side effects of antidepressants/antipsychotics or pain assessments. Additionally, gloves were not worn during the blood collection procedure (glucose monitoring) for residents' #'s 1, 2, 3, 6, 11, 13 and 18. This deficiency was cited as a pattern, with no actual harm, but potential for more than minimal harm. 5. Quality of Care F309 Providing care/services for the highest well being was cited. The facility failed to provide the necessary care and services for a physically dependent resident, who left the facility independently, and returned with [MEDICAL CONDITION]/or injury to her skin. Facility administration had knowledge of the repetitive events, but interventions were not implemented to prevent future occurrences for resident #1, and resident #24 had no investigation or interventions for his injury completed. Immediate jeopardy was cited for the deficiency related to resident #1's repetitive injuries. The facility's lack of response to the resident's injuries was identified as immediate jeopardy to resident health and/or safety (see F224 for detailed information on resident's injuries). 6. Administration a. F 490 Administration was cited. The facility failed to ensure it was administered effectively, utilizing it's resources, for resident #'s 1, 2, 3, 6, 8, 11, 12, 13, 14, 18, 20, 21, 24, and 26. F 490 is cited at immediate jeopardy to resident health and/or safety. b. F514 Resident records/complete and accurate and accessible was cited. The facility failed to maintain accurate and complete medical records for residents' to provide information for: the identification, assessment, progress and monitoring of skin; sexual and aggressive behaviors; and obtaining consent for the use of [MEDICAL CONDITION] medication to include the documentation of the consent and education provided for the medication use. Resident's affected by this deficiency include #'s 1, 2, 14, 20. The deficiency was a pattern, with no actual harm with potential for more than minimal harm.

Based on resident and staff interview, record review and observation, the facility failed to provide the necessary care or services for a physically dependent resident, who left the facility independently and returned with [MEDICAL CONDITION]/or injury to her skin. Facility administration had knowledge of the safety concerns. This occurred for 1 (#1) of 26 sampled and supplemental residents. The facility failed to address 1 (#24) of 26 sampled and supplemental residents who had increased depression and a delay of treatment after a fall. IMMEDIATE JEOPARDY One resident did not receive the necessary care or services related [MEDICAL CONDITION]/or skin injuries. Failures included: a. Failure to report injuries of unknown origin b. Failure to respond to a resident's concern for an injury c. Failure to communicate a resident's medical status for needed treatment d. Failure to develop a plan of care, based on the resident's history, preferences and current status, and risk factors e. Failure to implement preventative measures for injuries f. Failure to notify the physician or responsible party timely for injuries or trends with repeated injuries g. The facility failed to ensure the resident was provided education for her independent choices, which put her at risk of injury, and document the education h. The facility failed to implement preventative measures for identified risk factors for when the resident was out of the facility without supervision i. Nursing failed to notify the physician or responsible party timely for injuries or trends with repeated injuries for the physician to make an informed decision regarding the resident's care. PLAN TO ABATE THE IMMEDIATE JEOPARDY The facility submitted an acceptable plan to abate the immediate jeopardy on 05/23/14 at 10:50 a.m. A summary of the facility's abatement plan to remove the immediate jeopardy was as follows: Action Plan is to attempt to prevent (Resident's name) from harm following an independent outing from the facility. 1) Upon returning to the facility from an outing, (Resident's name) will be offered a full body assessment by the nurses. She will be asked if she experienced any injury during her outing. Staff will ask her, if she is agreeable, to do an assessment. If she declines, the refusal will be documented in the medical record. 2) [MEDICAL CONDITION] other skin issues are identified, during an assessment, the nurse will complete the following: a. incident report form, appropriate skin b. appropriate Condition Reporting form c. document in narrative notes and complete the HPHC skin notification form d. apply appropriate treatment e. contact treating physician. Family/POA as appropriate f. update resident care plan g. notify the Director of Nursing and Administrator within 24 hours 3) The Maintenance Supervisor, Director of Nursing and Administrator will meet with (Resident's name) to discuss the possibility of her wanting to have a cup holder for her wheelchair. The facility Occupational Therapist may assist/assess in this addition to her wheelchair. (Resident's) refusal of options will be documented in the Medical Record. The IDT will look at other interventions to prevent harm. 4) These procedures will be offered to al residents that have independent outings from the facility, as appropriate. 5) The DON will in-service all nursing staff as to the procedures required for full body assessments for residents that leave the facility on independent outings. Training will include CNA documentation, MDS documentation as well as wound tracking documentation. 6) Care Manager will assure that the Sign Out book is accessible to residents with disabilities, such as (Resident's name), utilizing a clipboard when appropriate, and assist when appropriate. 7) Educate resident(s) prior to leaving the facility. Discuss with the resident the possible health and safety risks and consequences of refusal of skin and/or injury assessments. 8) QA follow-up, by Care Managers/DON for monitoring of progress or barriers will be completed monthly. 9) Monitoring of progress of barriers will be completed by the Administrator and QA committee members, monthly for 3 months. 10) QA will review the abatement plan and sustainability. The Immediate Jeopardy was abated on 5/23/14 at 1:20 p.m. The deficient practice remained at a severity and scope of H once the immediate jeopardy was abated. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS, dated with an ARD of 1/22/14, coded resident #1 as cognitively intact. She did not exhibit rejection to care and was dependent on staff for ADL care. Resident #1 was able to maintain her independence by utilizing a motorized wheelchair and left the faciity on a regular basis for activities in the community. These activities included, smoking while off facility grounds, having coffee at a local coffee shop or sitting in the sun on warm days. a. Review of the nursing progress notes dated 6/6/13 at 6:15 a.m., the nurse documented a new sunburn and that the resident was complaining of pain on her left lower extremity. A large blister and red area on the resident's left leg was also present. The resident explained she could not feel the blister but it was making her whole left side hurt. The physician was notified of the burn. -On 6/13/13 at 11:11 a.m., the nurse documented the description of the healing sunburn and the blister had now opened. She measured it to be 2.5 cm x 6 cm with scant serous drainage. The nurse faxed the physician for a treatment, which included triple antibiotic daily. A Non-Pressure Skin Condition Report, dated 6/13/13, was completed on the sunburn, which was measured as 15 cm long. Consecutive Non-Pressure Skin Condition Reports were completed for the healing progress of the sunburn for the time period of 6/19/13-7/29/13 and on 9/5/13-9/12/13. On 9/12/13 the nurse documented the wound had resolved. Through this time period, the medical record did not show evidence of preventative measures for sunburns. b. The wound team completed a skin assessment on resident #1 on 9/12/13, and documented the identification of 13 new skin concerns, and completed Non Pressure Skin Condition Reports. The reports included a description and size of each wound (see F224 for detailed wound information). On 9/25/13 a follow-up assessment was completed on the 13 wounds, which were not healed as of this date. Findings were documented on the Non Pressure Skin Condition Report. There was no evidence of any further documentation for the healing or monitoring of the 13 areas identified on 9/12/13. c. Review of 78 skin assessments, completed by the CNAs during the dates of 6/14/13 to 5/2/14, revealed: seven of the skin checks documented the resident as having clear skin, free of injury. The remaining 71 checks included documentation of a minimum of one skin concern, up to a maximum of nine skin concerns at any given time. These were documented as burns, skin tears, scabs, bruises or ulcers. The medical record did not provide evidence for causes of the majority of the skin injuries. d. On 11/27/13, a CNA skin check identified resident #1 as having a new burn to her abdomen. The medical record did not show evidence of nursing follow up of the new burn. e. A nursing note dated 12/2/13, included the documentation, "Open wound 3 cm x 3 cm left posterior thigh." The medical record did not include evidence of the cause of the new wound, or interventions to prevent future recurrences. f. On 12/24/13 at 3:51 p.m., the nursing notes described how the resident complained about burning her abdomen the day before. The resident's skin was assessed and found to have a new fluid filled blister to her abdomen, which had ruptured. A large red excoriated area surrounded the blister and the top layer of skin was gone. The wound was treated with triple antibiotic, [MEDICATION NAME] and [MEDICATION NAME] dressing. - On 1/13/14 the nurse documented the open area for the burn, which measured 4 cm x 3 cm x .1 cm and the physician was notified. The notification to the physician occurred 20 days after the burn was identified. g. The resident reported a new skin concern on her finger to the nurse on 3/9/14. The nurse documented the observation of a 0.25 cm diameter skin wound with thick white drainage measuring 2-3 cc. No cause was documented. h. At 10:15 a.m., on 4/11/14, the resident reported a new burn on her abdomen from coffee a few days prior. When assessed by the nurse, the new burn was measured at 4 cm and included a popped blister in the center of the burn, which measured 1.5 cm. -At 10:36 p.m., the nurse assessed the burn and identified two distinct parts. These measured 3 cm x 2 cm, noted to be a second degree burn, which was over an old burn scar. The second area measured 2 cm x .5 cm, and was a blister, which remained intact. At 11:00 p.m., on 4/11/14, the nurse faxed a communication to notify the physician of the burn and blister. The two areas were documented as a 3 cm x 2 cm and the second as a 1.5 cm x .5 cm. (different from the measurement 1/2 hour prior). The nurse requested a treatment from the physician, which was approved. A physician progress notes [REDACTED]. A Nursing Home Patient Encounter Form, completed by the physician, dated 4/17/14, documented the size of the burn to the abdomen as, "palm size." The CAAs, dated 1/28/14, included two areas of concern;[MEDICAL CONDITION] the tops of fingers and burn to her abdomen "3 cm x 1 cm - hot coffee." The care plan for resident #1, which is not all inclusive, included the following problems: 1. Resident cannot smoke at HP d/t no smoking policy and doctors order. 2. The resident preferred independent activities of choice. 3. Resident had, "Skin at risk assessment elevated." 4. The resident is totally dependent on the staff for bathing, toileting, repositioning and transfers and extensive assistance for dressing. 5. Stage 2 pressure ulcers on left calf and right ischeal area. 6. Resident had a power chair and required supervision. 7. For locomotion off the unit, the resident had a power chair, which required supervision and cueing. 8. For nutrition, the resident required meal set up and supervision. She required adaptive equipment. On 5/20/14 at 10:10 a.m., the resident was observed in her room sitting in her electric wheelchair. She attempted to pick up an article off her bedside table, which she knocked to the floor on accident, due to her lack of hand mobility. The resident then used her hands, palms facing each other, fingers together, and held an item between her two hands. During the observation, the resident voiced her frustrations for not having items accessible to meet her disabilities. On 5/22/14 at 1:15 p.m., resident #1 was observed at a local coffee shop, sitting in her wheelchair in the parking lot. The resident was holding a lit cigarette in her hand. She had two visible small scabs, one on each hand, both round and approximately 1cm in diameter. The resident had numerous round scars on each hand, which were whiter than her normal skin tone, measuring approximately 1 cm in diameter. The resident was wearing a light weight skirt, which was blowing in the wind. Using the hand with the lit cigarette, she attempted several times to hold the skirt down as the wind was blowing the skirt up over her legs. On 5/22/14 at 3:30 p.m., resident #1 discussed the difficulty she had with signing out of the facility due to her disability and the book was kept behind the nursing station, which was not always manned. Because of this, the resident will, "Just go" and leave the facility on her own without signing out. The resident explained on one occasion when she returned to the facility, date unknown but fairly recently, she reported a new burn on her abdomen to the nurse, who replied, "Well I guess you can't go to (business name) anymore now can you?" She said the nurse did not complete a skin assessment at that time but walked away. The following morning she stated the CNAs identified a burn and blister to her abdomen and notified the nurse. Staff member C, ADON, was interviewed on 5/21/14 at 9:25 a.m., and stated, "She (resident) is independent and goes out with family. It's her choice. We have nothing set up that I know of for skin checks on her return." The ADON confirmed she was aware of resident #1 smoking, her repetitive injuries, and repetitive burns. Staff member E, care manager, was interviewed on 5/21/14 at 9:35 a.m., and stated, "It's her option to go out and do the things she does." He also stated he was not aware of any interventions in place to prevent the injuries because the resident was not in the facility at the time she received the injuries. Staff member A, administrator, was interviewed on 5/21/14 at 2:30 p.m. He was aware of the resident smoking when she left the facility and that she sustained repetitive burns. The administrator explained how he had set up a meeting with the Ombudsman, family and resident to discuss the resident's preference to smoke. The meeting was not documented in the medical record per the Administrator. He stated, "What do we do; she leaves; she checks out." The facility did not pursue preventative interventions for the resident as she was not on facility property when the injuries occurred. Staff member A, administrator and staff member B, DON, were interviewed on 5/20/14 at 9:00 a.m with regards to residents leaving the facility and sustaining injuries while off facility grounds. Staff member A stated, "When a resident leaves the facility or signs themselves out, the facility is not responsible for any accidents that happen to them." Staff member B agreed with Staff member A and stated, "We can't be responsible for things that happen to them when they aren't here." Staff member A and staff member B were asked if residents were assessed when they returned to the facility from an outing. Staff member A stated, "No, they're not." Staff member B stated, "We don't have the staff available to assess every resident, every time they come back from an outing." 2. Resident #24 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The resident's cognition was moderately impaired per her quarterly MDS with an ARD of 1/15/14. Nursing notes indicated the resident fell on [DATE] with complaints of left hip pain. The physician was in to visit the resident on 12/5/13 and did not document any assessment of the resident's left hip pain. Nursing notes from 12/5/13 to 12/9/13 indicated that the resident continued to complain of pain to the left hip and leg. A nursing note on 12/9/13 indicated that the resident continued to "have a high pain level, rating a 9/10 (where 0 is no pain and 10 is the highest amount of pain) five hours after [MEDICATION NAME] administration and one hour after Tylenol administration, with ice applied." -On 12/9/13 at 11:50 p.m. the facility received a verbal order from the nurse practitioner for an x-ray of the resident's left hip to rule out a fracture. -On 12/10/13 at 8:08 p.m. nursing notes stated; "No results back from x-rays at this time. C/o pain to left leg from knee to hip." -On 12/11/13 at 2:30 p.m. nursing notes stated; "Hip X-ray results arrived. Negative for fracture. Informed resident, who was quite relieved. Hip pain does continue and res. is receiving PRN Moro and ice packs to help with pain." -On 12/11/13 at 10:55 p.m. nursing notes stated; "Resident has been complaining of left hip and back pain through the shift. PRN pain medication administered with some relief. Ice pack applied to hip." -On 12/12/13 at 12:05 p.m. nursing notes stated; "Took call from (clinic) for Alpine Wing LN from (name) NP. (Resident name) is unable to bear weight on the left leg related to hip pain. Because the X-ray did not indicated any fractures, (name) NP has ordered a CT of the left hip and pelvis without contrast." "Gave report to the LN on the unit and the CT is scheduled for 1445." -On 12/12/13 nursing notes stated; "Received results of CT scan per (name) NP. Positive for fracture, however will not require surgery. Resident should be weight bearing as tolerated on L leg. Leg should not be abducted for any reason. Follow up with Dr. (name) at (name) orthopedics in one week. Update (name) with increasing pain or other concerns." Staff member B, DON, was interviewed on 5/21/14 at 3 p.m. pertaining to documentation of falls and other unexplained incidents that occurred to residents. Staff member B explained that an incident report was completed by the nursing staff on duty at the time of the incident. That incident report was then passed on to the DON for further investigation. Notification to the physician and/or family member regarding changes in health conditions. The incident reports for the past six months were reviewed and no incident report for the resident's 12/5/13 fall was found. Review of the resident's Social Service Review dated 1/30/14 under, "Mood/Behavior Status"reflected, "(Resident) has depression and anxiety, feeling down, is tired with little energy, feels bad. Has trouble with concentration (anxiety) (sic) is restless and has thought about death - not suicide - but thinks about her husband and child and can't wait to see them again." Resident #24's MDS was reviewed for 7/15/13, 10/14/13, and 1/15/14. Section D, question D0600 indicated that the resident's depression had increased from a 1 (minimal depression) on 7/15/13 to a 5 (mild depression) on 10/14/13 to a 14 (moderate depression) on 1/15/14. It was noted the resident was receiving [MEDICATION NAME] 50mg once a day for depression. This dose was ordered on [DATE], upon her transfer from an acute care facility, and was not increased at any time during the resident's stay at the facility. Nursing staff did not contact the physician and inform him that the resident's depression had increased significantly over a six month period. Social service notes did not indicate they had contacted the physician regarding the resident's increased depression. No documentation was found in resident #24's clinical record that indicated that her increased depression was being addressed.

Based on resident interview, staff interview, record review and observation, the facility failed to provide the necessary care and services for a physically dependent resident, who left the facility independently and returned [MEDICAL CONDITION]/or injury to her skin. Facility administration and staff had knowledge of the resident's repetitive injuries, but failed to implement interventions for safety to prevent future injuries. This occurred for 1 resident (#1) of 26 sampled and supplemental residents. The facility failed to provide the necessary care and services for a resident who had an unobserved fall and subsequently suffered a [MEDICAL CONDITION]. IMMEDIATE JEOPARDY The facility failed to report injuries of unknown origin. The facility failed to respond to a resident's concern for an injury. The facility failed to communicate a resident's medical status for care or treatment to the physician. The facility failed to develop a plan of care, based on the resident's history, preferences and current status. The facility failed to implement preventative measures for injuries. The facility failed to notify the physician and/or responsible party timely for injuries or trends with repeated injuries. The facility failed to provide and document the provision of education for the risk of potential harm of resident's independent choices. On 5/22 /14 at 3:00 p.m., the facility administrator was notified by the surveyors that an immediate jeopardy situation existed for 2 of 26 sampled residents. PLAN TO ABATE THE IMMEDIATE JEOPARDY The facility submitted an acceptable plan to abate the immediate jeopardy on 05/22/14 at 8:15 p.m. A summary of the facility's abatement plan to remove the immediate jeopardy was as follows: Action Plan is to attempt to prevent (Resident's name) from harm following an independent outing from the facility. 1) Upon returning to the facility from an outing, (Resident's name) will be offered a full body assessment by the nurses. She will be asked if she experienced any injury during her outing. Staff will ask her, if she is agreeable, to do an assessment. If she declines, the refusal will be documented in the medical record. 2) [MEDICAL CONDITION] other skin issues are identified, during an assessment, the nurse will complete the following: a. incident report form, appropriate skin b. appropriate Condition Reporting form c. document in narrative notes and complete the HPHC skin notification form d. apply appropriate treatment e. contact treating physician. Family/POA as appropriate f. update resident care plan g. notify the Director of Nursing and Administrator within 24 hours 3) The Maintenance Supervisor, Director of Nursing and Administrator will meet with (Resident's name) to discuss the possibility of her wanting to have a cup holder for her wheelchair. The facility Occupational Therapist may assist/assess in this addition to her wheelchair. (Resident's) refusal of options will be documented in the Medical Record. The IDT will look at other interventions to prevent harm. 4) These procedures will be offered to al residents that have independent outings from the facility, as appropriate. 5) The DON will in-service all nursing staff as to the procedures required for full body assessments for residents that leave the facility on independent outings. Training will include CNA documentation, MDS documentation as well as wound tracking documentation. 6) Care Manager will assure that the Sign Out book is accessible to residents with disabilities, such as (Resident's name), utilizing a clipboard when appropriate, and assist when appropriate. 7) Educate resident(s) prior to leaving the facility. Discuss with the resident the possible health and safety risks and consequences of refusal of skin and/or injury assessments. 8) QA follow-up, by Care Managers/DON for monitoring of progress or barriers will be completed monthly. 9) Monitoring of progress of barriers will be completed by the Administrator and QA committee members, monthly for 3 months. 10) QA will review the abatement plan and sustainability. The Immediate Jeopardy was abated on 5/23/14 at 1:20 p.m. The deficient practice remained at a severity and scope of H once the immediate jeopardy was abated. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS, dated with an ARD of 1/22/14, coded resident #1 as cognitively intact. She did not exhibit rejection to care and was dependent on staff for ADL care. Resident was able to maintain her independence by utilizing a motorized wheelchair and left the faciity on a regular basis for activities in the community. These activities included smoking while off facility grounds, having coffee at a local coffee shop and sitting in the sun on warm days. a. Review of resident #1's nursing notes identified the following concerns: -On 6/6/13 at 6:15 a.m., the nurse documented a new sunburn and the resident was complaining of pain on her left lower extremity. A large blister and red area on the resident's left leg was identified. The resident explained she could not feel the blister but it was making her whole left side hurt. A fax communication was sent to the physician on 6/6/14 documenting the burn as having two areas, being: 3 cm x 1 cm and 6 cm x 3.5 cm. -On 6/13/13 at 11:11 a.m., the nurse documented a description of the healing sunburn and that the blister had opened. The blister measured 2.5 cm x 6 cm with scant serous drainage the physician was notified. A Non-Pressure Skin Condition Report, dated 6/13/13, documented the burned area including the blister as 15 cm long. Consecutive Non-Pressure Skin Condition Reports were completed on the healing progress of the blister and sunburn for the dates of 6/19/13-7/29/13 and 9/5/13-9/12/13. On 9/12/13 the nurse documented the wound had resolved. The medical record did not provide evidence of any interventions for prevention of future sunburns. b. On 9/12/13, the nursing notes in the medical record included documentation of a skin assessment completed by the wound team. The assessment resulted in 13 skin concerns being identified. Non Pressure Skin Condition Reports were completed for the 13 wounds with a description and size of each wound. The facility did not provide documentation for potential causes for the wounds or preventative efforts for future wounds. The wounds were: -Left hand abrasion to the little finger measuring 2.2 cm by 0.8 cm -Right hand distal little finger (unidentified type of wound) measuring 0.4 cm x 0.4 cm -First finger right hand (unidentified type of wound) measuring 1.4 cm x 1.6 cm -Top of left hand (unidentified type) 0.8 cm x 0.5 cm -Right hand abrasion to the little finger proximal measuring 0.3 cm x 0.2 cm -Abrasion to the top of the right hand measuring 0.2 cm x 0.7 cm -Left heel (unidentified type of wound) measuring 0.9 cm x 0.4 cm -Great toe (unidentified type of wound) to left foot measuring 0.7 cm x 0.3 cm -Second toe (unidentified type of wound) left foot measuring 0.6 cm x 0.6 cm -First finger distal phalange (unidentified type of wound) left hand measuring 0.5 cm x 0.2 cm -Little finger abrasion on left hand measuring 0.8 cm x 0.8 cm -Third finger abrasion to the first knuckle on the left hand measuring 0.5 cm x 0.5 cm -Second finger abrasion to the first knuckle on the left hand measuring 0.8 cm x 1.0 cm On 9/25/13 a follow-up assessment was completed for the 13 wounds. Findings were documented on the Non Pressure Skin Condition Reports. At this time the wounds were not healed. This was the last documentation in the medical record for each wound. The medical record did not include physician or responsible party notification for the wounds on either 9/12/13 or 9/25/13. c. Review of 78 skin assessments, completed by the CNAs during the dates of 6/14/13 to 5/2/14 revealed: seven of the skin checks documented the resident as having clear skin, free of injury. The remaining 71 checks included documentation of a minimum of one skin concern, up to a maximum of nine skin concerns at any given time. These were documented as burns, skin tears, scabs, bruises or ulcers. The medical record did not provide the cause of every injury. On 11/27/13, a CNA skin check included documentation of a new burn to the resident's abdomen. The nurses' notes did not provide the cause of the new burn or an indication that the physician was notified. d. A nursing note dated 12/2/13, included the documentation, "Open wound 3 cm x 3 cm left posterior thigh." The medical record did not provide evidence for a cause of the new wound to the thigh. The medical record did not include documentation of physician or responsible party notification for the new wound. e. On 12/24/13 at 3:51 p.m., nursing progress notes included documentation about the resident burning her abdomen the day before. The resident's skin was assessed and a new burn was found with a fluid filled blister, which was on the abdomen. The blister had ruptured. A large red excoriated area surrounded the blister. The top layer of skin was gone. The wound was treated with triple antibiotic, [MEDICATION NAME] and [MEDICATION NAME] dressing. On 1/3/14 The nurse documented that the burn on the abdomen, identified on 12/24/13, was healing. The nurse documented that the open area measured 4 cm x 3 cm x 0.1 cm. The physician was notified by fax and treatment orders were requested. The nurse requested a treatment of [REDACTED]. The physician approved the request. Physician notification occurred 20 days after the burn was identified. No interventions were identified in the plan of care for burn prevention. f. The resident reported a new skin concern on her finger on 3/9/14, and this was documented in the nurse's notes of the same day. The nurse documented an observation of a 0.25 cm diameter skin injury with thick white drainage measuring 2-3 cc. The medical record did not indicate a potential cause of the skin injury. g. On 4/11/14, nursing progress notes included: -At 10:15 a.m., the resident reported a new burn from hot coffee on her abdomen from a few days prior. When assessed by the nurse, the new burn was measured at 4 cm and included a popped blister in the center of the burn, which measured 1.5 cm. -At 10:36 p.m., the nurse assessed the burn and identified two distinct parts, which measured 3 cm x 2 cm. The new burn was "a second degree burn over an old burn scar" per the documentation. The second area measured 2 cm x 0.5 cm, and was a blister, which remained intact. At 11:00 p.m., on 4/11/14, the nurse faxed a communication to notify the physician of the progress of the burn. Two areas were documented as a 3 cm x 2 cm and the second as a 1.5 cm x 0.5 cm. The nurse requested treatment orders. On 4/17/14 the physician gave a telephone order. This included the treatment to the burn with a [MEDICATION NAME] dressing, which was to be changed daily. The medical record did not provide evidence of any interventions for prevention of future burns. A physician progress notes [REDACTED]. A Nursing Home Patient Encounter Form, completed by the physician and dated 4/17/14, documented the size of the burn to the abdomen as, "palm size." The CAAs, dated 1/28/14, included two burns, one on the tops of her fingers and the other to the abdomen, "3 cm x 1 cm - hot coffee." The care plan for resident #1 did not provide evidence of interventions [MEDICAL CONDITION] skin injury prevention, for the repeated injuries. Some interventions included: -Resident cannot smoke at HP d/t no smoking policy and doctor's order. -The resident preferred independent activities of choice. -Resident had, "Skin at risk assessment elevated." -The resident is totally dependent on the staff for bathing, toileting, repositioning and transfers and extensive assistance for dressing. -Stage II pressure ulcers on left calf and right ischeal area. -Resident has a power chair and required supervision. -For locomotion off the unit, the resident has a power chair, which required supervision and cueing. -For nutrition, the resident requires meal set up and supervision. She requires adaptive equipment. The SA event log, for facility reported allegations of abuse/neglect or unknown injuries did not include any injuries for resident #1. On 5/20/14 at 10:10 a.m., the resident was observed in her room sitting in her electric wheelchair. The resident moved her arms and hands in one motion, with her fingers together. She attempted to pick up an article off her bedside table, which she knocked off the table. The resident then used her hands, palms facing each other, fingers together, and held an item between her two hands. In order to move her hands to another location, the resident adjusted her upper torso, which in turn moved her arms and hands in one movement. The resident exhibited difficulty in her tasks and voiced frustration with not having items accessible to meet her disabilities. On 5/22/14 at 3:30 p.m., resident #1 explained the difficulty she had with signing out of the facility. The sign out sheet was maintained in a book/binder behind the nursing station, which was not always manned. The resident stated she will wait, but then, "Just go" and leave the facility on her own because she gets upset that she must wait to sign out because the book is not accessible for her. The resident explained on one occasion, date unknown, she returned to the facility and reported to the nurse a new burn on her abdomen, who replied, "Well I guess you can't go to (business name) anymore now can you?" She stated the nurse did not complete a skin assessment at that time, but rather disregarded her report of the injury. The following morning, the resident said the CNAs found the burn and notified the nurse on duty. Staff member C, ADON, was interviewed on 5/21/14 at 9:25 a.m., and stated, "She (resident) is independent and goes out with family. It's her choice. We have nothing set up that I know of for skin checks on her return." The ADON confirmed she was aware of resident #1 smoking, burning herself from cigarettes, the sunburn, repetitive injuries and coffee burns. Staff member E, care manager, was interviewed on 5/21/14 at 9:35 a.m., and stated, "It's her option to go out and do the things she does." He was not aware of any interventions in place to prevent the injuries because the resident was not in the facility when she received them. The care manager was responsible for completing the comprehensive care plan for resident #1. Staff member H, RN, was interviewed on 5/23/14 at 8:30 a.m. She explained the following must be completed on a new skin concern: -Observe the area to assess -Fill out incident report -Document specific findings in the medical record to include size, color, depth, odor and/or drainage -Notify the physician/responsible party -Begin treatment as ordered -Determine cause for future prevention Staff member A, administrator, was interviewed on 5/21/14 at 2:30 p.m. He said he had knowledge of the resident leaving the facility and smoking cigarettes, and he was aware of [MEDICAL CONDITION] from the cigarettes to her skin, the sun, and coffee. In the past, the administrator had set up a meeting with the Ombudsman, resident's family and the resident to discuss the resident's preference for smoking. The administrator said this meeting was not documented. He stated, "What do we do? She leaves; she checks out." The administrator states that the resident was independent in her activity choices and left the facility property. Because of this, the facility did not pursue preventative interventions for the resident. Staff member A, administrator, and staff member B, DON, were interviewed on 5/20/14 at 9:00 a.m. in regards to residents leaving the facility and sustaining injuries while off facility grounds. Staff member A stated; "When a resident leaves the facility or signs themselves out, the facility is not responsible for any accidents that happen to them." Staff member B agreed with Staff member A and stated, "We can't be responsible for things that happen to them when they aren't here." Staff member A and staff member B were asked if residents were assessed when they returned to the facility from an outing. Staff member A stated, "No, they're not." Staff member B stated, "We don't have the staff available to assess every resident, every time they come back from an outing." 3. Resident #24 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The resident's cognition was moderately impaired per her quarterly MDS with an ARD of 1/15/14. Nursing notes indicated that the resident had an unobserved fall on 12/5/13 with complaints of left hip pain. The physician visited the resident on 12/5/13, but the record lacked the physician's assessment of the resident's left hip pain. Nursing notes from 12/5/13 to 12/9/13 indicated that the resident continued to complain of pain to the left hip and leg. A nursing note on 12/9/13 indicated that the resident continued to "have a high pain level, rating a 9/10 (where 0 is no pain and 10 is the most severe pain) five hours after [MEDICATION NAME] administration and one hour after Tylenol administration, with ice applied." -On 12/9/13 at 11:50 p.m., the facility received a verbal order from the nurse practitioner for an x-ray of the resident's left hip to rule out a fracture. -On 12/10/13 at 8:08 p.m. nursing notes stated; "No results back from x-rays at this time. C/o pain to left leg from knee to hip." -On 12/11/13 at 2:30 p.m. nursing notes stated; "Hip X-ray results arrived. Negative for fracture. Informed resident, who was quite relieved. Hip pain does continue and res. is receiving PRN [MEDICATION NAME] and ice packs to help with pain." -On 12/11/13 at 10:55 p.m. nursing notes stated; "Resident has been complaining of left hip and back pain through the shift. PRN pain medication administered with some relief. Ice pack applied to hip." -On 12/12/13 at 12:05 p.m. nursing notes stated; "Took call from (clinic) for Alpine Wing LN from (name) NP. (Resident name) is unable to bear weight on the left leg related to hip pain. Because the X-ray did not indicate any fractures, (name) NP has ordered a CT of the left hip and pelvis without contrast." "Gave report to the LN on the unit and the CT is scheduled for 1445." -On 12/12/13 nursing notes stated, "Received results of CT scan per (name) NP. Positive for fracture, however will not require surgery. Resident should be weight bearing as tolerated on L leg. Leg should not be abducted for any reason. Follow up with Dr. (name) at (name) orthopedics in one week. Update (name) with increasing pain or other concerns."

Based on staff interview and record review, the facility failed to ensure that standards of quality for insulin administration were followed for 2 (#s 14 and 20) of 33 residents.?,? Findings include: 1. During an interview on 2/14/11 at 8:10 p.m., staff member M, and RN, stated resident #14 was out of a supply of Lantis insulin and the facility had been using resident #20's Lantis insulin for resident #14. Staff member M stated she had informed staff member I, the unit E manager, that there was no further supply of Lantis insulin for resident #14. Staff member M stated the facility had contacted the pharmacy, and she was informed that resident #14's insurance would not pay for anymore Lantis insulin at this time. Staff member M stated that she borrowed the Lantis insulin from resident #20. During an interview on 2/15/11 at 10:20 a.m. with staff member J, she stated that resident #14 had been out of Lantis insulin for at least 3 days. She then stated that, for the past three days, she used resident #20's Lantis insulin for resident #14. She stated that staff member I had instructed her to use resident #20's Lantis insulin for resident #14. Staff member J stated she spoke with the pharmacy and was informed that the pharmacy sent Lantis insulin on 2/6/11 for resident #14 and that the supply of insulin should have lasted for 12 days with her current physician orders [REDACTED]. During a telephone interview on 2/15/11 at 12:15 p.m., with a representative for the pharmacy, he stated the pharmacy instructed the facility that resident #14's insurance would not pay for anymore Lantis insulin, and it was too soon for re-order. He stated that if the facility needed more Lantis insulin, the pharmacy would send it as long as there was a pay source for the Lantis insulin. He stated the pharmacy did not refuse to send the Lantis insulin to the facility. During an interview on 2/15/11 at 4:30 p.m., with staff member I, he stated that he was informed on 2/14/11 that resident #14 was out of Lantis insulin. He then stated that he informed the nurses to do what they had to do. Staff member B, the DON, informed the surveyors at 4:50 p.m. on 2/15/11 that she had spoken with the Operations Manager for the pharmacy, and the facility would be receiving Lantis insulin for resident #14. She stated that she was not aware that resident #14 did not have any Lantis insulin until the morning of 2/15/11. She stated her night shift nurse had left her a note on the morning of 2/15/11 regarding resident #14 not having any Lantis insulin. ?According to the Nurses' Guide to Clinical Procedures, "Compare Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Check for the right client, drug, dosage, time, and route. ?"Nurses who administer medications are responsible for their own actions." Kozier, Erb, and Olivieri; Fundamentals of Nursing, 4th ed. Addison-Wesley; Redwood City, CA. 1991. pp 1265.

Based on observations, staff and family interview, and record review, the facility failed to prevent significant weight loss or demonstrate that such weight loss was unavoidable for 4 (#s 6, 9, 12, and 19) of 19 sampled residents. Findings include: 1. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. Weights According to documentation from staff member R, the Care Manager, the monthly weights for the resident were as follows: - 07/10 - 200#; - 08/10 - 191#, a decrease of 9#; - 09/10 - 176#, a decrease of 15#; - 10/10 - 179#, an increase of 3#; - 11/10 - 171#, a decrease of 8#; - 12/10 - 168#, a decrease of 3#; - 01/11 - 163#, a decrease of 5#; - 02/11 - 161#, a decrease of 2#; In summary, the weight loss changes for resident #9 are outlined below: - From July to August 2010, a decrease of 7.85% of body weight; - From July to September 2010, a decrease of 12%, which is severe; - From July to December 2010, a decrease of 16%, which is severe; - From October to December 2010, a decrease of 6.15%; - From August 2010 to January 2011, a decrease of 14.66%, which is severe; - From September 2010 to February 2011, a decrease of 8.52%. b. Nutritional assessment and interventions - Staff member Q, an RD, completed a monthly nutrition review dated 9/25/10 and stated that the resident was at 176.5# and had a decrease of 8.5% body weight in 30 days, 10.9% in 90 days, and 12.6% in 180 days. The review stated that the resident, "Is max (maximum) assist (assistance) at meal. Staff report resident frequently refusing to eat or drink. Anticipate further weight loss if oral intake remains poor." - Staff member Q completed a monthly nutrition review dated 10/24/10 and stated the resident was at 179# and had a decrease of 10.5% body weight in 90 days and 10.1% in 180 days. The review stated, "Staff report resident eating very little. Blood sugars have been low. Anticipate further weight loss if oral intake remains poor". - Staff member R, the Dietary Manager, completed a quarterly assessment dated [DATE] and stated the resident triggered for significant weight loss in 90 and 180 days. Staff member P, an RD, signed this assessment on 11/3/11. It was noted the resident required total dependence of staff with "feeding." The interventions included diet high calorie supplements three times per day, honey thick pureed foods with honey thick fluids, and weights monitored monthly. The assessment concluded with the statement, "No referrals. proceed to care plan (sic)". - Staff member Q completed a monthly nutrition review dated 11/27/10 and stated the resident was at 166.8# and had a decrease of 6.8% body weight in 30 days, 13.6% in 90 days and 16.6% in 180 days. The assessment concluded with the statement, "Anticipate further weight loss as condition declines". - Staff member Q completed a monthly nutrition review dated 12/27/10 and stated the resident was at 168.8# with a decrease of 14.7% body weight in 180 days. The assessment concluded with the statement, "Anticipate further wt loss as resident condition declines & (and) poor oral intake". - Staff member R completed an annual assessment dated [DATE] and stated the resident triggered for significant weight loss in 180 days. The resident received extensive assist with meals. The interventions included diet high calorie supplements three times per day, honey thick pureed foods with honey thick fluids, and weights monitored monthly. The resident had skin breakdown and received pro-Jello three times per day to aid with skin integrity. The assessment concluded with the statement, "Will continue to provide md (physician) ordered diet. Will continue monitor weights monthly. No referrals. proceed to care plan. (sic)" - Staff Member P, an RD, completed an assessment dated [DATE] and stated the resident weighed 163#. The resident's weight was down 10% in 90 days and 9% in 180 days and indicated severe weight loss at 180 and 90 days. High calorie supplements were provided three times per day. On 2/15/11, the surveyor reviewed the meal intake documentation for the time period from 7/5/10 to 2/14/11. The facility's documentation lacked information regarding the intake of the high calorie supplements and the pro-Jello which were to be given three times a day. The documentation lacked a reason for the continued weight loss and lacked any change in the interventions for the resident by the RD, DM, or interdisciplinary care plan team. There was no change in the interventions from the 10/29/10 assessment to the 2/10/11 assessment to address weight loss. c. Feeding and swallowing guidelines Staff member S, the SLP, completed an evaluation dated 10/02/10. The evaluation resulted in guidelines for mealtime safety and interventions for the resident. The guidelines stated the resident had an oral aversion to metal utensils. The resident's food was to be honey consistency pureed and placed in small, disposable plastic cups. He should be allowed to drink/sip the presentations throughout the meal. If a spoon was needed to get the final amount from the glass, a plastic spoon should be used and placed sideways at his lips. The resident should be reclined to 75 degrees to be placed in a natural chin tuck position. d. Care plan The care plan for the resident dated 1/19/11 stated the problem of therapeutic diet, mechanically altered diet, and skin breakdown. Swallowing problems and weight loss were expected to continue as the current medical condition declined. The goals included increasing meal intakes to 50%, increasing fluid intakes to 50%, and being free from skin breakdown. His weight should be maintained as his condition allows. The Interventions listed included, "Report 5 lbs. weight loss to dietary manager report any skin breakdown to dietary manager report any complaints/signs of pain to nursing staff. provide md (physician)ordered diet - rcs, honey thick pureed diet with honey thick liquids use small med cups to feed (resident's name) encourage (resident's name) to take high calorie supplement and pro-Jello with meals. offer hydration between meals provide assist with hydration chart all meal/fluid intakes (sic)." The care plan lacked new interventions to address the resident's continued unplanned weight loss. e. Staff interview During an interview with staff member HH, an LPN, on 2/14/11 at 8:18 p.m., the surveyor asked about the resident's meal intake. She stated the resident's wife comes at noon to assist him and she can get him to eat when she is here. She stated the resident consumed 50-75% of his supper tonight. During an interview with staff member N, the Care Manager, on 2/15/11 at 9:39 a.m., the surveyor asked what interventions were in place for the resident's weight loss. She stated the resident received pro-Jello, honey consistency foods, and small cups are used at meals. The nursing staff instructed the CNAs regarding the resident's feeding and swallowing guidelines. After the surveyor spoke to the CM, a plastic spoon was on the table in front of the resident rather than a metal spoon. During an interview with Staff Member R, on 2/15/11 at 10:16 a.m., the surveyor asked what she does when weight loss is reported to her. She stated she monitored the weight loss further. The resident received high calorie meals, supplements, and pro-Jello three times per day for skin healing. The surveyor asked what type of snacks the resident received at bedtime and she stated that he receives pudding. Then she commented further that she does not know for sure. Staff member R stated the significant weight loss occurred from August to September 2010. During a telephone interview with staff member S, on 2/15/11 at 3:25 p.m., she stated she wrote meal guidelines for the resident in October 2010. She did not do any consultations regarding the resident since October and she was not invited to participate in the care plan meeting held in January 2011. She inserviced the CNAs on the meal guidelines after they were written. During an interview on 2/16/11 at 9:00 a.m., staff member P and staff member I stated the residents were weighed monthly and a report was generated and given to staff member Q. Staff member Q would then come to the facility and document in the resident's chart regarding the weight loss or gain. The RD and physician would not know about weight loss or gain for a month since the report is monthly. f. Meal observation/snack observation The resident ate at a table in the main dining room and was seated at a table for residents who needed assistance with meals. 1) 2/14/11 breakfast meal At 9:32 a.m., a CNA was observed assisting the resident. The food was presented to him in small cups as ordered and the contents were spooned out of the cup with a metal spoon which was not according to his care plan or meal guidelines. None of the breakfast was consumed by the resident. 2) 2/14/11 dinner meal At 1:06 p.m., the resident was observed being assisted by a family member. The food was presented to him in small cups and the contents were spooned out of the cup with a metal spoon which was not according to his care plan or meal guidelines. The resident consumed all of the meal. 3) 2/14/11 evening snack At 8:02 p.m. to 8:10 p.m., the snack cart was observed in hallway C, where the resident resides. The surveyor observed the resident was not offered an evening snack during the time the cart was present in the hallway. The resident was in his room, seated in a recliner with his eyes closed. 4) 2/15/11 breakfast meal At 9:31 a.m., a CNA was observed assisting the resident. The food was presented to him in small cups and the contents were spooned out of the cup with a metal spoon which was not according to his care plan or meal guidelines. The resident would not open his mouth to accept the food. At 9:32 a.m., another CNA was observed assisting the resident with his breakfast. The food contents were spooned out of the cup with a metal spoon which was not according to his care plan or meal guidelines. When the cup was presented, the resident opened his mouth and accepted the food. In summary, from July to September 2010, the resident had a severe weight loss of 12%. From July to December 2010, the resident had a severe weight loss of 16%. From August 2010 to January 2011, the resident had a severe weight loss of 14.66%. The trend in the resident's weight loss was identified by the DM and an RD; however, the care plan interventions were not updated or revised to address the issue of continued weight loss from July 2010 to present. The resident's weight loss was not planned and was not prescribed by the physician. The facility did not demonstrate that weight loss was unavoidable. 2. Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. Weights According to documentation from Staff member R, the Care Manager, the monthly weights for the resident were as follows: - 10/10 - 167#, which the facility states is an anomaly; - 11/10 - 145# (reweigh), a decrease of 22#; - 12/10 - 144#, a decrease of 1#; - 01/11 - 140#, a decrease of 4#; - 02/11 - 135#(reweigh), a decrease of 5#. In summary, the weight loss changes are outlined as follows: - From October to November 2010 there was a decrease of 13.17%, which is severe; - From October to December 2010 there was a decrease of 13.77%; - From October 2010 to January 2011 there was a decrease of 16.17%, which is severe; - From October 2010 to February 2011 there was a decrease of 19.16%. b. Nutritional assessment and interventions - Staff member P completed an initial nutritional assessment dated [DATE] and noted the resident gained 12.6# in 9 days likely due to fluid retention in the hospital. The goal identified was to maintain normal weight and have adequate intake. The interventions included a rcs, reduced sodium, mechanical soft and nectar thick liquids diet. "Restorative dining with assistance and encouragement for meals. Offer diet appropriate snacks between meals. Encourage fluids with and between meals. Honor food preferences. Monitor wt, labs, food and fluid intake for appropriate intervention." - Staff member R completed an assessment dated [DATE] and stated the resident was 167# at admission. The resident "requires extensive assist (assistance) with meals. he requires max (maximum) set up assist with meals. he requires staff assist with meals at times, and at times he is self feeding. he continues used sippy cups for his fluids and a divided plate with his meals..." The interventions included a mechanical soft diet and nectar thick liquids, honoring food requests if available and in compliance with his diet, and monitor weights monthly. The assessment concluded with the statement, "No referrals. Proceed to care plan." - Staff member R completed a quarterly assessment dated [DATE] and stated the resident's weight decreased 27# in 90 days and the weight in October was an anomaly. "(Resident's name) was on finger foods for self feeding purposes, and the family did not want this so he is no longer receiving finger foods." The assessment concluded with the statement, "No referrals. proceed to care plan (sic)." No new interventions were identified in this assessment. In summary, documentation lacked notification to the RD of the weight loss identified in January 2011, revisions to the care plan to address the unplanned weight loss, and identification as to the cause of the weight loss. c. Care plan The care plan, which had been completed on 10/26/10, showed the problem of poor meal intakes, poor fluid intakes, dysphagia, dementia, therapeutic diet assist with meals, and maintaining weight. The goals were listed as, increase meal intakes to 65%, increase fluid intakes to 65%, independence with self feeding, and maintain weight as condition allows. The Interventions were listed as, "report 5 lbs. weight loss to dietary manager. report any skin breakdown to dietary manager. report any complaints/signs of pain to nursing staff. provide MD (physician) ordered diet - regular texture, 2 gr sodium, rcs diet with finger foods. divided plate and sippy cups for independence with self feeding. nectar thick liquids, is at an assist table for max (maximum) set up assist, supervision, and encouragement with meals. provide staff assist with feeding (resident name). assist (resident name) with transportation to from meals. offer hydration between meals. offer snack at bedtime. chart all meal/fluid intakes." (sic) The care plan was reviewed by the interdisciplinary team on 2/1/11. The comments state, "No problems. Res (resident) settling well." The goal dates were revised and no changes were made to any of the problems, goals, or interventions in the care plan to address continued unplanned weight loss. 3. Resident #12 was admitted to the facility on [DATE]. Admit [DIAGNOSES REDACTED]. The Interdisciplinary Note of 11/27/10, entered by staff member Q, documented that resident #12 had lost 11.9% of her body weight in 180 days, which signified a significant weight loss. The note stated, "Will continue to monitor & (and) provide oral supplements if indicated." The note did not specify when supplements would be provided. The Interdisciplinary Note of 12/30/10, entered by staff member Q, documented that the resident continued to demonstrate significant weight loss. The note stated, "Will continue to monitor if wt loss continues will add interventions." The dietary department's annual assessment, dated 1/7/11, documented significant weight loss, stating that resident #12 had lost 10% of her body weight in 180 days, dropping from 145 lbs. during June 2010 to 130 lbs. in December 2010. The assessment stated, "RD is aware of weight loss, see IDN (interdisciplinary note) of 12/30/10." The assessment also documented, "Will continue to provide MD ordered diet. will (sic) honor food requests if available and in compliance with diet. will (sic) continue to monitor weights monthly. no (sic) referrals. Proceed to care plan." These statements above were the same as those described in the Quarterly assessment of 10/11/10, before the resident developed significant weight loss. No changes in nutritional interventions were discussed on dietary department assessments regarding the resident's weight loss. The Interdisciplinary Note of 1/20/11, entered by staff member Q, documented that resident #12 had lost 14% of her body weight in 180 days, and that her weight was continuing to decrease. The note stated, "Will monitor." The note did not indicate what would be monitored, or how the monitoring would be achieved. No nutritional interventions were suggested or added by the RD in any of the notes she documented between 11/27/10 and 1/20/11. All notes simply mentioned that the resident had a regular or "regular puree" diet. No rationales for resident #12's weight loss were documented in these dietitican notes. On 2/16/11 at 1:06 p.m., staff member P stated that, in response to weight loss, dietitian notes typically list interventions to be implemented and the rationale for weight loss. At 9:20 a.m. on 2/16/11, staff member L, a RN, stated that resident #12 received a supplement to address her weight loss. When asked to provide documentation regarding the supplement, she was unable to find it in the chart. The nutrition CAA of 1/14/11 stated, "(Resident #12) does trigger for wt (weight) loss in 180 days...RD (dietitian) is aware of wt loss see IDN (Interdisciplinary Note) of 12/30/10. will try (resident #12) on a high calorie supplement, if she is willing to take will start bid to maintain wt." Per record review of the supplement lists, resident #12's name was not on the list of residents receiving high calorie supplements for February 2011. On 2/16/11 at 9:30 a.m., during the observation of resident #12's breakfast meal, resident #12's meal did not include a high calorie supplement. Per review of faxes to the physician, the physician was notified of resident #12's weight loss on 2/15/11, 80 days after the resident was initially identified as having significant weight loss. 4. Resident #6 was readmitted to the facility on [DATE] after two hospital stays [MEDICAL CONDITION] and pneumonia. The weights for the resident before his admission to the hospital ranged 139# in July 2010 to 142# in October 2010. His weights after his return from the hospital were 144# in December and then 119# in January 2011. The resident's quarterly assessment note completed on 1/25/11 included the statements that the RD was aware of weight loss and would be charting in February and that "expected weight loss as med (medical) condition declines". The note also included the statement "no referrals" and "proceed to care plan". The note also stated that the January weight triggered for a significant weight loss. A review of the dietary care plan for resident #6 revealed included problems, goals and interventions that had not been updated since the print date of 4/27/10. The effective date of the care plan was 4/14/10-Present. At the time of survey, no new interventions had been added to the care plan since the weight loss was noted in January 2011 through the end of the survey.

Based on observation, staff interview, record review, the facility failed to ensure sufficient fluid intake to maintain proper hydration and health for 2 (#s 3 and 4) of 19 sampled residents. Findings include: 1. Resident #4's care plan, dated 9/28/10, stated the following regarding dehydration: --"Need for monitoring....Provide cues/assist (resident #4) to drink fluids with medications and between meals." --"Poor fluid intakes....provide hydration between meals...chart all meal/fluid intakes." Resident #4's laboratory record, dated 12/28/10, indicated signs of dehydration. The record documented the following values: --BUN (blood urea nitrogen) was 42, outside the normal range of 7-21; --sodium was 155, outside the normal range of 135-145; --hemoglobin was 18.5, outside the normal range of 12-16; and --hematocrit 57.1, outside the normal range of 37-47. On 1/7/11, resident #4 was admitted to the hospital with [REDACTED]. The orders stated, "MUST have at least 1000 cc qd." Transfer paper work from the hospital documented that the resident was unable to make her needs know due to mental, speech, hearing, vision, and sensation impairments. The MDS, with an ARD of 1/13/11, documented in section G that the resident received extensive assistance for eating and failed to document a [DIAGNOSES REDACTED]. The dietary assessment, dated 1/23/11, documented that the resident's fluid intake was 924 cc in 24 hours and that her fluid requirement was 1530 cc in 24 hours. The assessment also documented that dietician's goal for the resident was adequate fluid intake. On 2/15/11 at 10:55 a.m., staff member I, the E wing unit manager, stated that fluid intake was documented on meal intake sheets and CNA hydration sheets. Meal intake sheets and CNA hydration sheets documented the following: --from 12/1/10 to 12/31/10, resident #4 received an average of 612 cc per 24 hours; --from 1/1/11 to 1/6/11, resident #4 received an average of 681 cc in 24 hours; --from 1/10/11 to 1/16/11, resident #4 received an average of 622 cc in 24 hours Resident # 4's CNA hydration sheets for January 2011 lacked documentation of hydration for 43 of 105 opportunities. The CNA hydration sheet for February 2011 lacked documentation of hydration for 30 of 65 opportunities. On 2/16/11 at 8:05 a.m, staff member U, an RN, stated, "The CNAs document hydration intake and I monitor hydration sheets at the end of my shift." On 2/16/11, from 9:05 a.m. until 9:30 a.m., resident #4 sat sitting in the E wing dining room, with her breakfast meal in front of her. No staff members assisted or cued resident #4 to eat or drink fluids. 2. Resident # 3 was admitted to the hospital on [DATE] and discharged back to the facility on [DATE] with [DIAGNOSES REDACTED]. The Active [DIAGNOSES REDACTED]. The dietary assessment, dated 12/31/10, documented that the resident's fluid requirement was for 1700 cc per 24 hours. Resident #4's care plan, dated 1/31/11, stated, "encourage (resident #3) to continue fluid intakes at 100%....(resident #3) is receiving diuretics...." Resident #3's CNA hydration sheets for February 2011 lacked documentation of hydration for 37 of 65 opportunities. The dietary meal intake sheet and CNA hydration sheet documented that resident #3 received an average of 978 cc of fluid between 2/7/11- 2/13/11. On 2/16/11 at 8:05 a.m, staff member U, an RN, stated, "The CNAs document hydration intake and I monitor hydration sheets at the end of my shift." 3. On 2/14/11 at 7:45 p.m., staff member T was offering snacks to residents from the hydration and snack cart, but did not offer juice or water. He did not have any juice or water available to offer residents. 4. The facility policy entitled Encouraging and Restricting Fluids, stated the following: --"Review the resident's care plan and/or your daily assignment sheet to assess for any special needs of the resident." --"Follow specific instructions concerning fluid intake or restrictions." --"Be accurate when recording fluid intake." The policy also stated that resident refusal should be documented and reported to the supervisor.