Every finding on record at La Villa Grande Care Center

Based on record review and interviews, the facility failed to prevent a significant medication error for warfarin (a blood thinner medication) for one (#8) of three residents reviewed for medication errors out of 10 sample residents.Specifically, the facility failed to prevent a significant medication error when Resident #8 received warfarin, a blood-thinning medication, twice a day (once in the morning and once in the evening), instead of once a day at bedtime.Resident #8 was admitted on [DATE] and discharged to home on 9/22/25. Resident #8's diagnoses included hypertension, kidney disease, diabetes, stroke, and left-sided paralysis. Resident #8 was admitted to the facility from the hospital with stroke treatment and prevention orders for warfarin and laboratory monitoring of the blood level international normalized ratio (INR), which is used to monitor the ability for blood to clot. Resident #8's admitting physician's orders on 8/25/25 included testing of the INR on 8/26/25 and warfarin 1 milligram (mg) in the morning and monitoring the INR daily for warfarin dose titrations. A review of Resident #8's electronic medical record (EMR) revealed on 8/22/25 that the resident's INR level tested at the hospital before discharge was 2.44.On 8/26/25, Resident #8's INR level was tested, and the result was 1.69. The result was forwarded to the physician's office. On 8/27/25, the physician gave a verbal telephone order to the facility nurse for warfarin 1.5 mg, by mouth, one time a day, in the evening. The physician gave an order to document the resident's most recent INR level in Resident #8's medication administration record (MAR) and to draw the next INR level on 8/29/25. The 8/27/25 verbal physician's order did not include an order to discontinue the resident's previous 1 mg warfarin dose, which had been administered in the morning. As a result, Resident #8 received warfarin in the morning and in the evening from 8/28/25 to 9/9/25.Additionally, a review of Resident #8's EMR revealed that facility nurses failed to document the resident's most recent INR level from 8/26/25 and instead reported the 8/22/25 hospital result of 2.44 from 8/28/25 to 9/9/25. On 9/10/25, Resident #8's INR level was checked, and the result was 4.5. The physician gave new orders to hold the warfarin medication for three days and recheck the INR level on 9/15/25. The facility's failure to monitor Resident #8's warfarin dosages and INR levels resulted in a significant medication error, which placed Resident #8 at risk for a likely serious outcome. Serious harm to Resident #8 was likely to have occurred as a result of the significant medication error.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation from 12/15/25 to 12/18/25, resulting in the deficiency being cited as past noncompliance with a correction date of 9/11/25. I. Situation of serious harmResident #8's admitting physician orders on 8/25/25 included testing of the INR on 8/26/25 and warfarin 1 mg in the morning and monitoring the INR daily for warfarin dose titrations. A review of Resident #8's electronic medical record (EMR) revealed on 8/22/25 the resident's INR level tested at the hospital before discharge was 2.44.On 8/26/25 Resident #8's INR level was tested and the result was 1.69. The result was forwarded to the physician's office. On 8/27/25, the physician gave a verbal telephone order to the facility nurse for warfarin, by mouth 1.5 mg, one time a day, in the evening. The physician gave an order to document the most recent INR level in Resident #8's MAR and to draw the next INR level on 8/29/25. The 8/27/25 verbal physician's order did not include an order to discontinue the resident's previous 1 mg warfarin dose, which had been administered in the morning. As a result, Resident #8 received warfarin in the morning and in the evening from 8/28/25 to 9/9/25.Additionally, a review of Resident #8's EMR revealed that facility nurses failed to document the resident's most recent INR level from 8/26/25 and instead documented the 8/22/25 hospital result of 2.44 from 8/28/25 to 9/9/25. On 9/10/25, Resident #8's INR level was checked, and the result was 4.5. The physician gave new orders to hold the warfarin medication for three days and recheck the INR level on 9/15/25. The facility's failure to monitor Resident #8's warfarin dosages and INR levels resulted in a significant medication error and placed Resident #8 at risk for a likely serious outcome. II. Facility plan of correctionThe corrective action plan the facility implemented in response to Resident #8's significant medication error was provided by the director of nursing (DON) on 12/17/25 at 9:05 a.m. The plan documented the following:A. Immediate actionResident #8 was evaluated by the outpatient clinic on 9/10/25. Resident #8 had an INR level tested on [DATE] with a result of 4.5. The physician gave new orders to hold the warfarin for three days, restart the warfarin on 9/14/25, and repeat INR testing on 9/15/25 in the morning. The INR result on 9/15/25 will determine the next steps for warfarin therapy.The facility completed a change in condition assessments for Resident #8 from 9/10/25 to 9/13/25 and determined Resident #8 had no adverse outcome after taking the additional warfarin twice a day from 8/28/25 to 9/9/25.B. Identification of other residentsThe facility completed an audit for all residents prescribed warfarin on 9/10/25. The audit included identified residents prescribed warfarin. The audit included a review of physician's orders for warfarin and monitoring for INR level and for any adverse side effects from the warfarin. The audit was completed on 9/10/25.C. Systemic changesOn 9/10/25 education on the Warfarin policy for administration and monitoring was initiated for all nursing staff. The education was added to the new employee education and temporary nursing staff education. The education was provided by the DON and the staff development coordinator (SDC). Education for the nursing staff was completed on 9/11/25.The process for verifying warfarin orders was updated on 9/10/25. The process included a daily review of the warfarin tracking log and new physician orders for warfarin by the DON. The review of physician's orders included all new admissions, verbal orders and orders from outpatient treating physicians.D. MonitoringThe DON or designee would audit the physician's orders and warfarin tracking log daily for four weeks. The DON or designee reported the auditing results daily with nursing staff and weekly to the interdisciplinary team (IDT). The quality assurance and performance improvement (QAPI) committee, with the medical director, reviewed the auditing results for recommendations of process changes if indicated. III. Facility policy and procedureThe Administering Medications policy and procedure, revised April 2019, was provided by the DON on 12/17/25 at 9:05 a.m. It read in pertinent part, Medications are administered in a safe and timely manner, and as prescribed. The DON supervises and directs all personnel who administer medications and/or related functions. Medications are administered in accordance with prescriber orders. Medication errors are documented, reported, and reviewed by the quality committee to inform process changes and or the need for additional staff training. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse outcomes, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. The individual administering the medication initials the resident's medication administration record (MAR) on the appropriate line after giving each medication.The Anticoagulation protocol, dated 2001, was received from the DON on 12/17/25 at 9:05 a.m. It read in pertinent part, The physician will prescribe anticoagulation therapy appropriately consistent with recognized guidelines. If warfarin is used, staff should use a warfarin flow sheet to follow trends in anticoagulant dosage and response in individuals on warfarin.IV. Resident #8A. Resident statusResident #8, age [AGE], was admitted on [DATE] and discharged home on 9/22/25. According to the September 2025 computerized physician orders (CPO), diagnoses included hypertension, kidney disease, diabetes mellitus, stroke, and one-sided paralysis. The 9/1/25 minimum data set (MDS) assessment revealed Resident #8 was cognitively intact with a brief interview for a mental status (BIMS) score of 14 out of 15. Resident #8 had left-sided impairments and used a motorized wheelchair for mobility. Resident #8 was dependent on transfers and required substantial to maximal assistance for bed mobility, dressing, toileting, showering, and hygiene. B. Record reviewResident #8's hospital discharge instructions, dated [DATE], included a physician's order for warfarin 1 mg by mouth in the morning and to check the INR level daily. The hospital discharge recommendations read to monitor warfarin according to the nursing home provider(s) and titrate (warfarin) accordingly.Review of Resident #8's EMR revealed Resident #8 did not have a care plan for warfarin/anticoagulation medication therapy. Review of Resident #8's August 2025 and September 2025 CPO revealed the following physician's orders:-8/25/25 warfarin 1 mg by mouth one time day for stroke;-8/26/25 INR test (result 1.69);-8/27/25 warfarin 1 mg by mouth one time day for stroke;-8/27/25 warfarin 1.5 mg by mouth in the evening for preventing blood clots. Document the most recent INR in the supplemental documentation;-8/27/25 draw INR on 8/29/25. Call results to the coumadin clinic. Call anytime during the day. After hours can take results in the evening. One time only for monitoring, start 8/28/25;-8/29/25 INR laboratory testing ordered on 8/27/25 (was not completed);-9/10/25 warfarin 1 mg, give one tablet by mouth at bedtime for warfarin therapy; and,-9/15/25 INR test (result 2.41).Resident #8's August 2025 MAR documented the following:-8/28/25 INR 2.44 (resulted 8/22/25 in the hospital). Resident #8 was administered 1 mg of warfarin in the morning and 1.5 mg in the evening;-8/29/25 INR 2.44 (resulted 8/22/25 in the hospital). Resident #8 was administered 1 mg of warfarin in the morning and 1.5 mg in the evening;-8/30/25 INR 2.44 (resulted 8/22/25 in the hospital). Resident #8 was administered 1 mg of warfarin in the morning and 1.5 mg in the evening; and,-8/31/25 INR 2.44 (resulted 8/22/25 in the hospital). Resident #8 was administered 1 mg of warfarin in the morning and 1.5 mg in the evening. Resident #8's September 2025 MAR documented the following:-9/1/25 INR 2.44 (resulted 8/22/25 in the hospital). Resident #8 was administered 1 mg of warfarin in the morning and 1.5 mg in the evening; -9/2/25 INR 2.44 (resulted 8/22/25 in the hospital). Resident #8 was administered 1 mg of warfarin in the morning and 1.5 mg in the evening; -9/3/25 INR 2.44 (resulted 8/22/25 in the hospital). Resident #8 was administered 1 mg of warfarin in the morning and 1.5 mg in the evening; -9/4/25 INR 2.44 (resulted 8/22/25 in the hospital). Resident #8 was administered 1 mg of warfarin in the morning and 1.5 mg in the evening; -9/5/25 INR 2.44 (resulted 8/22/25 in the hospital). Resident #8 was administered 1 mg of warfarin in the morning and 1.5 mg in the evening; -9/6/25 INR 2.44 (resulted 8/22/25 in the hospital). Resident #8 was administered 1 mg of warfarin in the morning and 1.5 mg in the evening; -9/7/25 INR 2.44 (resulted 8/22/25 in the hospital). Resident #8 was administered 1 mg of warfarin in the morning and 1.5 mg in the evening; and,-9/8/25 INR 2.41 (resulted 8/22/25 in the hospital).V. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 12/16/25 at 9:05 a.m. LPN #1 said she had worked in the facility for approximately two years. LPN #1 said the facility's nursing leadership team had recently educated nurses with the policy on reviewing physician's orders for warfarin. LPN #1 said each physician's order was verified and confirmed by a second nurse. LPN #1 said when a resident was prescribed a new order for warfarin, the nurse that entered the order in the EMR was responsible for reviewing existing orders and verifying duplicate orders with the physician. LPN #1 said the education included documentation on the warfarin tracking log which was used by facility staff for daily monitoring of INR levels and served as a tracking tool to ensure INR monitoring and warfarin dosing. LPN #1 said before administering warfarin, the nurse should review the tracking log for the most recent INR level and confirm the warfarin dose to be administered. LPN #1 said the monitoring of the INR level was used to ensure blood clotting times were sufficient to prevent blood clots while at the same time ensuring warfarin did not reach toxic levels and cause adverse side effects, such as heavy bleeding. LPN #1 said every resident taking warfarin had monitoring orders that included screening for bruising, nosebleeds, bleeding gums, or changes in vital signs that could indicate internal bleeding.The DON was interviewed on 12/16/25 at 1:05 p.m. The DON said she was not employed at the facility when the medication error for Resident #8 occurred. The DON said she was hired in October 2025. The DON said since October 2025 she had made auditing facility nurse practices a daily priority. The DON said she reviewed all new admission orders and physician's orders from clinic visits for warfarin. The DON said the warfarin tracking log was reviewed daily. The DON said one current resident in the facility was prescribed warfarin and there had been no order entry errors or failures to monitor warfarin levels. The DON said she and the SDC ensured newly hired nurses received education on physician order entry and warfarin monitoring before they were scheduled to care for residents. The DON said the facility's plan of correction was effective and there had been no subsequent significant medication errors for any residents with warfarin therapy.The nurse practitioner (NP) was interviewed on 12/17/25 at 9:50 a.m. The NP said warfarin was prescribed to be administered one time a day. The NP said nurses should verify the current warfarin dose and INR level before administering warfarin and contact the provider if there were concerns. The NP said the facility's protocol was to prescribe all warfarin to be administered one time a day, at bedtime, and all residents prescribed warfarin had their INR levels tested each Thursday.

Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#28) of three residents out of 37 sample residents. Resident #28, who was at risk for falls, was admitted on [DATE] with diagnoses of dementia, history of falling, abnormalities of gait and mobility, weakness and insomnia. On 5/1/25 the physician recommended the resident transition to a walker without wheels for safety and have a physical therapy (PT) evaluation. However, Resident #28 continued to use her four-wheel walker and a PT evaluation was not conducted until 5/13/25. Resident #28 fell three times in less than a week (on 5/6/25, 5/9/25 and 5/10/25). She was identified to have high blood pressure after the falls and was discovered to have a urinary tract infection (UTI) after the last fall on 5/10/25, increasing her risk for falls. All three of the falls occurred in the early morning hours when Resident #28 got out of bed independently. However, the facility failed to identify a pattern with the falls. Two of the three falls resulted in injuries, including facial injuries. The 5/10/25 fall resulted in the resident going to the hospital for stitches to her head. Specifically, the facility failed to identify and implement timely interventions for Resident #28 to help decrease her risk for patterned falls and risk of falls with injury. Findings include: I. Facility policy and procedure The Falls-Clinical Protocol policy, revised September 2012, was provided by the nursing home administrator (NHA) on 5/22/25 at 6:00 p.m. The policy read in pertinent part, For an individual who has fallen, staff will attempt to find possible causes within 24 hours of the fall. Causes refer to factors that are associated with or that directly result in the fall. Often multiple factors in varying degrees contribute to a fall problem. The staff and the physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. Frail elderly individuals are often at a greater risk for serious adverse consequences of the fall. Risk of serious adverse consequences can sometimes be minimized if falls can not be prevented. If interventions have been successful in preventing falls, the staff will continue the current approaches or reconsider whether the measures are still needed if the problem that required the intervention has been resolved. If the individual continues to fall, the staff and the physician will reevaluate the situation and consider other possible reasons for the resident falling and will reevaluate the continued relevance of current interventions. II. Resident #28 A. Resident status Resident #28, age greater than 65, was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease with late onset, unspecified dementia, without behavioral disturbance, history of falling, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits (stoke), other abnormalities of gait and mobility, weakness and insomnia. The 2/8/25 minimum data set (MDS) assessment documented Resident #28 had severe cognitive impairments with a brief interview for mental status (BIMS) score of six out of 15. According to the MDS assessment, Resident #28 needed partial to moderate assistance with dressing, including putting on and taking off footwear, toileting and personal hygiene. She needed touching or supervision with a sit to stand position. She used a walker for mobility. B. Resident observation and interview On 5/19/25 Resident #28 was observed throughout the day in the memory care unit. The resident had red, purple and green bruising on her face. The bruising was primarily under her left eye, on her left cheek and on her forehead. Resident #28 used a four-wheel walker for ambulation. Resident #28 was interviewed on 5/19/25 at 2:45 p.m. Resident #28 said she did not know what happened to cause the bruising on her face but she was happy the bruises were getting better. C. Record review The fall care plan, initiated 8/2/24 and revised 5/6/25, identified Resident #28 was at risk for falls. Interventions included reminding the resident to use her walker (initiated 8/22/24), ensuring the resident was wearing appropriate footwear and/or non-skid socks when she was ambulating (initiated 8/22/24 and revised 5/6/25), providing a therapy screen as needed (initiated 5/6/25), the resident was participating in a restorative program (initiated 5/7/25), a medication review was conducted with Resident #28's physician (initiated 5/9/25), placing the resident on a toileting schedule (initiated 5/12/25), keeping the resident's bed in the lowest position (initiated 5/11/25 and revised 5/21/25, during the survey), encouraging the resident to participate in activities that promoted exercise, physical activity for strengthening and improved mobility (initiated 5/21/25, during the survey) and reviewing information on past falls and attempting to determine the cause of falls, recording possible root causes, altering or removing any potential causes if possible and educating the resident/family/caregivers and the interdisciplinary team (IDT) of the fall causes (initiated 5/21/25, during the survey). The 5/1/25 history and physical physician's note documented Resident #28's blood pressure was 140/82 millimeters of mercury (mmHg). The note identified Resident #28's blood pressure was well-controlled during the visit and the resident would continue on her current medications of amlodipine and lisinopril (high blood pressure/hypertension medications). The physician's note indicated Resident #28 had mobility issues and recommended the resident transition to a walker without wheels for safety, have a PT evaluation and have fall preventive measures in place. -However, the resident continued to use the four-wheel walker (see observations above and progress notes below). The 5/6/25 general progress note documented Resident #28 was found sitting on the floor at 4:45 a.m. She was putting her shoes on and her four-wheeled walker was beside her. Resident #28 was not able to identify if she fell or not but asked if it was time to get up. According to the note, the nurse who observed the resident on the floor felt the resident was possibly trying to get her shoes on while sitting on her four-wheel walker and the walker slid back, causing her to sit on the floor. The note identified the resident did not have skin trauma or shearing and was able to walk from the bed to the toilet without difficulty. The 5/6/25 fall risk data collection evaluation identified Resident #28 scored a 12, indicating she was a fall risk. According to the fall risk data collection evaluation instructions, interventions should promptly be put in place when a resident's score was 10 or more. The change of condition evaluation identified Resident #28 had a blood pressure of 148/76 mmHg on 5/6/25 at 5:12 a.m., indicating a high blood pressure. The 5/7/25 health status note documented Resident #28 was reminded not to sit on her walker for safety, but she was forgetful about the reminder and sat down her walker multiple times without locking her walker brakes. The 5/7/25 IDT at-risk note documented Resident #28's current fall intervention was to ensure she was wearing appropriate footwear and non-skid socks when she was ambulating and to remind her to use her walker. The at-risk note documented occupational therapy (OT) would evaluate and treat the resident for lower body dressing and the resident would participate in the restorative nursing program. The 5/9/25 at 4:45 a.m. nursing progress note documented Resident #28 came out of her room scooting on her buttocks and said she fell. The nursing assessment identified Resident #28 had a bruise forming to her left eye and cheek area and superficial cuts above her eyebrow. The area was cleaned and a bandage was applied. According to the progress note, the resident said she fell and hit her cheek on the floor when she got out of bed. The 5/9/25 at 5:40 a.m. health status note documented Resident #28 was being monitored for a fall on 5/6/25. She complained of left leg discomfort prior to going to bed this shift (5/8/25 into 5/9/25). According to the note, Resident #28 was sleeping in her bed prior to her 5/9/25 fall. The 5/9/25 IDT post-fall investigation documented Resident #28 had an unwitnessed fall at 2:45 a.m. The investigation identified the resident was last checked on by staff at 12:00 a.m. According to the fall investigation, the resident's current fall risk was high. The fall investigation indicated the fall factors included an unsteady gait, getting out of bed and poor lighting. The determining cause of the fall was weakness while ambulating without assistance. The resident was wearing socks at the time of the fall. The investigation indicated the resident was last toileted (on 5/8/25) at 9:00 p.m. The fall investigation documented there was not a noted pattern of falls. -However, the resident previously fell on 5/6/25 in the early morning hours after getting out of bed without assistance. -The note identified Resident #28 was last checked on by staff two hours and 45 minutes before the resident fell and scooted out of her room on her buttocks. The 5/9/25 fall risk data collection evaluation identified Resident #28's fall risk increased from a score of 12 to a 23 after her second fall. The resident's mobility was unsteady with problems and with devices. The 5/9/25 change of condition evaluation identified Resident #28's blood pressure was 182/88 mmHg at the time of the 2:45 a.m. fall, indicating a high blood pressure. According to the evaluation, she was having some discomfort to the left side of her face. The 5/9/25 fall incident report identified Resident #28 was not using her walker and had only regular socks on her feet while attempting to get out of bed to ambulate when she fell. According to the blood pressure log, the resident's blood pressure was trending upward and the medical director would elevate and perform a medication review. The 5/10/25 at 6:05 a.m. nursing progress note documented a certified nurse aide (CNA) was rounding in Resident #28's room and found the resident on the floor, bleeding from her head. According to the note, Resident #28 told the CNA that she fell and hit her head on the floor. The note identified the resident had a round dollar-size area noted to the middle top of her forehead/head, a bruise on her left knee, a bruise and a skin tear to her right knee and a bruise and a skin tear to her right elbow. The injured areas were cleaned and dressed. The 5/10/25 at 8:00 a.m. nursing progress note documented Resident #28 complained of left hip and knee pain and was sent to the hospital for Xrays. The 5/10/25 at 11:00 a.m. nursing progress note identified Resident #28 returned from the hospital with two staples in her forehead. The 5/10/25 post-fall investigation documented Resident #28 fell at 5:25 a.m. when she got out of bed and was walking. The investigation identified the resident was last checked on by staff at 2:00 a.m. The investigation identified she self-toileted herself at times throughout the night and was last known to toilet at 4:00 a.m. The investigation indicated the resident had an increased need for assistance with noted weakness and a positive UA. The new interventions after the 5/10/25 fall included a PT evaluation and placing the resident on a toileting program. According to the post fall investigation, Resident #28 did not have a pattern associated with her falls. -However, each of the falls on 5/6/25, 5/9/25 and 5/10/25 were unwitnessed, occurred on the overnight shift in the early morning hours and happened when the resident got herself out of bed. -Additionally, the physician recommended a PT evaluation on 5/1/25, prior to the three falls on 5/6/25, 5/9/25 and 5/10/25 (see physician's note above). The 5/10/25 incident report documented Resident #28 was ambulating in her room without her walker in the dark room with only a night light on. The 5/10/25 at 5:37 p.m. nursing progress note identified the hospital did not complete the requested Xrays of the resident's left hip and knee and the resident had to return to the hospital. A 5/10/25 at 10:00 p.m. encounter note identified a nurse requested a physician's order for urine analysis (UA) laboratory (lab) work due to Resident #28's increased confusion and frequency and difficulty with urinating. The 5/11/25 at 4:31 a.m. health status note documented Resident #28 returned from the hospital at 9:35 p.m. (on 5/10/25) with no fractures. A second health status note on 5/11/25 at 4:33 a.m. documented Resident #28 was being monitored for her multiple falls, multiple bruises to her bilateral arms and knees, skin tears to her left knee and right elbow, a laceration with staples to her head and bruising to her face and both eyes. According to the note, Resident #28 complained of pain and discomfort. The note identified the resident continued to be a high fall risk and she almost fell again when she was observed to walk from her bed to the bathroom. The note indicated the nurse conducted multiple checks on the resident and kept her bedroom door open so the resident could be monitored. Resident #28 was dressed with non-skid socks on her feet for safety. The 5/11/25 at 8:45 a.m. electronic medical administration (eMAR) general note identified Resident #28 received oxycodone pain medication for 8 out of 10 pain and was limping. The 5/11/25 at 5:27 p.m. eMAR general note identified Resident #28 received oxycodone pain medication for 9 out of 10 pain to her left leg and face when she got up for dinner. The 5/12/25 physician's progress note identified Resident #28 had a UTI and was prescribed antibiotics. According to the note, the resident would continue to remain on amlodipine and lisinopril for high blood pressure. The 5/12/25 health status note identified Resident #28 was monitored every hour and offered toileting to prevent her from falling. The 5/13/25 health status note documented Resident #28 was administered oxycodone twice due to her complaints of generalized pain. According to the note, the pain medication was only a temporary relief because she complained again when she was toileted. The 5/13/25 PT evaluation and plan of treatment and three PT skilled service notes, dated 5/13/25, 5/14/25 and 5/19/25, were provided by the NHA on 5/22/25 at 1:05 p.m. The PT evaluation and plan of treatment identified Resident #28 was evaluated on 5/13/25. -The resident was not evaluated by PT until 12 days after the physician recommended a PT evaluation (on 5/1/25) and after the resident had three falls on 5/6/25, 5/9/25 and 5/10/25 (see above). The provided PT notes identified Resident #28 needed reminders and cueing for safety. The 5/14/25 PT skilled services note revealed Resident #28's four-wheel walker brakes were significantly loose and ineffective. The note identified PT replaced the walker with a different four-wheel walker from the facility's storage and adjusted it for the resident. The 5/21 at-risk meeting minutes documented Resident #28 completed her round of antibiotics for her UTI and fall interventions remained in place and were effective because she had had no further falls. -However, the facility failed to identify the resident had a UTI, ensure effective interventions were in place and obtain a PT evaluation until after Resident #28 sustained three consecutive falls in four days, one of which resulted in the resident being transferred to the hospital where she received two staples for a head laceration (see record review above). D. Staff interviews The NHA, the director of nursing (DON) and the corporate consultant (CC) were interviewed together on 5/22/25 at 12:12 p.m. The NHA said falls were reviewed the next business day at the at-risk meeting. He said the IDT reviewed current fall interventions, the root cause of the fall and what new intervention would be implemented. The NHA said over the last review months, the facility had implemented a fall reduction staff incentive plan to help reduce the occurrence of falls. The DON said the staff was trained to watch for clutter on the floor, conduct frequent rounding and make sure the residents' basic needs were met. The NHA said all new fall interventions were communicated through the facility's online communication board, verbal communication and the residents' care plans. The NHA said the former DON used to lead the facility's fall review and oversight. The NHA said the current DON was new to her position and would be trained to take over the fall program. The NHA said Resident #28 was found on the floor on 5/6/25 putting on her shoes. He said the IDT determined a shoe rack by her bed within her reach could help reduce a similar fall. He said he believed the shoe rack was in place. The DON said a shoe rack was not ordered yet. The CC said the shoe rack would be ordered today (5/22/25). The NHA reviewed the 5/6/25 progress note identifying the nurse thought Resident #28's fall was possibly contributed to the resident's walker sliding back, resulting in the resident on the floor. The NHA said he would look into Resident #28's walker. He said the resident was currently on the therapy caseload. He said he was not sure what the PT's fall interventions were at this time. The CC said all of Resident #28's falls were in the early morning. She said she did not see interventions specific to fall risks in the early morning hours. The CC said the resident was identified to have high blood pressure and a UTI after the falls. The CC said she did not see the staff identified what footwear Resident #28 was wearing when she fell on 5/6/25. The CC said Resident #28 did not have the right socks on when she fell on 5/9/25. The NHA said he was not sure if socks were identified as a concern or if staff was educated on the need for non-skid socks after the 5/9/25 fall. The NHA said the IDT discussed providing Resident #28 more assistance in the early mornings. The DON said staff should be checking on residents during rounding every hour making sure needs were met and checking for safety. She said Resident #28 should have been checked on more frequently on the nights before she fell. The DON said Resident #28 would need staff assistance to get dressed. The DON said after the 5/10/25 fall, Resident #28 was placed on a toileting program. She said the resident would be offered toileting when she woke up, before and after meals and at bed time. She said the staff would offer the resident toileting assistance if she woke up in the middle of the night. The NHA said red lights were installed in resident rooms to help residents see at night a couple of years ago. He said he did not know if the red lights were on at the time of Resident #28's falls. The CC and the NHA said they would look at the lighting in Resident #28's room, the status of her shoe shelf and her walker. The NHA and the CC said staff would be educated on non-skid sock use and rounding hourly.

VI. Resident #387 A. Resident status Resident #387, age over 65, was admitted on [DATE]. According to the May 2025 CPO, diagnoses included stage three chronic kidney disease and bipolar disorder. The 7/4/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. She required partial to moderate assistance with toileting, personal hygiene, bathing and lower body dressing. B. Record review A review of Resident #387's May 2025 CPO revealed the following physician's orders: Olanzapine (Zyprexa, an antipsychotic medication) oral tablet 5 mg, give 2.5 mg (half tablet) by mouth as needed (PRN) for agitation daily at night, ordered 5/17/25 with an end date of 5/31/25. Lorazepam (an antianxiety medication) oral tablet 0.5 mg, give one tablet by mouth daily PRN for anxiety, ordered 5//25 with an end date of 5/31/25. Lamotrigine oral tablet give 50 mg by mouth one time a day related to bipolar disorder, ordered 5/18/25. Monitor resident's behaviors, such as rapid mood changes and paranoia while prescribed Zyprexa related to bipolar disorder. Interventions included calling the resident's son and changing the resident's environment, ordered 5/17/25. Monitor resident's behaviors, such as voicing depression and negative comments while prescribed Lamotrigine related to bipolar disorder. Interventions included one-on-one interactions and group activities, ordered 5/17/25. Monitor residents behavior, such as voicing being worried and perseveration while prescribed Lorazepam for anxiety. Interventions included decreased stimulation and providing reassurance, ordered 5/19/25. Review of the May 2025 MAR, from 5/17/25 to 5/21/25, revealed Resident #387 was not administered the PRN Zyprexa or PRN Ativan. -A review of Resident #387's May 2025 MAR and treatment administration record (TAR) revealed the physician's orders for behavior monitoring were not transcribed onto the TAR and there was no place on the TAR for staff to document if the resident was exhibiting behaviors. -A review of the progress notes did not reveal documentation to indicate Resident #387 had exhibited episodes of anxiety, rapid mood changes or paranoia prior to the physician prescribing PRN Zyprexa and PRN Ativan for the resident. -Additionally, Resident #387's EMR did not reveal documentation from the physician which provided a diagnosed specific condition and indication for use of the medication in order to justify starting the resident's PRN antipsychotic and PRN antianxiety medications. C. Staff interviews CNA #11 was interviewed on 5/22/25 at 3:54 p.m. CNA #11 said Resident #387 had been pleasant since her admission to the facility. CNA #11 said Resident #387 had not displayed any aggressive behaviors. Registered nurse (RN) #1 was interviewed on 5/22/25 at 3:56 p.m. RN #1 said staff were monitoring Resident #387 for repetitive delusions. RN #1 said he had not seen Resident #387 display any delusional behaviors. RN #1 said Resident #387 was prescribed lorazepam for anxiety and olanzapine at bedtime for agitation as needed. He said Resident #387 had not been given olanzapine since the medication had been prescribed because Resident #387 had not displayed any aggressive behaviors. RN #1 said the resident's EMR did not have a place to record the resident's behaviors if they were exhibited. RN #1 said Resident #387 had not displayed any agitated behaviors since her arrival to the facility. RN #1 said the olanzapine was ordered to manage Resident #387's agitation. RN #1 said the physician saw Resident #387 on 5/22/25 and did not make any changes to her medications. The DON and the CC were interviewed on 5/22/25 at 5:06 p.m. The DON said she did not think Resident #387 had displayed any kind of aggressive or anxious behaviors since her admission to the facility. The DON said she was not sure if Resident #387 needed to be prescribed olanzapine and lorazepam. The DON said the medication was prescribed for fourteen days and would more than likely be discontinued on 5/31/25. -However, there was no documented rationale to justify the medications being prescribed initially (see record review above). V. Resident #5 A. Resident status Resident #5, age [AGE], was admitted on [DATE]. According to the May 2025 CPO, diagnoses included dementia in other diseases classified elsewhere, severe with psychotic disturbance, Parkinsonism (a condition that causes tremors, stiffness and slowed movement) and need for assistance with personal care. According to the 2/26/25 MDS assessment, the resident had severe cognitive impairment with a BIMS score of four out of 15. She required staff assistance for most activities of daily living (ADL), including setup assistance with eating and personal hygiene and moderate assistance with dressing, bathing, and toileting. The MDS assessment revealed the resident did not display physical behaviors directed towards others and did not exhibit any verbal or behavioral outbursts during the assessment period. B. Record review A review of Resident #5's May 2025 CPO revealed the following physician's order: -Olanzapine, give 7.5 mg by mouth at bedtime for dementia with psychosis, ordered 11/18/24. -Review of Resident #5's MARs, from 11/1/24 to 5/20/25, did not reveal documentation of a targeted behavior or any behavior monitoring for the use of the resident's olanzapine medication. A review of the nursing progress notes, from 1/1/25 to 5/20/25, revealed the resident exhibited only one episode of verbal aggression and paranoid delusions on 4/30/25. -Despite Resident #5's EMR revealing no documentation of outbursts or physical behaviors to justify the continued use of the resident's antipsychotic medication, the facility continued administering olanzapine, citing poor interaction with her children as the rationale. The 2/24/25 monthly MRR indicated that the resident's olanzapine 7.5 mg dose exceeded the recommended maximum for dementia with psychosis. The pharmacist recommended reducing the dose to 5 mg, in accordance with standards of practice and gradual dose reduction (GDR) requirements. The physician declined the recommendation, citing a recent poor interaction between the resident and her children. -However, review of progress notes, behavior tracking logs, and psychotropic medication notes did not reveal documentation of ongoing targeted behaviors for Resident #5 or any incidents of verbal aggression or paranoid delusions in order to justify the continued use of the higher dose of the medication. C. Staff interviews The consultant pharmacist was interviewed on 5/22/25 at 11:08 a.m. The consultant pharmacist said it was not typical to continue a high dose of an antipsychotic medication based on a single behavioral incident. The consultant pharmacist said the dose prescribed for Resident #5 exceeded the maximum recommended dosage of olanzapine and she recommended a reduction of the medication for the resident. She said she was not aware Resident #5 had exhibited any behaviors to continue the medication at such a high dose. Certified nurse aide (CNA) #8 was interviewed on 5/22/25 at 2:20 p.m. CNA #8 said Resident #5 had not exhibited any verbal or physical aggression, yelling, hitting, or wandering. CNA #8 said the resident sometimes became anxious due to sun downing but was redirectable to activities, such as playing bingo or visiting with other residents. CNA #8 said the resident had not had any outbursts or done anything that put herself or others at risk. CNA #8 said when Resident #5 seemed upset or anxious, the staff redirected her and allowed the resident to talk because letting her express herself helped calm her down. CNA #11 was interviewed on 5/22/25 at 2:43 p.m. CNA #11 said Resident #5 sometimes mentioned that her roommate should pay rent, but staff redirected her by reassuring her that the roommate was paying rent and there were no further issues. CNA #11 said the resident had not exhibited any verbal or physical aggression. CNA #11 said the resident did not usually appear anxious and had not had any outbursts. The DON was interviewed on 5/22/25 at 4:20 p.m. The DON said both the physician and nursing leadership reviewed the pharmacist's recommendations monthly. The DON said the facility monitored all residents on antipsychotic medications, including those with dementia, through behavior tracking, which was documented on the MAR and quarterly psychotropic medication reviews by the leadership team. The DON said a thorough risk versus benefit assessment and statement should have been completed for Resident #5's use of olanzapine. She said targeted behavior monitoring was required for all psychotropic medications and should have been documented in the MAR for Resident #5's use of olanzapine. She said the current dosage of olanzapine medication for Resident #5 exceeded the therapeutic range.Based on record review and interviews, the facility failed to ensure four (#48, #61, #5 and #387) of seven residents reviewed for psychotropic medications were free from chemical restraint out of 37 sample residents. Specifically, the facility failed to: -Ensure a physicians rationale, which included the diagnosed specific condition and indication for use of the medication, was documented for the use of an as needed (PRN) antianxiety medication beyond 14 days for Resident #48; -Ensure Resident #48 was not administered a PRN psychotropic medication prescribed for anxiety without appropriate behavior documentation; -Ensure a physicians rationale, which included the diagnosed specific condition and indication for use of the medication, was documented for the use of a PRN antianxiety medication for Resident #61; -Document consistent behaviors or a physician's rationale for Resident #5 to justify the continued use of an antipsychotic medication; and, -Ensure a physicians rationale, which included the diagnosed specific condition and indication for use, was documented for the use of an antipsychotic medication and an antianxiety medication for Resident #387. Findings include: I. Facility policy and procedure The Psychotropic Medication Use policy and procedure, revised July 2022, was provided by the nursing home administrator (NHA) on 5/22/25 at 6:00 p.m. It revealed in pertinent part, Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. PRN orders for psychotropic medications are limited to 14 days. For psychotropic medications that are not antipsychotics: if the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. When determining whether to initiate, modify, or discontinue medication therapy, the interdisciplinary team (IDT) conducts an evaluation of the resident. The evaluation will attempt to clarify whether or not the resident has signs and symptoms that are clinically significant enough to warrant medication therapy. II. Resident #48 A. Resident status Resident #48, age greater than 65, was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included cerebral infarction (stroke), emotional lability and depression. The 3/25/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident was dependent on staff for bathing and required moderate assistance with personal hygiene and toileting. The MDS assessment revealed the resident had moderately severe depression symptoms with no aggressive behavior observed toward herself or others. B. Resident interview Resident #48 was interviewed on 5/20/25 at 2:30 p.m. Resident #48 said when she was admitted to the facility she was on hospice services, but a few weeks ago she was told she was doing well and discharged from hospice services. Resident #48 said she did not have any anxiety. C. Record review A review of Resident #48's physician order history revealed the following physicians orders: Diazepam two milligrams (mg) oral tablet. Give one tablet by mouth three times a day as needed for anxiety related to emotional lability, ordered 3/19/25 with an end date of 4/8/25. Diazepam two mg oral tablet. Give one tablet by mouth every eight hours as needed for anxiety related to emotional lability for 90 Days, ordered 4/8/25 with an end date of 7/7/25. The monthly pharmacy medication regimen review (MRR), dated 3/26/25, documented the consultant pharmacist sent a recommendation to the prescribing physician to reassess the use of the PRN diazepam. The prescribing physician's response, dated 4/7/25, documented the physician disagreed with the recommendation with the word hospice hand written as the rationale to continue the PRN order for 90 days. -Review of Resident #48's electronic medical record (EMR) revealed there was no further documentation from the physician which provided a diagnosed specific condition and indication for use of the medication in order to justify extending the residents PRN diazepam beyond 14 days. A review of Resident #48's medication administration records (MAR), from 4/8/25 through 5/21/25 revealed the resident received one PRN dose of diazepam during that time period, on 4/14/25 at 4:55 a.m. A review of the April 2025 treatment administration record (TAR) revealed Resident #48 did not have any documented episodes of anxiety since the orders initial start date, including on the 4/14/25, when the medication was administered. The April 2025 MAR additionally revealed that Resident #48 received a PRN dose of oxycodone 2.5 mg for pain at the same time the diazepam was administered on 4/14/25 at 4:55 a.m. The progress note, dated 4/14/25, documented Resident #48 had a difficult night due to severe low back pain. Resident #48's pain was initially treated with acetaminophen without relief. Resident #48 subsequently received PRN oxycodone and diazepam with good effect. Resident #48 was able to sleep in the recliner afterward. -However the physician's order for PRN diazepam indicated the medication was prescribed for a diagnosis of anxiety and there was no documentation in the residents EMR to indicate the resident was exhibiting or reporting anxiety at the time the medication was administered. The nursing progress note, dated 5/12/25, documented Resident #48 was discontinued from hospice services. -However, there were no changes made to Resident #48's PRN physicians order for diazepam or a new rationale documented by the physician, despite hospice services being the only rationale documented for extending the physicians order past 14 days. III Resident # 61 A. Resident status Resident #61, age greater than 65, was admitted on [DATE]. According to the May 2025 CPO, diagnoses included vascular dementia without behavioral disturbance, amyloidosis and repeated falls. The 3/26/25 MDS assessment revealed that the resident had severe cognitive impairment with a BIMS score of five out of 15. The resident required substantial assistance with bathing, and moderate assistance with toileting, transfers, hygiene and dressing. The MDS assessment revealed the resident did not have anxiety, depression or aggressive behavior toward himself or others. B. Record review A review of Resident #61's March 2025 CPO revealed the following physician's order upon Resident #61's admission to the facility: Lorazepam 0.5 mg tablet, give 0.5 mg by mouth every four hours as needed for anxiety or shortness of breath, ordered 3/13/25 with an end date of 4/8/25. A review of the March 2025 and April 2025 MAR revealed Resident #61 received no doses of PRN lorazepam from 3/13/25 through 4/8/25. A review of the March 2025 and April 2025 TAR documented Resident #61 had no observations of anxiety from 3/13/25 through 4/8/25. The nursing progress note, dated 3/18/25 at 12:52 p.m., documented the facility reviewed Resident #61's current use of psychotropic medications. It documented Resident #61's family denied a significant history of anxiety or depression for Resident #61. The family said he had been doing very well and they did not have any concerns. -Additionally, there was no documentation in the nursing progress notes to indicate the resident was having anxiety from 3/13/25 through 4/8/25. The monthly pharmacy MRR, dated 3/26/25, documented the consultant pharmacist sent a recommendation to the prescribing physician to reassess the use of the Resident #61's PRN lorazepam. The prescribing physician's response, dated 4/7/25, documented the physician disagreed with the recommendation with the word palliative hand written in the rationale and to continue the PRN order for 90 days. -Review of Resident #61's EMR revealed there was no further documentation from the physician which provided a diagnosed specific condition and indication for use of the medication in order to justify extending the residents PRN lorazepam beyond 14 days. A review of Resident #61's May 2025 CPO revealed the following physicians order: Lorazepam 0.5 mg tablet, give 0.5 mg by mouth every four hours as needed for anxiety or shortness of breath for 90 days, ordered 4/8/25 with an end date of 7/7/25. A review of Resident #61's April 2025 and May 2025 MAR revealed Resident #61 was not administered any doses of the PRN Lorazepam from 4/8/25 through 5/21/25. The April 2025 and May 2025 TAR revealed Resident #61 had no observations of anxiety from 4/8/25 through 5/21/25. The progress note, dated 5/12/25, documented Resident #61 expressed feeling anxious during a mental health screening. -However no further interventions were documented, no PRN use of the ordered lorazepam was documented and there was no documentation of anxiety in the behavior tracking on the May 2025 TAR for 5/12/25. IV. Staff interviews The consultant pharmacist was interviewed on 5/22/25 at 10:44 a.m. The consultant pharmacist said diazepam could be used for spastic pain (muscle spasms), but otherwise she would not recommend the use of diazepam for back pain. The consultant pharmacist said giving both medications (diazepam and oxycodone) together could increase the risk for sedation and death. The consultant pharmacist said she sent notifications, for both the PRN diazepam for Resident #48 and the PRN lorazepam for Resident #61, to the physician when she completed the March 2025 monthly MRRs. She said the physician disagreed with her recommendation to discontinue both medications. She said both medications were not necessary because both residents were not exhibiting signs or symptoms of anxiety and there was non-use of the medications. The director of nursing (DON) and the corporate consultant (CC) were interviewed together on 5/22/25 at 4:01 p.m. The DON said PRN antianxiety medications should be written with a 14-day stop date. She said after the 14 days ended, the physician was required to evaluate the appropriateness of the medication and provide a new prescription with a new stop date. The DON said the evaluation should include an appropriate risk versus benefit assessment and evidence that other interventions were not effective. The DON said PRN antianxiety medications should be discontinued due to a lack of effectiveness of the medication or non-use. She said the PRN antianxiety orders for both Resident #48 and #61 should be discontinued if both residents did not display signs and symptoms of anxiety. The DON said diazepam and oxycodone should not be administered together for documented back pain without the resident indicating they were also experiencing anxiety.

Based on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure resident food was palatable in temperature and taste. Findings include: I. Facility policy and procedure The Assistance with Meal policy, revised March 2022, was provided by the nursing home administrator (NHA) on 5/22/25 at 6:00 p.m. The policy read in pertinent part, Hot food shall be held at a temperature of 135 degrees or above until served. Cold food shall be held at 41 degrees or below until served. Nursing and dietary services will establish procedures such that delivery of food to serving areas accommodates this requirement. II. Resident interviews Resident #53 was interviewed on 5/19/25 at 11:02 a.m. She said the food could taste better. Resident #58 was interviewed on 5/19/25 at 11:38 a.m. He said about three times a week the hot food was not hot or warm. Resident #44 was interviewed on 5/19/25 at 5:47 p.m. He said meat at the facility was always too dry and did not have any taste to it. Resident #20 was interviewed 5/20/25 at 9:36 a.m. She said sometimes the food did not taste good. II. Resident council minutes The March 2025 resident council minutes documented some of the residents told the dietary manager (DM) the meals were lukewarm. According to the minutes, the DM told the council she would make sure the meals were at the correct temperatures for the residents. The April 2025 resident council minutes documented on occasion the food could be hotter. According to the minutes a few residents said on occasion the meals served in the dining room were not hot enough. Some of the residents who were served meals in their room said the meals were often lukewarm and not very hot. III. Observations During a continuous observation on 5/19/25, beginning at 12:00 p.m. and ending at 12:32 p.m. the following was observed during room tray delivery in the north hall: At 12:01 p.m. the room tray meal cart arrived at the north hall. At 12:02 p.m. the cart sat in the hall while an unidentified staff member answered a call light. At 12:07 p.m. the staff started serving the room trays down the north hall. At 12:32 p.m. all room trays on the north were delivered. -The observation on the north hall identified the room tray cart sat in the hall for six minutes before delivery began. During a continuous observation on 5/21/25, beginning at 11:31 a.m. and ending at 12:09 p.m., the following was observed during room tray delivery in the north hall: At 11:57 a.m. the test tray was plated and placed on the room tray cart for delivery to south hall. At 12:06 p.m. the remainder of the plated and ready resident's room trays were loaded on cart. At 12:09 p.m. the cart door remained open until the cart left the kitchen and proceeded to the south hall. At 12:10 p.m. the room tray cart arrived in the south hall. At 12:15 p.m. the staff began passing the room trays. At 12:50 p.m. the last resident received their room tray and the test tray was pulled from the room tray cart and the temperature of the meal was immediately taken. -The room tray delivery began in the south hall five minutes after it arrived. IV. Test tray A test tray for a regular diet was evaluated immediately after the last resident had been served their room tray for lunch on 5/20/25 at 12:55 p.m. by four surveyors: The test tray was not served at palatable food temperatures and consisted of Salisbury steak, oven-fried potatoes, spinach, chicken and rice stew and a slice of coconut pie. -The Salisbury steak with gravy was 111.6 degrees Fahrenheit (F). The Salisbury steak was salty. -The oven-fried potatoes were 103 degrees F. The potatoes were not crispy and had a mushy texture. -The spinach was 109.5 degrees F. The spinach was watery. -The chicken and rice stew was 114.3 degrees F. The stew was bland. -The slice of coconut pie was 67.2 degrees F. The pie was not cold in taste. Each of the meal items of the test tray were cold or lukewarm in temperature. V. Staff interviews The director of nursing (DON) was interviewed on 5/21/25 at 3:26 p.m. She said the CNAs and the nurses should deliver the meal trays when the cart arrived at the hall. The DON said if the staff delivered the room trays in a timely manner they could provide meal assistance in other areas and help ensure appropriate temperatures of the room tray meals. The registered dietitian (RD) was interviewed on 5/21/25 at 2:11 p.m. The RD said if a meal was not warm enough when it was eaten, it would not be as delicious as it could be. The DM was interviewed on 5/22/25 at 1:23 p.m. The DM said she had heard from residents that the pork was too tough and temperatures for the room trays were on the cooler side. She said to help with the tough pork she began ordering pork from a different source. She said to help with room tray temperatures she observed the meal tray delivery times and identified some long waits before the trays were served. She said she had spoken to the former DON and was told the nursing staff would pass the trays in the halls as soon as the room tray cart would arrive to help maintain the meal temperatures. The DM said during the 5/22/25 lunch observation, the dietary staff was making a grilled cheese to be placed on the room tray cart. She said during that time the room tray cart was left open.The DM said the south hall cart door should have been closed and quickly delivered to the south hall to help maintain temperatures of the rest of the room trays. She said the alternate meal should have been sent separately after it was ready. The DM said the coconut cream pie served at 67.2 degrees, which was too warm. She said she believed the pie contained dairy and should have been served at 41 degrees F or less. She said cold food should remain cold to ensure palatable temperatures. She said she would look at placing room tray cold food items in coolers with ice until they are delivered to the residents' room. The DM was interviewed again on 5/22/25 at 2:31 p.m. She said she would provide education to the cooks to help improve food palatability.

II. Failure to use consistent hand hygiene practices when providing meal assistance A. Professional reference According to The Centers for Disease Control and Prevention's (CDC) Handwashing Facts dated 4/17/24, retrieved on 6/1/25 from https://www.cdc.gov/clean-hands/data-research/facts-stats/index.html, Hand washing with soap removes germs from hands. This helps prevent infections because people frequently touch their eyes, nose and mouth without even realizing it. Germs get into the body through the eyes, nose and mouth and make us sick. Germs from unwashed hands can get into food and drinks while people prepare or consume it. Germs can multiply and some types of foods or drinks, under certain conditions and make people sick. Germs from unwashed hands could be transferred to other objects and then transferred to another person's hands. B. Facility policy and procedure The Handwashing/Hand Hygiene policy, dated 2001, was provided by the nursing home administrator (NHA) on 5/22/25 at 2:45 p.m. The policy read in part, This facility considers hand hygiene the primary means to prevent the spread of health care associated infections. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene products and supplies are readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. C. Observations On 5/20/25 during a continuous observation of the lunch meal on the memory care unit, beginning at 11:55 a.m. and ending at 1:17 p.m., the following was observed: At 11:55 a.m. CNA #13 was assisting residents, at the assisted dining table and other more independent residents in the dining room. At 12:15 p.m. CNA #13 sat down at the assisted dining table between Resident #49 and Resident #70 and across from Resident #36. She used alcohol-based hand rub (ABHR) from her pocket before assisting the residents. At 12:21 p.m. CNA #13 touched the side of her nose and dropped a pen on the floor. CNA #13 picked up the pen off the floor and proceeded to provide meal assistance and touch the fork of Resident #49 before she used ABHR again. At 12:31 p.m. CNA #13 dropped the ABHR cap on the floor. She picked up the cap off the floor. CNA #13 did not reapply ABHR after picking up the item off the floor. CNA #13 proceeded to offer Resident #36 a sip of her beverage, touching the resident's cup in the process. At 12:33 p.m. CNA #13 assisted Resident #70 with positioning her cup and then performed hand hygiene with the ABHR. CNA #13 did not perform hand hygiene before helping the two residents or in between assisting each resident. At 12:36 p.m. a second CNA (CNA #14) sat down between Resident #49 and Resident #36. CNA #14 provided meal assistance to Resident #49 and helped position a utensil in Resident #36's hand. CNA #14 did not perform hand hygiene in between assisting the two residents. D. Staff interviews CNA #14 was interviewed on 5/20/25 at 1:16 p.m. CNA #14 said staff should perform hand hygiene between assisting different residents. CNA #14 said she did not have ABHR with her. She said her ABHR was in her back pack and the facility was out of ABHR in the supply cabinet. CNA #14 said she was primarily providing meal assistance for Resident #49. She said she only provided cueing for Resident #36. -However, CNA #14 assisted Resident #36 with positioning a utensil in her hand (see observations above). CNA #13 was interviewed on 5/20/25 at 1:18 p.m. CNA #13 said staff should perform hand hygiene before serving each resident food and between assisting residents with their meals. The IP was interviewed on 5/21/25 at 3:08 p.m. The IP said staff should perform hand hygiene before assisting residents with their meals, between passing trays and between assisting multiple residents. The IP said hand hygiene should be conducted anytime there was a risk of cross-contamination, including after picking something off the floor. She said she had recently observed staff and conducted oversight in the main dining room during meals but had not observed any concerns. She said she would provide on the spot education with staff if she saw hand hygiene concerns. She said she had not recently observed staff's hand hygiene practices in the memory care unit. The IP said she would immediately have hand hygiene education conducted with staff. The director of nursing (DON) was interviewed on 5/21/25 at 3:26 p.m. The DON said staff were provided hand hygiene training when hired and anytime there was an outbreak. She said she did not know when the staff last had hand hygiene training. The DON said cross-contamination could occur if staff picked up an item off the floor and did not perform hand hygiene when providing meal assistance to residents. She said she would ensure hand hygiene education was conducted with staff. The CC was interviewed on 5/22/25 at 10:37 a.m. The CC said she could not find any recent training that had been provided to staff regarding performing hand hygiene when assisting residents with meals. Based on observations and interviews, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections on four of four hallways. Specifically the facility failed to: -Ensure an effective process was in place to ensure staff were aware of which residents were on enhanced barrier precautions (EBP); -Ensure staff donned (put on) appropriate personal protective equipment (PPE) when providing direct care to residents who should be on EBP; and, -Ensure staff performed consistent hand hygiene when providing meal assistance to residents. Findings include: I. EBP failures A. Facility policy and procedure The Infection Prevention and Control Program policy and procedure, dated December 2023, was provided by the nursing home administrator (NHA) on 5/22/25 at 6:00 p.m. It read in pertinent part, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections. Important facets of infection prevention include identifying possible infections or potential complications of existing infections; instituting measures to avoid complications or dissemination; educating staff and ensuring that they adhere to proper techniques and procedures and implementing appropriate enhanced barrier and transmission based precautions when necessary. Those with potential direct exposure to blood or body fluids are trained in and required to use appropriate precautions and personal protective equipment. The facility provides personal protective equipment and checks for its proper use. B. Observations On 5/19/25 at 4:38 p.m. Resident #83's and Resident #6's room was observed. Resident #83 had a urinary catheter and Resident #6 had a Stage 2 pressure ulcer on the left buttock. There was no PPE inside or outside of the room for staff to put on when providing direct care to the residents. On 5/19/25 at 5:40 p.m. Resident #44's room was observed. Resident #44 had a catheter and multiple pressure wounds. There was no PPE inside or outside of the room for staff to put on when providing direct care to the resident. On 5/20/25 at 11:39 a.m. Resident #44's room was observed again. There was no PPE inside or outside of the room for staff to put on when providing direct care to the residents. Resident #44 was lying in bed watching television. Two unidentified staff members entered the room with a mechanical lift to get Resident #44 out of bed. -The two unidentified staff members did not don PPE before entering the room. At 11:43 a.m. both unidentified staff members exited the room with Resident #44 in his wheelchair. One of the unidentified staff members wheeled Resident #44 to the dining room. On 5/21/25 at 1:15 p.m. Resident #83 and Resident #6's room was observed. There was no PPE equipment inside or outside of the room for staff to put on when providing direct care to the residents. On 5/21/25 at 1:18 p.m. Resident #58's room was observed. Resident #58 had a catheter. There was no PPE inside or outside of the room for staff to put on when providing direct care to the resident. C. Resident interview On 5/21/25 at 1:55 p.m. a resident who wished to remain anonymous was interviewed. The resident said staff did not put a gown on when providing care for them. The resident said a bin with PPE equipment was recently brought to their room. The resident said during their showers, staff wore gloves and masks but did not put on a gown when providing the resident with a shower. D. Staff interviews Certified nurse aide (CNA) #6 was interviewed on 5/21/25 at 4:11 p.m. CNA #6 said she had never heard of a resident being placed on precautions requiring PPE because of having a catheter. CNA #6 said when providing care for residents who had a catheter the only PPE she used was gloves. CNA #6 said she did not have to use additional PPE when draining a catheter bag or when providing care to the resident. She said she had never worn a gown when providing care for a resident who had a catheter. CNA #6 said for residents who had pressure ulcer wounds, the only PPE she would use was gloves. CNA #6 said if there was no precaution sign on a resident's door she just used gloves to provide care for residents. CNA #6 said there were no residents who were on EBP in the facility. Registered nurse (RN) #2 was interviewed on 5/21/25 at 4:44 p.m. RN #2 said residents who had a catheter should be on standard precautions, which only required the use of gloves when providing care. RN #2 said staff should be using gloves when providing care to all residents. RN #2 said staff should be using gloves when providing care to residents who had a closed wound. RN #2 said if a resident's skin was not intact and open, the resident was at high risk for infection, so she said she would wear a gown and goggles when providing care. She said there were no residents in the facility who were on EBP. The infection preventionist (IP) and the corporate consultant (CC) were interviewed together on 5/22/25 at 3:13 p.m. The IP said she was responsible for initiating EBP for residents. IP said signs should be placed on the residents' doors and bins placed with PPE. The IP said signs placed on residents' doors were important so that staff were aware of what kind of PPE they should be using when providing care for the residents. The IP said residents who had a catheter or pressure ulcer should be placed on EBP.staff should be wearing gloves and gowns when providing direct care to the residents. The IP said she started providing education to all staff on EBP on 5/21/25.

Based on observations, interviews and record review, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#15) of one resident out of 37 sample residents. Specifically, the facility failed to ensure an assessment was conducted to determine whether the self-administration of medications was clinically appropriate for Resident #15. Findings include: I. Facility policy and procedure The Self-Administration of Medications policy and procedure, revised February 2021, was provided by the nursing home administrator (NHA) on 5/22/25 at 6:00 p.m. It revealed in pertinent part, As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is re-assessed periodically based on changes in the resident's medical and/or decision-making status. Residents who are identified as being able to self-administer medications are asked whether they wish to do so. II. Resident #15 A. Resident status Resident #15, age greater than 65 was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included gastro-esophageal reflux disease (GERD) and osteoporosis. The 5/16/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required moderate assistance with toileting, bathing, dressing and set up assistance with eating and oral hygiene. B. Resident observation and interview On 5/21/25 at 9:35 a.m. during the medication administration observation, a medication cup with one chewable tablet was observed on Resident #15's bedside table. Registered nurse (RN) #3 said Resident #15 frequently requested her scheduled Calcium Carbonate chewable tablet to be left at the bedside to take at a later time. When RN #3 attempted to administer the scheduled Calcium Carbonate chewable tablet, Resident #15 declined and requested to leave one tablet on the bedside table. RN #3 left the Calcium Carbonate in a cup on Resident #15's bedside table and exited the room. Resident #15 was interviewed on 5/21/25 at 5:03 p.m. Resident #15 said some staff at the facility did not allow her to keep the Calcium Carbonate chewable tablets at her bedside, but she said most of the nurses did. She said she preferred to have the medication available after her meals. Resident #15 said she was not aware of an assessment being conducted to determine if she was able to safely administer her own medications. C. Record review A review of Resident #15's May 2025 CPO revealed the following physician's order: Calcium Carbonate chewable tablet 500 milligrams (mg) by mouth three times daily, ordered 3/7/24. The May 2025 medication administration record (MAR) revealed RN #3 documented Resident #15's scheduled dose of Calcium Carbonate chewable tablets as administered. Cross reference F759: the facility failed to ensure the medication error rate was less than five percent. -A review of Resident #15's electronic medical record (EMR) did not reveal documentation to indicate that an assessment had been conducted to determine if Resident #15 was able to safely administer her own medication. -The EMR did not reveal a physician's order for Resident #15 to self-administer the Calcium Carbonate and approval for it to be kept at the resident's bedside. III. Staff interviews RN #3 was interviewed on 5/21/25 at 9:35 a.m. RN #3 said Resident #15 had worked in healthcare in the past and was particular about taking the Calcium Carbonate chewable tablet with her meals. RN #3 said she felt it was safe for Resident #15 to administer this medication on her own, but she said she could not recall if a formal assessment for self-administration of medications was previously completed. RN #1 was interviewed on 5/22 at 12:08 p.m. RN #1 said he would leave medications such as eye drops or nasal spray at a resident's bedside upon request if the resident was physically capable of self-administering medications and cognitively able to understand how and why to take the medication. RN #1 said he was aware the facility had a policy to allow residents to self-adminster medications, but he said he could not recall if a specific assessment was required. The director of nursing (DON) and the corporate consultant (CC) were interviewed together on 5/22/25 at 4:01 p.m. The DON said if a resident requested to self-administer medications, a self-administration assessment should be completed by a nurse. She said the physician should be notified and a physician's order obtained for the resident to self-administer medications. She said the resident's comprehensive care plan should be updated to show the resident was assessed and determined to be safe self-administering medication. The DON said she did not think a medication self-administration assessment had been completed for Resident #15. The DON said the nurses must witness a resident consuming a medication in order to document it as administered in the resident's MAR.

Based on observations and interviews, the facility failed to ensure residents received notices orally and in writing which included a written description of their legal rights. Specifically, the facility failed to ensure the State Survey Agency (SSA) contact information, including the phone number, address and email address were posted and in a manner accessible and understandable to all residents. Findings include: I. Resident group interview A group interview was conducted on 5/21/25 at 10:00 a.m. with five residents (#14, #52, #64, #66 and #77) who were deemed interviewable through the facility and assessment. All five of the residents said they were not aware they could contact the SA and did not know where to get the SA's contact information. II. Observations On 5/21/25 at 9:50 a.m., a walk-through of the facility was conducted and did not reveal a posting for the SA's contact information, to include the agency's phone number, address and email address. III. Staff interview The nursing home administrator (NHA) was interviewed on 5/21/25 at 11:15 a.m. The NHA confirmed the required SA contact information was not posted in the facility.

Based on observations, record review and interviews, the facility failed to ensure two (#68 and #71) of seven residents out of 37 sample residents were kept free from abuse. Specifically, the facility failed to: -Prevent an altercation between Resident #68 and Resident #71; -Protect Resident #68 from physical abuse by Resident #65; and, -Protect Resident #71 from physical abuse by Resident #68. Findings include: I. Facility policy and procedure The Abuse, Neglect, exploitation or misappropriation-Reporting and Investigating policy, revised September 2022, was provided by the nursing home administrator (NHA) on 5/22/25 at 6:00 p.m. The policy read in pertinent part, If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. II. Altercation between Resident #68 and Resident #71 on 2/14/25 A. Facility investigation The facility investigation was provided by the NHA on 5/21/25 at approximately 3:00 p.m. The investigation documented that on 2/14/25 two residents (Resident #68 and Resident #71) were sitting at the lunch table on the secured unit and experienced an altercation. Resident #71 had spilled a glass of water on the table. According to the investigation, a certified nurse aide (CNA) witnessed Resident #71 take a cup of water and throw it at the Resident #68. The CNA was able to intervene and redirect the residents to prevent further escalation of the incident. The investigation identified the CNA helped Resident #68 changed her shirt and no further incidents occurred. The residents were placed on frequent checks when they were in their rooms and line of sight supervision when they were in common areas in order to prevent additional occurrences. According to the investigation, the incident was substantiated as it did occur. According to the investigation, the incident did not cause psychosocial stress to either resident and interventions were successful for preventing additional incidents. The investigation documented Resident #68 and Resident #71 were interviewed after the incident and neither resident recalled the incident and said they felt safe. The residents returned to their normal daily life and had positive interactions while being monitored in line of sight. B. Resident #68 1. Resident status Resident #68, age greater than 65, was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included unspecified dementia with moderate agitation, Alzheimer's disease with late onset and anxiety disorder due to known physiological conditions. The 5/9/25 minimum data set (MDS) assessment identified Resident #68 had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. Resident #68 did not use a mobility device but required some staff assistance with activities of daily living (ADLs). According to the MDS assessment, Resident #68 had inattention and disorganized thinking. The resident did not have physical or verbal behavioral symptoms directed towards others. 2. Record review The behavior care plan care plan, revised 6/4/24, identified Resident #68 had a history of cursing at others and hitting and shoving others. Interventions included administering medications as ordered and monitoring and documenting for side effects and effectiveness (initiated 5/8/24), allowing time for the resident to express herself and her feelings towards the situation and assessing her understanding of the situation (initiated 5/8/24) and giving the resident as many choices as possible about her care and activities (initiated 5/8/24). According to the behavior care plan interventions, revised 10/2/24, Resident #68 could be redirected with walking outside, reminiscing, conservations about horses, providing changes in her environment, humor, decreased stimulation, validation and asking her to play her piano. The behavior care plan, revised 2/26/25, identified at times Resident #68 would curse and hit staff. According to the care plan interventions, initiated 2/28/25, staff was to attempt non-pharmological approaches to redirect her behavior to include showing the resident the patio and calling her family. The wandering and elopement risk care plan, revised 12/4/24, identified Resident #68 had impaired safety awareness and her safety should be maintained. Interventions included frequent monitoring checks (initiated 10/25/23). -Review of Resident #68's care plan did not indicate Resident #68 was at risk for abuse or had been a victim of physical abuse. The 2/14/25 situation background assessment and recommendation (SBAR) summary documented Resident #68 had a partial cup of water thrown on her by another resident and was assisted into dry clothes. She had no recollection of the incident and displayed no signs of apprehension or fear. Progress notes on 2/15/25 through 2/20/25 identified that Resident #68 was monitored following the incident with Resident #71. C. Resident #71 1. Resident status Resident #71, age greater than 65, was admitted on [DATE]. According to the May 2025 CPO, diagnoses included Alzheimer's disease with late onset, dementia and other diseases elsewhere classified, unspecified severity with agitation and anxiety, cognitive communication deficit, major depression disorder, recurrent with severe psychotic features, mood disturbance and anxiety. The 3/12/25 MDS assessment identified Resident #71 had severe cognitive impairments with a BIMS score of three out of 15. Resident #71 did not use a mobility device but required some staff assistance with her ADLs. According to the MDS assessment, Resident #71 had inattention, disorganized thinking and delusions. The resident had physical behavioral symptoms directed towards others. 2. Record review The physical aggression care plan, revised 1/23/24, identified Resident #71 had a history of physical aggression. Interventions included providing the resident as many choices as possible about her care and activities (initiated 12/29/23), intervening when the resident was agitated, before she escalated with calmly engaging her in conversation (initiated 12/29/23) and if the resident continued to escalate, staff should calmly walk away from her, keep her safe, approach her later and monitor/document/report any signs of danger to herself and others (initiated 12/29/23). The care plan intervention, revised 12/4/24, identified the resident could be redirected with a stuffed bunny, realistic baby dolls, adult coloring books, reminiscing about growing up on the farm, selling corn and raising kids, calling family, being outside, validating her feelings, offering music, such as Elvis and music based activities, one-to-one visiting and deep breathing with mediation. The behavior care plan care plan, initiated 12/7/23 and revised 3/25/25, identified Resident #71 had a history of yelling and cursing at others. Interventions included assessing and anticipating her needs for food, thirst, toileting, comfort level, body positioning and pain (revised 12/4/24), allowing time for the resident to express herself and her feelings towards the situation and assessing her understanding of the situation (initiated 12/7/23) and giving her as many choices as possible about her care and activities. The care plan interventions, revised 7/9/24, identified the resident could be redirected with activity groups, [NAME] pigs and changes in the environment. The 2/14/25 SBAR summary documented Resident #71 threw water from a partially filled cup onto another resident without provocation. According to the note, the resident remained chronically delirious with visual and auditory hallucinations. The 2/16/25 eMAR (electronic medication administration record) general note identified Resident #71 was very anxious. The note documented she attempted to pull a cable and refused to let go when asked. According to the note, the resident became physically and verbally aggressive. The resident was provided a doll and a PRN (as needed) Ativan (anti-anxiety) medication. The progress note did not identify who the resident was physically and verbally aggressive towards. The 2/18/25 health status note documented Resident #71 continued to be monitored for being a physical aggressor towards another resident (on 2/14/25). According to the note, she was verbally aggressive towards staff. The note indicated Resident #71 was being kept within staff's sight to prevent any verbal or physical aggression. III. Incident of physical abuse of Resident #68 by Resident #65 on 4/6/25 A. Facility investigation The facility investigation was provided by the NHA on 5/21/25 at approximately 3:00 p.m. The investigation identified that on 4/6/25 the clinical nurse on-call was notified that a female resident on the secured unit entered another female resident's room. The investigation documented Resident #65 kicked the other female resident (Resident #68) in the leg/foot. According to the investigation report, Resident #65 was wandering when she entered Resident #68's room. The staff attempted to redirect and intervene but Resident #65 became upset and began kicking at Resident #68 when she was asked to leave the room. The staff removed Resident #65 from Resident #68's room. According to the investigation, Resident #68 was not injured and did not report pain. The investigation indicated neither resident recalled the incident and returned to their normal daily routines. Resident #65 was placed on line of sight in order to prevent additional incidents. The facility investigation identified the incident was witnessed by the CNA. The CNA witness statement identified the CNA heard yelling coming from a resident's room and witnessed Resident #65 kicking Resident #68. The CNA removed Resident #65 from Resident #68's room to separate the residents. According to the facility investigation, neither resident could recall the incident and both residents felt safe. The facility documented the incident was substantiated because physical contact was witnessed. The interventions documented in the facility investigation identified Resident #65 was placed in line of sight in order to prevent a recurrence and medications were reviewed and orders were changed by the physician. Resident #68 was checked in on by the social services assistant and monitored by staff to ensure she exhibited no psychosocial distress. According to the facility investigation, the interventions had been successful as there had not been further incidents. B. Resident #68 (victim) 1. Record review The 4/6/25 SBAR summary documented a resident (Resident #65) entered Resident #68's room. Resident #68 asked Resident #65 to leave which upset Resident #65. Resident #65 kicked Resident #68 in the right lower extremity (RLE). According to the summary, there was no injury, the residents were separated and were back to their baseline behaviors. The 4/8/25 nursing progress note documented Resident #68 was monitored for a resident-to-resident altercation where she was the recipient of being kicked on the RLE. According to the note, the RLE was clear of any injury and no bruising was noted. C. Resident #65 (assailant) 1. Resident status Resident #65, age greater than 65, was admitted on [DATE]. According to the May 2025 CPO, diagnoses included Alzheimer's disease with late onset, unspecified dementia, unspecified severity with anxiety and other behavioral disturbances and wandering in diseases classified elsewhere. The 3/18/25 MDS assessment identified Resident #65 had severe cognitive impairments with a staff assessment for mental status. The resident required partial to moderate staff assistance with her most ADLs. According to the MDS assessment, Resident #65 had inattention, disorganized thinking and delusions. The resident had verbal behavioral symptoms directed towards others. The MDS identified her behaviors had worsened. 2. Record review The behavior care plan, initiated 7/17/24, identified Resident #65 was intrusive with her peers. According to the care plan, the resident went into other residents' rooms, rifled through their things and took items that did not belong to her. The care planned interventions, initiated (7/17/24), included encouraging the resident to participate in activities of her choice and to utilize the courtyard in appropriate weather, continuing to identify purposeful activities to keep her happy, fulfilled and busy, redirecting her from other residents, their rooms and their possessions while reminding the resident to respect the space of other residents. According to the care plan, the resident liked to go on walks and directed staff to offer their hand to go on a walk. The behavior care plan, initiated 8/14/24 and revised 3/2/25, identified Resident #65 had a history of physical and verbal aggression. The care plan interventions, revised 9/4/24, included giving the resident as many choices about care as possible, intervening when the resident was agitated before she escalated, redirecting her to calm one-to-one conversations, walks outside and music and dancing. According to the care plan, if the resident continued to escalate, staff should walk away, keep her safe and reapproach later. The behavior care plan, revised 2/10/25, identified Resident #28 could become tearful and voice sadness. The intervention, initiated 3/12/25, directed staff to monitor her more closely when she was not in the commons area. -The care plan did not identify new interventions after Resident #65 entered Resident #68's room and kicked her when Resident #68 asked her to leave. The 4/6/25 nursing progress note documented a CNA heard Resident #65 upset, with her voice raised, in the room of Resident #68. The CNA entered Resident #68's room and saw Resident #65 kicking Resident #68 in the right lower extremity. According to the note, Resident #65 was cursing with a raised voice as she held a baby doll. The CNA assisted Resident #65 out of the room of Resident #68 and attempted to calm her down with a walk outside. The note documented Resident #65 was assessed and the resident's foot did not identify visible marks or discolorations. The note did not identify if Resident #68 was assessed for injury. The note indicated Resident #65 would be monitored every 15 minutes for 72 hours. The 4/7/25 health status note documented staff continued to conduct 15-minute checks on Resident #65. According to the note, Resident #65 was in and out of other residents' rooms, in the kitchen and in the dining room without resident-to-resident altercations and close monitoring would continue. The 4/8/25 nursing progress note documented Resident #65 continued to go in and out of residents' rooms without resident-to-resident aggressive interactions. The 4/10/25 nursing progress note documented Resident #65 continued to pace up and down the hallway and outside and go in and out of other residents' rooms. According to the note, the resident was easily redirected. IV. Incident of physical abuse directed toward Resident #71 by Resident #68 on 5/18/25 A. Facility investigation The facility investigation was provided by the NHA on 5/22/25 at approximately 11:00 a.m. The investigation identified a physical altercation on 5/18/25 was witnessed by a registered nurse (RN) and a CNA on the secured unit. The RN witness statement documented she witnessed Resident #71 telling people off. According to the witness statement, Resident #71 and Resident #68 were in the dining room together and Resident #71 was being verbal towards Resident #68. Resident #68 started to walk away from Resident #71 when Resident #71 called her a foul name. Resident #68 then slapped Resident #71. The investigation documented the residents were separated, there were no injuries to either resident and neither resident could recall the incident. The CNA witness statement documented Resident #68 entered the dining room and Resident #71 started saying things to Resident #68. According to the witness statement, the CNA attempted to redirect Resident #68 out of the dining room when Resident #71 called Resident #68 a derogatory name. The witness statement identified Resident #68 turned around and slapped Resident #71. B. Resident #71(victim) 1. Record review The 5/18/25 at 2:49 p.m. nursing progress note documented Resident #71 and Resident #68 were standing in the dining area exchanging unpleasant words. Resident #68 started to walk away when Resident #71 called Resident #68 a bad name. The note documented Resident #68 turned around and slapped Resident #71 on the left side of her face. The 5/19/25 at 2:09 p.m. health status note documented Resident #71 was observed to be restless on the evening of 5/19/25. According to the note, Resident #71 was monitored for being a physical aggression recipient and was followed around by staff to prevent further physical aggression. C. Resident #68 (assailant) 1. Record review The 5/21/25 health status note documented Resident #68 was being monitored for initiating physical violence towards another resident (Resident #71). According to note, there had been no further episodes of physical aggression and Resident #68 had been friendly to other residents and staff. V. Staff interviews The director of nursing (DON) was interviewed on 5/21/25 at 3:26 p.m. The DON said to prevent resident-to-resident altercations the facility had been working on identifying staff that worked well with the memory care population, incorporating interventions and offering individualized activities and snacks. She said staff should look for cues of agitation and redirect the residents by taking them on a walk and changing their location if needed. The DON said if an incident occurred, staff should separate the residents, provide 15- minute checks for 72 hours or longer if needed, keep the residents in line of sight and provide ongoing checks on the residents, as needed, if determined in the care plan. The DON said Resident #68 had a history of altercations with residents. She said the resident could get easily frustrated and agitated with other residents and could increase other residents' agitation. She said pain and fatigue could contribute to her agitation. She said staff addressed her pain as needed. The social services assistant (SSA) was interviewed on 5/21/25 at 4:08 p.m. The SSA said she conducted the facility abuse investigations and the NHA determined if abuse was substantiated. She said she collected the data, interviewed staff and residents involved to identify what happened and checked if other residents were impacted and if everyone felt safe. She said the interdisciplinary team (IDT) would try to find the root cause and look at interventions to help prevent the incidents from happening again. She said staff would be verbally educated if needed. The SSA said Resident #71 and Resident #68 did not recall past altercations with each other and desired to be around each other. She said staff should keep both residents in their line of sight and observe their interactions with each other. The activities director (AD) was interviewed on 5/22/25 at 3:01 p.m. The AD said the facility recently had dementia training and she started a new activity program on the secured unit to help provide more meaningful and purposeful activities that offered more rummaging, sensory and past lifestyle chore- like activities. She said she had seen an improvement in residents' engagement and behaviors. The infection preventionist (IP) and the corporate consultant (CC) were interviewed together on 5/22/25 at 4:34 p.m. The IP identified herself as the secured unit manager. She said her role in helping prevent abuse and resident-to-resident altercations was to support her staff and provide them with an extra set of eyes on the residents. The IP said she tried to go into the secured unit daily, depending on how much else she had going on throughout the day. The IP said if Resident #71 was agitated, staff should redirect the resident with a walk outside or an activity to change her focus and try to keep her away from Resident #68. She said staff should try to keep Resident #68 away from Resident #71 when they were able to and offer activities that she liked. The IP said Resident #65 went into other residents' rooms. She said staff should redirect Resident #65 from going into a resident's room if she had prior issues with that particular resident. The IP said she had tried putting stop sign banners across the residents' doors but the residents would tear them down. The IP said it was staff's goal to minimize resident-to-resident incidents so staff tried to keep eyes on everyone. She said all residents were kept in line of sight. She said anytime there was a new incident, staff would look at incorporating new interventions and determine what interventions were working and what interventions were not. The CC said the facility had an increase in resident-to-resident altercations so they brought in a certified dementia trainer to provide additional dementia education. She said the training was in March 2025 and in April 2025 so all the staff could receive the training. The IP said she was not available for the dementia training that was offered but the training was available online. The CC said the facility was going to continue to try to revamp the activity program, continue to train staff and rotate staff that did well working with residents with dementia. The NHA was interviewed on 5/22/25 at 5:18 p.m. The NHA identified the above incidents all occurred during the day between lunch time and 2:45 p.m. He said Resident #71 was a resident that staff worked with everyday and with her family to try to meet her needs and de-escalate her behaviors. He said staff continued to try to prevent resident-to-resident altercations but could not prevent them all. The NHA said the facility would continue to provide specialized dementia training and continue to focus on activities that engaged the residents to help mitigate behaviors. He said the facility had not identified a trend/pattern in the resident-to-resident altercations. The NHA said the facility would continue to offer residents and staff support and offer education.

Based on observations, record review and interviews, the facility failed to ensure one (#80) of two residents with limited range of motion out of 37 sample residents received appropriate treatment and services. Specifically, the facility failed to ensure Resident #80 was consistently provided services through the walk-to-dine program in order to maintain the resident's ambulation status. Findings include: I. Facility policy and procedure The Restorative Nursing Services policy, revised July 2017 was provided by the nursing home administrator (NHA) on 5/22/25 at 6:00 p.m. It revealed in pertinent part, Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (physical, occupational or speech therapies). Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. The resident or representative will be included in determining goals and the plan of care. Restorative goals may include, but are not limited to supporting and assisting the resident in: adjusting or adapting to changing abilities; developing, maintaining or strengthening his/her physiological and psychological resources; maintaining his/her dignity, independence and self-esteem; and participating in the development and implementation of his/her plan of care. II. Resident #80 A. Resident status Resident #80, age greater than 65, was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included functional quadriplegia (immobility related to weakness without injury to the brain or spinal cord), history of falls, altered mental status and fibromyalgia (chronic widespread body pain and fatigue). The 3/19/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The resident was dependent on staff for bathing and required moderate to substantial assistance with dressing, footwear and hygiene. The resident required moderate assistance with repositioning in a chair or bed as well as transferring (moving from lying to sitting, sitting to standing or from bed to chair). B. Resident interview and observations On 5/19/25 at 10:35 a.m. Resident #80 was being assisted by an unidentified staff member transferring from the bed to her wheelchair. The unidentified staff member wheeled Resident #80 to the morning group activity. On 5/19/25 at 12:08 p.m. Resident #80 was wheeled in her wheelchair by an unidentified staff member from her room to the dining room. -The unidentified staff member did not offer to ambulate Resident #80 to the dining room. Resident #80 was interviewed on 5/19/25 at 4:21 p.m. Resident #80 said she thought the physical therapist put her on a program to walk to the dining room. She said she could only recall one time in the last two weeks that a staff member assisted her with ambulating to the dining room. Resident #80 said there was a green card on the back of her wheelchair that identified she was on the walk-to-dine program; however, staff did not offer to provide her with ambulation to the dining room. She said she was concerned with not being able to maintain her ambulation without the walk-to-dine program being provided. During the interview, Resident #80's wheelchair was observed with a green symbol of a walking man on the back handle of her wheelchair. On 5/20/25 at 11:47 a.m. Resident #80 was assisted by an unidentified staff member from her room to the dining room via her wheelchair. -The unidentified staff member did not offer to ambulate Resident #80 to the dining room. C. Record review The 3/25/25 progress note revealed Resident #80's representative requested a physical therapy (PT) referral for Resident #80. The 5/13/25 PT discharge summary revealed Resident #80 received physical therapy services from 4/2/25 to 5/13/25. The physical therapy discharge summary documented Resident #80 required the use of a four-wheeled walker with supervision or touching assistance to ambulate. The Kardex (a tool utilized by staff to provide consistent resident care)for Resident #80 was provided by the NHA on 5/22/25 at 6:00 p.m. It revealed instructions to the facility staff to offer Resident #80 assistance to ambulate to and from the dining room for every meal. -Review of Resident #80's activities of daily living (ADL) care plan, initiated 1/30/25, revealed the care plan was not updated to include ambulating the resident to the dining room for meals. III. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 5/22/25 at 1:18 p.m. CNA #3 said the green walking man symbol on residents' doorways and attached to different residents' assistive devices indicated a resident was on the walk-to-dine program. She said she thought Resident #80 was on the walk-to-dine program, but she said was not sure. Registered nurse (RN) #1 was interviewed on 5/22/25 at 12:08 p.m. RN #1 said he thought the green walking man symbol meant physical therapy approved the resident for weight-bearing status. RN #1 said he was not sure how physical therapy communicated to staff which residents were on the walk-to-dine program since usually the CNAs assisted residents to the dining room. The director of rehabilitation (DOR) was interviewed on 5/22/25 at 2:41 p.m. The DOR said the green walking man was the symbol to alert facility staff that the resident was part of the walk-to- dine program. The DOR said the walk-to-dine program meant staff assisted residents with ambulation to the dining room. She said staff were to maintain contact with the resident using a gait belt and a wheelchair following the resident, in case the resident needed to sit down. The DOR said the goal of the walk-to-dine program was to maintain the physical abilities of residents in the facility. The DOR said the physical therapist was responsible for providing the nursing staff with education of each particular resident that was placed on the walk-to-dine program. The DOR said Resident #80 was discharged from PT on 5/13/25. The DOR said the discharge summary did not specify Resident #80 was placed on the walk-to-dine program, however, she said the summary did recommend supervision with contact assistance to ambulate up to 75 feet with a four-wheeled walker, which described the walk-to-dine program. The DOR said she could not find any other communication in the resident's electronic medical record (EMR) to confirm the staff were informed whether or not Resident #80 was on the walk-to-dine program starting on 5/13/25. The director of nursing (DON) and the corporate consultant (CC) were interviewed on 5/22/25 at 4:01 p.m. The DON said she could not recall if Resident #80 was on the walk-to-dine program, but she said the green walking man symbol indicated that the resident was part of the program. The DON said the goal of the walk-to-dine program was to help residents maintain mobility. The DON said the walk-to-dine program was initiated by the PT and the minimum data set coordinator (MDSC). The DON said the resident's care plan and Kardex should be updated upon initiation of the program.

Based on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent (%). Specifically, the facility's medication error rate was 7.69%, which was two errors out of 26 opportunities for error. Findings include: I. Medication administration observations On 5/21/25 at 9:35 a.m. registered nurse (RN) #3 was preparing and administering medications for Resident #15. Resident #15 had physician's orders for the following medications: Carboxymethylcellulose-Glycerin ophthalmic gel 1-0.9 % (Genteal moisturizing gel), instill one drop to each eye twice a day for dry eyes, ordered 5/14/24. -However, RN #3 administered Hypromellose/Dextran/Glycerin ophthalmic eye drops (Genteal moisturizing eye drops) to Resident #15 instead of the Genteal moisturizing gel specified in the physician's order. Calcium Carbonate chewable tablet 500 milligrams (mg), give one tablet by mouth three times a day, ordered 3/7/24. RN #3 attempted to administer a Calcium Carbonate chewable tablet 500 mg as ordered by the physician to Resident #15. Resident #15 declined to take the medication and requested to keep the medication on her bedside table. RN#3 left the medication at the resident's bedside, exited the resident's room and returned to her medication cart. Review of Resident #15's May 2025 medication administration record (MAR) revealed RN #3 documented the resident's scheduled morning dose of Calcium Carbonate chewable tablets as administered. -However, Resident #15 had not taken the medication when RN #3 attempted to administer it to her (see observation above). Cross reference F554 for failure to ensure Resident #15 was assessed and a physician's order obtained for self-administration of medications. II. Staff interviews RN #3 was interviewed on 5/21/25 at 9:50 a.m. RN #3 said Resident #15 frequently asked for the Calcium Carbonate chewable tablets to remain at the bedside so she could self-administer them at a later time. RN #3 said the resident was a retired nurse and was particular about her medications. The consulting pharmacist was interviewed on 5/22/25 at 10:44 a.m. The consulting pharmacist said Genteal eye gel and Genteal eye drops provided the same overall effect; however, the Genteal eye gel had a longer lasting effect compared to the eye drops. The director of nursing (DON) and the corporate consultant (CC) were interviewed on 5/22/25 at 4:01 p.m. The DON said the nursing staff should contact the physician to clarify the physician's order prior to administering a medication if the medication order did not match the medication available. The DON said RN #3 should have witnessed Resident #15 consuming the medication in order to document it in the MAR as administered. She said if a resident requested to self-administer the medication at a later time, the nurse should not document the medication as administered.

Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in one of one kitchen. Specifically, the facility failed to: -Ensure safe and appropriate storage of food items in the refrigerators and pantry; and, -Ensure ready-to-eat foods were handled in a sanitary manner to prevent cross contamination. Findings include: I. Failure to store food items appropriately in the refrigerators and the dry storage area A. Professional reference The Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 10/16/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices and sugar shall be identified with the common name of the food. In a mechanically refrigerated or hot food storage unit, the sensor of a temperature measuring device shall be located to measure the air temperature or a simulated product temperature in the warmest part of a mechanically refrigerated unit and in the coolest part of a hot food storage unit. Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees celsius (41 degrees fahrenheit (f)) or less for a maximum of seven days. The day of preparation shall be counted as day one. According to the United States Department of Agriculture (USDA) Is Food In Dented Cans Dangerous? (9/18/24) retrieved on 10/16/24 from https://ask.usda.gov/s/article/Is-food-in-damaged-cans-dangerous, food from cans that were leaking, bulging, or badly dented should never be eaten. The damaged cans could contain clostridium botulinum (a toxic bacteria). According to the USDA How You Should Handle Food With Mold On It (9/18/24) retrieved on 10/16/24 from https://ask.usda.gov/s/article/How-should-you-handle-food-with-mold-on-it, It documented in pertinent part, Buying small amounts and using food quickly can help prevent mold growth. But when you see moldy food: Don't sniff the moldy item. This can cause respiratory trouble. If food is covered with mold, discard it. Put it into a small paper bag or wrap it in plastic and dispose of it in a covered trash can that children and animals can't get into. Clean the refrigerator or pantry at the spot where the food was stored. Check nearby items the moldy food might have touched. Mold spreads quickly in fruits and vegetables. B. Facility policy and procedure The Food Receiving and Storage policy, revised November 2022, was provided by the dietary manager (DM) on 10/8/24 at 1:58 p.m. The policy read in pertinent part, Foods shall be received and stored in a manner that complies with food handling practices. When food is delivered to the facility it is inspected for safe transport and quality before being accepted. Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready for use. Refrigerated foods are labeled, dated and monitored so they are used by their use by date, frozen or discarded. The hand hygiene policy, revised November 2022, was provided by the dietary manager (DM) on 10/8/24 at 1:59 p.m. The policy read in pertinent part, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. C. Observations On 10/8/24 at 9:35 a.m. a can of corn was stocked on the first row of the can goods rack in the dry storage room of the kitchen. The can of corn had a large and deep dent on the side of the can. At 9:40 a.m. the following items were observed in the kitchen's walk-in refrigerator: -Multiple containers of undated strawberries were sitting on a shelf. Four of the containers had moldy strawberries in them; -There were pre-bowled berries in a pan covered with parchment paper. The bowls of berries contained strawberries, blueberries and blackberries. The bowls were not labeled or dated; -A plastic lidded tub of lettuce that was not labeled or dated; and, -A plastic tub of white cheese covered in aluminum foil was not labeled or dated. At 11:52 a.m. the moldy containers of strawberries remained on the shelf in the walk-in refrigerator. The cheese and lettuce tubs remained undated. -During the lunch meal service, beginning at 11:50 a.m. and ending at 1:10 p.m., seven bowls of the undated pre-bowled berries were served. At 12:45 p.m. The DM entered the walk-in refrigerator and removed the moldy strawberry containers. II. Failure to ensure ready-to-eat foods were handled in a sanitary manner A. Professional reference The Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 10/16/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. The Center for Disease Control and Prevention (CDC) About Hand Hygiene For Patients in Healthcare Settings (2/27/24), retrieved on 10/16/24 from https://www.cdc.gov/clean-hands/about/hand-hygiene-for-healthcare.html, read in pertinent part, Patients in healthcare settings are at risk of getting infections while receiving treatment for other conditions. Cleaning your hands can prevent the spread of germs, including those that are resistant to antibiotics, and protects healthcare personnel and patients. According to the CDC, hand washing should occur before preparing or eating food, before touching the eyes, nose or mouth, and after touching potential contaminated surfaces. B. Observations During a continuous observation of the lunch meal service in the kitchen on 10/8/24, beginning at 11:50 a.m and ending at 1:10 p.m., the following was observed: Cook (CK) #1 was observed plating ready-to-eat food for the lunch meal service. At 12:02 p.m. CK #1 touched the side of her head with her left hand and then continued to plate resident meals. -CK #1 did not not perform hand hygiene after touching her head. At 12:35 p.m. CK #2 placed a glove on one hand. -CK #2 did not perform hand hygiene before donning the glove. CK #2 picked up a stack of meal tickets, flipped through the tickets with the gloved hand and separated the tickets in two piles. -CK #2 did not remove the glove or perform hand hygiene after handling the meal tickets. CK #2 placed four premade hamburger patties on to a skillet with the same gloved hand he had used to handle the meal tickets. III. Staff interviews The DM was interviewed on 10/8/24 at 12:12 p.m. The DM said all cans of food should be checked for any dents and/or missing labels. She said all the cans should be checked for dents when delivered and stocked. She said damaged cans should be removed from the supply for use and set aside to return to the delivery driver on the next shipment. The DM said a can with a dent could have a small hole in it. She said a hole could allow air to get into the can and cause contamination. She said dents in canned food posed a risk of foodborne illnesses, such as botulism. The DM said all dented cans should be removed because staff would not know if there were small puncture holes that they could not see in the can or if the food inside had gone bad. The DM observed the dented can of corn on the can supply rack. She said the can should not have been placed on the rack with other cans ready for use. She said she would remove the can from the supply and set it in the delivery pick up pile from return. CK #1 was interviewed on 10/8/24 at 12:20 p.m. CK #1 said she prepped the strawberries, blueberries and blackberries for the lunch meal after the new shipment of strawberries arrived. She said she only used the new stock of strawberries that were delivered on the morning of 10/8/24. -However, the parchment paper covering the prepared bowls of berries was not dated to indicate when the berries should be discarded and mold was observed on the strawberries in the remaining containers in the refrigerator (see observation above). CK #2 was interviewed on 10/8/24 at 12:20 p.m. CK #2 said most of the produce that arrived at the facility arrived fresh. He said if he saw mold on any of the produce, he would throw it away. CK #2 said the kitchen staff did not have a routine schedule to check the produce in the refrigerator. He said the kitchen went through so much produce and the ongoing use created a quick turnover which decreased the need for scheduled checks. He said the produce supply was used faster than it went bad. CK #2 said dented cans could be used if they had a dent on them. He said he would not use the cans of food if the seal of the can was broken, if it was visibly open to air, and/or if there was liquid running out of it. The DM was interviewed a second time on 10/8/24 at 12:45 p.m. as she removed the moldy strawberries from the shelf in the walk-in refrigerator (see observation above). The DM said she found four and a half containers of moldy strawberries in the refrigerator. She said one of the strawberry containers had been opened and used. The DM could not identify when the opened pack of strawberries was last used. She said she needed to remove the moldy strawberries because of the risk of mold spreading to the rest of the produce. She said mold grew quickly on strawberries and if one strawberry had mold on it, the mold would quickly spread onto the other strawberries. The DM said all produce in the refrigerator should be labeled and dated. The DM was informed of the undated and labeled tub of cheese covered with an aluminum foil and a covered tub of lettuce. The DM said the cheese and the lettuce should have been dated and labeled. She said the cheese should have been covered with a fitted lid so there was no risk for air entering the cheese. She said a fitted lid for the tub should have been used instead of the aluminum foil. The DM said staff should have been checking the produce daily to make sure there was no mold on the produce and everything was labeled and dated. She said checking the produce daily was an expectation but she did not have it as a set task or a log to sign off that the task had been completed. The DM said she would re-educate staff and create a log to sign off on to ensure the kitchen staff checked all produce in the refrigerator for freshness and made sure all refrigerated items were labeled and dated. Registered nurse (RN) #1 was interviewed on 10/8/24 at 2:26 p.m. RN #1 said she was the facility's infection preventionist. She said all staff received hand hygiene training during the new hire orientation and during the July 2024 skills fair. RN #1 said she did hand hygiene audits throughout the facility to include the kitchen staff. She said she conducted the audit monthly to ensure staff was following safe infection control practices and provide additional training as needed. RN #1 said she reminded the kitchen staff to perform hand hygiene before food preparation and every time they touched a potentially contaminated surface. The registered dietitian (RD) was interviewed on 10/8/24 at 2:31 p.m. The RD said she conducted routine oversight of the kitchen. The RD said, during kitchen walk-throughs, she would make sure the kitchen was clean and in good repair, staff was practicing good hand hygiene and using gloves appropriately. She said she would also make sure food items were labeled and dated. The RD said dented cans should be removed and set aside and not used because of the risk of botulism. She said had not been involved in educating the dietary staff on food borne illnesses. The RD said all produce with mold on it should be removed from the supply stock because of the risk of the mold spreading. The DM was interviewed a third time on 10/8/24 at 2:58 p.m. The DM said she reviewed and re-educated the dietary staff on hand washing, appropriate glove use and making sure the stored food for resident use was routinely inspected for safe consumption and removed from the stock when problems were identified.

Based on observation, interviews, and record review, the facility failed to ensure services provided met professional standards of practice for two (#3 and #9) of seven residents out of 5 sample residents. Specifically, the facility failed to: -Ensure Resident #9's fluid intake was monitored and managed effectively, which resulted in the resident being sent to the hospital for fluid overload; -Provide Resident #3, who chose not to consistently follow her recommended diabetic diet, with education related to the specific risks associated with not following her dietary recommendations; and, -Ensure Resident #3's diabetic care plan was updated to include documentation of the resident's refusals to comply with her recommended diabetic diet. Findings include: I. Professional standards According to the National Institutes of Health Library of Medicine: Interventions For Improving Adherence To Dietary Salt and Fluid Restrictions In People With Chronic Kidney Disease Stage 4 and 5, retrieved on 10/9/24 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9620929, When prescribed, fluid restrictions are typically 1000 to 1500 milliliters (ml) per day. According to the National Institutes of Health Library of Medicine: Cardiology Explained chapter 4, retrieved on 10/9/24 from https://www.ncbi.nlm.nih.gov/books/NBK2215, LV (left ventricular) systolic dysfunction (heart failure on the left side of the heart) is assessed using the ejection fraction (the percentage of the end diastolic volume ejected during systole). In most cases, this is estimated by eye from all the available echocardiogram views. A normal ejection fraction is 50%-80%, but values as low as 5% are compatible with life (end-stage heart failure). II. Facility policy The Resident Hydration and Prevention of Dehydration policy, revised October 2017, was received from the director of nursing (DON) on 10/8/24 at 3:44 p.m. It documented in pertinent part, Physician orders to limit fluids will take priority over calculated fluid needs. The dietitian and nursing staff will educate the resident and family regarding hydration and preventing dehydration. Nursing will monitor and document fluid intake and the dietitian will be kept informed of status, the interdisciplinary team (IDT) will update the care plan and document resident responses to interventions until the team agrees that fluid intake and relating factors are resolved. The Hydration-Clinical Protocol policy, revised September 2017, was received from the DON on 10/8/24 at 3:44 p.m. It documented in pertinent part, Staff, with physician's input, will identify and report to the physician individuals with signs and symptoms or lab (laboratory) test results that might reflect existing fluid and electrolyte imbalance. The Comprehensive Person-Centered Care Plan policy, revised March 2022, was received from the DON on 10/8/24 at 3:44 p.m. It documented in pertinent part, If the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process. The comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including services that would otherwise be provided for the above but are not provided due to the resident exercising his of her rights, including the right to refuse treatment. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision-making. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies. III. Resident #9 A. Resident status Resident #9, age greater than 65, was admitted on [DATE] and discharged to the hospital on 8/14/24. According to the August 2024 computerized physician order (CPO), diagnoses included stage 4 chronic kidney disease, chronic respiratory failure and epileptic seizures. The 8/14/24 minimum data set (MDS) assessment documented the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 11 out of 15. The assessment documented the resident was a poor decision-maker and required cueing and supervision. The resident required moderate assistance with toileting and bathing and was independent with eating. The assessment documented the resident did not have a swallowing disorder and was receiving a therapeutic diet. The assessment documented the resident had no rejections of care. B. Resident representative interview Resident #9's legal representative was interviewed on 10/8/24 at 11:13 a.m. The representative said Resident #9 could not make decisions for herself and she had been her legally-appointed guardian for several years. The representative said she usually visited Resident #9 weekly. The representative said she became sick in late July 2024 to early August 2024 and did not visit Resident #9 for about two weeks. The representative said when she returned to visit after recovering from her illness, Resident #9's feet and legs had become so swollen with fluid that the skin was red and taut on both legs, up to the level of the hip. The resident's representative said she had asked Resident #9's physician for a 2,000 ml fluid restriction per day in April 2024 or May 2024 because it was recommended by Resident #9's kidney doctor. She said she was surprised when the physician ordered a 3,000 ml fluid restriction because that did not seem like a fluid restriction to her. The representative said the fluid restriction was later reduced to 2,500 ml. The representative said she felt the facility gave Resident #9 too much water when the resident requested it. The resident's representative said she was not aware of any interventions the facility had in place to help Resident #9 adhere to her fluid restrictions. The representative said she could not recall if she or Resident #9 were given education regarding techniques to help Resident #9 adhere to her fluid restrictions. The resident's representative said when Resident #9 was hospitalized on [DATE], she was told by the emergency room physicians that Resident #9 was given too much water at the facility which caused fluid to build up in Resident #9's lungs and required significant medication and oxygen, for more than two weeks in the hospital, to improve. C. Record review Resident #9's kidney disease plan of care was initiated on 7/2/24 and revised on 8/22/24. The plan of care documented a goal for Resident #9 to have no signs or symptoms of complications related to fluid overload. Interventions included elevating the resident's feet when she was sitting in a chair, monitoring vital signs as ordered, monitoring changes in the resident's mental status and obtaining weights as ordered. Review of Resident #9's weights documented in the electronic medical record (EMR) revealed the following: -On 5/15/24, the resident weighed 241.4 pounds (lbs); -On 5/17/24, the resident weighed 240.8 lbs; -On 5/18/24, the resident weighed 240.4 lbs; -On 5/29/24, the resident weighed 243 lbs; -On 6/7/24, the resident weighed 257.8 lbs; -On 7/3/24, the resident weighed 261.8 lbs; and, -On 8/6/24, the resident weighed 275.4 lbs. The resident gained 35 lbs from 5/18/24 to 8/6/24, a period of three months. -Despite Resident #9's continued weight gain, there was no documentation to indicate the resident's physician was notified or that the facility put interventions in place to more closely monitor the resident and identify the cause of the resident's significant weight gain after 6/7/24. Review of Resident #9's August 2024 CPO revealed the following physician orders: Consistent Carbohydrate (CCHO) diet with regular texture and thin liquids. No soda or dark colored [NAME]. 2500 ml fluid restriction, ordered on 5/28/24. 3,000 ml fluid restriction every shift for nutrition, ordered on 5/16/24 and discontinued on 6/6/24. -The physician's order indicated the resident's fluid restrictions were per shift instead of per day. 2,500 ml fluid restriction every shift for nutrition, ordered on 6/6/24. -The physician's order indicated the resident's fluid restrictions were per shift instead of per day. Resident #9's medication administration record (MAR) fluid intakes were reviewed from 6/6/24 to 8/14/24. The 69 days of 2,500 ml fluid intake/restriction documentation revealed the following: -The resident received more than 2,500 ml of fluid in a 24-hour period of time on nine of those days; -The resident received more than 3,000 ml of fluid in a 24-hour period on seven of those days; and, -The resident received more than 4,000 ml of fluid in a 24-hour period on two of those days. A skilled evaluation nursing note dated 6/25/24 documented Resident #9 was compliant with her fluid restrictions. A skilled evaluation nursing note dated 8/6/24 documented Resident #9 was compliant with her fluid restrictions. -However, according to review of Resident #9's fluid intake documentation on the MARs, the resident had more fluids than was physician ordered on several days (see above). Hospital documentation for Resident #9's hospital stay indicated Resident #9 was admitted for shortness of breath on 8/14/24 and was discharged from the hospital on 9/3/24. An emergency department physician note dated 8/14/24 documented Resident #9's fluid retention was caused by poor fluid intake management of the facility. A hospital physician note dated 8/15/24 documented Resident #9 required 5 liters per minute (LPM) of oxygen to maintain oxygen saturations, which was an increase from her baseline oxygen setting of 1.5 LPM. The note documented Resident #9 was placed on a fluid restriction of 2,000 ml per day in the hospital. The note documented Resident #9 was being admitted to the hospital for heart failure caused by increased fluid intake. The note documented Resident #9 had an ejection fraction of 55% on her echocardiogram performed on 2/18/2020, but it had now worsened to a 40% ejection fraction on the echocardiogram performed 8/15/24. The note documented Resident #9's left ventricle systolic performance was less vigorous and the posterior wall of the heart appeared hypokinetic (less activity). IV. Resident #3 A. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the October 2024 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), type two diabetes with long term use of insulin, gastroesophageal reflux disease (GERD) and diabetic retinopathy of the eye (damage to the eye from high blood sugar levels). The 8/16/24 MDS assessment documented the resident was cognitively intact with a BIMS score of 15 out of 15. The resident required setup or clean-up assistance with eating. The assessment documented the resident did not have a swallowing disorder and was receiving a therapeutic diet. The assessment documented the resident had no rejections of care. B. Resident observation and interview Resident #3 was observed in her room on 10/8/24 at 10:22 a.m. On the resident's nightstand was a full size box of cinnamon toast crunch, two boxes of chocolate teddy grahams, two apples and a banana. The resident was eating a separate individual container of cinnamon toast crunch with whole milk and drinking a 7-up soda. Resident #3 said she had been diabetic since 1996. Resident #3 said she did not plan to adhere to her diabetic diet because she never had. She said she knew she was on a consistent carbohydrate (CCHO) diet, but she did not agree with many parts of that diet. Resident #3 said she would not allow anyone to take away her favorite foods or soda for any reason. She said she had four full size candy bars inside her nightstand as well so she could snack whenever she wanted to. Resident #3 said the facility provided her with the individually wrapped cinnamon toast crunch and whole milk for breakfast, but not the 7-up soda she consumed or the other food items on her nightstand. Resident #3 said she had not received education from a dietician or a nurse regarding adherence to her CCHO diet. She said she was not aware she was always supposed to adhere to her CCHO diet. C. Record review Review of Resident #3's medical diagnoses plan of care, initiated 6/19/24, documented the resident was on a regular CCHO diet. Interventions included providing and serving Resident #3's CCHO diet as ordered. The type 2 diabetes plan of care was initiated on 9/26/24. Interventions included a dietary consult for nutritional regimen and ongoing monitoring, providing the resident with diabetes education, encouraging the resident to comply with dietary restrictions, monitor compliance with diet and documenting any problems and monitoring and documenting the resident's current level of understanding of the disease process and treatment regimen. -The care plan did not document Resident #3 frequently refused to comply with her recommended diabetic diet. -Despite the care plan documenting the resident was to be provided with education related to her diabetic diet and compliance with the diet, there was no documentation in the resident's EMR to indicate education had been provided to the resident. The GERD plan of care was initiated on 9/26/24. Interventions included avoiding overeating, encouraging a bland diet and avoiding foods and beverages that irritated the esophageal lining, such as alcohol, chocolate, caffeine, acidic or spicy foods and fried or fatty foods. Review of Resident #3's October 2024 CPO revealed a physician's order for a consistent carbohydrate diet, ordered on 8/3/23. An IDT note dated 5/8/24 documented Resident #3 was on a CCHO diet and had variable intakes and refusals. -However, there was no documentation in the resident's EMR regarding the resident's refusals of her recommended diet. A care conference note dated 8/20/24 documented the resident was an insulin dependent diabetic. The care conference documented nursing was managing Resident #3's diabetes and blood sugars. -The care conference note did not indicate the resident's CCHO dietary recommendations were discussed. A performance improvement plan (PIP), dated 8/15/24, was received from the DON on 10/8/24 at 3:19 p.m. The PIP documented the facility's IDT committee would complete an audit of current residents in the facility who may have fluid restrictions and/or dietary recommendations in order to identify those residents who choose not to follow dietary recommendations. It documented the IDT team would complete education with identified residents to inform them of specific risks associated with not following recommendations and update resident care plans if needed. -However, Resident #3's care plan had not been updated to include her refusals to follow her recommended diet and there was no documentation in the resident's EMR to indicate she had been educated about the specific risks associated with not following her dietary recommendations (see above). V. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 10/8/24 at 1:28 p.m. CNA #1 said if something had been ordered per shift, it meant it was done twice per day. CNA #1 said Resident #3 only occasionally adhered to her diet order. CNA #1 said Resident #3's family had brought her food items that were typically not given to residents on a CCHO diet. CNA #1 said she did not know if diet education had been provided to Resident #3 or her family. Licensed practical nurse (LPN) # 2 was interviewed on 10/8/24 at 1:32 p.m. LPN #2 said if a resident was non-adherent to their diet order, it would be communicated to the physician and the dietitian and documented in progress notes. LPN #2 said refusals of dietary recommendations would normally be documented in progress notes and discussed with the dietitian. LPN #2 said if something was ordered each shift it could mean either two or three times per day, depending on how many staff shifts the facility had. Registered nurse (RN) #2 was interviewed on 10/8/24 at 1:37 p.m. RN #2 said if a resident did not want to adhere to their diet, the nursing staff would try and educate the resident of the importance of diet adherence. RN #2 said nursing staff would try to involve the dietitian in this process. RN #2 said she was unfamiliar with the process of changing a resident's diet order and would need to ask her peers for assistance in that process. LPN #1 was interviewed on 10/8/24 at 1:44 p.m. LPN #1 said when a resident refused to follow the physician-prescribed diet order, the physician would be notified. LPN #1 said the physician notification should be documented in the progress notes. LPN #1 said nursing staff provided residents with education about the importance of adhering to the physician-prescribed diet and that education should be documented in the progress notes section of the resident's EMR. The registered dietitian (RD) was interviewed on 10/8/24 at 2:28 p.m. The RD said she was present in the facility one day per week on Wednesdays. The RD said it was important that residents with diabetes on a CCHO diet received appropriate servings with meals to ensure resident blood sugars were not erratic. The RD said the facility did not count carbohydrates for diabetic residents on a CCHO diet, but rather, the facility would simply halve the portion of the dessert option. The RD said if the dessert option was cake, the diabetic resident on a CCHO diet would receive a half of a piece of that cake instead of a whole piece. The RD said anyone present in the resident's vicinity while eating was responsible for ensuring the resident was adherent to the physician-prescribed diet order. The RD said nurses could provide education to residents on the importance of diet adherence. The RD said if she were notified, she could provide education to the residents on the importance of diet adherence for diabetes management as well. The RD said if a resident was not interested in diet adherence, she would communicate the resident's preference to the nursing management team. The RD said she would discuss the resident's preference with the physician and the resident's family to identify additional interventions to assist with diet adherence. The RD said the care plan should be updated to reflect the current plan of care. The RD said she had not been informed of any concerns with diet adherence for Resident #3. The RD said she was not aware the resident was eating food items in her room that were not on her recommended diet. The RD said if Resident #3 was consistently making the choice to eat cereal and soda for breakfast then she would need to provide education to the resident and her family regarding the importance of diet adherence. The RD said physician's orders should always be followed. The RD said if something were to be ordered per shift, it could mean very different things, depending on the facility. The RD said it could mean every six hours, every eight hours, or every 12 hours. The RD said she was typically more familiar with seeing a fluid restriction ordered per day rather than per shift. The RD said that the 2,500 ml fluid restriction ordered per shift for Resident #9 did not seem to be an appropriate order and should have been clarified. The RD said a 2,500 ml fluid restriction per shift, even for two shifts a day, would equal 5,000 ml of fluid intake per day, which she did not consider to be a fluid restriction. The RD said she was not aware of how Resident #9's fluid restriction order had been written. The DON was interviewed on 10/8/24 at 2:59 p.m. The DON said if a resident did not want to follow a physician-ordered diet, he would expect nursing staff to educate the resident on the importance of adhering to the diet. The DON said if the education was not effective, he would expect nursing staff to inform the IDT team or the registered dietitian. The DON said nursing administration would then discuss the situation on the next day, identify root causes and perform a dietary assessment of risks and benefits to diet adherence. The DON said he was not aware Resident #3 was non-adherent to her diet. The DON said there were two shifts at the facility. The DON said fluid restrictions varied based on the physician's order. The DON reviewed Resident #9's physician orders. The DON said a 2,500 ml fluid restriction per shift did not seem correct. The DON said his staff should know that a 2,500 ml fluid restriction order always means per day and not per shift. -An attempt to interview Resident #9's physician on 10/8/24, during the survey, was unsuccessful.

Based on observations, record review, and interviews the facility failed to ensure one resident (#83) of five sample residents received care consistent with professional standards of practice to prevent pressure injuries and did not develop pressure injuries unless the individual's clinical condition demonstrated they were unavoidable, and to promote healing, prevent infection and prevent new ulcers from developing. Specifically, the facility failed to ensure timely interventions were put in place to prevent the development of pressure injuries to Resident #83's heels which resulted in two unstageable pressure injuries. Resident #83 was admitted to the facility after a fall resulting in her impaired mobility. The resident was at risk for pressure injuries and had a current pressure injury to her sacrum on admission. The resident developed a stage II pressure injury to her right heel and a deep tissue pressure injury to her left heel in less than a week after her admission. The pressure injuries were not identified as unavoidable. Both pressure injuries were identified as healable. The stage II pressure injury to the right heel and the deep tissue pressure injury to the resident's left heel worsened to unstageable pressure injuries a month later. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 11/29/23, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedures The Prevention of Pressure Injuries policy, revised April 2020, was provided by the director of nursing (DON) on 11/16/23 at 8:25 p.m. The policy read in part: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Review the residents care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Assess the resident on admission for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes of condition. Use a standardized pressure injury screening tool to determine and document risk factors. Supplement the use of a risk assessment tool with assessment of additional risk factors. Conduct a comprehensive assessment upon or soon after admission, with each risk assessment as indicated according to the resident's risk factors, and prior to discharge. During a skin assessment, inspect the presence of erythema, temperature of the skin and soft tissue and edema. Inspect the skin on a daily basis when performing or assisting with personal care ADLs (activities of daily living). Identify any signs of developing pressure injuries. For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, and ischium, trochanter). Use facility-approved protective dressings for at risk individuals. III. Resident #83 status Resident #83, age greater than 90, was admitted on [DATE] and readmitted on [DATE]. According to the November 2023 computerized physician orders (CPO), diagnoses included multiple fractures of pelvis without disruption of pelvic ring, subsequent encounter for fracture with routine healing, unspecified abnormalities of gait and mobility, weakness, other reduced mobility, muscle weakness, other lack of coordination, osteoarthritis, chronic kidney disease and need for assistance with personal care. The 10/23/23 minimum data set (MDS) assessment indicated the resident had moderate cognitive impairment with a staff assessment for mental status. According to the 10/23/23 MDS assessment, the resident had one or more unhealed pressure ulcers. The resident had two stage II pressure ulcers, one of which was facility acquired. It read the resident had an unstageable pressure injury. The 9/25/23 MDS assessment identified the resident required substantial to maximal assistance for bed mobility and transfers. IV. Record review The 9/18/23 admission data collection with care plan assessment identified Resident #83 had a stage II pressure ulcer to her sacrum on admission. The admission assessment indicated the resident did not have pressure ulcers/deep tissue injuries or any skin issues to the heels of her feet on admission to the facility. The 9/25/23 Braden scale for predicting pressure sore risk identified Resident #83 was at risk for developing pressure sores. According to the Braden scale, the resident sensory perception was slightly limited. She responded to verbal commands but could not always communicate discomfort or the need to be turned or had some sensory impairment which limits ability to feel pain or discomfort in one or two extremities. Her skin was occasionally moist requiring extra linen changes. Her ability to change and control body position was very limited. The resident was able to make occasional slight changes in her body or extremity position but unable to make frequent or significant changes independently. Resident #83 had a friction and sheer potential problem. The resident had the probability that during a move the resident's skin slid down to some extent against sheets, chairs or other devices. The pressure skin care plan, initiated on 9/19/23, read Resident #83 had an actual impairment to her skin integrity. The care plan goal was for the resident to be free from skin breakdown. Interventions included staff to identify and document potential causative factors and eliminate/resolve where possible. The pressure injury care plan, initiated on 9/29/23, read Resident #83 had a stage II pressure ulcer to her sacrum and right heel and a deep tissue injury to her left heel related to a history of ulcers and impaired mobility due to pelvic fractures. The stage II pressure ulcer to the sacrum resolved on 10/5/23. Interventions initiated on 9/29/23 included to avoid positioning the resident's heels flat on the bed and laying flat on her heels for an extended period of time. A letter from the registered nurse (RN) #2 was provided by the nursing home administrator (NHA) via email on 11/20/23. According to the letter, RN #2 covered the wound rounds the week of 9/17/23 to 9/23/23. The letter read the resident had interventions put in place on the day of her admission (9/18/23) related to stage II pressure injury (sacrum), comorbidities and pressure injury risk. The interventions were identified as turning and repositioning every two hours, air mattress, the registered dietitian to evaluate nutritional needs, protect bony prominences, elevate legs to minimize swelling, pressure relieving cushion to her wheelchair and physical and occupational therapy to increase functional mobility. -The letter did not identify specific interventions to prevent the development of pressure injuries to her heels. A. Right heel unstageable pressure injury The pressure wound log for the week of 9/24/23 and 9/30/23 read Resident #83 had a stage II pressure injury to her right heel. A foam heel protector and heel protective boots were put in place. The 9/25/23 CPO directed staff to float heels at all times while the resident was in bed using a wedge or boots as tolerated. The 9/25/23 CPO directed staff to provide daily wound review to her right heel. The 9/27/23 wound care physician assistant (PA) progress note read Resident #84 developed two new pressure wounds on her heels on 9/27/23 (9/24/23). According to the progress note, the initial wound encounter measurement of the resident's right heel stage II pressure injury was 5 centimeters (cm) in length by 5 cm in width with a serum filled blister. The PA recommended the staff to implement pressure relieving measures and offloading as tolerated to include a speciality device of a heel protector. The 9/27/23 skin and wound assessment read Resident #83 had a new stage II pressure injury/ulcer to her right heel. The pressure injury was facility acquired on 9/24/23. The stage II pressure injury to her right heel measured 3.9 cm in length by 2 cm in width. According to the assessment, the stage II pressure injury was healable. Interventions included heel suspension/protection device, a mattress with a pump, nutritional supplementation, reposition devices and turning/repositioning program. The assessment read Resident #83 was admitted to the facility due to a fall with left pubic fracture with a history of pressure ulcers. Her mobility was impaired and the resident required assistance with repositioning/loading heels. The resident was noted to have a stage II pressure injury presenting as a serum filled blister. Staff continue to offload heels. No dressing would be applied until the blister ruptured. The staff educated the resident on the importance of offloading pressure to bony prominences frequently. The resident verbalized understanding but would require assistance due to her limited mobility. The 10/11/23 skin and wound assessment identified Resident #83's stage II pressure injury/ulcer to her right heel measured 2.4 cm in length by 2 cm in width. The assessment read Resident #83's blister to the right heel ruptured and there was 60% eschar (necrotic) tissue present. The wound physician assistant (PA) assessed and diagnosed the wound as an unstageable pressure ulcer. New orders were placed for Santyl ointment applied daily to break down eschar tissue. The 10/18/23 skin and wound assessment read Resident #83's right heel unstageable pressure injury had improved as evidenced by most of the eschar had broken down to slough (thick, yellow nonviable tissue). The skilled evaluations between 10/26/23 and 11/15/23 were provided by the facility on 11/15/23 at 2:25 p.m. The skilled evaluations all identified the right heel needed to be reviewed. The skilled evaluations between 10/26/23 and 11/15/23 all identified the wound to the right heel was a stage II pressure injury with slough on the wound bed, thin, watery, pale, red/pink drainage with moderate dressing saturation of 26-75%. There was partial thickness skin loss with exposed dermis. The skin tissue was boggy (mushy to the touch) and the resident had episodic pain. -However, the stage II pressure injury was identified as an unstageable pressure injury beginning on 10/11/23. The skin evaluation documentation did not change between 10/26/23 and 11/15/23, indicating the resident's right heel was not reviewed daily as ordered (refer to the 9/25/23 CPO above). The 11/1/23 skin and wound assessment read Resident #83's right heel unstageable pressure injury had 40% of wound filled eschar. The resident returned from the hospital with new orders for Triad cream and a foam dressing applied three times a week and as needed. The 11/7/23 skin and wound assessment read Resident #83's right heel unstageable pressure injury was showing improvement. According to the assessment, the resident continued with heel protective boots to float heels while in bed. Her legs were elevated when the resident was in her chair to aid with pressure reduction and fluid. B. Left heel unstageable pressure injury The pressure wound log for the week of 9/24/23 and 9/30/23 read Resident #83 had a deep tissue injury to her left heel. The resident was treated with betadine qd (daily) and heel protective boots were put in place. The 9/27/23 wound care physician assistant (PA) progress note described the left heel deep tissue pressure injury as a persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer measuring 2 cm by 1.7 cm. The PA recommended applying betadine and floating heels. The 9/27/23 skin and wound assessment read Resident #83 had a new dark purple discoloration to the left heel consistent with a deep tissue injury (DTI) from pressure which was facility acquired on 9/24/23. The left heel DTI measured 2.1 cm in length by 1.5 cm in width. The DTI was identified as healable. Interventions included heel suspension/protection device, a mattress with a pump, nutritional supplementation, reposition devices and turning/repositioning program and a daily treatment of betadine. The staff educated the resident on the importance of offloading pressure to bony prominences frequently. The resident verbalized understanding but would require assistance due to her limited mobility. The 10/5/23 skin and wound assessment identified Resident #83's DTI had a slight increase in size. The DTI measured 2.5 cm in length by 2.1 cm in width. The pressure wound log for the week of 10/8/23 and 10/14/23 for Resident #83's left heel DTI identified the resident was COVID-19 positive and required more frequent repositioning. The 10/11/23 skin and wound assessment identified the resident's left heel DTI had an intact blister. The 10/11/23 CPO directed staff to provide daily wound review to her left heel. The 10/18/23 skin and wound assessment identified Resident #83's DTI measured 2.7 cm in length by 1.8 cm in width. The 10/23/23 health status note read Resident #83 was sent to the hospital. The 10/26/23 evaluation summary note read the resident had pressure ulcers to her bilateral heels. The skilled evaluations between 10/26/23 and 11/15/23 were provided by the facility on 11/15/23 at 2:25 p.m. The skilled evaluations all identified the left heel needed to be reviewed. The skilled evaluations between 10/26/23 and 11/15/23 all identified the left heel was a DTI with episodic pain and minimal saturation. According to the skilled evaluations a pressure ulcer staging was not applicable. -However, the DTI was identified as an unstageable pressure injury beginning on 10/11/23. The skin evaluation documentation did not change between 10/26/23 and 11/15/23, indicating the resident's left heel was not reviewed daily as ordered (refer to the 10/11/23 CPO above). The 10/27/23 CPO directed staff to apply a thick layer of Triad Hydrophilic barrier cream to the resident's bilateral heels and cover with foam dressing three times a week and as needed. The 11/1/23 skin and wound assessment identified Resident #83's the facility acquired DTI was now an unstageable pressure injury/ulcer to her left heel. She had 60% wound filled eschar. The 11/7/23 skin and wound assessment read the wound was improving with no eschar present. V. Staff interview The assistant director of nursing (ADON) was interviewed on 11/15/23 at 1:21 p.m. The ADON identified she was the facility wound nurse. The ADON said Resident #83 was admitted on [DATE]. The resident was admitted with stage II pressure ulcer to her sacrum. The ADON said she was on leave at the time of the resident's admission. She said staff initiated interventions related to the sacrum pressure ulcer but preventive measures directly to prevent pressure ulcers to the resident's heels were not in place. The ADON said the resident was at risk for pressure injuries to her heels because of her history of pressure ulcers, her impaired mobility after a recent fall prior to her admission and her need for more assistance. She said she would have added heel protective boots to protect the heels on admission and a wedge to lift the heels off of the surface of the bed. She said proper interventions were not put in place to prevent the development of pressure injuries to the resident's heels. The ADON said the weekend nurse identified the right heel stage II pressure injury and the left heel DTI on 9/24/23. The ADON said the resident's heels were off loaded starting on 9/25/23. The ADON said both wounds had decreased in size but currently both of the heels had unstageable pressure injuries.

Based on observations and interviews the facility failed to employ sufficient dietary and food and nutrition staff to carry out the functions of the food and nutrition services. Specifically, the facility failed to provide sufficient numbers of adequately trained food and nutrition staff which contributed to prolonged wait times for meals and overall decreased the residents ' satisfaction with their dining experience. Findings included: I. Meal times The meal service times were posted outside of the facility ' s dining room: A. Breakfast Hush no rush breakfast: 6:30 a.m. to 8:45 a.m. Aspen cart: 7:00 a.m. to 7:15 a.m. Columbine cart: 7:15 a.m. to 7:30 a.m. Blue Spruce cart: 7:30 a.m. to 7:45 a.m. B. Lunch Aspen cart: 11:25 a.m. to 11:35 a.m. Columbine cart: 11:35 a.m. to 11:55 a.m. Blue Spruce cart: 11:45 a.m. to 12:00 p.m. Main dining room: 12:00 p.m. to 1:00 p.m. C. Dinner Aspen cart: 4:30 p.m. to 4:45 p.m. Blue Spruce cart: 4:45 p.m. tp 5:00 p.m. Main dining room: 5:00 p.m. to 6:00 p.m. Columbine cart: 5:20 p.m. to 5:35 p.m. II. Resident interviews Resident #71 was interviewed on 11/13/23 at 10:42 a.m. The resident said he was assisted to the dining room prior to 12:00 p.m., but then he sat there for nearly an hour before his meal was served. Resident #16 was interviewed on 11/13/23 at 12:43 p.m. The resident said that the meals were routinely late and served 45 minutes to over an hour late. He said this was a daily occurrence, and that noon meal was the worst. He said it was frustrating. Resident #61 was interviewed on 11/13/23 at 12:46 p.m. Resident #61 said the dining room was always late, and it made her angry that she had to sit and wait for over an hour. She said it was late daily. She said the kitchen did not have enough staff. She said they do not change the service in the dining room, so because she is in the back she always gets her meal about an hour late past the posted meal time. Resident #18 was interviewed on 11/13/23 at 2:46 p.m. She said the meals were served late and it was ridiculous. Resident #65 was interviewed on 11/13/23 at 3:39 p.m. He said meals were served an hour late. Resident #61 was interviewed a second time on 11/13/23 at 6:08 p.m. The resident said she received her dinner meal just about 10 minutes ago. Resident #56 was interviewed on 11/14/23 at 8:53 a.m. Resident #56 said the meals were an hour late. She said it did not make her feel good that she had to sit in the dining room for such a long time waiting for her meal. Resident #27 and Resident #71 were interviewed on 11/15/23 at 1:01 p.m. Resident #27 said he had been in the dining room since 12:00 p.m. He said his patience was wearing thin. He said the facility knew what time they were supposed to be ready with meals each day but continued to be late as the residents just sat there and waited. Resident #71 said the food should be served remotely close to 12:00 p.m. and it frustrated him. Resident #13 and Resident #78 were interviewed on 11/15/23 at 1:01 p.m. They said they had been waiting for over an hour. Resident #13 said the facility had a hard time keeping staff. Resident #54 was interviewed on 11/15/23 at 1:01 p.m. She said she had been in the dining room since 12:00 p.m. She said waiting drove her crazy and the kitchen needed to get it together. Resident #10 was interviewed on 11/15/23 at 1:10 p.m. She said she waited a long time for her meal. She said waiting made her feel unwanted. Resident #10 said she had family coming to visit her and she felt she would not be able to see them because she was still in the dining room waiting for lunch. Resident #15 and her daughter were interviewed on 11/15/23 at 1:11 p.m. Resident #15 said she had been in the dining room since a little before 12:00 p.m. She said the kitchen often did not serve lunch until 1:15 p.m. and sometimes lunch was not served until 2:15 p.m. Resident #15 ' s daughter said her mom got tired of waiting and went back and forth between the dining room and her bedroom. III. Observations A. The main dining room was observed on 11/13/23 -At 11:50 a.m., there were approximately 20 residents in the dining room awaiting their meal. -At 11:58 a.m., Resident #26 was talking to her tablemate that she was wondering why the service had not started. She asked a staff member, and she was told that it was not time for lunch. -At 12:20 p.m. an unidentified staff member told the residents in the dining room that drinks were coming and thanked the residents for their patience. -At 12:28 p.m., the window from the kitchen to the dining room was open -At 12:38 p.m., an unidentified certified nurse aide began to pass drinks to the residents in the dining room. -At 12:44 p.m., the first tray was served out to the dining room. -At 1:20 p.m., the last tray was served. B. The Columbine hallway meal trays were observed on 11/13/23. -At 12:20 p.m., the meal trays arrived and the registered nurse (RN) started checking the trays. -At 12:22 p.m., the director of nursing (DON) assisted the RN and certified nurse aide (CNA) with delivering the trays. The CNA went to the dining room and retrieved some sodas for a few residents. -At 12:47 p.m., all meal trays were delivered to the residents of Columbine Hall. C. The main dining room was observed on 11/14/23 -At 12:08 p.m., the dining room was filled with 29 residents waiting for the noon meal service. -At 12:41 p.m., the first lunch tray was served in the dining room. -At 1:24 p.m., the last tray was served in the dining room. D. The breakfast room trays on the Blue Spruce [NAME] were observed on 11/15/23. The posted meal time for the Blue Spruce cart was between 7:30 a.m. and 7:45 a.m. -At 8:53 a.m., the first tray was passed from the meal cart. E. The kitchen tray line service On 11/15/23 at 11:26 a.m. the tray line was observed for the noon meal. The kitchen had a dishwasher, a dietary aide, cook #1 and cook #2. Cook #2 came in earlier than scheduled to help with the noon meal. -At 11:26 a.m., the meal continued to be prepared. -At 11:32 a.m., cook #1 began to take the food temperatures on the tray line. The mashed potatoes and gravy were under temperature and had to be placed in the warmer. -At 11:48 a.m., Cook #1 began to serve the room trays for the Aspen unit. She began plating the first four plates but waited before she made more since the potatoes and gravy were being warmed up. -At 12:20 p.m., the puree salisbury steak needed to be remade as there was a metal shaving in the meat. -At 12:26 p.m. a CNA entered the kitchen and asked for Aspen Hall ' s cart and was told it was not ready yet. Aspen Hall ' s meal cart went out at 12:28 p.m. incomplete because the puree was not ready. -At 1:07 p.m. Columbine hall room trays were sent out. -At 1:07 a.m., the dining room window was opened, however, realized she had forgotten about Blue Spruce Hall ' s meal cart. Cook #2 assisted with Blue Spruce trays while Cook #1 served the dining room. The restorative assistant (RA) took the meal tickets for the dining room so the trays would be served by the table. The RA got frustrated because Cook #1 mixed up the meal tickets and the trays were not being served as a table. Cook #1 left the kitchen and Cook #2 took over and served plates. -At 1:12 p.m., the meal service stopped as the tray line ran out of salisbury steaks. -At 1:38 p.m., the tray line ran out of the mechanical soft salisbury steak, and had to make additional. -At 1:41 p.m., there were not enough pies cut for dessert. The dietary aide had to cut and dish up more pies. -At 1:40 p.m., the Blue Spruce trays were completed and sent to the hall. -At 1:50 p.m., the dining room was completed with service. F. The dinner meal trays were observed on 11/15/23. -At 5:15 p.m. Aspen ' s meal cart was sent out from the kitchen. -At 5:25 p.m. Columbine ' s meal cart was sent out from the kitchen. IV. Staff interviews Cook #1 was interviewed on 11/15/23 at 11:30 a.m. The cook #1 said she was fairly new in the position. She said that she did not have enough time to prepare the meal between breakfast and lunch. She said the kitchen needed additional staff to help with the service. Cook #2 was interviewed on 11/15/23 at 1:30 p.m. The cook #2 said the kitchen lacked experienced staff. He said the tray line needed to learn how to start lunch when still working with the breakfast meal. CNA #3 was interviewed on 11/15/23 at 1:13 p.m. She said lunch was usually served late and was the worst of all the meals. CNA #1 was interviewed on 11/15/23 at 1:17 p.m. She said the CNAs checked the meal tickets and the trays to ensure the orders were correct and if the trays were wrong they were sent back to the table to be fixed. She said the meals were late because the kitchen staff were a new team and were trying to figure things out. The dietary manager (DM) was interviewed on 11/16/23 at 6:08 p.m. She said the residents and staff had complained about the meals being late and she felt it was because of a lack of time management. She said the staff needed to prioritize the meals and what needed to be cooked or prepped. She said the kitchen staff did not understand multitasking and said if pork was on the menu for lunch the staff needed to cook it in the oven while they served breakfast. She said there was usually a dishwasher, cook, dietary aide (DA), and bistro cook in the kitchen, at least four staff worked during the day. She said four staff were enough to run the kitchen and it ran smoothly. The DM said the cook and bistro cook ran into each other sometimes because of the kitchen ' s layout. She said the bistro side should be set up so staff did not run around the kitchen or run out of things during meal service. She said all the kitchen staff needed training and they did not have a dietary manager for a month and a half. She said she was going to provide training to the kitchen staff on the menu extensions, menus, and recipes because they were very confusing to read.

Based on observations, record review, and staff interviews the facility failed to store, prepare, distribute, and serve food in a sanitary manner. Specifically, the facility failed to: -Ensure cold food items were held at the proper temperature to reduce the potential risk of foodborne illness; -Ensure the garbage disposal was not held up by cement blocks which were not cleanable; -Ensure the kitchen had a cleaning schedule; -Ensure the nourishment refrigerators were monitored; -Ensure the temperature of the refrigerators were taken; and -Ensure the health shakes were stored properly Findings included: I. Facility policy The Food Receiving and Storage policy, revised in November of 2022, was provided by the director of nursing (DON) on 11/16/23 at 8:25 p.m. and read in pertinent: Policy Interpretation and Implementation: 1. Critical control point- means a specific point, procedure, or step in the food preparation and serving process at which control can be exercised to reduce, eliminate, or prevent the possibility of a food safety hazard. Some operational steps that are critical to control in facilities to prevent or eliminate food safety hazards are thawing, cooking, cooling, holding, reheating of foods, and employee hygienic practices. 2. Danger zone- means temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that all the rapid growth of pathogenic microorganisms that can cause foodborne illness. 4. Food services, or other designated staff, maintain clean and temperature-appropriate or humidity-appropriate food storage areas at all times. Dry food storage: 1. Non-refrigerated foods are stored in a designated dry storage unit which is temperature and humidity-controlled, free of insects and rodents, and kept clean. 3. Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. 4. Dry foods that are stored in bins are removed from their original packaging, labeled, and dated (use by date). Such foods are rotated using a first in-first out system. Refrigerated/Frozen Storage: 1. All foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date). 5. The functioning of the refrigeration and food temperatures are monitored daily and at designated intervals throughout the day by the food and nutrition services manager or designees and documented according to state-specific requirements. 7. Refrigerated foods are labeled, dated, and monitored so they are used by their use by date, frozen, or discarded. Foods and snacks kept on nursing units: 1. All food items to be kept at or below 41 degrees Fahrenheit located at the nurses ' stations and labeled with a use by date. 5. Other opened containers are dated and sealed or covered during storage. 6. Partially eaten food is not kept in the refrigerator. 7. Medications, blood, or blood products are not stored in the same refrigerator with food. II. Reach in refrigerator A refrigerator temperature log was hanging on the outside of the main kitchen ' s prepped food refrigerator. The log documented temperatures for: 11/18/23 at 8:00 a.m. at 37 degrees Fahrenheit, 11/18/23 at 4:30 p.m. at 36 degrees Fahrenheit, And 11/19/23 at 5:00 a.m. at 37 degrees Fahrenheit. No other temperatures were documented for 11/1/23 to 11/17/23. The low-temperature machines log only had temperatures documented for 11/14/23, 11/15/23, and 11/16/23. Temperatures were not recorded for 11/1/23 to 11/13/23. III. Failure to ensure the kitchen had cleanable surface A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. Wall and ceiling covering materials shall be attached so that they are easily cleanable. B. Observations On 11/13/23 at 8:30 a.m., the initial tour of the kitchen showed the garbage disposal near the dish machine was held up by three cement blocks (4 inches wide X 8 inches height and 16 inches long). The blocks were visibly dirty. The surface was not cleanable. C. Interview The maintenance director (MTD) was interviewed on 11/16/23 at 8:11 p.m. The MTD said that the garbage disposal was replaced in August 2023. He said that the new garbage disposal was too heavy as it was a heavier duty disposal and it could not stand alone. He said he had not seen the cement blocks. He said he was unaware all surfaces in the kitchen needed to be cleanable. IV. Health shakes Health shakes directions on the carton documented to store frozen. Once thawed, it had to be used within 14 days. A. Observations Aspen nutrition freezer -The freezer had approximately 15 health shakes. The health shakes had stickers with various dates which were older than two weeks. Blue Spruce -The freezer had approximately 15 health shakes. The health shakes had stickers with various dates which were older than two weeks. B. Interview The DM was interviewed on 11/16/23 at 6:08 p.m. The DM said the health shakes were sent from the kitchen thawed. She said the date on the health shake were when it was to be used by. She said the shakes should not be thawed and then refrozen. She said if something was dated it should not go back into the freezer, if it was not used completely then it should be discarded. V. Ensure the entire kitchen area was clean and free from dirt, grime and food debris. Initial tour kitchen observations on 11/13/23 -The trash can by the hand-washing sink was overflowing. -The floor in the kitchen needed to be scrubbed. The floor had dark substances in the grout of the tile and dried food on the floor. -The walk in refrigerator floor needed to be swept and mopped. -Two large trash cans were covered in grime and old food. 11/15/23 -At 11:26 a.m., the two large trash cans were covered in grime and old food. -The floor continued to need cleaning. The floor continued to have the dark substance in the grout of the tile and dried food on the floor. - B. Interview The DM was interviewed on 11/16/23 at 6:08 p.m. She said the kitchen floor did look grubby but the kitchen staff swept and mopped every night. She said the kitchen did not have a cleaning schedule but she would implement one. She said the trash can needed to be emptied more frequently so it did not over flow. VI. Holding temperatures on the medication carts A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf, retrieved on 11/29/23. It read in pertinent part; The food shall have an initial temperature of 41 F or less when removed from cold holding temperature control or 135 F or greater when removed from hot holding temperature control. B. Observations on 11/16/23 The following temperatures were observed with the dietary manager. -At 6:46 p.m., the Blue spruce East had an open applesauce which was at 52.5 degrees F. The cooler had a melted cold pack. -At 6:49 p.m., the medication cart on Blue Spruce was observed to have a cooler on it. Inside the cooler was an opened Ensure nutritional shake. The temperature was 62.4 degrees F. An open applesauce was on the cart with no mechanism to keep cold the temperature was 74 degrees F. -At 6;56 p.m., the Columbine medication cart had a open yogurt in the cooler. The ice packs were melted and it was 70.5 degrees F. C. Interview Registered nurse (RN) #6 was interviewed on 11/16/23 at 12:19 p.m. She said the night shift cleaned the coolers on the medication carts. She said that when she started her shift she would put the ice packs into the cooler. The DM was interviewed on 11/16/23 at 6:08 p.m. The DM said the cold food needed to be at 41 degrees F and below. She said the nurses handled the food on the medication carts. She said she would provide education about the importance of ice packs. VII. Nutrition refrigerator A. Observations Columbine nutrition refrigerator Blue spruce refrigerator -At 12:12 p.m. there was an ice pack which was used for injuries in the freezer. -At 12:19 p.m., there was an ice pack which was used for injuries in the freezer. -A partially drank coffee cup was in the refrigerator with no name and was undated. There was a sandwich labeled in the refrigerator but was dated 10/20/23. Aspen nutrition refrigerator -At 12:23 p.m. there was an ice pack which was used for injuries in the freezer. Blue spruce refrigerator -At 12:12 p.m. there was an ice pack which was used for injuries in the freezer. B. Interview The DM was interviewed on 11/16/23 at 6:08 p.m. The DM said the nutrition refrigerators should not have ice packs used for body injuries. She said only food and fluid for residents was to be stored in the refrigerators. She said anything in the refrigerator needed to be labeled and dated.

Based on resident and staff interviews and record review the facility failed to address and/or act promptly upon the grievances and recommendations of resident council and individual resident concerns on issues of resident care and life in the facility that were important to the residents. Specifically, the facility failed to: -Ensure timely interventions were implemented and sustained in response to resident grievances related to consistent palatable temperatures when food was delivered to the residents; and, -Ensure a grievance for Resident #56 was followed up on and resolved in a timely manner. Findings include: I. Facility policy and procedures The Grievances/Complaint Filing policy, revised April 2017, was provided by the regional operational manager (ROM) on 11/16/23 at 9:30 a.m. The policy read in part: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and or representative. Any resident, family member, or appointed resident representative may file grievances or complaints concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances may also be voiced or filed regarding care that has not been furnished. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing including a rationale for the response. Upon the receipt of a grievance and or a complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five working days of receiving the grievance and or complaint. The resident, or person filing the grievance and or complaint on the behalf of the resident, will be informed verbally and in writing of the findings of the investigation and the actions will be taken to correct any identified problems. II. Resident council minutes The October 2023 resident council minutes after the 10/10/23 resident council meeting were provided by the facility on 11/13/23. The residents identified food temperatures for meals were cold, specifically room trays. The October 2023 resident council grievance/concern form for the cold food concern was provided by the activity director (AD) on 11/16/23. The grievance form identified the concern with meal temperature and provided the grievance to the nursing home administrator (NHA) on 10/12/23. The NHA responded to the grievance on 11/6/23. According to the grievance form, a corrective action was identified and changes were made to the dietary manager position. The new dietary manager was to start on 11/15/23. The NHA and the dietary manager would educate dietary staff on the use of the hot plates. The November 2023 resident council minutes were reviewed for concern follow up. -The November 2023 resident council minutes did not identify the October 2023 resident council food temperatures concerns were reviewed in the November 2023 resident council meeting for resident resolution to determine if residents felt there were still concerns pertaining to cold food. -The November 2023 resident council minutes did not identify if the October 2023 resident council action plan to educate the staff on the use of hot plates occurred and was effective. -The November 2023 resident council minutes did not identify if the residents felt the concern was resolved or if it was still a concern to be readdressed. -Interviews with residents both in group and individually identified residents still had concerns regarding the temperatures of the food. III. Resident interviews and observations On 11/13/23 at 12:20 p.m. the director of nursing (DON) handed out resident meal trays and asked CNA #3 to warm up Resident #18's soup because it was cold. The DON asked CNA #3 how long she warmed up the soup for and the CNA said until it bubbled. Resident #18 was interviewed on 11/13/23 at 2:46 p.m. She said the food was served late, cold, and it was ridiculous. Resident #71 was interviewed on 11/13/23 at 10:45 a.m. Resident #71 said he mainly ate in the dining room. He said lately his meals had been cold. The resident said the meatloaf served on 11/12/23 was cold. Resident #56 was interviewed on 11/14/23 at 8:53 p.m. Resident #56 said she ate in the dining room mainly, however, her meals were sometimes served cold. Resident #189 was interviewed on 11/14/23 at 9:28 a.m. He said he ate in his room and the food was always cold. During the interview the resident was served his breakfast on a room tray. He tasted his breakfast and said the eggs were warm but the bagel was cold. Resident #189 was observed eating breakfast in his room on 11/15/23 at 8:55 a.m. He said the eggs were warm enough but the toast was cold. The resident attempted to butter the toast but the butter did not spread and dug deep into the bread. The resident said he could ask for staff to warm the toast but the other food would be cold as it could take a while for the staff to answer the call light. On 11/15/23 at 1:09 p.m., the tray line was observed. The room trays were served on warm ceramic glazed plates then put onto a hot metal pallet. Cook #1, who was serving the tray line, was observed to take a stack of white plastic dinner plates off the shelf and begin to serve the meal on the plastic plates. -The plastic plates were not warmed prior to placing the resident meals on the plates. The family member of Resident #42 was interviewed on 11/16/23 at 9:33 a.m. She said Resident #42 ate her meals in her room and the food was horrible. She said the food was never warmer than room temperature which affected the taste. IV. Resident group interview The resident group interview was conducted on 11/14/23 at 1:40 p.m. with seven residents (#16, #17 #18, #61, #76, #78 and #80). The residents were identified by the facility as interviewable. According to the residents, meal temperatures were still a concern. The residents said the temperature of the food was inconsistent. Some of the food served on the plate was cold when it should have been warm. The residents said the inconsistent temperatures of the food occurred almost daily. The residents said for lunch today (11/14/23) the grilled cheese sandwich was warm but the sweet potatoes were served cold. The residents said they had complained about the food temperatures but had been told by staff there would be a new dietary manager and to bear with us. The residents said the staff would rewarm the food when asked. V. Staff interviews The AD was interviewed on 11/16/23 at 12:04 p.m. The AD said all resident grievances should be followed up on. The AD said concerns from the month prior resident council meeting were reviewed at each resident council for resolution. The AD said if residents brought up new concerns during the monthly meeting she would write up the concern/grievance on a form and submit the concerns to management. The AD said she would make sure to follow up with the appropriate department heads and retrieve the grievance forms with the planned action plan. The AD said during this morning's November 2023 resident council meeting (11/14/23) the resident council did not express a concern with food temperatures. The AD said the NHA spoke to the residents regarding the kitchen and the residents did not have new food complaints related to the temperature. The dietary manager (DM) was interviewed on 11/16/23 at 6:00 p.m. The DM said she had ordered more of the colored ceramic glazed plates. She said the plastic plates were used because the facility did not have enough of the colored ceramic glazed plates. The NHA was interviewed on 11/16/23 at 9:07 p.m. He said the interdisciplinary team (IDT) reviewed the kitchen process regarding food concerns. The IDT looked at how the food delivery training and how the service line was working. He said he was trying to get the right people in the right positions. The NHA identified the dietary staff was not trained properly. There was a lack of direction and leadership and meals needed to get the residents quicker. He said the whole dietary system needed to be worked on. The NHA said he knew there were problems in the kitchen and he needed to make a change in kitchen management. He said he hired a new dietary manager this week to help address the needed changes. 20287 II. Failure to follow up on grievance A. Resident status Resident #56, age 83, was admitted on [DATE]. According to the November 2023 computerized physician orders, diagnoses included dementia without behavioral disturbance, anxiety and abnormalities of gait and mobility. The 6/30/23 minimum data set (MDS) assessment showed the resident had minimal cognitive deficits with a score of 13 out of 15. The resident required limited assistance with activities of daily living. B. Resident interview Resident #56 was interviewed on 11/14/23 at 8:43 a.m. Resident #56 said certified nurse aide (CNA) #6 worked the night shift. She said that she used her call light quite a bit and CNA #6 did not like this. She said the CNA called her a name. She said she asked the CNA #6 to repeat what name she was called, as she had not heard it before but she knew it was derogatory. The CNA responded in a not nice manner that she should know what it meant. The resident said it did not make her feel good that she was called a derogatory name and that she was afraid of CNA #6. She said this occurred three days ago and she had reported it to the assistant director of nurses (ADON). C. Record review A complaint grievance form dated 10/17/23 documented, (name of CNA #6) called me a name I asked her to repeat it. She did but I did not know what it was then she said you don' t know what that means. I know I call a lot for help but I shouldn't be treated like. that. The grievance form dated 10/17/23 failed to show evidence there was a resolution to the grievance and no action plan. The form was not signed by the nursing home administrator. The written notes were as follows: The ADON spoke with the resident and asked her three questions. What word did you hear the CNA #6 say? Resident #56 said no. Was the word in English or Spanish? The resident said English but she did not know what it was. Have you had issues with this CNA before? The resident said, never had a good experience, but never had a negative experience. The director of nurses interviewed the charge nurse, no date on when the interview occurred. Registered nurse (RN) #2 said to her knowledge there were no negative interactions. However, Resident #56 had told RN #2 in the past that she does not prefer CNA #6 as her CNA. The DON interviewed CNA #6 in regards to the grievance on 10/17/23. The DON asked CNA #6 if she called Resident #56 any negative or derogatory names even in jest (joking manner). CNA #6 denied and said that Resident #56 was a two person transfer. -The progress notes failed to show any evidence that the resident was provided any follow up to the incident or provided support. D. Interviews The ADON was interviewed on 11/14/23 at 1:35 p.m. The ADON said she did receive the grievance/complaint from the resident. She said a grievance form was filled out. She said a little investigation was completed. She said it was not three days ago, but about a month ago. She said had not heard the resident was afraid of CNA #6. She said that the director of nurses (DON) spoke with CNA #6 and she denied the allegation. The ADON said other residents were not interviewed and not all staff working the shift were interviewed. The social service director (SSD) was interviewed on 11/15/23 at 11:00 a.m. The SSD said that she had been made aware of the grievance form, however, she had not followed up with the resident to report an outcome or to ensure a resolution had occurred and no further issues.

Based on observations, record review, and interviews the facility failed to accurately reflect the resident's status on the minimum data set (MDS) assessments accurately for four (#62, #3, #56, and #51) of 18 residents reviewed out of 48 sample residents. Specifically, the facility failed to: -Ensure Resident #62 was accurately documented as a one-person transfer; -Resident #3 and Resident #51 had pneumococcal vaccination status was accurate; and -The use of antidepressants was coded accurately for Resident #56 Findings include: I. Resident #62 A. Resident status Resident #62, age under 95, was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO) diagnoses included dementia, unspecified sequelae of cerebral infarction (stroke), muscle weakness, difficulty in walking, lack of coordination, need for assistance with personal care, and cognitive communication deficit. The 8/23/23 minimum data set (MDS) assessment documented no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment documented the resident required a two-person physical assistance for bed mobility and transferring between surfaces. B. Observations On 11/13/23 at 2:10 p.m. Resident #62 was observed in his wheelchair and requested to go to bed. Certified nurse aide (CNA) #7 went into the resident's room at 2:17 p.m. and assisted the resident to bed. CNA #5 entered the room but only provided a shift report and went home. CNA #7 finished getting Resident #62 into bed at 2:25 p.m. On 11/14/23 at 2:37 p.m. Resident #62 was sleeping in bed. Above his bed, he had a picture of a sailboat with one sail. C. Record review The 8/29/23 MDS failed to show the resident's transfer status was accurately documented. The MDS was inaccurate under section G ( functional abilities) as it documented the resident was a two-person transfer. Whereas through observations and interviews, the resident required a one-person assist with transfers. The 6/25/23 and 3/6/23 MDS assessments were also inaccurate. C. Staff interviews CNA #3 was interviewed on 11/14/23 at 1:42 p.m. CNA #3 said each resident had a sailboat picture in the room which explained what type of transfer they were. One sail meant the resident was a one-person transfer. If the sailboat had two [NAME] the resident was a two-person transfer. Licensed Practical Nurse (LPN) #2 and LPN #3 were interviewed on 11/15/23 at 3:26 p.m. LPN #3 said Resident #62 was a one-person transfer and had never been a two-person transfer. The assistant director of nursing (ADON) was interviewed on 11/15/23 at 3:45 p.m. She said Resident #62 was not a two-person assist for transfer and had never been. She said she did not know why the MDS assessment documented the resident as a two-person transfer. The restorative assistant (RA) was interviewed on 11/15/23 at 3:51 p.m. She said Resident #62 was on her caseload and he was a contact guard and a one-person transfer. The RA said once he was dressed and his bed was raised he stood up with his walker. She said if he was a two-person transfer it had to have been a long time ago. The minimum data set coordinator (MDSC) was interviewed on 11/16/23 at 3:18 p.m. The MDSC said she pulled data from a seven-day look back period when she completed the assessment for transfers. She said she used the highest level of care charted by the staff for the assessment. During Resident #62's assessment he had one entry which was a two-person transfer. The MDSC said after the seven-day look back period she completed a bedside assessment of the resident. She said charting was very important for the MDS assessment. She said the new changes were implemented after Resident #62's MDS assessment was completed in August 2023. 20287 II. Resident #3 A. Resident status Resident #3, age 85, was admitted on [DATE]. According to the November 2023 CPO, diagnoses included atrial fibrillation (an irregular and very rapid heart beat), heart failure and hypertension. The 8/17/23 MDS assessment documented Resident #3 had severe cognitive impairment with a BIMS score of three out of 15. -Section O (special treatments, procedures and programs) of the MDS assessment revealed the resident was up to date on her pneumococcal vaccination. -However, this was inaccurate as the resident was not up to date on her pneumococcal vaccination -The MDS did not answer the question if the resident was offered the vaccination. B. Record review A review of Resident #3's electronic medical record (EMR) revealed the immunization tracking sheet showed the resident received the pneumococcal vaccination on 10/1/16. However, the resident had signed a consent form on 5/25/22 giving permission to receive the updated pneumococcal vaccination and the flu vaccination yearly. C. Interview The MDSC was interviewed on 11/16/23 at 3:18 p.m. The MDSC said she reviewed the record and confirmed the resident's pneumococcal vaccination was not up to date, and the MDS should have reflected that it was not up to date. III. Resident #56 A. Resident status Resident #56, age 83, was admitted on [DATE]. According to the November 2023 CPO, diagnoses included dementia without behavioral disturbance, anxiety and abnormalities of gait and mobility. The 9/30/23 MDS assessment showed the resident had minimal cognitive deficits with a BIMS score of 13 out of 15. The resident required limited assistance with activities of daily living. B. Record review The November 2023 CPO showed an order for Sertraline HCI (an antidepressant medication) tablet 100 mg. Give one tablet one time a day for depression. The start date was 8/4/23. -The MDS assessment inaccurately documented that the resident did not receive an antidepressant. C. Interview The MDSC was interviewed on 11/16/23 at 3:18 p.m. The MDSC said she reviewed the record and confirmed the latest MDS assessment dated [DATE] was inaccurate. She said she was going to complete a correction MDS assessment. IV. Resident #51 A. Resident status Resident #51, age 83, was admitted on [DATE]. According to the November 2023 CPO, diagnoses included dementia, unspecified sequelae of cerebral infarction (stroke) and muscle weakness. The 10/6/23 MDS assessment documented Resident #51 had moderate cognitive impairment with a BIMS score of eight out of 15. -The MDS assessment inaccurately documented that the resident was up to date on her pneumococcal vaccination. -The MDS assessment failed to document if the vaccination was offered. B. Record review A review of Resident #51's EMR revealed the immunization tracking sheet showed the resident received the pneumococcal vaccination on 7/1/16. However, the resident had signed a consent form on 11/1/21 giving permission to receive the updated pneumococcal vaccination. C. Interview The MDSC was interviewed on 11/16/23 at 3:18 p.m. The MDSC said she reviewed the record and confirmed the resident's pneumococcal vaccination was not up to date and the MDS should have reflected that it was not up to date.

Based on interviews and record review the facility failed to provide sufficient nursing staff to ensure the residents received the care and services they required in a timely manner. Specifically, the facility failed to answer call lights in a timely manner for residents requesting help. Findings included: I. Facility policy The Resident Call System policy, revised September 2022, was provided by the director of nursing (DON) on 11/15/23 at 4:50 p.m. The policy read in pertinent part, Each resident is provided with a means to call staff directly for assistance from his or her bed, from toileting or bathing facilities, and from the floor. The resident call system is routinely maintained and tested by the maintenance department. Calls for assistance are answered as soon as possible. Urgent requests for assistance are addressed immediately. Call light response times are reviewed as part of the quality assurance and performance improvement (QAPI) program. II. Resident council meeting minutes Resident council meeting minutes from 7/12/23 documented the residents had concerns that certified nurse aides (CNA) took too long to answer the call lights in June 2023 and July 2023. According to the meeting minutes, the nursing home administrator (NHA) informed the residents that a new call light system was installed. Resident council meeting minutes from 10/10/23 documented multiple residents said they were waiting 15 to 30 minutes for their call lights to be answered. Many of the residents said call lights took a long time to answer during meal times and at shift change. III. Family interviews Resident #42' s medical durable power of attorney (MDPOA) was interviewed on 11/16/23 at 9:33 a.m. She said her mom was unable to use the restroom alone and the facility never had enough CNAs. She said Resident #42 had to wait 45 minutes to use the restroom multiple times. IV. Observations On 11/13/23 at 10:26 a.m. room [ROOM NUMBER] triggered their call light. The call light was not answered until 10:48 a.m., 22 minutes after the resident pressed the button. V. Resident interviews Resident #32 was interviewed on 11/13/23 at 10:09 a.m. She said it took a while for staff to answer her call light and it felt like the facility did not have enough staff all the time. She said sometimes she waited for 30 minutes for staff to answer her call light. Resident #71 was interviewed on 11/13/23 at 10:42 a.m. He said the staff should answer call lights quicker than 15 minutes. He said one time he waited close to 30 minutes for assistance from staff. Resident #71 said he waited 25 minutes on the toilet for staff to answer his call light. He said his roommate grabbed staff if they did not answer his call light. Resident #83 was interviewed on 11/13/23 at 2:15 p.m. The resident said often when staff came in to answer her call light the staff turned off the call light. She said staff would tell her they would be back to help but then it took a long time before the staff would come back to her to assist her. Resident #83 said before breakfast this morning (11/13/23) she was assisted to the restroom by a CNA who left her in the restroom. Resident #83 said when she was done using the restroom she pulled the bathroom call light but no one came to help her. The resident said she was yelling for help until the ADON heard her and came in. Resident #83 said she felt she was in the bathroom for almost two hours waiting for staff to assist her. Resident #83 said it was an awful long and scary time. She said staff were usually not available around meal times because they were all in the dining rooms. Resident #190 was interviewed on 1/13/23 at 3:28 p.m. She said she was new to the facility but her main concern was it took at least 15 to 20 minutes for staff to answer her call light. She said it was a frequent occurrence for her call light to be on over 15 minutes before it was answered. She said she felt there was not enough staff to assist her timely. Resident #59 was interviewed on 11/13/23 at 2:40 p.m. He said he waited 35 to 45 minutes for staff to answer his call light when he was in the bathroom. He said he waited longer in the evening hours for his call light to be answered. Resident #56 was interviewed on 11/14/23 at 8:51 a.m. She said the staff put her call light where she could not reach it and she waited 30 minutes for staff to assist her when she used her call light. Resident #189 was interviewed on 11/14/23 at 9:27 a.m. He said the facility was short-handed. Resident #189 said when he used his call light staff did not always come in to help him. He said there was one night during the night shift he had to wait four hours to use the restroom. VI. Resident group interview The resident group interview was conducted on 11/14/23 at 1:40 p.m. with seven residents (#16, #17 #18, #61, #76, #78, and #80). The residents were identified by the facility as interviewable. Four of the residents in the group said they wished staff would answer the resident' s call light sooner when the call light was pushed. The residents said the facility was short-staffed, especially at night. Resident #61 and Resident #18 said when the staff came into the room to answer the call light the staff turned the call light off and would come back later. Resident #61 said sometimes the staff would forget to come back. Resident #61 said she had to wait up to three hours for her call light to be answered. She said the call light response was slow, usually around shift change and around 10:00 p.m. The resident said staff told her they were short-staffed. VII. Call light records from 10/16/23 to 11/15/23 A. room [ROOM NUMBER] On 10/16/23 at 12:53 a.m. room [ROOM NUMBER]' s call light was answered 17 minutes after being turned on. On 10/16/23 at 10:50 a.m. room [ROOM NUMBER]' s call light was answered 22 minutes after being turned on. On 10/17/23 at 9:09 p.m. room [ROOM NUMBER]' s call light was answered 17 minutes after being turned on. On 10/18/23 at 11:38 a.m. room [ROOM NUMBER]' s call light was answered 21 minutes after being turned on. On 10/18/23 at 6:28 a.m. room [ROOM NUMBER]' s call light was answered 23 minutes after being turned on. On 10/19/23 at 9:54 a.m. room [ROOM NUMBER]' s call light was answered 20 minutes after being turned on. On 10/20/23 at 5:52 a.m. room [ROOM NUMBER]' s call light was answered 37 minutes after being turned on. On 10/20/23 at 11:01 a.m. room [ROOM NUMBER]' s call light was answered 18 minutes after being turned on. On 10/20/23 at 6:52 p.m. room [ROOM NUMBER]' s call light was answered 21 minutes after being turned on. On 10/20/23 at 9:02 p.m. room [ROOM NUMBER]' s call light was answered 28 minutes after being turned on. On 10/20/23 at 11:12 p.m. room [ROOM NUMBER]' s call light was answered 23 minutes after being turned on. On 10/21/23 at 2:47 a.m. room [ROOM NUMBER]' s call light was answered 38 minutes after being turned on. On 10/22/23 at 5:57 a.m. room [ROOM NUMBER]' s call light was answered 29 minutes after being turned on. On 10/22/23 at 1:50 p.m. room [ROOM NUMBER]' s call light was answered 23 minutes after being turned on. On 10/23/23 at 2:34 p.m. room [ROOM NUMBER]' s call light was answered 19 minutes after being turned on. On 10/24/23 at 1:42 a.m. room [ROOM NUMBER]' s call light was answered 17 minutes after being turned on. On 10/24/23 at 6:59 p.m. room [ROOM NUMBER]' s call light was answered 17 minutes after being turned on. On 10/25/23 at 3:33 p.m. room [ROOM NUMBER]' s call light was answered 25 minutes after being turned on. On 10/26/23 at 2:05 a.m. room [ROOM NUMBER]' s call light was answered 24 minutes after being turned on. On 10/26/23 at 11:56 a.m. room [ROOM NUMBER]' s call light was answered 21 minutes after being turned on. On 10/27/23 at 10:20 a.m. room [ROOM NUMBER]' s call light was answered 20 minutes after being turned on. On 10/27/23 at 1:20 p.m. room [ROOM NUMBER]' s call light was answered 41 minutes after being turned on. On 10/27/23 at 9:59 p.m. room [ROOM NUMBER]' s call light was answered 19 minutes after being turned on. On 10/28/23 at 6:53 a.m. room [ROOM NUMBER]' s call light was answered 24 minutes after being turned on. On 10/28/23 at 7:30 p.m. room [ROOM NUMBER]' s call light was answered 17 minutes after being turned on. On 10/28/23 at 10:41 p.m. room [ROOM NUMBER]' s call light was answered 20 minutes after being turned on. On 10/29/23 at 3:21 p.m. room [ROOM NUMBER]' s call light was answered 26 minutes after being turned on. On 10/30/23 at 4:09 a.m. room [ROOM NUMBER]' s call light was answered 36 minutes after being turned on. On 10/30/23 at 11:06 a.m. room [ROOM NUMBER]' s call light was answered 19 minutes after being turned on. On 10/31/23 at 5:50 p.m. room [ROOM NUMBER]' s call light was answered 24 minutes after being turned on. On 10/31/23 at 6:23 p.m. room [ROOM NUMBER]' s call light was answered 42 minutes after being turned on. On 10/31/23 at 8:43 p.m. room [ROOM NUMBER]' s call light was answered 48 minutes after being turned on. On 10/31/23 at 9:59 p.m. room [ROOM NUMBER]' s call light was answered 50 minutes after being turned on. On 10/31/23 at 11:08 p.m. room [ROOM NUMBER]' s call light was answered 28 minutes after being turned on. On 11/1/23 at 6:06 a.m. room [ROOM NUMBER]' s call light was answered 74 minutes after being turned on. On 11/1/23 at 9:47 a.m. room [ROOM NUMBER]' s call light was answered 17 minutes after being turned on. On 11/1/23 at 4:15 p.m. room [ROOM NUMBER]' s call light was answered 27 minutes after being turned on. On 11/1/23 at 7:18 p.m. room [ROOM NUMBER]' s call light was answered 18 minutes after being turned on. On 11/1/23 at 10:23 p.m. room [ROOM NUMBER]' s call light was answered 28 minutes after being turned on. On 11/2/23 at 4:08 a.m. room [ROOM NUMBER]' s call light was answered 66 minutes after being turned on. On 11/2/23 at 8:30 p.m. room [ROOM NUMBER]' s call light was answered 20 minutes after being turned on. On 11/3/23 at 5:55 a.m. room [ROOM NUMBER]' s call light was answered 58 minutes after being turned on. On 11/4/23 at 6:21 a.m. room [ROOM NUMBER]' s call light was answered 39 minutes after being turned on. On 11/4/23 at 7:30 p.m. room [ROOM NUMBER]' s call light was answered 23 minutes after being turned on. On 11/5/23 at 1:49 a.m. room [ROOM NUMBER]' s call light was answered 16 minutes after being turned on. On 11/5/23 at 6:55 a.m. room [ROOM NUMBER]' s call light was answered 31 minutes after being turned on. On 11/6/23 at 7:02 a.m. room [ROOM NUMBER]' s call light was answered 16 minutes after being turned on. On 11/8/23 at 4:28 p.m. room [ROOM NUMBER]' s call light was answered 19 minutes after being turned on. On 11/9/23 at 4:04 a.m. room [ROOM NUMBER]' s call light was answered 44 minutes after being turned on. On 11/9/23 at 11:17 a.m. room [ROOM NUMBER]' s call light was answered 34 minutes after being turned on. On 11/9/23 at 3:40 p.m. room [ROOM NUMBER]' s call light was answered 17 minutes after being turned on. On 11/9/23 at 7:32 p.m. room [ROOM NUMBER]' s call light was answered 34 minutes after being turned on. On 11/10/23 at 10:45 a.m. room [ROOM NUMBER]' s call light was answered 18 minutes after being turned on. On 11/10/23 at 3:23 p.m. room [ROOM NUMBER]' s call light was answered 18 minutes after being turned on. On 11/12/23 at 1:19 p.m. room [ROOM NUMBER]' s call light was answered 28 minutes after being turned on. On 11/13/23 at 6:59 a.m. room [ROOM NUMBER]' s call light was answered 17 minutes after being turned on. On 11/13/23 at 3:53 p.m. room [ROOM NUMBER]' s call light was answered 31 minutes after being turned on. On 11/14/23 at 6:13 a.m. room [ROOM NUMBER]' s call light was answered 21 minutes after being turned on. B. room [ROOM NUMBER] On 10/16/23 at 4:27 a.m. room [ROOM NUMBER]' s call light was answered 21 minutes after being turned on. On 10/19/23 at 8:35 p.m. room [ROOM NUMBER]' s call light was answered 26 minutes after being turned on. On 10/21/23 at 9:40 p.m. room [ROOM NUMBER]' s call light was answered 18 minutes after being turned on. On 10/22/23 at 7:12 p.m. room [ROOM NUMBER]' s call light was answered 28 minutes after being turned on. On 10/22/23 at 8:50 p.m. room [ROOM NUMBER]' s call light was answered 24 minutes after being turned on. On 10/23/23 at 4:36 a.m. room [ROOM NUMBER]' s call light was answered 24 minutes after being turned on. On 10/26/23 at 8:20 p.m. room [ROOM NUMBER]' s call light was answered 18 minutes after being turned on. On 10/27/23 at 11:40 a.m. room [ROOM NUMBER]' s call light was answered 34 minutes after being turned on. On 10/28/23 at 7:24 p.m. room [ROOM NUMBER]' s call light was answered 83 minutes after being turned on. On 10/29/23 at 12:50 a.m. room [ROOM NUMBER]' s call light was answered 17 minutes after being turned on. On 10/29/23 at 6:33 a.m. room [ROOM NUMBER]' s call light was answered 62 minutes after being turned on. On 10/30/23 at 3:54 a.m. room [ROOM NUMBER]' s call light was answered 27 minutes after being turned on. On 10/30/23 at 6:07 a.m. room [ROOM NUMBER]' s call light was answered 48 minutes after being turned on. On 10/30/23 at 10:43 a.m. room [ROOM NUMBER]' s call light was answered 24 minutes after being turned on. On 11/1/23 at 3:57 a.m. room [ROOM NUMBER]' s call light was answered 30 minutes after being turned on. On 11/1/23 at 6:26 a.m. room [ROOM NUMBER]' s call light was answered 23 minutes after being turned on. On 11/2/23 at 4:39 a.m. room [ROOM NUMBER]' s call light was answered 26 minutes after being turned on. On 11/2/23 at 11:19 p.m. room [ROOM NUMBER]' s call light was answered 22 minutes after being turned on. On 11/3/23 at 11:10 a.m. room [ROOM NUMBER]' s call light was answered 18 minutes after being turned on. On 11/3/23 at 11:37 a.m. room [ROOM NUMBER]' s call light was answered 50 minutes after being turned on. On 11/4/23 at 6:44 a.m. room [ROOM NUMBER]' s call light was answered 37 minutes after being turned on. On 11/4/23 at 10:21 a.m. room [ROOM NUMBER]' s call light was answered 30 minutes after being turned on. On 11/4/23 at 3:39 p.m. room [ROOM NUMBER]' s call light was answered 18 minutes after being turned on. On 11/5/23 at 6:13 a.m. room [ROOM NUMBER]' s call light was answered 19 minutes after being turned on. On 11/5/23 at 9:25 a.m. room [ROOM NUMBER]' s call light was answered 22 minutes after being turned on. On 11/5/23 at 4:30 p.m. room [ROOM NUMBER]' s call light was answered 17 minutes after being turned on. On 11/7/23 at 3:45 a.m. room [ROOM NUMBER]' s call light was answered 33 minutes after being turned on. On 11/7/23 at 6:00 a.m. room [ROOM NUMBER]' s call light was answered 28 minutes after being turned on. On 11/7/23 at 11:01 a.m. room [ROOM NUMBER]' s call light was answered 16 minutes after being turned on. On 11/8/23 at 2:28 a.m. room [ROOM NUMBER]' s call light was answered 32 minutes after being turned on. On 11/8/23 at 8:07 p.m. room [ROOM NUMBER]' s call light was answered 16 minutes after being turned on. On 11/9/23 at 3:16 a.m. room [ROOM NUMBER]' s call light was answered 29 minutes after being turned on. On 11/9/23 at 7:06 a.m. room [ROOM NUMBER]' s call light was answered 21 minutes after being turned on. On 11/13/23 at 6:18 a.m. room [ROOM NUMBER]' s call light was answered 25 minutes after being turned on. On 11/14/23 at 1:05 a.m. room [ROOM NUMBER]' s call light was answered 16 minutes after being turned on. On 11/15/23 at 10:52 a.m. room [ROOM NUMBER]' s call light was answered 22 minutes after being turned on. C. room [ROOM NUMBER] On 11/7/23 at 4:38 p.m. room [ROOM NUMBER]' s call light was answered 16 minutes after being turned on. On 11/8/23 at 6:50 a.m. room [ROOM NUMBER]' s call light was answered 21 minutes after being turned on. On 11/8/23 at 8:42 a.m. room [ROOM NUMBER]' s call light was answered 23 minutes after being turned on. On 11/8/23 at 7:18 p.m. room [ROOM NUMBER]' s call light was answered 24 minutes after being turned on. On 11/8/23 at 8:18 p.m. room [ROOM NUMBER]' s call light was answered 16 minutes after being turned on. On 11/9/23 at 5:45 p.m. room [ROOM NUMBER]' s call light was answered 19 minutes after being turned on. On 11/9/23 at 7:38 p.m. room [ROOM NUMBER]' s call light was answered 19 minutes after being turned on. On 11/10/23 at 2:25 a.m. room [ROOM NUMBER]' s call light was answered 48 minutes after being turned on. On 11/10/23 at 6:10 a.m. room [ROOM NUMBER]' s call light was answered 46 minutes after being turned on. On 11/10/23 at 7:17 a.m. room [ROOM NUMBER]' s call light was answered 22 minutes after being turned on. On 11/10/23 at 7:44 a.m. room [ROOM NUMBER]' s call light was answered 41 minutes after being turned on. On 11/10/23 at 12:45 p.m. room [ROOM NUMBER]' s call light was answered 18 minutes after being turned on. On 11/10/23 at 3:19 p.m. room [ROOM NUMBER]' s call light was answered 48 minutes after being turned on. On 11/11/23 at 2:28 a.m. room [ROOM NUMBER]' s call light was answered 30 minutes after being turned on. On 11/11/23 at 7:51 a.m. room [ROOM NUMBER]' s call light was answered 45 minutes after being turned on. On 11/11/23 at 12:11 p.m. room [ROOM NUMBER]' s call light was answered 16 minutes after being turned on. On 11/11/23 at 5:41 p.m. room [ROOM NUMBER]' s call light was answered 19 minutes after being turned on. On 11/12/23 at 7:54 a.m. room [ROOM NUMBER]' s call light was answered 34 minutes after being turned on. On 11/12/23 at 9:17 a.m. room [ROOM NUMBER]' s call light was answered 16 minutes after being turned on. On 11/12/23 at 8:58 a.m. room [ROOM NUMBER]' s call light was answered 17 minutes after being turned on. On 11/14/23 at 4:56 a.m. room [ROOM NUMBER]' s call light was answered 27 minutes after being turned on. On 11/15/23 at 6:19 a.m. room [ROOM NUMBER]' s call light was answered 19 minutes after being turned on. On 11/15/23 at 1:28 p.m. room [ROOM NUMBER]' s call light was answered 17 minutes after being turned on. D. room [ROOM NUMBER] On 10/18/23 at 9:41 a.m. room [ROOM NUMBER]' s call light was answered 17 minutes after being turned on. On 11/10/23 at 5:07 a.m. room [ROOM NUMBER]' s call light was answered 22 minutes after being turned on. On 11/10/23 at 6:14 a.m. room [ROOM NUMBER]' s call light was answered 32 minutes after being turned on. On 11/10/23 at 1:57 p.m. room [ROOM NUMBER]' s call light was answered 17 minutes after being turned on. On 11/10/23 at 5:22 p.m. room [ROOM NUMBER]' s call light was answered 27 minutes after being turned on. On 11/10/23 at 6:37 p.m. room [ROOM NUMBER]' s call light was answered 27 minutes after being turned on. On 11/10/23 at 7:51 p.m. room [ROOM NUMBER]' s call light was answered 36 minutes after being turned on. On 11/11/23 at 4:40 p.m. room [ROOM NUMBER]' s call light was answered 28 minutes after being turned on. On 11/11/23 at 5:55 p.m. room [ROOM NUMBER]' s call light was answered 32 minutes after being turned on. On 11/11/23 at 6:34 p.m. room [ROOM NUMBER]' s call light was answered 17 minutes after being turned on. On 11/13/23 at 12:36 a.m. room [ROOM NUMBER]' s call light was answered 25 minutes after being turned on. On 11/13/23 at 4:14 a.m. room [ROOM NUMBER]' s call light was answered 16 minutes after being turned on. On 11/13/23 at 8:23 a.m. room [ROOM NUMBER]' s call light was answered 33 minutes after being turned on. On 11/13/23 at 2:50 p.m. room [ROOM NUMBER]' s call light was answered 19 minutes after being turned on. On 11/13/23 at 8:41 p.m. room [ROOM NUMBER]' s call light was answered 17 minutes after being turned on. On 11/14/23 at 1:02 a.m. room [ROOM NUMBER]' s call light was answered 19 minutes after being turned on. On 11/15/23 at 1:30 a.m. room [ROOM NUMBER]' s call light was answered 18 minutes after being turned on. On 11/15/23 at 11:44 a.m. room [ROOM NUMBER]' s call light was answered 18 minutes after being turned on. E. room [ROOM NUMBER] On 10/16/23 at 1:33 a.m. room [ROOM NUMBER]' s call light was answered 44 minutes after being turned on. On 10/16/23 at 4:14 p.m. room [ROOM NUMBER]' s call light was answered 31 minutes after being turned on. On 10/16/23 at 8:24 p.m. room [ROOM NUMBER]' s call light was answered 38 minutes after being turned on. On 10/17/23 at 9:26 a.m. room [ROOM NUMBER]' s call light was answered 31 minutes after being turned on. On 10/17/23 at 1:18 p.m. room [ROOM NUMBER]' s call light was answered 33 minutes after being turned on. On 10/17/23 at 6:20 p.m. room [ROOM NUMBER]' s call light was answered 24 minutes after being turned on. On 10/18/23 at 7:29 a.m. room [ROOM NUMBER]' s call light was answered 18 minutes after being turned on. On 10/18/23 at 6:55 p.m. room [ROOM NUMBER]' s call light was answered 45 minutes after being turned on. On 10/18/23 at 8:49 p.m. room [ROOM NUMBER]' s call light was answered 38 minutes after being turned on. On 10/18/23 at 10:46 p.m. room [ROOM NUMBER]' s call light was answered 27 minutes after being turned on. On 10/19/23 at 5:59 a.m. room [ROOM NUMBER]' s call light was answered 16 minutes after being turned on. On 10/19/23 at 4:01 p.m. room [ROOM NUMBER]' s call light was answered 16 minutes after being turned on. On 10/20/23 at 6:42 a.m. room [ROOM NUMBER]' s call light was answered 39 minutes after being turned on. On 10/20/23 at 9:20 a.m. room [ROOM NUMBER]' s call light was answered 25 minutes after being turned on. On 10/20/23 at 6:22 p.m. room [ROOM NUMBER]' s call light was answered 16 minutes after being turned on. On 10/20/23 at 8:27 p.m. room [ROOM NUMBER]' s call light was answered 17 minutes after being turned on. On 10/21/23 at 1:33 a.m. room [ROOM NUMBER]' s call light was answered 17 minutes after being turned on. On 10/21/23 at 3:51 a.m. room [ROOM NUMBER]' s call light was answered 35 minutes after being turned on. On 10/21/23 at 6:29 a.m. room [ROOM NUMBER]' s call light was answered 20 minutes after being turned on. On 10/22/23 at 6:45 a.m. room [ROOM NUMBER]' s call light was answered 54 minutes after being turned on. On 10/22/23 at 1:32 p.m. room [ROOM NUMBER]' s call light was answered 24 minutes after being turned on. On 10/22/23 at 3:28 p.m. room [ROOM NUMBER]' s call light was answered 23 minutes after being turned on. On 10/22/23 at 3:58 p.m. room [ROOM NUMBER]' s call light was answered 16 minutes after being turned on. On 10/23/23 at 7:01 a.m. room [ROOM NUMBER]' s call light was answered 16 minutes after being turned on. On 10/23/23 at 10:41 a.m. room [ROOM NUMBER]' s call light was answered 19 minutes after being turned on. On 10/23/23 at 6:35 p.m. room [ROOM NUMBER]' s call light was answered 19 minutes after being turned on. On 10/23/23 at 8:37 p.m. room [ROOM NUMBER]' s call light was answered 29 minutes after being turned on. On 10/23/23 at 10:54 p.m. room [ROOM NUMBER]' s call light was answered 16 minutes after being turned on. On 10/25/23 at 6:39 p.m. room [ROOM NUMBER]' s call light was answered 25 minutes after being turned on. On 10/25/23 at 11:40 p.m. room [ROOM NUMBER]' s call light was answered 30 minutes after being turned on. On 10/26/23 at 5:05 a.m. room [ROOM NUMBER]' s call light was answered 20 minutes after being turned on. On 10/27/23 at 8:36 a.m. room [ROOM NUMBER]' s call light was answered 21 minutes after being turned on. On 10/28/23 at 3:27 a.m. room [ROOM NUMBER]' s call light was answered 30 minutes after being turned on. On 10/28/23 at 11:42 a.m. room [ROOM NUMBER]' s call light was answered 40 minutes after being turned on. On 10/28/23 at 5:43 p.m. room [ROOM NUMBER]' s call light was answered 24 minutes after being turned on. On 10/28/23 at 6:52 p.m. room [ROOM NUMBER]' s call light was answered 17 minutes after being turned on. On 10/28/23 at 8:35 p.m. room [ROOM NUMBER]' s call light was answered 54 minutes after being turned on. On 10/29/23 at 4:21 a.m. room [ROOM NUMBER]' s call light was answered 40 minutes after being turned on. On 10/29/23 at 8:43 a.m. room [ROOM NUMBER]' s call light was answered 19 minutes after being turned on. On 10/29/23 at 11:46 a.m. room [ROOM NUMBER]' s call light was answered 18 minutes after being turned on. On 10/29/23 at 3:50 p.m. room [ROOM NUMBER]' s call light was answered 16 minutes after being turned on. On 10/29/23 at 10:09 p.m. room [ROOM NUMBER]' s call light was answered 17 minutes after being turned on. On 10/30/23 at 2:08 a.m. room [ROOM NUMBER]' s call light was answered 19 minutes after being turned on. On 10/30/23 at 4:03 p.m. room [ROOM NUMBER]' s call light was answered 32 minutes after being turned on. On 10/30/23 at 6:07 p.m. room [ROOM NUMBER]' s call light was answered 21 minutes after being turned on. On 10/30/23 at 6:09 p.m. another call light in room [ROOM NUMBER] was answered 31 minutes after being turned on. On 10/31/23 at 7:25 p.m. room [ROOM NUMBER]' s call light was answered 26 minutes after being turned on. On 10/31/23 at 8:38 p.m. room [ROOM NUMBER]' s call light was answered 24 minutes after being turned on. On 11/1/23 at 12:16 a.m. room [ROOM NUMBER]' s call light was answered 38 minutes after being turned on. On 11/1/23 at 4:23 a.m. room [ROOM NUMBER]' s call light was answered 37 minutes after being turned on. On 11/2/23 at 2:19 a.m. room [ROOM NUMBER]' s call light was answered 28 minutes after being turned on. On 11/3/23 at 1:46 a.m. room [ROOM NUMBER]' s call light was answered 19 minutes after being turned on. On 11/3/23 at 8:50 a.m. room [ROOM NUMBER]' s call light was answered 17 minutes after being turned on. On 11/3/23 at 8:12 p.m. room [ROOM NUMBER]' s call light was answered 20 minutes after being turned on. On 11/3/23 at 10:52 p.m. room [ROOM NUMBER]' s call light was answered 21 minutes after being turned on. On 11/4/23 at 6:03 a.m. room [ROOM NUMBER]' s call light was answered 21 minutes after being turned on. On 11/4/23 at 7:23 a.m. room [ROOM NUMBER]' s call light was answered 25 minutes after being turned on. On 11/5/23 at 7:02 p.m. room [ROOM NUMBER]' s call light was answered 31 minutes after being turned on. On 11/7/23 at 8:58 a.m. room [ROOM NUMBER]' s call light was answered 31 minutes after being turned on. On 11/7/23 at 3:45 p.m. room [ROOM NUMBER]' s call light was answered 22 minutes after being turned on. F. room [ROOM NUMBER] On 10/16/23 at 6:05 a.m. room [ROOM NUMBER]' s call light was answered 23 minutes after being turned on. On 10/16/23 at 12:30 p.m. room [ROOM NUMBER]' s call light was answered 24 minutes after being turned on. On 10/16/23 at 8:47 p.m. room [ROOM NUMBER]' s call light was answered 23 minutes after being turned on. On 10/18/23 at 4:08 a.m. room [ROOM NUMBER]' s call light was answered 27 minutes after being turned on. On 10/18/23 at 3:44 p.m. room [ROOM NUMBER]' s call light was answered 31 minutes after being turned on. On 10/18/23 at 4:47 p.m. room [ROOM NUMBER]' s call light was answered 22 minutes after being turned on. On 10/18/23 at 6:19 p.m. room [ROOM NUMBER]' s call light was answered 26 minutes after being turned on. On 10/18/23 at 7:26 p.m. room [ROOM NUMBER]' s call light was answered 17 minutes after being turned on. On 10/18/23 at 7:29 p.m. another call light in room [ROOM NUMBER] was answered 30 minutes after being turned on. On 10/19/23 at 10:24 a.m. room [ROOM NUMBER]' s call light was answered 16 minutes after being turned on. On 10/19/23 at 11:46 a.m. room [ROOM NUMBER]' s call light was answered 30 minutes after being turned on. On 10/19/23 at 2:21 p.m. room [ROOM NUMBER]' s call light was answered 17 minutes after being turned on. On 10/19/23 at 4:23 p.m. room [ROOM NUMBER]' s call light was answered 18 minutes after being turned on. On 10/19.23 at 5:55 p.m. room [ROOM NUMBER]' s call light was answered 24 minutes after being turned on. On 10/20/23 at 6:36 a.m. room [ROOM NUMBER]' s call light was answered 26 minutes after being turned on. On 10/20/23 at 8:56 a.m. room [ROOM NUMBER]' s call light was answered 34 minutes after being turned on. On 10/20/23 at 6:52 p.m. room [ROOM NUMBER]' s call light was answered 37 minutes after being turned on. On 10/20/23 at 8:24 p.m. room [ROOM NUMBER]' s call light was answered 21 minutes after being turned on. On 10/21/23 at 12:18 p.m. room [ROOM NUMBER]' s call light was answered 19 minutes after being turned on. On 10/21/23 at 12:41 p.m. room [ROOM NUMBER]' s call light was answered 72 minutes after being turned on. On 10/21/23 at 6:05 p.m. room [ROOM NUMBER]' s call light was answered 18 minutes after being turned on. On 10/22/23 at 2:34 p.m. room [ROOM NUMBER]' s call light was answered 17 minutes after being turned on. On 10/22/23 at 2:36 p.m. another call light in room [ROOM NUMBER] was answered 30 minutes after being turned on. On 10/22/23 at 7:47 p.m. room [ROOM NUMBER]' s call light was answered 16 minutes after being turned on. On 10/22/23 at 7:48 p.m. another call light in room [ROOM NUMBER] was answered 16 minutes after being turned on. On 10/23/23 at 7:31 a.m. room [ROOM NUMBER]' s call light was answered 19 minutes after being turned on. On 10/23/23 at 4:30 p.m. room [ROOM NUMBER]' s call light was answered 16 minutes after being turned on. On 10/23/23 at 7:01 p.m. room [ROOM NUMBER]' s call light was answered 70 minutes after being turned on. On 10/23/23 at 8:47 p.m. room [ROOM NUMBER]' s call light was answered 22 minutes after being turned on. On 10/23/23 at 10:40 p.m. room [ROOM NUMBER]' s call light was answered 17 minutes after being turned on. On 10/24/23 at 12:51 a.m. room [ROOM NUMBER]' s call light was answered 19 minutes after being turned on. On 10/24/23 at 9:50 p.m. room [ROOM NUMBER]' s call light was answered 21 minutes after being turned on. On 10/25/23 at 9:40 a.m. room [ROOM NUMBER]' s call light was answered 31 minutes after being turned on. On 10/26/23 at 10:19 a.m. room [ROOM NUMBER]' s call light was answered 29 minutes after being turned on. On 10/27/23 at 6:46 p.m. room [ROOM NUMBER]' s call light was answered 16 minutes after being turned on. On 10/28/23 at 1:05 a.m. room [ROOM NUMBER]' s call light was answered 23 minutes after being turned on. On 10/28/23 at 9:00 a.m. room [ROOM NUMBER]' s call light was answered 21 minutes after being turned on. On 10/28/23 at 10:44 a.m. room [ROOM NUMBER]' s call light was answered 34 minutes after being turned on. On 10/28/23 at 11:54 a.m. room [ROOM NUMBER]' s call light was answered 26 minutes after being turned on. On 10/29/23 at 7:09 p.m. room [ROOM NUMBER]' s call light was answered 27 minutes after being turned on. On 10/29/23 at 10:11 p.m. room [ROOM NUMBER]' s call light was answered 27 minutes after being turned on. On 10/30/23 at 1:49 p.m. room [ROOM NUMBER]' s call light was answered 31 minutes after being turned on. On 10/30/23 at 2:24 p.m. room [ROOM NUMBER]' s call light was answered 43 minutes after being turned on. On 10/30/23 at 7:04 p.m. room [ROOM NUMBER]' s call light was answered 17 minutes after being turned on. On 10/31/23 at 5:33 a.m. room [ROOM NUMBER]' s call light was answered 26 minutes after being turned on. On 10/31/23 at 7:32 a.m. room [ROOM NUMBER]' s call light was answered 47 minutes after being turned on. On 10/31/23 at 10:15 a.m. room [ROOM NUMBER]' s call light was answered 40 minutes after being turned on. On 10/31/23 at 10:16 a.m. another call light in room [ROOM NUMBER] was answered 17 minutes after being turned on. On 10/31/23 at 11:01 a.m. room [ROOM NUMBER]' s call light was answe

Based on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for three out of three units at the facility. Specifically, the facility failed to: -Ensure residents were provided with an opportunity to participate in hand hygiene before meals; -Ensure staff performed hand hygiene in between tasks; -Ensure proper use of a clean field/surface during wound care for Resident #83; -Ensure proper hand hygiene was in place during wound care, specifically when donning and doffing gloves; and, -Ensure appropriate personal protective equipment was used as ordered during wound care, specifically a gown. Findings include: I. Failure to ensure residents were provided with an opportunity to participate in hand hygiene before meals and staff performed hand hygiene A. Professional reference The Centers for Disease Control (CDC) Hand Hygiene updated 2/7/23, retrieved on 11/10/23 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html revealed in part, Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. CDC recommendations reflect this important role. The exact contribution of hand hygiene to the reduction of direct and indirect spread of coronaviruses between people is currently unknown. However, hand washing mechanically removes pathogens, and laboratory data demonstrate that ABHR formulations in the range of alcohol concentrations recommended by the CDC, inactivate SARS-CoV-2. ABHR effectively reduces the number of pathogens that may be present on the hands of healthcare providers after brief interactions with patients or the care environment. The CDC recommends using ABHR with greater than 60% ethanol or 70% isopropanol in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink. B. Facility policy The Handwashing/Hand Hygiene policy, dated August 2019, was provided by the infection control preventionist (IP) on 11/16/23 at 4:00 p.m. The policy read in pertinent part, This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare -associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. C. Observations On 11/13/23 at 12:19 p.m., the main dining room was observed. Certified nurse aide (CNA) #10 had gloves on and was observed to touch a resident's back to wake a resident up. CNA #10 proceeded to assist another resident with the same gloved hands. She then passed out the wet wipes to the residents to wash their hands prior to the meal, however, did not perform hand hygiene in between each task. With the same gloved hands she then cleaned the hands of Resident #59. On 11/13/23 at 12:20 p.m. the noon meals were served to the residents eating in their rooms on the Columbine unit, however, hand hygiene was not offered or provided to the residents. On 11/15/23 at 8:46 a.m., an unidentified CNA was taking the vitals of a resident. She did not perform hand hygiene prior to taking the vitals of another resident. On 11/15/23 at 12:08 p.m., CNA #11 was assisting a resident to the table and offered the resident hand wipes. She then immediately assisted another resident to the table. She did not perform hand hygiene in between tasks. CNA #11 proceeded to physically assist a resident with cleaning her hands with the wipes. She failed to perform hand hygiene prior to touching the glasses to pass out drinks to the residents. On 11/14/23 at 11:50 a.m., the IP was observed to pass wet wipes to the residents. As he passed out the clean wipes other residents would hand him the dirty used wipes. He would then continue to hand out clean wipes using the hand with the dirty wipes. The IP did not perform hand hygiene in between tasks or residents. On 11/15/23 at 8:39 a.m. breakfast was served to the residents eating in their rooms on the Columbine unit, however, hand hygiene was not offered or provided to the residents. On 11/15/23 at 8:53 p.m., the trays on the Blue Spruce [NAME] unit were passed to residents in their rooms. However, hand washing did not get offered to the residents in the rooms. On 11/15/23 at 8:39 a.m. breakfast was served to the residents eating in their rooms on the Columbine unit, however, hand hygiene was not offered or provided to the residents. D. Interview The infection preventionist (IP) and the regional nurse consultant (RNC) were interviewed on 11/16/23 at 2:02 p.m. The IP said the staff were to wash their hands with soap and water or use hand sanitizer before and after each task. The IP said the staff had been trained and educated on hand hygiene. He said the staff were to offer handwashing to residents prior to their meals being served. 40467 II. Failure to ensure appropriate infection control procedures during wound care A. Facility policy The Wound Care policy, dated October 2010, was provided by the director of nursing (DON) on 11/16/23 at 8:25 p.m. The policy read in pertinent part: -The purpose of this procedure is to provide guidelines for care of wounds to promote healing. -Verify that there is a physician's order for this procedure. -The following equipment supplies will be necessary when performing this procedure: dressing material as indicated; disposable cloth, as indicated; antiseptic as ordered; and personal protective equipment. -Use disposable cloth to establish a clean field on the resident's overbed table. Place all items to be used during the procedure on the clean field. Arrange supplies so they can be easily reached. -Wash and dry hands thoroughly. -Position the resident. Place a disposable cloth next to the resident under the wound to serve as a barrier to protect the bed lining and other body sites. -Put on exam glove. Loosen tape and remove dressing. -Pull glove over dressing and discard onto proper reciprocal. Wash and dry hands thoroughly. -Put on gloves. Gowns will only be necessary if soiling of your skin or clothing with blood, urine, feces or other body fluids is likely. Mask and eyewear will only be necessary if splashing of blood or other body fluids into eyes or mouth is likely. -Use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers. -Pour liquid solutions directly on the gauze sponges on their papers. -Wear exam gloves for holding gauze to catch irrigation solutions that pour directly over the wound. -Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. -Place one gauze to cover all broken skin. Wash tissue around that usually is covered by the dressing tape or gauze with antiseptic or soap and water. -Dress wound. Pick up the sponge with paper and apply directly to the area. [NAME] tape with initials time and date and apply to dressing. Be certain all clean items are on a clean field. -Remove the Disposable cloth next to the resident and discard into the designated container. -Discard disposable items in the designated container. discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. B. Resident status Resident #189, age 78, was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO), diagnoses included unspecified systolic congestive heart failure, contusion of the left lower leg, subsequent encounter, fluid overload, reduced mobility and need for assistance with personal care. Resident #189 was a new admission to the facility and the minimum data set (MDS) assessment was not due for completion. C. Resident interview Resident #189 was interviewed on 11/14/23 at 9:15 a.m. He said he was newly admitted from the hospital after an accident on his scooter. He said his left lower leg was injured in the accident and he had a wound vacuum on his leg over the contusion (bruise). D. Record The 11/7/23 CPO directed staff to provide skin care per facility protocol, including when skin issues were present. The 11/08/23 care plan read Resident #83 had an actual impairment to his skin integrity. According to the care plan, staff should keep the resident' s skin clean and dry. The 11/8/23 CPO directed staff to practice enhanced barrier precautions of gown and gloves with wound care or involved personal care related to the presence of the wound. The 11/10/23 CPO directed staff to change the wound vacuum dressing on Tuesdays and Fridays. The 11/10/23 skin and wound evaluation read Resident #83 had a hematoma (pooling of blood outside the blood vessels contained under the skin) to his front left lateral (outside surface) lower leg from an accident on 10/23/23, prior to the resident' s admission. The hematoma measured 11.8 centimeters (cm) in length by 7.1 cm in width. According to the evaluation, the skin was fragile and at risk for breakdown. His wound was treated with negative pressure wound therapy (a wound vacuum/suction pump, tubing and dressing to promote healing). The evaluation identified the dressing would be changed on 11/15/23 when the wound physician assistant (PA) was in the facility to assess the wound. E. Observation Wound care observations for Resident #189 were conducted between 11/15/23 at 9:07 a.m. and 9:27 a.m. The wound care was completed by the assistant director of nursing (ADON). The wound PA assessed the condition of the wound during the dressing change. The wound was measured at 12.2 cm by 8 cm. The following practices were observed during the wound care by the ADON: -The ADON wore gloves but she did not wear a gown for enhanced barrier precautions as ordered by the physician (see CPO above). -The clean negative pressure wound therapy supplies were placed directly on top of the residents table next to books, papers and other personal items of the resident. -The clean wound supplies were not placed on a disposable cloth. -The table was not disinfected to kill potential viruses and bacteria on the surface of the table. -The supplies were not placed on a clean field/surface. -The resident had his left leg elevated on a pillow with a pillow case he used throughout the day. The wound care was conducted while the leg remained directly on the pillow. A disposable cloth was not placed near the resident and under the wound as a barrier to protect bedding surfaces and other body sites. -A disposable cloth was not placed near the resident during the wound care to establish a clean field/surface for wound care supplies. -Unused alcohol wipe packets and used alcohol wipes used to remove the old wound dressing were placed directly on the resident's leg pillow. -The packaged peel and stick dressing was placed directly on top of the pillow. -The ADON removed the packaged dressing with her gloved hands and placed the scissors directly on top of the pillow next to the resident' s leg. -The ADON then used the scissors to cut the peel and stick dressing. She placed the cut edges of the dressing on half of the wound surface edges. The ADON placed the scissors back on the pillow. -The ADON picked up the scissors and proceeded to cut more of the peel and stick dressing. Her gloves got stuck to the dressing. She removed her gloves and threw the dressing away. She donned new gloves. -The ADON did not perform hand hygiene after doffing her gloves and donning new gloves. She picked up the scissors again from the pillow and completed shaping the dressing. -The ADON dropped the scissors on the floor. She picked up the scissors and left the room to sterilize them. The ADON returned to the room with clean gloves and retrieved the packaged foam and tubing from the resident' s table. The ADON opened the packaging with her gloved hands and proceeded to complete the wound dressing and attach the tubing to the wound vac. F. Staff interview The ADON was interviewed on 11/15/23 at 1:35 p.m. The ADON said Resident #189 admitted to the facility with a large hematoma that required drainage through a wound vac. The ADON said she was not wound certified but had had a lot of experience with wound care. The ADON said during wound care, infection control procedures needed to be practiced. She said hand hygiene needed to be completed before and after wound care. The ADON said gloves needed to be changed after touching a wound area. She said she probably should have used hand hygiene everytime she changed her gloves. The ADON said the wound care should have been completed with a clean work surface to prevent potential contamination to the resident' s wound. She said she would not consider his table or his pillow a clean surface to place his wound care supplies on. She said she should not have put the scissors she was using to cut his dressing onto his pillow where he rested his leg. She said she should have wiped off his table before placing the clean wound supplies on the surface of the table.

Based on record review and staff interviews the facility failed to implement policies and procedures related to pneumococcal immunizations for five (#3, #16 #62, #51 and #59) of eight residents reviewed for immunizations out of eight sample residents. Specifically, the facility failed to: -Offer Resident #62 a pneumococcal vaccination upon admission; -Offer additional doses of the pneumococcal vaccine to Residents #3, #16 and #51; and, -Administer annual flu vaccinations to Residents #51, #3, #59. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged [AGE] years or Older, United States, 2023, retrieved on 9/28/23, from: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, in pertinent part: Routine vaccination - pneumococcal -For those ages 19 or older with an additional risk factor or another indication was: One (1) dose PCV15 (pneumococcal 15-valent conjugate vaccine PCV15 Vaxneuvance) followed by PPSV23 (pneumococcal 23-valent polysaccharide vaccine PPSV23 Pneumovax 23)or one (1) dose PCV20 (pneumococcal 20-valent conjugate vaccine PCV20 Prevnar 20). (see notes) -For those over the age of 65 who meet age requirement and lack documentation of vaccination, or lack evidence of past infection was: One (1) dose PCV15 followed by PPSV23 or one (1) dose PCV20. Special situations: Age 19-[AGE] years with certain underlying medical conditions or other risk factors who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown: One (1) dose PCV15 or one (1) dose PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose. A minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak to minimize the risk of invasive pneumococcal disease caused by serotypes unique to PPSV23 in these vulnerable groups. -Note: Immunocompromising conditions include chronic renal failure, nephrotic syndrome, immunodeficiency, iatrogenic immunosuppression, generalized malignancy, human immunodeficiency virus (HIV), Hodgkin disease, leukemia, lymphoma, multiple myeloma, solid organ transplants, congenital or acquired asplenia, sickle cell disease, or other hemoglobinopathies. -Note: Underlying medical conditions or other risk factors include alcoholism, chronic heart/liver/lung disease, chronic renal failure, cigarette smoking, cochlear implant, congenital or acquired asplenia, CSF (cerebral spinal fluid) leak, diabetes mellitus, generalized malignancy, HIV, Hodgkin disease, immunodeficiency, iatrogenic immunosuppression, leukemia, lymphoma, multiple myeloma, nephrotic syndrome, solid organ transplants, or sickle cell disease or other hemoglobinopathies. II. Facility policy The Influenza, Prevention and Control of Seasonal Vaccine policy, revised March 2022, was provided by the nursing home administrator (NHA) on 11/13/23. It read in pertinent part, The infection preventionist organizes and oversees an annual influenza vaccine campaign. All residents and staff are offered the vaccine prior to the onset of the influenza season. The Pneumococcal Vaccine policy, revised March 2022, was provided by the NHA on 11/13/23 at 4:47 p.m. It read in pertinent part, All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. III. Resident #62 A. Resident #62 Resident #62, age greater than 90, was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO), diagnoses included dementia, unspecified sequelae of cerebral infarction (stroke) and muscle weakness. The 8/23/23 minimum data set (MDS) assessment documented no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. -The MDS inaccurately documented that the resident was not offered the pneumococcal vaccination. B. Record review A review of Resident #62's electronic medical record (EMR) revealed the immunization tracking sheet did not show the resident received the pneumococcal vaccination. However, the resident had signed a consent form on 8/19/22 giving permission to receive the pneumococcal vaccination. -The EMR failed to show that the resident had been administered the pneumococcal vaccination after the consent was signed. -The Colorado Immunization Information System (CIIS) showed the pneumococcal vaccination was recommended on 5/31/22. IV. Resident #3 A. Resident status Resident #3, age 85, was admitted on [DATE]. According to the November 2023 CPO, diagnoses included atrial l fibrillation (a quivering or irregular heartbeat), heart failure and hypertension. The 8/17/23 MDS assessment documented Resident #3 had severe cognitive impairment with a BIMS score of three out of 15. -The MDS assessment inaccurately documented the resident was up to date on her pneumococcal vaccination. -The MDS assessment failed to document if the vaccination was offered. B. Record review A review of Resident #3's EMR revealed the immunization tracking sheet showed the resident received a pneumococcal vaccination on 10/1/16. However, the resident had signed a consent form on 5/25/22 giving permission to receive the updated pneumococcal vaccination and the flu vaccination yearly. -The EMR failed to show that the resident had been administered the pneumococcal vaccination after the consent was signed. -The resident had not yet received the flu vaccination as of 11/16/23 for the 2023-2024 flu season. V. Resident #51 A. Resident #51 Resident #51, age 83, was admitted on [DATE]. According to the November 2023 CPO, diagnoses included dementia, unspecified sequelae of cerebral infarction (stroke) and muscle weakness. The 10/6/23 minimum data set (MDS) assessment documented Resident #51 had moderate cognitive impairment with a BIMS score of eight out of 15. -The MDS assessment inaccurately documented the resident was up to date on her pneumococcal vaccination. -The MDS assessment failed to document if the vaccination was offered. B. Record review A review of Resident #51's EMR revealed the immunization tracking sheet showed the resident received the pneumococcal vaccination on 7/1/16. However, the resident had signed a consent form on 11/1/21 giving permission to receive the updated pneumococcal vaccination and the flu vaccination yearly. -The EMR failed to show that the resident had been administered the pneumococcal vaccination after the consent was signed. -The resident had not yet received the flu vaccination as of 11/16/23 for the 2023-2024 flu season. VI. Resident #16 A. Resident status Resident #16, age 85, was admitted on [DATE]. According to the November 2023 CPO, diagnoses included hypertension and peripheral vascular disease. The 9/23/23 MDS assessment revealed Resident #16 was cognitively intact with a BIMS score of 15 out of 15. -The MDS assessment inaccurately documented the resident was up to date on his pneumococcal vaccination. -The MDS assessment failed to document if the vaccination was offered. B. Record review A review of Resident #16's EMR revealed the immunization tracking sheet showed the resident received the pneumococcal vaccination dose two on 10/23/07. However, the EMR failed to show evidence that the resident received the first dose of the pneumococcal vaccination. The EMR failed to show a CIIS was reviewed to verify the resident's vaccination status. A consent was signed by the resident's power of attorney requesting a pneumococcal vaccination to be administered on 6/8/23. VII. Resident #59 A. Resident status Resident #59, age 80, was admitted on [DATE]. According to the November 2023 CPO, diagnoses included cerebral vascular disease and hypertension. The 9/26/23 MDS assessment revealed Resident #59 was cognitively intact with a BIMS score of 15 out of 15. -The MDS inaccurately documented that the resident had been offered and refused the annual flu vaccination, whereas, he had provided consent to receive the flu vaccination yearly. B. Record review A review of Resident #59's EMR revealed the immunization tracking sheet showed the resident had not received the flu vaccination. However, the resident had signed a consent form on 6/27/22 giving permission to receive the flu vaccination yearly. -The EMR failed to show that the resident had been administered the pneumococcal vaccination after the consent was signed. -The resident had not yet received the flu vaccination as of 11/16/23 for the 2023-2024 flu season. VII. Interviews The infection preventionist (IP) and the regional nurse consultant was interviewed on 11/16/23 at 2:02 p.m. The IP said the Colorado Immunization Information system (CIIS) database was utilized to ensure the resident's vaccination record was received. He said the admitting nurse would then offer and provide education to the resident in regard to the importance of being vaccinated against pneumonia and influenza. He said if the resident accepted the pneumonia vaccination then the consent was signed and the vaccination was administered after receiving the physician's order. He said if the resident refused then the resident signed the consent form documenting that they refused. He said that the facility followed the CDC pneumococcal vaccination timing for adults. The IP said that he had performed an audit last week during a mock survey, and he realized not all of the residents were up to date on the pneumococcal vaccinations. He said he had no plan developed for getting residents up to date on their pneumococcal vaccinations. The IP said the flu vaccinations had not yet been administered for the 2023-2024 flu season. He said that he had not received the vaccinations. He said the flu vaccination was ordered late. On 10/1/23 he emailed the pharmacy consultant to inquire about ordering the flu vaccine. However, did not receive a timely response, and once he received a response he ordered the flu vaccinations on 11/6/23. The IP said he had attempted to get a mobile flu clinic to come to the facility, however, they were all booked up. He said the medical director was aware the vaccinations had not been provided. He said the vaccinations could take six weeks to arrive at the facility.

Based on record review and interviews, the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents for one (#1) of three residents reviewed for falls out of eight sample residents. Specifically, the facility: -Failed to ensure certified nurse aide (CNA) #4 followed proper procedure while providing cares to Resident #1 and ensure the resident was safe; -Failed to implement two-person assistance when providing cares to Resident #1, which was identified as a resident need on their minimum data set (MDS) assessment, and, -Failed to implement a care-planned intervention to provide two-person assistance when providing cares to Resident #1. On the morning of 12/30/22, CNA #4 was preparing to assist Resident #1 with personal cares while she was in bed. The resident required two-person extensive assistance with activities of daily living (ADL). However, the CNA assisted the resident independently, without a second person, and the resident suffered a fall from the bed that resulted in pain, transportation to the emergency department, bilateral femur fractures and a hematoma (solid swelling of clotted blood) on her thigh. Findings include: I. Facility policy and procedure The Managing Falls and Fall Risk policy and procedure, dated March 2018, was provided by the assistant director of nurses (ADON) on 3/22/23 at 3:22 p.m. It included in pertinent part: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Fall risk factors included delirium or other cognitive impairment, pain, lower extremity weakness, medication side effects, functional impairments, visual deficits, incontinence, heart failure, neurological disorders and balance and gait disorders. A resident-centered fall prevention plan would be implemented to reduce the specific risk factors for falls for each resident. II. Resident #1 A. Resident status Resident #1, age 71, was admitted on [DATE] and readmitted on [DATE]. According to the March 2023 computerized physician orders, diagnoses included severe morbid obesity, generalized muscle weakness, difficulty in walking, and fractures of right and left femurs. The 10/11/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required extensive assistance with two plus person's physical assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. She had no rejection of care. B. Record review The care plan, initiated 11/27/2020 and revised 3/17/23, identified the resident preferred to have only female caregivers provide personal cares. Interventions included she would let female caregivers provide all personal cares, if possible provide female staff from other units to provide care, and staff would provide cares in teams of two for safety. The care plan, initiated 7/4/17 and revised 3/17/23, identified the resident required assistance with ADLs related to obesity, decreased mobility, and the aging process. Interventions included she was totally dependent on two-plus staff for repositioning and turning in bed, required extensive assistance by two staff to dress her, and was totally dependent on at least two staff to check and change her incontinence brief. The CNA Kardex Report dated 12/30/22, included the following categories and interventions: she was totally dependent on two-plus staff for repositioning and turning in bed, she was totally dependent on at least two staff to check and change her incontinence brief, she required extensive assistance by two staff members to dress her The Nursing Quarterly Data Collection for Fall Risk, dated 10/10/22, identified the resident's score was 0.0, which indicated she was not at risk to fall. A progress note, dated 12/30/22 at 6:27 a.m., was written by a registered nurse (RN) and documented she was called to assess Resident #1 after a fall out of the bed. The resident was being turned when she rolled out of the left side of the bed onto her anterior surface. The RN assessed all of the resident's joints with pain noted in the anterior right knee. She was turned to her back with the assistance of four staff members with splinting provided to the lower extremities. A mechanical lift was used to transfer the resident into the bed. The resident had a large discoloration to her right knee that extended to the proximal lower leg and discoloration to the anterior right foot with swelling in both areas. There was a discoloration to her left knee and a small area on the mid anterior lower leg with swelling. Any assessment attempted by the RN of the right knee resulted in extreme pain. The resident was being changed by only one CNA at the time, which resulted in her rolling out of the bed. The medical doctor was contacted to obtain an order to transfer the resident to the hospital. The progress note included, Future intervention would be to always have two staff for all cares. The facility's investigation was reviewed and included the following: A CNA assigned to Resident #1's hall stated that he and CNA #4 began their check and changes and had completed changing all of the residents on the hall, with Resident #1 being their last resident. He stated CNA #4 went in on her own to speak to the resident due to him recently being kicked out because he was a male, which was the resident's preference to not have male caregivers. CNA #4 voiced that it was okay for her to change Resident #1 alone, due to trust amongst one another. The investigation documented CNA #4 was interviewed and reported during the care the resident rolled out of bed and experienced a witnessed fall. The resident stated, I rolled out of the bed. The CNA verbalized that Resident #1 fell while she was attempting to adjust/reach for a personal item, causing her momentum to shift without the ability to stop herself, which resulted in the fall. Interviews conducted indicated that the resident had a history of kicking other staff members out and declining cares. The resident's preference is not to have males change her. CNA #4 stated that the resident verbalized okay to being changed alone. The hospital emergency department admission history and physical, dated 12/30/23, was reviewed and documented the x-ray results of her bilateral legs included pain after a fall which resulted in severely comminuted (multiple bone splinters or fragments) impacted distal femur fracture with some posterior displacement. The patella (knee cap) was displaced laterally (to the side). The resident experienced low blood pressure and heart rate after she was given pain medication and required resuscitation with fluids. She was admitted to the hospital and did not return to the facility until 1/13/23 (14 days later). III. Staff interviews The director of nurses (DON), ADON and nursing home administrator (NHA) were interviewed on 3/21/23 at approximately 3:30 p.m. and explained the facility did not currently have an MDS coordinator who could be interviewed. The MDS assessment dated [DATE] was reviewed and the DON said Resident #1 was assessed to require extensive assistance of two people for bed mobility. The ADON clarified the staff were providing more than 50 percent of the assistance but the resident was able to participate some, less than 50 percent. The ADON said the two people would mean there was one person on each side of the bed so one would help roll and the other would help hold the resident during turning and bed mobility. The NHA was interviewed on 3/21/23 at 4:04 p.m., and he said on the day Resident #1 fell out of bed, two CNAs working on that floor; a male and a female CNA (CNA #4) were conducting rounds. He said CNA #4 made the decision to go in and ask Resident #1 if it was okay to provide cares to her without the assistance of a second staff member, and that CNA #4 admitted to not asking anyone for help. The NHA said staffing was not low and there was an extra staff member working that morning until 10:00 a.m. He said CNA #4 had initiated cares with the resident by herself, when the resident reached for a personal item and then fell out of bed. He said there was a time prior when Resident #1 would accuse the staff of stealing things from her, so they initiated cares in pairs for mechanical lift use as well as for behavioral reasons. Restorative certified nurse aide (RCNA) #1 was interviewed on 3/21/23 at 4:20 p.m., and she said she routinely worked with Resident #1. She said the facility had multiple ways to communicate to staff which residents required two-person cares and assistance. A sign was posted on the wall in each resident's room above their bed to indicate whether the person required a mechanical lift for transfers as well as how many staff were required to provide assistance for cares. In addition, she said a CNA Book was located at each of the nurses' stations with a list of which residents required a mechanical lift, the sling size, their room number and their name. She said all clinical staff were trained prior to starting work on the floors about this. The RCNA showed the list that was posted in the CNA book in December 2022, and it revealed Resident #1 required transfers with a Hoyer mechanical lift with a green sling. The RCNA said she also checked the residents' care plans to ensure the interventions were care-planned approaches. The RCNA said Resident #1 was supposed to have two-person assistance for personal cares as well, which included bed mobility, which was for both the resident's and the staff's safety. The RCNA said Resident #1 was able to make safe decisions about her care sometimes, but not always, and at times the resident would grab the straps on the mechanical lift during transfers, and that was not safe. She said Resident #1 had a history of falsely accusing staff of mistreating her, so the facility began providing care to her in pairs, with two staff members present. The RCNA said the resident was particular about which CNAs provided her with care, and she did not like male caregivers. CNA #3 was interviewed on 3/21/23 at 4:55 p.m., and she said she routinely worked with Resident #1. She said Resident #1 could brush her hair, wash her face, and brush her teeth if she was provided with set up assistance. She said when the resident was turned in bed, they were always supposed to provide assistance with two people because the resident was very large and could roll off. The CNA said Resident #1 had days where she was alert and could make good safety decisions about her care, and she had days where she was confused, and was not consistently alert and oriented. CNA #3 said the facility had provided clinical staff with additional training on how to safely provide care for Resident #1 after her fall, but said she did not receive the training. Instead, she said she was told by nurses what they were doing now to provide care for the resident. RN #3 was interviewed on 3/21/23 at 5:07 p.m., and she said she routinely worked with Resident #1. She said the resident could not provide much care for herself and before the accident, she required two-person assistance for ADL care, transfers, changing her, and rolling her in bed because she was very large. She said Resident #1 was confused at times and would accuse staff of random things that were not true, and did not like men in her room. She had a cognitive communication deficit with garbled speech and was difficult to understand at times. RN #3 said it was not a normal behavior of Resident #1 that she would accept care assistance from a single staff person because she was always scared she was going to roll off the bed, and knew it was in her best interest for safety to have the assistance of two staff members at a time. RN #3 stated, She didn't really have good safety awareness and had a fear of falling. RN #3 said one staff member would go in and help her at times because there was not enough staff. She said as recently as last night, she was aware of a single staff member providing care and assistance to a resident who required two-person assistance. RN #3 said after Resident #1 fell on [DATE] and returned to the facility from the hospital, a change was made that required her to receive the assistance of four staff members during cares and transfers, and there was never a time after that she did not have four people assist her. The RN stated, Everyone felt really bad. We did that to her. The medical director (MD) was interviewed on 3/21/23 at 3:08 p.m., and she said since Resident #1 was assessed by the facility to need two-person assistance for bed mobility and cares, then she should have been provided with that assistance. The MD said the resident's history with making her own reasonable, safe decisions was not reliable and she did not make appropriate decisions at times. The DON, ADON and NHA were interviewed on 3/21/23 at 5:29 p.m. The ADON said staff knew which residents required two-person cares because it was listed on the CNA Kardex, which could be accessed by CNAs and nurses. She said each residents' room also had laminated signs above the bed that indicated how much assistance they required. If a resident who required two-person assistance told a staff member it was acceptable to provide one-person assistance to them, they should still provide assistance of two staff members because it was for resident and staff safety. IV. Facility follow-up The NHA provided the following documentation on 3/22/23 at 4:11 p.m., which included the facility's response to Resident #1's fall on 12/30/22. The NHA said the audits were done recently and not during the time, the performance improvement plan was put in place, and included the following: An Ad Hoc Quality Assurance Performance Improvement/Four Point Plan of Correction Agenda and Summary, which was dated 1/3/23. The meeting was attended by 11 interdisciplinary team (IDT) members and identified an opportunity for improvement that included verifying that residents who required two-person cares was reflected on both the resident care plans and Kardex. Audits were to be completed by 1/6/23. All direct care staff would be educated on residents who required two-person cares and educated to check the Kardex when cares were provided, which was to be completed by 1/20/23. In addition, the DON or designee would complete the audits twice a week for four weeks to ensure that staff were following the plan of care. A Staff In-Service Summary, dated 1/12/23, included a review by the ADON that explained what the Kardex was and where it was located. There was no attendance record included. An undated, untitled Attendance record was provided, which included the signatures of 25 staff members. Four staff (two CNAs, one licensed practical nurse, and one RN) audits were included, which were undated to know when they were completed, and each included the following three questions: 1.When you are unsure of how a resident transfers, where can you find this information? 2. Do you know how to access the Kardex/Care Plan to find this information? 3. Ask for demonstration on where to find how a specific resident transfers. One of the four staff members audited did not know how to access the Kardex/Care Plan, and required a demonstration of the process.

Based on observations, record review and interviews, the facility failed to ensure effective and timely fall prevention practices to prevent falls for two (#19 and #49) of 12 residents out of 30 sample residents. Specifically, the facility failed to: -Conduct timely post fall investigations or at all; -Review residents' falls with the interdisciplinary team (IDT); -Update residents' care plans to reflect interventions to prevent falls; -Educate new staff on fall preventions for residents; and, -Follow care planned interventions to prevent falls. These failures led Resident #19 to experience six falls since admission from 2/2/22 through 7/18/22, the date of last fall, which resulted in the resident being treated at the emergency room for excessive bleeding of a head wound sustained during the fall requiring the resident to receive six staples to his head to close the wound. These failure also led Resident #49 to experience eight falls since admission from 3/7/22 through 7/9/22, the date of last fall. Early failures for the resident contributed to the resident experiencing a fall which resulted in a fracture to his leg, causing the resident pain and decreased mobility. Findings include: I. Facility policy and procedure The Fall Management and Investigation policy, effective 9/1/18, provided by the nursing home administrator (NHA) on 3/11/22 at 3:00 p.m., read in pertinent part, the facility utilized all reasonable efforts to provide a system to review residents' potential risk for falls and provide a proactive program of supervision, assistive devices and interventions to manage and minimize fall and identify residents continued needs. Post fall management and plan of care procedure included: -Fall interventions were reviewed for continued effectiveness at the weekly at risk meeting, -Revised interventions are routinely reviewed and updated to ensure effectiveness at the weekly at risk meeting, -Person Centered interventions were reviewed with the staff, family and resident for safety awareness and the risk and benefits of fall prevention. Post fall investigation procedures included: -Falls were investigated, reported, and documented using root cause analysis concepts. The administrator was responsible for instituting/commencing the investigation process. -A careful review and analysis of the possible contributing factors to the fall with or without injuries was completed using the QAPI (quality assurance process improvement )Post Fall Investigation Form. -The director of nursing (DON), or designee, analyzed results for trends and patterns in the resident falls to use as the basis for implementation of process improvement. II. Resident #19 A. Resident status Resident #19, age 80, was admitted on [DATE]. The August 2022 computerized physician orders (CPO) included diagnosis of [CONDITION(S)], dementia with lewy bodies, and difficulty in walking. According to the 5/13/22 minimum data set (MDS) assessment, the resident scored a nine out of 15 on the brief interview for mental status (BIMS) assessment indicating the resident was moderately cognitively impaired. The resident required two person physical assistance with bed mobility, toileting, and transfers. The resident was not steady and only able to stabilize with human assistance with moving from a seated to standing position and surface-to-surface transfers. The resident used a wheelchair for mobility. The resident was noted to have a history of falls after admission and was identified on the 2/11/22 admission MDS to have fallen prior to admission. The resident was not identified on either the admission MDS or the 5/13/22 MDS for being on hospice. A social services note on 2/3/22 at 11:27 a.m. showed the resident was admitted for end of life care with no plans for discharge. B. Fall #1 The situation, background, assessment, and recommendations (SBAR) form dated 2/5/22 at 6:15 p.m. showed new interventions for frequent checks (no time frame). A nursing progress note on 2/5/22 at 7:12 p.m. showed the resident was found lying on his back on the floor at the foot of his bed. His head was leaning against the leg of a chair in the corner of the room. No apparent injuries were noted, but the resident reported he was in pain in his left ribs where he stated he broke them two weeks prior to admission and his pain was a seven or eight out of 10 (with 10 being the worst pain on the scale). He also reported a dull headache about a level three out of 10. His wheelchair was noted to be several feet away from the resident and he reported he was getting up to put a book over by the door and tripped walking towards the TV (television). The resident was noted to report he broke his ribs falling while getting out of the car and had fallen many times prior to that as well. An interdisciplinary team (IDT) fall review note dated 2/8/22 at 2:11 p.m. read the resident was status post fall on 2/5/22 at 6:15 p.m. He was found on the floor next to his bed. The resident was new to the facility and his primary diagnosis was [CONDITION(S)]. He was mobile throughout the facility using his wheelchair. He was able to take one or two steps, but only with staff present and with a gait belt. He is pleasant and cooperative, but his wife says at times does not understand his limitations. He was still adjusting to the facility. At the time of the fall he was attempting to turn on his TV. Staff were reminded to ensure his bedside table with needed items (call light, bed remote, TV remote) were within reach. Would continue to monitor the resident and anticipate needs. -A quality assurance and performance improvement (QAPI) post fall investigation was not provided for this fall. A Fall Risk Data Collection form, dated 2/5/22 at 6:15 p.m. showed the resident scored a 14 (no numerical range given) and any score 10 or more indicated more interventions should promptly be put into place. The resident's care plan initiated on 2/5/22 identified the resident was at risk for falls related to [CONDITION(S)], a history of falls, oxygen use, back pain, and [CONDITION(S)] medications. -Although this fall was noted to be reviewed in the care plan, there were no new interventions or revisions to the care plan to prevent further falls. B. Fall #2 An SBAR form on 2/5/22 at 8:15 p.m, two hours after the first fall, showed the resident had fallen again. There were no new interventions or orders listed. The nursing progress note on 2/6/22 at 12:07 p.m. showed while doing a nurse report a loud noise was heard from the resident's room. When entering the room the resident was noted on the floor on his back by the foot of his bed. Upon assessment by the registered nurse (RN) there were no injuries noted. The resident stated he was trying to turn on the TV. The resident was assisted back to bed using a mechanical lift with no pain and was able to move all extremities. The director of nursing (DON) and hospice were notified, and the primary care provider (PCP) notified via fax. The staff were educated to monitor the resident more often. -There were no IDT notes or post fall investigation provided for this fall. -The care plan did not address this fall nor did it provide any new information or interventions to prevent further falls. C. Fall #3 A nursing note on 2/27/22 at 11:07 a.m. showed at approximately 9:55 a.m. Resident #19 was found by a staff member on the ground between the two beds in the room. The resident had not attempted to call staff to assist with transferring as the call light was not activated. A skin tear was noted to the left upper anterior forearm with scant exudate noted. The resident was noted to have footwear in place, non-skid strips present at the side of the bed, and the floor was free of clutter with adequate lighting. The resident was able to freely move all extremities with no complaints of pain. The resident was reminded to call for transfers. The resident was with minimal complaints of pain overall. -The SBAR summary note on 2/27/22 at 9:55 a.m. did not list any new orders or interventions. A follow up nursing note on 2/27/22 at 2:27 p.m. showed the resident fell trying to self ambulate from wheelchair to bed. The resident wanted to lie down in bed and did not use the call light. His wheelchair brakes were noted to be unlocked, and he was wearing shoes. The resident did have a skin tear on his left forearm from the fall and was well approximated with steri-strips. -There were no QAPI post fall investigations or IDT fall review notes provided for this fall. On 3/2/22 a health status note indicated the resident had bruising and swelling of his left ring finger and had no pain and was attending meals in the dining room. A faxed order from the PCP regarding the fall on 2/27/22 ordered physical therapy to evaluate, orthostatic blood pressures, and his cerumen (ear wax) to be checked. -Although there was noted to be a revised goal on 2/28/22 the resident would have decreased risk for injury associated with a fall through the next review date, there were no new interventions noted in the care plan to prevent further falls. D. Fall #4 A nursing note on 3/4/22 at 3:24 p.m. showed the resident had a witnessed fall in the bathroom. He stood up from the toilet and fell against the wall while sliding to the floor. He had a small abrasion to the back of his head. He denied pain and discomfort, and there was no bleeding or other injuries noted. The plan of action was noted to not leave him unattended while in the bathroom. The SBAR summary noted new interventions of monitoring the resident while in the restroom. An incident report dated 3/9/22, five days after the fall, read the care plan was updated to reflect the stipulation of toileting, the resident was not to be left alone while sitting on the toilet. A health status note on 3/4/22 at 5:56 p.m. showed the resident had some bruising to the inner left forearm and swelling to the outer aspect of the left forearm. Sensation to his fingers was intact, warm to touch and he could move his arm without difficulty. A health status note on 3/6/22 at 3:20 p.m. showed the resident was exhibining limited range of motion in the left arm and favoring it. He winced and guarded that arm when touched. The entire left forearm was swollen, bruised, and tender with capillary refill in less than five seconds. The facility spoke to the resident's spouse and explained that due to the resident's increased pain to the area and limited range of motion (ROM) an evaluation would be appropriate. The spouse agreed and an order was obtained by the on-call provider to send the resident to the emergency room for evaluation. The resident returned the same day with no fractures noted, and an order for an antibiotic topical [MEDICATION(S)] ointment to be administered to his skin tear on his left forearm (from the previous fall). A QAPI post fall investigation dated 3/4/22 at 4:46 p.m. showed the resident was last checked on at 2:38 p.m. by a certified nurse aide (CNA). It was a witnessed fall in the bathroom getting up off the toilet although equipment involved was noted to be a low bed at the time of the fall. -Revisions to the care plan were noted to have been completed on 3/7/22, three days after the fall and time of the QAPI notes effective date. It did not specify the revisions to the care plan. An intervention in the resident's care plan initiated on 3/9/22 (five days after the fall) showed the resident was not to be left unattended while utilizing the toilet. E. Fall #5 An SBAR summary dated 3/7/22 at 6:00 p.m. indicated the resident experienced a fall. The note provided no detail to the nature of the fall. New interventions noted were increased observations. -There were no associated nursing notes or IDT notes providing information about the nature of the fall. A QAPI post fall investigation dated 3/9/22 at 4:00 p.m, two business days after the fall, was provided. It showed the fall on 3/7/22 was unwitnessed and in the resident's room. The resident was found on the floor. The time the resident was last checked on was left blank. The resident was noted to have not sustained any injuries and was not transported to the hospital. The form asked if there was a pattern with falls including time, location, or activity and it was documented as no. Activity at the time of fall was indicated to be moving between surfaces and equipment involved showed the resident wheelchair. A revision to the care plan was noted to have been completed on 3/8/22, it did specify the changes made. -There was no mention of the 3/7/22 fall in the resident's care plan, nor were there updates or revisions specific to this fall. F. Fall #6 A nursing progress note on 7/18/22 at 4:36 p.m. showed the nurse was called to the resident's room around 3:45 p.m. and the resident was lying prone (on stomach) and parallel to the bed on the floor. The resident was fully dressed with non-skid socks on. Two CNAs and the floor nurse turned the resident to the supine position (on his back). The nurse noted she attended to the resident's injuries sustained to his head, which were lacerations to the right eyebrow, top of right scalp, and base of right scalp. Hematomas were noted on the top and base of the right scalp. The nurse applied pressure to the wounds and cleaned blood from the resident's face and around his head. The nurse asked the resident what happened and it was noted the resident replied he was answering the front door. The nurse reassured the resident that the paramedics were on the way. A nursing note the next day by another RN on 7/19/22 at 11:47 a.m. detailed the fall. It showed the RN heard yelling coming from the patient's room. The RN entered the room to find the resident prone next to his bed. A large pool of blood was underneath the resident and blood was pouring out of his head. The resident was fully dressed with non-skid socks on. It was noted the resident's bed was way higher than it normally was. The resident was noted to have a right eyebrow laceration and two large hematomas, one of which was bleeding heavily. The resident also sustained two large skin tears to the right arm. 911 was called and the resident was sent to the hospital. The SBAR summary dated 7/18/22 at 3:55 p.m. showed the resident was sent out to the hospital emergency room and received six staples to the head and a head CT (computed tomography) scan. The final transcription from the hospital record showed the resident arrived at the hospital at 4:10 p.m. and discharged back to the facility at 9:50 p.m. on 7/18/22. The emergency room physician's note showed the resident was brought to the emergency room from a skilled nursing facility after a fall. The resident sustained a laceration to his right scalp which was stapled (six staples). The imaging performed showed no acute traumatic injuries and the resident was deemed safe to return to the facility. An IDT note on 7/27/22 at 1:19 p.m. showed staff were educated on the appropriate level of where the resident bed should be. A lipped mattress was ordered to help prevent rolling out of bed for safety. No falls were noted since 7/18/22, the time of the note. The resident's staples were noted to be removed on 7/28/22 without difficulty or signs or symptoms of infections. A QAPI post fall investigation dated 7/20/22 at 12:19 a.m. (two business days after fall) showed the resident was last checked on by a CNA at 3:00 p.m. the day of the fall. The location of the fall was in the resident's room. Revision to the care plans were documented as being completed on 7/19/22 and other pertinent information was noted the resident would be within sight while toileting. -There was no indication the resident was using the toilet during the time of this fall, as well as this intervention was added to the care plan for a previous fall on 3/9/22. If the resident was using the toilet, the care plan was not followed. -The resident's care plan under a focus of The resident has had an actual fall with no injury (the care plan did not focus on falls with injury) showed an initiation date of 2/6/22 and a revision date of 7/19/22. Although listed as revised, there were no new interventions listed to prevent the resident from further falls. Revisions made to the care plan addressed monitoring for change in condition and neurological status checks for 72 hours. An intervention dated 4/12/22 showed staff needed to keep the resident's bed at an appropriate height to allow the resident to get up and down safely; it did not specify what height that was. G. Observations The resident was observed in his wheelchair on 8/10/22 at 3:19 p.m. next to his bed alone with no staff present. The resident was leaning forward grabbing at his socks. H. Interviews Licensed practical nurse (LPN) #2 was interviewed on 8/11/22 at 9:02 a.m. She said the fall interventions for Resident #19 were to keep him in line of sight and busy in activities. She said the staff would not put him in the wheelchair by his bed because he would try to transfer on his own and fall. She said he did fall out of bed recently which was new for him and now they have a bolster on his bed to prevent him from rolling out of bed. She said the main goal was to keep him within line of sight of the staff. -These interventions (bolster to bed and line of sight) were not listed in the resident's care plan. -The resident was observed parked in his wheelchair next to his bed the day prior despite the LPN saying this was a preventive fall measure. LPN #3 was interviewed on 8/10/22 at 3:26 p.m. She was Resident #19 was pleasant but oriented to himself only. She said he could not make his needs known and the staff anticipated his needs as he required total care by staff. She said she had only worked at the facility for a few months and the resident had a fall in that time when he rolled out of bed and lacerated his forehead and needed six staples. She said fall interventions for the resident included non-skid socks, a high back wheelchair, and the bolster which was added in July (2022). -However, there were no care plan updates to address the resident rolling out of bed or mention of the bolster to his bed in the care plan. The DON was interviewed on 8/11/22 at 5:41 p.m. She said when a resident had a fall the IDT team usually meets the next business day to review the information from the nurses and CNAs. She said she looked at what happened, what was the cause, and reviewed and updated the resident's care plan. She said Resident #19 required full assistance from staff due to his advanced [CONDITION(S)]. She said the IDT team would look at it from all perspectives because the interdisciplinary team has staff that were not nurses and maybe then could identify causes and interventions that she and the nurses did not see. She said the facility did an investigation form for each fall. She said she would have to look at the resident's information but she thought the resident's falls were under control. She was unaware of specific fall interventions for the resident but she said she would expect his bed to be in the low position because he was assessed and determined to be a fall risk. She was not familiar with the resident's falls and was unaware of interventions put in place since. -The resident's care plan did not specify the bed should be in the low position but at an appropriate height to allow the resident to get up and down from bed safely. -There was no further information provided by the DON after the survey by close of business the next day on 8/12/22. V. Resident #49 A. Resident status Resident #49, age 81, was admitted on [DATE]. The August 2022 CPO diagnoses included Alzhiemer's disease, muscle weakness, and type 2 diabetes mellitus. According to the 7/5/22 MDS assessment the resident scored a four out of 10 on the brief interview for mental status indicating severe cognitive impairment. The resident was a two person physical assist with bed mobility, transferring, and toileting. The resident was not steady and could only stabilize with human assistance with moving from a seated to standing position. The 3/18/22 admission MDS showed it was undetermined if the resident had any falls prior to admission but did show the resident had a fall since admission on 3/7/22. B. Record review Fall risk The resident's admission fall risk assessment dated [DATE], day of admission, identified the resident was a fall risk. 1. Fall #1 A nursing note progress note on 3/10/22 at 6:36 p.m. showed the resident experienced an unwitnessed fall by his recliner. He was found on the floor on his left side. Non-skid socks were on and his walker was within reach. The resident's power of attorney (POA) was noted to have said the resident could not have his foot rest on his recliner up. -The SBAR summary dated 3/10/22 at 10:17 p.m. did not include any updates or new interventions -The IDT team note dated 3/15/22 at 11:34 a.m. did not address the resident's fall. There was noted to be some aggressive behavior, which was the focus of the note. -A QAPI post fall investigation was not completed. The resident's care plan did address the fall on 3/10/22. -However, interventions noted were to monitor the resident 72 hours post fall for change in condition. There were no interventions to prevent further falls. 2. Fall #2 A nursing progress note on 3/11/22 at 11:00 p.m. showed the resident was found on the floor sitting next to his recliner. The foot of the recliner was still elevated. The resident was noted to say I just wanted to get up. The resident's walker was noted to be at his bedside and he was wearing regular socks. The room was well lit with no obstacles on the floor, and his shoes were next to the chair. There were no new injuries noted and future prevention was to have non-skid socks on and non-skid strips at the bedside and chair. -There was no mention of the recliner's footrest as the POA had already informed the facility staff the resident had issues with the footrest on his recliner. -The QAPI post fall investigation dated 3/12/22 at 6:27 p.m. indicated fall factors related to the resident's walker and shoes despite the nurses progress note stating the resident was not wearing shoes and the walker was at the resident's bedside. There was no mention of the recliners listed in the investigation form. -An IDT team note on 3/15/22 at 11:34 p.m. showed the team had discussed the resident's aggressive behaviors with other residents at the time. There was no mention of falls or a fall review noted. -The resident's care plan did not address the resident's fall on 3/11/22 nor were there any updates, revisions, or new interventions added to prevent further falls. There was no mention of the resident's reclining footrest. -The SBAR summary for the fall on 3/11/22 did not note any new orders or interventions. 3. Fall #3 with injury On 4/4/22 at 3:29 a.m. a nursing progress note showed staff heard a crashing noise come down the hall. The nurse and CNA on the hall went to find the noise and found Resident #49 on the floor in his bedroom with his shoes and brief on. The CNA was noted to have checked on the resident just 30 to 45 minutes previously and he was sleeping in his recliner with his shoes on. The resident's walker was noted to be beside the resident and as if he had pushed it away from himself. The resident had an abrasion to his left knee and skin tear to his left forearm. The staff used a mechanical lift to return the resident to his recliner as this was where he preferred to sleep. There were no other observable injuries noted at this time. A QAPI post fall investigation on 4/6/22 at 1:51 p.m. showed the resident fell at 3:15 a.m. and was last checked on by a CNA at 1:45 a.m. and a fall pattern was noted to be at night when he was more confused. A revision to the care plan was noted to have been completed on 4/5/22 and staff had been informed of the necessary changes. An alert note on 4/4/22 at 7:00 p.m. showed the staff had notified the resident's wife the resident was having pain and some swelling to his left leg which they were elevating and icing and would reevaluate in the morning. An IDT note on 4/5/22 at 4:30 p.m. showed the resident had fallen on 4/4/22 with immediate injuries noted to be an abrasion to left knee, left hand skin tear, and a blister to the left third toe. The resident was ambulatory but complained of pain to the left knee with weight bearing. A knee x-ray was ordered and performed which revealed a left tibial tip (shin bone) fracture. The PCP was notified and ordered non weight bearing status for 12 weeks and an immobilizer to the left knee. A full lift was to be used for transfers to prevent weight bearing. Restorative was to get a wheelchair with extended leg support to allow for elevation of the left leg. Pharmacy was noted to have reviewed medications and made no recommendations for changes. The IDT team was to follow up with further interventions as indicated. A health status note on 4/7/22 at 10:55 a.m. showed the resident had become combative during care if the left leg was touched. He would yell out for help, but became verbally abusive when helped. Tylenol was given for pain. Another IDT note on 4/7/22 at 1:11 p.m. showed the team reviewed the fall on 4/4/22. The resident continued to be non weight bearing due to a tibial tip fracture. An initial fall intervention to keep the walker close to the recliner was noted to be no longer appropriate as the resident was non weight bearing. A new intervention was noted: the resident had a wheelchair with an elevated leg to allow for improved mobility as well as a call don't fall sign placed in his room. Reminders to call for assistance were being offered to the resident, non-skid socks were in place, staff were offering to assist the resident outside for some time in the sunshine, staff retraining was done (did not specify what training was done), and skin tears and abrasions were being monitored. The family was noted to not have any further suggestions and staff would continue to implement any additional interventions as indicated. The resident's care plan showed updates (4/6/22) as: -Wheelchair with extended leg rest; -Knee immobilizer in place for 12 weeks, may be removed for bathing and skin care; and, -Pharmacy has reviewed medications. -There were no new interventions listed in the care plan to prevent further falls. 4. Fall #4 An SBAR summary note on 4/24/22 at 7:07 p.m. showed the resident experienced a fall with new intervention orders as increased observations overnight. A nursing progress note on 4/24/22 at 7:35 p.m. showed the resident was assessed by the RN for a fall and did not have any new injuries. His brace remained in proper position and he was assisted to bed using a lift and four staff members. The resident was incontinent of bowel at the time and did report a headache which was not new and was treated with non pharmacological methods. He was reported to have received a new wheelchair on 4/22/22 and the RN noted she would have therapy evaluate the wheelchair positioning and cushion to ensure they are appropriate for him. An IDT note on 4/25/22 at 11:19 for review of fall showed the resident fell out of his wheelchair the night previous after his evening meal. He was incontinent of bowel at the time of the fall and there were no new injuries. The resident was noted to be joking with staff following the fall, and the family was requesting a video monitor be placed and that was in process. The family and PCP were noted to have been notified and the care plan updated. A QAPI post fall investigation was completed on 4/25/22 at 11:07 a.m. and showed the resident fell on [DATE] at 7:10 p.m. in his room and was found on the floor, and was last checked on by staff at 6:30 p.m. The care plan was noted to be revised on 4/25/22. Care plan updates were noted on 4/25/22: -Urinal to be kept at bedside to assist with urinary incontinence and have a commode bedside to encourage fecal continence; -PT consult for strength and mobility; -Pharmacy consult to evaluate medications; and, -On 4/27/22 a video monitor was placed to allow for staff oversight without multiple interruptions. An IDT note on 4/27/22 at 2:43 p.m. showed for weekly fall review the resident fell out of his wheelchair on 4/24/22. There were no injuries from the fall and no latent injuries discovered. He was participating in therapy and a video monitor was in place to allow staff better oversight of the resident without agitating him. A call don't fall sign was placed and although the resident does not use the call light he did yell out I'm calling, not falling; this allowed the staff to respond. The room was being kept clean and clear of clutter and the resident was offered assistance to the recliner or bed often to increase comfort. The family was noted to be happy with the plan of care. 5. Fall #5 A nursing progress note on 5/14/22 at 3:59 p.m. showed the resident was found lying on the floor on his left side leaning his head and torso against his recliner. No injuries were reported. Another nursing note at 8:07 p.m. showed the resident fell unwitnessed and denied pain with no apparent injuries. The resident stated he was sleeping and does not remember falling. The SBAR summary on 5/14/22 at 3:38 p.m. summarized the resident was lying in his recliner when it tipped over causing him to slide to the ground. -The nursing notes did not indicate the recliner was tipped over. The QAPI post fall investigation dated 5/16/22 at 12:58 a.m. (two days after fall) did not indicate when the resident was last checked on prior to fall. A pattern was identified as the resident was often attempting to self transfer as he has dementia and does not recall his limitations. Other pertinent information documented was the resident was settling in more at the facility and was improving with therapies which may be contributing to his over estimation of his abilities. The care plan was noted to be revised 5/16/22. The care plan was revised on 5/16/22 with an intervention to keep the video monitor on the medication cart during high care times to ensure safety at all times. An IDT note on 5/16/22 at 1:56 p.m showed the resident had slid out of his recliner and stated he was just sleeping. There were no injuries and the area was checked and was free of trip hazards and spills. The resident was wearing his shoes and socks and he did not often use the call light and did have a sign to call don't fall, which had been helping him to remember to call out but he did not call out this time. He was noted to lack safety awareness and had been participating in therapies which may have him overestimating his abilities. The staff were to have the video monitor on their med cart now to allow visualization during higher care times when the staff was not readily at the station. 6. Fall #6 A nursing progress note on 5/18/22 at 4:09 p.m. showed the resident had an unwitnessed fall. The resident was lying on the floor on his right side. His shoes were on and the resident was able to move all extremities. He was heard yelling for help just prior to the fall and found by the CNA. The camera was noted to be in the proper position and within view of the nurse. He was standing prior to the fall and the wheelchair was to his left side. The floor was dry, and the call light was nearby. The family was notified and requested the resident not be left in his wheelchair alone. The SBAR summary on 5/18/22 at 4:33 p.m. showed the resident was able to stand and ambulate there were no new interventions ordered. The IDT note on 5/19/22 at 3:27 p.m. showed the resident had returned from an activity and was placed in his room in the wheelchair. He had attempted to

Based on resident and staff interviews, and record review, the facility failed to protect facility residents, including two of two out of 41 residents sampled (#30 and #41), who reported allegations of abuse to staff. Resident #30 and his spouse reported to facility staff that on 10/15/15, resident #30 was punched, pushed back into bed and told to stay in bed, and don't try to get up by a staff member. Resident #41 reported to facility staff that about six months ago a staff member refused to assist her, told the resident her to stay in her chair until staff came back, and left the resident in her room partially undressed; staff did not return. Interviews and record review revealed the facility failed to recognize the residents' allegations as potential abuse and, therefore, failed to correct and intervene as expected per facility policy, which declares resident protection as the first priority in response to any allegation of abuse or neglect. The facility's failure to identify the residents' allegations as potential abuse led to a limited facility response which left facility residents vulnerable to abuse, and created a situation of immediate jeopardy for serious harm. The findings included: I. Imposition of Immediate Jeopardy On 11/5/15 at 5:44 p.m., the NHA, director of nursing (DON), and regional director of health services (RDH) were informed by the Colorado Department of Public Health and Environment (CDPHE) that the facility's failure to protect residents from alleged abuse created a situation of immediate jeopardy for serious resident harm. II. Facility Response and Removal of the Immediate Jeopardy On 11/5/15 at 7:30 p.m., the following plan was submitted by the facility to CDPHE to keep facility residents safe that night. The plan read: Regional Director of Health Services (RDH-RN) reviewed the company's policy on keeping residents safe from abuse with the facility leaders. Department leaders are re in-servicing staff on duty and will continue to do so until all staff members are re-educated prior to being in the resident care area. -(Residents #41 and #30) who are noted to have been allegedly abused are being evaluated for their freedom from abuse by company personnel who are not usually assigned to their care. Support is being offered with assurance of their safety. Other residents who reside in the facility are being interviewed to ensure their safety from abuse. -To ensure that the residents were supervised throughout the night on 11/5 - 11/6/15 the NHA (nursing home administrator) remained in the facility. (Per documented written report from the NHA, facility rounds occurred approximately every hour.) On 11/6/15 at 5:50 p.m., the NHA, Director of Nurses (DON) and RDH-RN were notified the facility's plan was accepted and the immediate jeopardy was removed. However, based on interviews and record review deficient practice remained at an E level, potential for more than minimal harm at a pattern. III. Resident Protection System - Preventing Abuse and Neglect The facility's Abuse Prohibition and Prevention Program Policy and Procedure (revised 10/1/12), provided by the facility on 11/11/15 at 11:54 a.m., read in pertinent part as follows: The policy expresses the Facility's commitment to: - provide a mechanism for prompt identification, reporting, and investigation of any allegation of abuse or complaint by a resident, family member, staff, visitor, or other person. Fundamental Information - Every resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, neglect, and involuntary seclusion. - The Facility will take reasonable, appropriate steps to ensure that each resident is free from neglect and abuse by anyone, including but not limited to: staff, other residents, family members, legal guardians, friends, or other individuals. - The Facility will conduct a prompt investigation of complaints or allegations of abuse and will notify and release information to the proper authorities according to state and federal regulations and Five Star Quality Care Policies and Procedures. - The Facility Administrator is responsible for the oversight and implementation of the Abuse Prevention Program. Reporting Requirements - Reporting to Facility Staff and Regional Staff. All Facility staff must notify the Administrator of the allegation of occurrence immediately. The Administrator must notify the Regional Director of Health (RDH-RN) or Regional Director of Operations (RDO) as soon as possible. Before reporting to the State Certification Agency or local law enforcement, the Facility must notify the RDH- RN or RDO. If there is a disagreement as to whether a particular report should be made, the RDO shall consult with the Divisional Vice President (DVP). If the DVP is unable to resolve the disagreement, the DVP shall consult with the Vice President of Clinical Services. If either the DVP or the Vice President of Clinical Services is not available, the Chief Operating Officer shall be consulted. Proactive Steps Towards Prevention - The facility must provide residents, families, and staff information on how to and to whom they may report concerns, incidents and grievances without fear of retribution. - The Facility must identify, correct, and intervene in situations in which abuse in any form may be facilitated. This includes analysis of: - Features of the physical environment that may make facilitate abuse and/or neglect, such as secluded areas of the Facility. - Staffing patterns to meet the needs of the residents and to assure that the assigned staff has knowledge of the individual resident's care needs. - Supervision of staff to identify and correct any inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, etc. - The assessment, care planning, and monitoring of residents with needs and behaviors that may contribute to situations involving conflict or neglect, such as a history of aggressive behaviors, intrusive behaviors, self injurious behaviors, or residents requiring total care. - Review all incident reports to identify events that could constitute abuse and determine if an investigation is warranted. Identification The Facility will provide tools and training to help staff identify events, such as incidents, events, or conduct and that may require investigation or additional administrative oversight. Investigation A complete investigation will be conducted for any allegation of abuse, neglect, and any injury of unknown source in accordance with the procedures set forth in the Incident/Accident Investigation Policy. A report of the investigation will be provided to the appropriate state agency within five working days of the incident, unless otherwise indicated by state law or regulations. Protection of Residents The first priority in responding to any allegation of abuse or neglect of a resident will be to protect the resident. If an allegation of abuse or neglect is directed at an employee, that employee will be immediately suspended pending the outcome of the investigation in accordance with the Human Resources Policy and Procedure . The Administrator or his/her designee will personally meet with the resident and or family member/responsible party to reassure him/her. IV. Failure to Recognize and Respond to Allegations of Abuse as Expected A. Resident #30 1. Resident Status Resident #30, age 84, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 10/7/15 quarterly Minimum Data Set (MDS), the resident's brief interview for mental status (BIMS) score was a four out of 15 which showed severe cognitive impairment. He required extensive assistance for bed mobility, transfers, dressing, toileting and personal hygiene. He required supervision with eating. He used a wheelchair for mobility. 2. Resident and Spouse Interview On 11/4/15 at 11:30 a.m., resident #30, with his wife present, stated that he had been punched in the stomach and then pushed back into bed one night while he was trying to get up to go to the bathroom. He was told to stay in bed and don't try to get up. The wife said her husband told her about it the following morning and she told the charge nurse and the administrator. On 11/6/15 at 11:22 a.m. the resident #30's wife was interviewed. She stated her husband told her one morning (10/10/15) that during the night, a staff person came into his room and punched him in the stomach. She checked for bruising on the resident's stomach on her own and didn't find any. She said she reported the incident to registered nurse (RN) #2 who brought her allegation to the NHA. She said she met with the NHA and RN #2 just after lunch on 10/10/15. The plan was to always have two caregivers answer the call light during the night shift. She did not indicate any other response to the allegation was discussed with her. 3. Staff Interview On 11/5/15 at 12:11 p.m. the social services director (SSD) #34 was interviewed. She stated her responsibilities included investigating allegations of abuse, neglect and mistreatment. When questioned about the allegation of abuse reported by resident #30 and his spouse, she stated that she was not aware of the allegation. On 11/5/15 at 2:35 p.m. the NHA was interviewed. When asked about the allegation of abuse reported by resident #30 and his spouse, he stated that other staff was getting that together and he had nothing to provide at this time in regard to the allegation or the facility's response to it. He did not indicate what steps, if any, had been taken to address the allegation and to ensure residents' safety. On 11/6/15 at 12:10 p.m. RN #2 was interviewed. She stated that on the morning of 10/10/15, resident #30's wife told one of the certified nurse aides (CNAs) that her husband was punched in the stomach by staff. The CNA brought the allegation to RN #2 because the CNA thought the resident was referring to the RN as the alleged perpetrator. The RN said she reported the allegation to the NHA. She said following lunch that same day, she and the NHA met with resident #30's wife in the NHA's office. According to RN #2, the resident's wife told the NHA that she was fine with the care her husband was receiving; however, the NHA stated he wanted two caregivers to provide care to resident #30 at all times. The NHA then directed RN#2 to write a note in the resident's medical record pertaining to this allegation, but she stated she got busy and forgot. The RN did not indicate what other steps, if any, had been taken to to address the allegation and to ensure residents' safety. 4. Record Review Review of resident #30's record revealed no documentation of the allegation of abuse; specifically, the review revealed no nurses' notes, skin assessments, incident reports, investigation reports, or care plan updates. B. Resident #41 1. Resident Status Resident #41, age 86, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 10/21/15 MDS assessment, the resident had adequate hearing, clear speech, could understand others and be understood, and had a BIMS score of eight out of 15, indicating moderate cognitive impairment. Mood and behavioral symptoms included disorganized thinking and delusions, and feeling tired or having little energy. No other behavioral symptoms were identified. -The resident required supervision/oversight and one-person physical assistance for bed mobility, transfers and personal hygiene. She needed two-plus person extensive assistance for dressing. Her balance was unsteady without assistance, and she used a walker or wheelchair for ambulation. -The resident was occasionally incontinent of bladder and always continent of bowel. She was 58 inches tall and weighed 87 pounds. Care plans dated 1/23/15 identified the following in pertinent part: Need for assistance with activities of daily living (ADLs) related to history of [MEDICAL CONDITIONS], dementia, depression and [MEDICAL CONDITION] with recent increased pain and immobility. Staff were to anticipate the resident's needs, keep her call light in reach, assist and cue her to participate in dressing and grooming, complete ADLs as needs indicated and respect dignity. The resident wishes to sleep in in AM and her bed time varies. -The goal was for the resident to get up and go to bed when she wished and be cooperative in morning and evening cares. Approaches included: -After 8:30 a.m. the resident would be spoken to and asked if she would like to get up, in a quiet, calm, audible manner. -If the resident chooses to sleep later she will be allowed to. Staff will check back at specific time requested or check in on resident if she does not verbalize another time. -The resident will be checked on quietly in morning and evening, and be kept dry and comfortable. 2. Resident interview Resident #41 was interviewed on 11/5/15 at 9:21 a.m. and was asked if anyone at the facility had abused her. The resident responded, Yes. The resident said, It happened about six months ago. A CNA made me get up at 8 a.m. She said, 'You don't put on any socks or shoes' and said 'you stay there in your chair till I come back.' And she never did come back. I just about froze to death. It's an experience I never want to go through again. -She (the CNA) is no longer working with me. She doesn't even see me and I don't care to see her either. We were real close friends . I couldn't understand the change in her . It made me wonder 'what did I do wrong to be treated like this,' especially by her. And to this day I wonder. -The resident said she rang her call light for help (when the CNA did not return) but the light did not turn on. The nurse from across the hall came over because I was crying. It hurt me so much. I'd never been treated that way by anybody else in this facility. For her to treat me that way was uncalled for. -I told them I never wanted her in my room again, period. So the following day she was gone and she's been on the other side (of the building) ever since. I see her every now and then .She did come back in my room one time after that and she was mad. I told her I didn't want her in my room anymore and she said, 'You don't tell me what to do.' I wanted her to explain to me why she was treating me this way but she never did. When I see her, I don't want to face her because I don't know what I did that was wrong that she turned against me like that . -When asked if she was afraid, the resident said, I was, because I didn't know what I was getting punished for, and no shoes or socks and my feet were froze(n) . When that nurse came from across the hall . she could tell I was upset . The resident said the nurse was gentle because I was distraught. I asked her, 'Why am I being treated like this?' -A person like that you get fear of and you don't want to go through that again. It's very, very scary. And I've never been intimidated by anything until this time. When something like that happens, you sit and wonder what did I do wrong? I still wonder 'what did I do wrong' to make (the CNA) treat me like that. -The resident said nobody else came to investigate or reassure her other than the nurse who found her crying. 3. NHA Interview The NHA was asked, on 11/5/15 at 1:15 p.m., for a copy of the investigation related to resident #41's abuse allegation. The NHA said this was the first he had heard of it. He reviewed his investigation files for the past year and said the resident's name was not on any of them. He said he had no reason to doubt what the resident had reported, that she was confused about some things, but this did not sound like one of them. He said they trained facility staff to report, and the nurse should have reported. He said they would begin an investigation and report to the state health department.

Based on resident and staff interviews and record review, the facility failed to ensure allegations of abuse, neglect, mistreatment and injury of unknown origin involving three of 41 sample residents (#30, #41, and #60) were reported, timely and thoroughly investigated, and steps were taken to protect these and other residents residing on the Blue Spruce hall from further abuse, neglect, mistreatment and injury. In addition, the facility failed to ensure one of nine staff (#26) was adequately screened prior to re-hire. Residents #30, #41, and #60 all resided on the same hall. Resident #41 reported that about six months ago, she was told by staff to stay put until staff returned but staff did not return. In early October, resident #60 was discovered with a large hematoma on left inner calf. And, in mid-October, resident #30 reported he was punch in the stomach and pushed back into bed by staff. These incidents of alleged abuse, neglect, mistreatment, and injury of unknown origin were not timely reported (resident #41's allegation), not timely or thoroughly investigated (resident #41 and #30's allegations and resident #60's injury) and sufficient steps were not taken to ensure these and other facility residents were safe from further potential abuse, neglect, mistreatment and injury. These failures led to a limited facility response which left facility residents vulnerable to abuse, neglect, mistreatment and injury and created a situation of immediate jeopardy for serious harm. Cross reference F223 - failure to protect residents from abuse. The findings include: I. Imposition of Immediate Jeopardy On 11/5/15 at 5:44 p.m., the nursing home administrator (NHA), director of nursing (DON), and regional director of health services (RDH) were informed by the Colorado Department of Public Health and Environment (CDPHE) that the facility's failures in abuse reporting, investigation, and resident protection, as well as procedures on staff rehire, left facility residents vulnerable to abuse, and created a situation of immediate jeopardy for serious harm. II. Facility Response and Removal of the Immediate Jeopardy. On 11/5/15 at 7:30 p.m., a plan was submitted by the facility to CDPHE. Nurses are performing skin checks on residents to identify any skin discolorations or injuries. These measures will be continued through the day and all residents (census of 80) will be completed. Any injuries of unknown origin will be investigated following the company's process. 1. Resident #41 was interviewed and she is being checked on by personnel at least hourly and offered emotional support. Her demeanor is calm and unchanged from her normal. As reported to the surveyor, the CNAs identified per the description of her hair was not moved to the other side although when she picked up prn (as needed) shifts she was needed on the other side of the building away from resident #41 ' s room is located. A review of staff members who would have worked the night shift at this time were identified per schedule. Nursing assistant #51 is no longer here as of 4/24/15. The female heavy set nurse is LPN #52 identified per time frame given by resident and is no longer here as of 6/30/15. 2. Resident #30 is being checked on by personnel at least hourly and offered emotional support. The CNAs assigned to resident on the night shift on 10/9/15 are both females #55 and #56. And the only male nurse was #57. The two nursing assistants worked last evening and were re-educated. They will be interviewed using the investigation process prior to being in the care area this evening (11/6/15) 3. Resident #60 is being checked on by personnel at least hourly and offered emotional support. An investigation was completed on 10/9/15 and re-opened on 11/6/15. 4. Members of the nursing leadership are confident that they have accurately identified the possible staff members allegedly involved in the allegations of abuse. This identification is contingent on the descriptive provided by the residents. A review of staff members who would have worked the night shift at this time were identified per schedule. Nursing assistant #51 assigned to Resident #41 ' s Blue Spruce is no longer here as of 4/24/15. The female heavy set nurse is #52 identified per time frame given by resident is no longer here as of 6/30/15. 5. Family members/POAs are being made aware of the two allegations and resident #60 ' s POA of the re-opened investigation of her lower extremity wound by the SSD (Social Services Director) with a completion date of 11/6/15. A care conference is being scheduled to review changes made to the plan of care on 11/6/15. 6. Residents #30 and #60 are being re-evaluated by the restorative and rehabilitation team for appropriate methods of transfer with a completion date of 11/6/15. Other residents residing in the facility will be re-evaluated by 11/13/15. Education will be provided and documented as needed. 7. All interviewable residents, their POAs, and or family member did not voice and concerns during the interview process. 8. Because resident #60 was out on a trip and transported by van the day prior when the wound on left lower extremity was identified, employees who operate the facility van for transporting residents and previously trained by an outside vendor are being checked off by the lead transport employee on 11/6/15. 9. The restorative nurse and a member of the therapy department will observe actual resident loading and positioning in van on 11/6/15. 10. Residents assigned to individual department heads for Weekly Room Rounds inclusive of interviewing residents using Form CMS- (7/2015) if there is a concern noted during their visual and verbal rounds. The NHA will review the findings of these rounds and interviews with a member of the regional team bi-monthly. 11. Social Workers will be following up on residents with current allegations and any in the future to ensure their psycho-social health. Facility will continue to educate on abuse and investigations on hire before staff is assigned in resident care areas. Employee folders are being checked to ensure that this process is in place. In progress at this time are continued interviews of residents, family and staff. The NHA is in process of reporting allegations of residents identified as not having appropriate investigations to the appropriate reporting agencies. Reporting will be completed on 11/6/15. The RDH has reviewed appropriate policies and will review with leadership to ensure that they have current policies and that they are in practice. The RDH will also re-educate the leadership team on the process for collecting allegations and thoroughly investigating them according to policy and CMA guidelines. Facility leaders will sign that they have comprehension of these processes. Furthermore, the NHA attests that thorough investigations will be documented and provide evidence of same. This document is signed by the facility NHA on 11/6/15. On 11/6/15 at 5:50 p.m., the NHA, Director of Nurses (DON) and RDH-RN were notified that the above plan was accepted and the immediate jeopardy was removed. However, based on interviews and record review deficient practice remained at an E level, potential for more than minimal harm at a pattern. III. Failure to timely and thoroughly investigate allegations of abuse and protect residents during and after investigations. A. Expectations The Abuse Prohibition and Prevention Program, revised 10/01/12, reads in pertinent part under investigation: A complete investigation will be conducted for any allegation of abuse, neglect, or injury of unknown origin source in accordance with the procedures set forth in the incident/accident investigation policy. A report of the investigation will be provided to the appropriate state agency within five (5) working days of the incident, unless otherwise indicated by state law or regulation. The Incident/Accident Reporting Process policy (revised 11/14/05) reads in pertinent part: - The definition of an Incident/Accident - Any event that is not consistent with routine resident care and services An event involving a resident . with unintended, undesirable or unexpected results or outcome. - Reportable Incidents/Accidents require completion of a written incident/accident report and include: assaults, resident injury of unknown source (bruising, lacerations, etc.) ,,, abuse allegations . - When the incident/accident involves a resident, the employee responding will notify the appropriate person in charge, document the occurrence, assessment and follow-up in the resident's medical record . - Documentation requirements - #6 - Any incident/accident involving a resident will be documented in the resident's progress notes, #7. A thorough investigation must be completed for all reportable incidents/accidents. - Follow up to Incidents/Accidents - All incidents, reportable or not will be documented on a Resident and Visitor Incident/Accident Report form. The Administrator and Director of Nurses/RSD will review ALL accident/incident reports for completeness and determine if the situation must be reported to a state agency and/or other applicable regulatory agencies. The Administrator and Director of Nursing will, as a matter of quality assurance, together with the safety committee, complete a Quality Assurance Review of all incidents/accidents. The Administrator will be accountable for all follow-up and investigations, and will insure that documentation is completed. B. Allegations of Abuse, Neglect, Mistreatment, and Injury of Unknown Origin.- Investigation Failures 1. Resident #30 Resident #30, age 84, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident resided on the Blue Spruce hall. According to the 10/7/15 quarterly Minimum Data Set (MDS), the resident's brief interview for mental status (BIMS) score was a four out of 15 which showed severe cognitive impairment. He required extensive assistance for bed mobility, transfers, dressing, toileting and personal hygiene. He required supervision with eating. He used a wheelchair for mobility. 2. Resident and Spouse Interview On 11/4/15 at 11:30 a.m., resident #30, with his wife present, stated that he had been punched in the stomach and then pushed back into bed one night while he was trying to get up to go to the bathroom. He was told to stay in bed and don't try to get up. The resident's wife said her husband told her about it the following morning and she told the charge nurse and the administrator. On 11/6/15 at 11:22 a.m. resident #30's wife was interviewed. She stated her husband told her one morning (10/10/15) that during the night, a staff person came into his room and punched him in the stomach. She checked for bruising on the resident's stomach on her own and didn't find any. She said she reported the incident to the CNA (certified nurse aide) who brought it to the attention of the registered nurse (RN) #2 who then brought the allegation to the NHA. She said she met with the NHA and RN #2 just after lunch on 10/10/15. The plan was to always have two caregivers answer the call light during the night shift. She did not indicate any other response to the allegation was discussed with her. b. Record Review On 11/4/15 at approximately 3:30 p.m. following the initial interview with resident #30 and his wife, the resident's medical record was reviewed. Review revealed no documentation of the allegation of abuse; specifically, the review revealed no nurses' notes, skin assessments, incident reports, investigation reports, or care plan updates. c. Staff Interview On 11/5/15 at 12:11 p.m. the Social Services Director was asked to provide copies of the investigative reports from abuse investigation conducted in response to resident #30's allegation of abuse. She said she was not aware of any abuse having been reported. On 11/5/15 at 2:35 p.m. the NHA was asked to provide copies of the investigative report from the abuse investigation conducted in response to resident #30's allegation of abuse. The NHA said that others were working on putting the report together and he had no report to provide at this time. However, no records were produced prior to survey exit 11/11/15, to show the resident's allegation of abuse was investigated when it was initially reported on 10/10/15 to staff by the resident's spouse. On 11/6/15 at 10:32 a.m. the DON and RHD were interviewed about the investigation of resident #30's allegation on 10/10/15. Although they were unable to produce an investigative report or any other documentation in resident #30's record or elsewhere about the allegation, both stated they understood resident #30 alleged the incident happened during the day shift, not the night shift, as reported to the NHA by the resident's spouse (see above). On 11/6/15 at 12:10 p.m. RN #2 was interviewed. She stated that she was the charge nurse on the morning of 10/10/15 when a CNA brought to her attention that resident #30 reported she (RN #2) had punched him in the stomach. -She said that as she was the alleged perpetrator, she immediately brought the allegation to the attention of the NHA. According to RN #2, the NHA asked licensed practical nurse (LPN) #58 to do a skin assessment on resident #30 specifically looking for bruising to his abdomen. -She said after lunch, she and resident #30's spouse, and the NHA all met. RN#2 stated the resident's spouse confirmed what her husband said, but also added she was pleased with the care at the facility. RN#2 also stated the NHA asked her to document the incident in the medical record. However, she said she got busy and forgot. When asked if she thought she should have been involved in the investigation since the resident had identified her as the alleged perpetrator, she answered no. However, she neither indicated she had discussed this with the NHA nor indicated she was subsequently interviewed as part of an investigation into the resident's allegation. d. Facility follow up On 11/11/15 at 10:05 a.m., six days after the facility's investigative report into resident #30's allegation of abuse was initially requested, the report again was requested from the NHA, DON and RDH. The NHA stated that on 10/10/15, he was told the alleged abuse happened on day shift, so that is what he focused on. Because the resident's spouse had reported to the surveyor on 11/4/15 that the abuse happened on the night shift (see interview above), the facility had to go back and re-open their investigation focusing on night shift. NHA stated that he did not document the allegation since he asked RN #2 to document. NHA also stated that he told the spouse on 10/10/15, that going forward, he would have two caregivers assist resident #30 during the night shift. Review of resident #30's progress notes and care plan, as well as the 24 hour report and CNA Kardex revealed no documentation that this plan was communicated to staff to ensure it was implemented. 2. Resident #60 Resident 60, [AGE] years old, was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident resided on the Blue Spruce hall. On 9/16/15, the annual Minimum Data Set (MDS) documented the resident needed extensive assist for the majority of her activities of daily living (ADLs) and she was unable to participate in her brief interview for mental status (BIMS). The resident's primary source of mobility is a wheelchair. a. Record Review - Investigation Failures On 11/4/15 at 5:58 p.m. the resident's record was reviewed. Review of nurses' notes, physician notes, wound report and care plan revealed a large, raised mass (bruising) was discovered on the resident's left lower leg on 10/1/15. None of the documentation identified what had caused the large, raised bruise. The only documentation of an investigation into the injury involved interviews with five staff. Specifically: -A nurses' note on 10/1/15 at 9:00 a.m. documented a bruised, swollen area approx 8 x 9 centimeters (cm), raised 2 cm. -Another nurses' note on 10/1/15 at 5:00 p.m. documented a bruised area to left inner calf which had increased in size to approximately 13 x 15 cm, raised approximately 6 cm. - An initial wound review form completed on 10/1/15. However, the form did not include any information on the cause of the bruised area. The form documented the bruise was found during morning cares at approximately 9 a.m. and was located on the resident's left lower extremity; specifically, her left inner calf. -A 10/1/15 at 3:01 p.m. a physician's note documented a new left lower leg mass. Enlarging mass on the inner left calf. There was no known trauma, but she was out in the van yesterday ( 9/29/15) for a drive. The physician assessment documented, Likely trauma and enlarging hematoma - worry that it might be vascular injury since it's growing - could be a bite with allergic reaction - but not hot/itchy. -A 10/13/15 physician's note documented a left leg mass: Likely trauma and now a resolving hematoma. -A care plan regarding the open wound to left calf was opened 10/19/15, directing staff to encourage nutrition and hydration, to monitor for infection and pain, and to notify the physician if the wound showed signs and symptoms if worsenubg. There was no reference to what had caused the injury. Review of an Investigatory Interview Form - Employee Interview, dated 10/1/15, revealed staff #3, #58, #21, #15, and #59, were each asked if they had noticed a reddened, bruised or raised area on resident #60's left lower leg the day before. All responded no. Although requested from the NHA, DON, and RHD, no other documentation relating to an investigation of the cause of the resident's injury was provided. b. Observations On 11/5/15 at approximately 2:00 p.m. the resident's left inner lower calf was observed. An area, about 13 cm x 15 cm and oval shaped was observed. The top part of the oval shaped area was raised and covered with skin while the bottom half was open and covered with eshcar. Her left ankle and foot appeared swollen (when compared to the right ankle and foot) and there was a bruise on her left knee. d. Staff interviews On 11/5/15 at approximately 2:00 p.m. the wound care nurse #30 and LPN #7 were interviewed. Both staff stated that they did not know what caused the hematoma. The LPN said the only question she was asked was whether she had observed the bruised area prior to 10/1/15. On 11/6/15 at 12:17 p.m. staff #42 was interviewed. She said she was the van driver and the staff member who had placed resident #60, who was in her wheelchair, in the van for a drive on 9/29/15. She explained how she loaded resident #60 and another resident, also in a wheelchair, into the van. -She said on 9/29/15, resident #60 was sitting just behind the bench seat in the van facing backwards in her wheelchair. The resident was placed in the center of the van with equal distance to the sides and the four tie down straps were also equal in length to provide stability and security. The last resident to be loaded into the van was also in a wheelchair and facing forward, centered between the sides of the van with about 8 inches of foot space between the two residents. She also used four tie down straps for stability and security. -She said employee #60 accompanied her on the drive in the van. While staff #42 was driving, employee #60 was sitting in the bench seat facing forward. -Staff #42 stated the first time the facility asked her about the drive on 9/29/15.and whether it was possible resident #60 had bumped her leg was on 11/5/15 (during survey). She indicated she had not been interviewed 10/1/15. -On 11/5/15 at 5:28 p.m. staff #60 was interviewed. She stated that she had received training on abuse reporting. She reported that she and staff #42 are both CNAs. She had not recalled or been witness to any type of abuse. On 11/6/15 at 9:45 a.m. CNA #23, who regularly cared for resident #60, was interviewed. She said she was not sure what happened to the resident's leg. She had heard at first that staff thought it was possibly a spider bite, but some people were skeptical and thought maybe it was a fracture or something. She said a thorough exam did not happen because the family just wants her to be comfortable. The CNA she said the resident needs two people to transfer her because she is non-weight bearing. 3. Resident #41 Resident #41, age 86, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident resided on the Blue Spruce hall. According to the 10/21/15 MDS assessment, the resident had adequate hearing, clear speech, could understand others and be understood, and had a BIMS score of eight out of 15 indicating moderate cognitive impairment. Mood and behavioral symptoms included disorganized thinking and delusions, and feeling tired or having little energy. No other behavioral symptoms were identified. -The resident required supervision/oversight and one-person physical assistance for bed mobility, transfers and personal hygiene. She needed two-plus person extensive assistance for dressing. Her balance was unsteady without assistance, and she used a walker or wheelchair for ambulation. -The resident was occasionally incontinent of bladder and always continent of bowel. She was 58 inches tall and weighed 87 pounds. Care plans dated 1/23/15 identified the following in pertinent part: Need for assistance with activities of daily living (ADLs) related to history of [MEDICAL CONDITIONS], dementia, depression and [MEDICAL CONDITION] with recent increased pain and immobility. Staff were to anticipate the resident's needs, keep her call light in reach, assist and cue her to participate in dressing and grooming, complete ADLs as needs indicated and respect dignity. The resident wishes to sleep in in AM and her bed time varies. -The goal was for the resident to get up and go to bed when she wished and be cooperative in morning and evening cares. Approaches included: -After 8:30 a.m. the resident would be spoken to and asked if she would like to get up, in a quiet, calm, audible manner. -If the resident chooses to sleep later she will be allowed to. Staff will check back at specific time requested or check in on resident if she does not verbalize another time. -The resident will be checked on quietly in morning and evening, and be kept dry and comfortable. a. Resident interview Resident #41 was interviewed on 11/5/15 at 9:21 a.m. and was asked if anyone at the facility had abused her. The resident responded, Yes. The resident said, It happened about six months ago. A CNA made me get up at 8 a.m. She said, 'You don't put on any socks or shoes' and said 'you stay there in your chair till I come back.' And she never did come back. I just about froze to death. It's an experience I never want to go through again. -She (the CNA) is no longer working with me. She doesn't even see me and I don't care to see her either. We were real close friends . I couldn't understand the change in her . It made me wonder 'what did I do wrong to be treated like this,' especially by her. And to this day I wonder. -The resident said she rang her call light for help (when the CNA did not return) but the light did not turn on. The nurse from across the hall came over because I was crying. It hurt me so much. I'd never been treated that way by anybody else in this facility. For her to treat me that way was uncalled for. -I told them I never wanted her in my room again, period. So the following day she was gone and she's been on the other side (of the building) ever since. I see her every now and then .She did come back in my room one time after that and she was mad. I told her I didn't want her in my room anymore and she said, 'You don't tell me what to do.' I wanted her to explain to me why she was treating me this way but she never did. When I see her, I don't want to face her because I don't know what I did that was wrong that she turned against me like that . -When asked if she was afraid, the resident said, I was, because I didn't know what I was getting punished for, and no shoes or socks and my feet were froze(n) . When that nurse came from across the hall . she could tell I was upset . The resident said the nurse was gentle because I was distraught. I asked her, 'Why am I being treated like this?' -A person like that you get fear of and you don't want to go through that again. It's very, very scary. And I've never been intimidated by anything until this time. When something like that happens, you sit and wonder what did I do wrong? I still wonder 'what did I do wrong' to make (the CNA) treat me like that. -The resident said nobody else came to investigate or reassure her other than the nurse who found her crying. b. Facility Failures in Response to Allegation (1) Failure of staff to report allegation: The NHA was asked, on 11/5/15 at 1:15 p.m., for a copy of the investigation related to resident #41's abuse allegation. The NHA said this was the first he had heard of it. He reviewed his investigation files for the past year and said the resident's name was not on any of them. He said he had no reason to doubt what the resident had reported, that she was confused about some things, but this did not sound like one of them. He said they trained facility staff to report, and the nurse should have reported. He said they would begin an investigation and report to officials according to state law. (2) Failure to timely and thoroughly investigate and respond to resident #41's allegation: (a) First investigative report submitted 11/11/15. Review of the first investigative report submitted by the NHA on 11/11/15 during a meeting beginning at 10:05 a.m., revealed it was incomplete. Specifically, it failed to include sufficient staff interviews to identify the staff who potentially were involved, failed to describe the facility response to the nurse's failure to identify and report an abuse allegation, and failed to identify what steps the facility would take to protect and support resident #41 and other facility residents from reoccurrence, noting only that the staff was no longer employed at the facility. The facility's investigation report was requested 11/6, 11/7/ 11/8, 11/9 and 11/10/15. It was provided 11/11/15. Review of the documentation submitted by the facility revealed it that read, 11/06/15 It was reported to the administrator, from state survey, that this resident stated a CNA got her up at 0800 (about 6 months ago) and told her to stand by her bed while she was barefoot and the CNA left her room. She said she told the nurse that was there. -Investigation initiated and all residents that are interviewable were interviewed and also some family members of residents. -Looked through the daily schedules of the approximate time frame that (resident) gave the surveyor and identified 2 people who fit the descriptives given. Nursing assistant (#51) is no longer here as of 4/24/15. LPN (#52) is no longer here as of 06/30/15. Accompanying the three-paragraph report were the following: -A copy of a resident census list, labeled Res & family interviews 11-6-15 with 28 of the resident names highlighted. -A Department of Health and Human Services Centers for Medicare & Medicaid Services Resident Interview & Resident Observation form, dated 11/5/15 at 8:15 p.m., completed by the facility during an interview with resident #41. When asked if she was treated with respect and dignity, the resident responded, Yes. Except nurse. Nurse who had baby got me up at 8 am - wouldn't let me put shoes on, in wintertime - she would never tell me what I did to make her mad. She was the only one who ever treated me bad. 'You sit in chair & do not put any socks or shoes. The nurse didn't come back. I told her to stay away so she did. We were close, I played with her baby. My feet froze. Nurse across hall (illegible) - I never did anything to her. -When asked if she had been abused, she answered, Yes - only one. When asked if she told staff, she responded, Yes . Nurse that was mean to me is now on other side, 'can't figure out what I did wrong.' -A previous interview form (as above) from a mock survey conducted by the facility, dated 10/21/15, revealed the resident said she was treated with respect and dignity, and had not experienced abuse. -Three staff member interviews, all dated 11/9/15, with LPN #14, LPN #11 and LPN #52. None of LPNs remembered hearing the resident crying, hearing reports of the resident being left up barefoot, or hearing of allegations of abuse from the resident. -An 11/6/15 interdisciplinary progress note documenting the resident's representative was notified of the resident's allegation. The resident representative was noted to say that usually when (the resident) had a concern she called him. (b) Second investigative report submitted 11/11/15 at 4:00 p.m. A second investigative report submitted by the NHA on 11/11/15 at 4:00 p.m. was comprehensive, but revealed the investigative report was not finalized until six days after allegation reported to facility. This report detailed the NHA's interview with resident #41 and revealed the resident's statements remained consistent. She had stated she was told to stay here until (staff) came back but staff never did come back. The nurse across the hall heard her crying and the resident told her what had happened. The resident said if she saw the nurse she could identify her; however, the resident was not asked if she could identify the aide, or when she last saw her. The report included an incident report, signed by the NHA and DON, dated 11/6/15 at 3 p.m. which noted the incident as an emotional/psychological abuse allegation. The report read that the physician, resident representative, health department and police had been notified, and it included interviews with 34 staff members (of whom 22 were CNAs, three were LPNs and two were RNs), most dated 11/11/15, asking if they had heard reports of abuse from resident #41. It also included copies of the CNA schedules for the past six months, but no copies of nurse schedules to compare CNA to nursing schedule and help identify the nurse who failed to report. Finally, the investigative summary report, provided by the NHA on 11/11/15 concluded that after interviewing several staff from various departments, only one staff member fit the descriptors given by resident #41 and she was no longer employed by the facility and had been asked not to return. Therefore, the residents were safe. c. Failure to document allegation and detailed monitoring and follow-up in the resident's medical record Review of nurses' notes revealed documentation that every two hour checks were being initiated beginning 11/6/15 starting this morning to determine resident needs. No complaints or requests noted today. Will continue to monitor res(ident) (every two hours) for future needs. Similar notes continued through 11/10/15, but the resident's allegation that initiated the two hour checks was not documented in nurses' notes. Although the resident's allegation was reported to the NHA on 11/5/15, there was no evidence in the medical record of nursing checks beginning that eve

Based on record review, family interview, and external and facility staff interviews, the facility failed to ensure one (#19) of four residents sampled for falls and accidents, out of 41 total residents sampled, received adequate supervision and assistance devices to prevent accidents. The facility failed to develop appropriate interventions to minimize resident #19's risk for falls arising from the resident's significant functional and cognitive limitations due to stroke, dementia, and weight, as well as her assistive devices, which included a Hoyer lift, a Broda chair, and a bariatric air mattress. Resident #19 fell twice while being assisted by two staff. The resident fell on [DATE] while being transferred with a Hoyer lift, sustaining a fractured patella when her knee hit the wall. The resident fell out of bed on [DATE] while being turned during personal cares, sustaining a fractured hip and arm. The findings include: A. Policy Review The facility policy, Fall Management & Investigation Program (SNF), originally dated [DATE] and most recently revised on [DATE], read in pertinent part: Purpose: -To utilize all reasonable efforts to provide a system to review the resident's risk potential for falls and provide a proactive program of supervision, assistive devices and interventions to manage and minimize falls and identify resident's continued needs . -The DON (director of nursing) is responsible for supervising the process of review, management and monitoring procedures . -When the level of risk has been determined (completed MDS, PT screening, etc), the information will be used to refine the resident plan of care .The resident's plan of care will be reviewed and revised in conjunction with the MDS review, or when there is a significant change in condition or a fall occurs. A resident's care plan will be reviewed and updated with each additional fall which might occur .Revised interventions will be routinely reviewed and updated to ensure effectiveness . B. Resident #19 1. Resident #19 was admitted to the facility on [DATE], and was discharged to the local hospital on [DATE]. She was discharged from the hospital on [DATE] to a hospice facility where she expired on [DATE]. According to the face sheet, resident #19's [DIAGNOSES REDACTED]. 2. Resident Status The quarterly minimum data set ((MDS) dated [DATE] read that resident #19 had a BIMS (cognition) score of 3, which indicated she was severely impaired with daily decision making. This MDS reflected that resident #19 was totally dependent on two+ staff for transfers, dressing, toileting, personal hygiene and bathing. It read that she required extensive assistance of two+ staff for bed mobility and ambulating in her bariatric Broda chair. She needed extensive assistance of one for eating. The discharge assessment MDS dated [DATE], section K0200, read that resident #19 was 67 inches tall (or 5'7) and weighed 253 pounds, which meant resident #19 was morbidly obese. Resident #19's weight on [DATE] (just prior to first fall) was 240#, per the Vital Signs and Weight Record located in the resident's chart. The resident's weight on [DATE] (date of second fall) was 242.6#, per the Vital Signs and Weight Record. Review of the computerized physician's orders [REDACTED]. medication for [DIAGNOSES REDACTED] (Glucagon). Review of telephone orders revealed an order dated [DATE], to Please lower bed and place pads on side of bed/next to bed. Record review revealed the resident utilized a bariatric air mattress on her bed, a Broda chair, and a Hoyer lift for transfers. The care plan, initiated on [DATE] and most recently reviewed on [DATE], revealed the facility had identified the resident was at risk for falls, had significant functional limitations, and required a mechanical lift for transfers. The care plan read in pertinent part: (1) (Resident #19) is at risk for falling related to immobility and medications used. The approaches included: Check straps on mattress before transferring resident in or out of bed .Keep bed in lowest position with brakes locked. (Resident #19) is limited in ability to maintain positioning during grooming/personal hygiene while in bed. The goal was: She will maintain safety, dignity, and personal hygiene with two-person assist with grooming and hygiene with cares done in bed over next 90 days. Approaches included: Allow sufficient time to complete grooming/personal hygiene. Engage resident, cue, redirect and complete with resident's dignity maintained .Provide non-distracting environment for grooming/personal hygiene. (2) (Resident #19) needs assistance with ADLs (activities of daily living) related to resident with history of CVA (stroke) with left sided deficits, dementia, depression, and DM with immobility and incontinence.Approaches included: Utilize mechanical lift for transfers needing significant weight-bearing assistance. (3) (Resident #19) has inability to move independently r/t (related to) [DIAGNOSES REDACTED] r/t history of CVA. The goal was: She will achieve surface to surface transfers without injury over next 90 days. Approaches included: Assess resident for use of mechanical lift .Ensure resident is comfortable with mechanical lift, transfers after resident is assessed for mechanical lift needs. Restorative to measure for correct size of sling. Resident to be re-assessed on size monthly and prn .Follow 5 Star guidelines and have at least two people on transfer. Keep Hoyer balanced while using .Reassure resident during transfers, cue as needed to keep resident positioned safely during transfer. The care plans for resident #19 were not amended nor modified in relation to the above issues. There was a handwritten note on the care plans dated [DATE], which read Reviewed and Continued and was signed by social services director #34. 3. Fall with injury [DATE] a. Documentation of fall Review of the resident's Interdisciplinary Progress Notes (IPN) revealed the resident fell from the Hoyer Lift on [DATE], sustaining a painful patellar fracture. The IPN revealed in pertinent part: - On [DATE] at 6:50 a.m.: Resident had fall from Hoyer, when transferring to W/C (wheelchair), Hoyer tipped over and resident went into wall, then on to floor. Two CNAs (certified nurse aides) present. I arrived, resident on floor on back at foot of bed, having difficulty breathing: set up to 30%. Placed back to bed for Hoyer. No head injury noted. C/O (complains of) pain to left leg. Left leg swelling noted, page out to MD on call, Family informed. - On [DATE] at 7:00 a.m.: Resident's neuro checks remain negative, continues to have left leg pain. Talked with POA (power of attorney) and is OK to send to (hospital) if needed for evaluation. Continue to monitor. - On [DATE] at 7:30 a.m.: Received order to send to (local hospital's emergency room ) for evaluation of left leg, non-emergent transport. Resident remains stable and is comfortable at this time . (A telephone order of [DATE] read in part, Patellar fracture. Percocet ,[DATE] mg tablet. Take one orally every four hours, as needed for pain.) - On [DATE] at 11:30 a.m.: Received call from ER, informed resident has patellar fracture to left knee and will be coming back with immobilizer and pain meds. b. Documentation post fall Review of documentation post fall (Incident Report on [DATE], Data Collection Tool, Pain Review tool) confirmed the sequence of events on [DATE] (fall during Hoyer transfer by 2 CNAs), and the outcome (patellar fracture, pain, to ER). The facility's Post Fall Investigation dated [DATE] revealed the facility interviewed the CNAs and re-enacted the resident's transfer and staff's actions following the fall. The investigation concluded staff had followed protocol during the Hoyer transfer and the resident's weight may have been a factor in the Hoyer tipping over. Intervention (retraining by the manufacturer of Hoyer lift) was initiated. 4. Facility Failures a. Failure pre-fall to develop a proactive program of supervision, assistive devices and interventions to manage and minimize resident #19's risk for fall as expected per policy. Review of the resident's care plans (see above) revealed the care plans identified the resident's dependency; however, other than stating the resident required a two person transfer, the care plan failed to include how to safety transfer the resident given her significant functional limitations due to stroke, as well as her weight. Further review of the care plans revealed the care plans identified the resident's use of a mechanical lift, but failed to include the resident also used a Broda chair and the plans included no instructions to staff on how to safely transfer the resident given her use of these two assistive devices. b. Failures post fall to develop individualized interventions to address the factors revealed in the investigation of the resident's fall [DATE]. (1) Interviews and walkthrough during the facility's post fall investigation revealed safety issues with the use of the Hoyer lift and Broda chair together in the limited space in the resident's room. Specifically: -The Investigatory Interview Form: Resident/Visitor Interview form for CNA #29, dated [DATE] read in pertinent part, On [DATE], transferring resident #19 from bed to chair with Hoyer, I was at back of chair. CNA #50 was running controls. Lowering into the chair, Hoyer was at a small angle, I was pulling resident back and the Hoyer tipped sideways, causing resident to fall against wall and slid(e) down to floor in sitting position with Hoyer still attached. Legs spread on Hoyer, brakes not locked. Resident was in position to be sitting in WC when Hoyer tipped. So when Hoyer tipped, it rolled away from chair, causing me to lose grip of resident and she slowly slid down wall to floor. -The Investigatory Interview Form: Resident/Visitor Interview form for CNA #50 dated [DATE], read in pertinent part, On [DATE], we were transferring resident #19 from bed to chair, using Hoyer, going in sideways. Legs on Hoyer closed, brakes unlocked, CNA #29 was pulling resident #19 to properly position in chair, pulling her back using sling, I was operating controls, Hoyer tipped sideways, opposite direction of CNA #29, causing resident #19 to turn ,[DATE] turn headed opposite direction of me. She then went into wall, not hard, and slid down to floor. Hoyer tipped semi-sideways . -An untitled document was attached to the fall investigation, dated [DATE]. It read a walkthrough of the incident showed no safety concerns or answered why the lift had tipped; however, see below; when demonstrating how they worked together to transfer the resident, the CNAs referred to the positioning of the resident, positioning of the bed, and the positioning of the Hoyer lift and Broda chair. Specifically, the document read, in pertinent part: . (We) had both CNA #29 and CNA #50 work together and show us what happened. CNA #29 and CNA #50 went into resident #19's room and provided personal care, one on each side of the bed. When care was completed, they were going to place her in the Broda chair. Because of the size of the room, CNA #50 got the Hoyer lift and turned it around, placing it under the bed frame and lifted resident up over the bed. CNA #29 was at the resident's head, adjusting the sling as (the resident) was being lifted by CNA #50. When she cleared the bed (the bed was in the waist high level), CNA #50 moved the resident in the sling over the Broda chair that was positioned next to and facing the wall at an angle. CNA #29 was guiding the resident into the chair with the handles on the sling pulling her back so she was positioned correctly in the chair when the top of the lift fell up against the wall, causing the resident's knee to hit the wall. CNA #29 steadied the resident as she was lowered to the floor using the Hoyer. The facility concluded that although the CNAs had followed training protocol, the resident's weight and the possibility of the resident being lifted too high while being positioned over the Broda chair may have caused the lift to tip when the resident was pulled back into position. (2) Interviews [DATE] (during survey) revealed additional information from the re-enactment that was not communicated to all staff through care plan revisions. The restorative nurse (#31) who participated in the restorative department's re-enactment of the accident was interviewed on [DATE] at 12:25 p.m. She said the results of that re-enactment were that the only way they felt that the Hoyer could have tipped was if the CNAs did not place the leg of the Hoyer lift between the smaller front wheels of resident #19's bariatric Broda chair. Restorative nurse #31 stated that the wheels from the bariatric Broda chair were spaced further apart than normal wheelchairs and that the legs of the Hoyer lift both fit between the Broda's legs due to the increased size of that chair. She stated that when they placed the Hoyer lift in that manner, it did tip over, just like when the Hoyer's lift's brakes were locked. She stated that the two CNAs adamantly denied that they locked the brakes on the Hoyer lift. She stated that during the re-enactment, the facility attempted to use many different sized chairs to re-enact the situation, but the only chair in which they could get the Hoyer lift to tip was with resident #19's 22-inch bariatric Broda chair. CNA #29 was interviewed on [DATE] at 1:44 p.m. (CNA #50 not longer worked at the facility.) He stated he guessed resident #19's weight tipped her over when the Hoyer was lowered. He stated that the Hoyer lift was in good condition, but when he attempted to lower the lift, the Hoyer flipped her. He said the facility had arranged for the Hoyer lift's manufacturer to come into the facility to provide training to the staff to learn how to set the resident in the chair and how to place the lift so that it did not tip in relation to chair placement. He stated, Basically, they taught us the right way to use the Hoyer lift. He stated that following the manufacturer's training, he had more confidence about using the Hoyer. He stated, It made a big difference. See care plans above; the care plan above directed staff to keep Hoyer balanced, but failed to include instructions to staff on how to do so; specifically, how to place the Hoyer lift properly with regard to the wheels on the Broda chair to ensure a staff transfer by all staff on all shifts. 5. Fall with Injury [DATE] a. Documentation of Fall Resident #19's IPN on [DATE] at 3:35 p.m. read in part: Notified by CNA resident fell out of bed, in resident's room and resident noted to be lying on floor next to bed. Vital signs taken, noted elevation in blood pressure, pulse and (respiratory rate). Resident crying on floor, stated that her right hip hurt. No apparent injury or dislocation noted. Resident assisted back to bed and placed on neuros (neurological checks), doctor called for x-ray of extremities . At 11:30 p.m., the IPN read in part: Orders were received for x-rays (to bilateral shoulders, humerus, radius, ulna and wrist and bilateral hip/pelvis per telephone order at 4:30 p.m.) - X-ray services present from 5:45 p.m. until approximately 7:50 p.m. obtaining multiple x-rays secondary to resident's inability to offer any indication of where pain was located. X-ray indicates a right femoral fracture likely. Acute nursing staff was unable to reach power of attorney, so contacted nephew, who is also listed as emergency contact. He requests she be sent to (local hospital) for evaluation. Non-emergent ambulance called at 11:15 p.m. and arrived at 11:20 p.m. Resident left facility via gurney . The Patient Transfer Form dated [DATE] read in part, Resident was being assisted with cares in bed by two CNAs when she was rolled over. She continued forward and rolled out of bed, landing on floor. CNA unable to prevent fall . The Patient Pain Review Tool dated [DATE] rated the resident's pain intensity as ,[DATE] (with 10 being the highest pain level). A [DATE] at 2:00 p.m. IPN read in part, (Local hospital) called and stated that they are going to admit resident, that at rest, resident has no pain, but with movement, resident has a lot of increased pain. Stated that they are placing a nerve block and going to try to get pain controlled on oral pain medications before discharging . b. Post fall documentation (1) Hospital Records The hospital ER report dated [DATE] at 12:07 a.m. read in pertinent part, Patient presents with fall . she was being rolled earlier in the day and fell to the floor . FINAL IMPRESSION: Intertrochanteric fracture right hip, closed . The hospital discharge summary read in part, Right intertrochanteric and subtrochanteric fracture .possibility of a pathologic fracture . apparent fracture of the humeral head . non-surgical management . (Hospice) recommended skilled nursing hospice care . for pain and anxiety management. (2) Hospice documentation Hospice records [DATE] - [DATE] documented uncontrolled symptoms of pain/ anxiety ([DATE]). A Fall Risk assessment dated [DATE] at 1:30 p.m. read in part: Serious injury because of fall . Patient was being turned and rolled out of bed. She was taken to (hospital). She was found to have fractures to the head of her humerus and trochanter. Hospice documentation revealed the resident complained of pain daily, often several times a day, and with increased pain reported beginning [DATE], and pain medication was increased. The resident expired [DATE]. A visit note at the time of death, dated [DATE] at 10:00 p.m. read in pertinent part, 'Patient's condition/symptom changes preceding death; . Requiring more medication to keep her comfortable. 6. Facility Failures Facility investigatory documentation and staff and resident interviews revealed facility failures contributed to the resident's fall. a. Record review revealed evidence of facility failure to ensure sufficient staff assistance per MDS assessment (2 + staff assist; see [DATE] MDS above), failure to ensure the correct size of bariatric mattress, failure to train staff on proper of inflation of mattress during cares, and failure to maintain bed in low position as care planned and with fall mats in place as ordered. The Investigation Form dated [DATE] and completed by the RN read, in part, that the CNAs stated the resident was on the edge on the bed just prior to the fall. A Hi/Lo bed was in place, but this RN stated that a larger bed could have possibly prevented this fall. A [DATE] at 11:30 a.m. IPN read in part, Fall review for fall on [DATE] at 3:45 p.m. Two CNAs were providing cares for resident, when they rolled her to her right side, resident slid between mattress and CNA toward the floor. CNA protected resident from hurting her head, but due to the weight of the resident, was unable to stop the fall from happening . Resident had in place a bariatric mattress (air), resident's current weight 242.6 on [DATE]. Due to resident's left sided [DIAGNOSES REDACTED] and inability to move independently, the girth of her hips has been assessed. IDT feels she would have benefitted from an even wider mattress . The facility's post-fall investigation involved interviews with staff involved in the events on [DATE], including interviews with CNA #29 and RN #3. -The facility's interview with CNA #29 revealed that when the resident was rolled toward him, she started sliding between the CNA and the mattress. He tried to hold her, but her weight was so much, he could not hold her. Documentation of this interview revealed CNA #29 was educated on firming the mattress during cares on larger resident and to use three people with cares on resident #19 and larger residents. -The facility's interview with RN #3 revealed the resident was on the floor when she entered the room and the bed was in high position. There was no evidence seen in resident #19's chart that physical therapy, occupational therapy or any discipline from the facility had ever assessed or evaluated resident #19's bariatric mattress prior to [DATE], per restorative nurse #31. b. Interviews confirmed the failures above. (1) Family interview A family member of resident #19 was interviewed by telephone on [DATE] at 3:12 p.m. He shared that he had questioned the facility at length about the fall because resident #19 was bed bound. He stated the DON of the facility told him that she investigated the fall and that the facility was planning on getting a larger mattress for resident #19. (2) Hospice nurse On [DATE] at 11:44 a.m., a registered nurse from the hospice care center was interviewed by telephone. She stated that she had worked at the hospice care center for the past 14 months. She said resident #19 weighed about 280 pounds and said she heard the resident had rolled off the bed when the bed was in a higher position, and there may not have been fall mats by the bed. (3) Roommate interview Resident #82, who was cognitively intact per MDS, was interviewed on [DATE] at 12:50 p.m. She stated she was resident #19's roommate for almost two years. She said the resident's fall from bed was at night and they did not have a fall mat down for her. She said staff usually had a fall mat down for resident #19 because the resident could not walk by herself. (4) Restorative nurse #31 The Restorative nurse was interviewed on [DATE] at 12:25 p.m. She said the day after resident #19 fell out of bed she and DON #1 interviewed the CNAs involved. -She said everyone went into resident #19's room to demonstrate what occurred during the resident's fall. She stated the two CNAs were present. The bed was raised waist high as the CNAs were providing cares. One of the CNAs was positioned on each side of the bed. The resident was rolled one way and then was rolled the other way. While one CNA was providing peri-care to the resident, resident #19 began sliding off the mattress. -She stated that the facility determined there were no glaring issues uncovered that could have potentially prevented this resident's fall. Restorative nurse #31 stated that resident #19's roommate (resident #82) was interviewed during the investigation; however, a requested a copy of the interview was not provided. -She stated the facility initially ordered a 48 inch mattress after the resident's fall in anticipation of resident #19's return and said resident #19 had been using a mattress that was 42 inches. But, they discovered there was no 48 inch bed frame which lowered and after looking at their larger residents in the facility, they determined that having a bed which would lower was more important than the resident having a wider mattress. (5) CNA #29 CNA #29 was interviewed on [DATE] at 1:44 p.m. He admitted resident #19's mattress was not inflated prior to providing cares to the resident. He stated that the resident fell out of bed as she rolled between him and the bed. He stated that prior to resident #19's fall from bed he did not know how to inflate the air mattress on the resident's bariatric bed. He stated that he had training on that since the accident and that he now knew how to inflate a resident's air mattress and that it should have been inflated prior to rolling the resident. (6) LPN #12 LPN #12 was interviewed on [DATE] at 2:34 p.m. -She stated that she was involved on [DATE] when resident #19 rolled out of bed. She said CNA #49 ran down the hall saying resident #19 had fallen. LPN #12 stated that she knew the situation would not be good because resident #19 was immobile and could not transfer by herself. She stated that she entered the resident's room and found resident #19 on the floor. -She said she thought the CNAs had followed facility protocol in providing resident #19's cares. She did feel, however, that there were a few things that may have prevented the resident's fall. They were a wider air mattress for the resident, using at least three staff members to assist this larger resident, and the conflicting information about air mattress inflation given to CNAs, as the nurse managers have told direct care staff not to change the settings on the air mattresses themselves, but to ensure that the setting was in the correct position. -She said the settings box for the bariatric mattress was located on the front of the bed and she could not be certain, but thought the setting was a 6 that evening. She did not explain the significance of this setting, however. (7) CNA #49 CNA #49 was interviewed on [DATE] at 2:54 p.m. -She stated she had worked in this facility for about 1 ½ months. She said she and CNA #29 were doing the check and change on the resident. She stated they rolled the resident toward CNA #29. She stated that the resident's air mattress was not inflated like it usually was. CNA #49 initially stated that she pushed the max air button twice, as she was previously instructed by another CNA, but did not feel that the mattress engaged properly. When asked why she thought that, she stated when the resident was rolled, the bed was not firm so the resident's weight was not properly distributed. She said she felt this was the primary reason the resident fell . She stated, I just know that we were doing our job, but the resident might have been rolled too far. She then stated she thought it was CNA #29 who had pushed the button to inflate the mattress, stating I think he did, but I'm not certain. -She stated she thought the resident's fall might have been prevented if the resident had been given a wider bed, her mattress inflated sufficiently prior to providing peri-care and rolling her, and more than two CNAs assisted in providing care to this larger resident. -She stated she had no subsequent training related to fall prevention following this incident because of her schedule. (8) RN #3 RN #3 was interviewed on [DATE] at 10:53 a.m. She stated DON #1 had interviewed her after the fact for the post fall investigation. RN #3 recalled that resident #19 had a bariatric bed, but the resident could have possibly benefitted from a wider bed. RN #3 acknowledged that she did not check the setting of the air mattress at the time: it was inflated, but she could not recall how firm it was. She believed that CNAs have had training on inflating air mattresses. (9) Staff development coordinator (SDC) #30 The SDC was interviewed on [DATE] at 11:06 a.m. She stated fall management and safety were topics covered in new employee orientation. SDC #30 stated that she was not present when resident #19 rolled out of bed, but that she was involved in some interviews after the incident. She stated the facility put out an in-service on air mattress inflation, explaining the in-service was placed in a book at each nurses' station. Staff was to follow up on their own and read over and sign off on the new in-services. SDC #30 stated that she would leave an in-service in the book for several months before she pulled it to check it to her master list. The SDC #30 provided documentation that air mattress/mobility in bed training was provided to both CNA #29 and CNA #49 on [DATE]. The in-service documentation read in pertinent part, When providing cares to residents on air mattresses, it is appropriate to increase the firmness of the mattress so that areas of the bed do not collapse. This can be done on the box at the end of the bed. (See LPN interview above, stating that the box on the bariatric bed is at the front of the bed.) (10) DON #1 DON #1 was interviewed on [DATE] at 5:19 p.m. -She stated that after resident #19 fell out of bed the facility immediately started an investigation and did a re-enactment. She stated that following the incident, the facility was now educating their staff that with morbidly obese residents, there needs to be at least three staff members assisting the resident with their cares and transfers. -She neither indicated she was not aware there was a physician's orders [REDACTED]. She stated, however, that if there was a physician's orders [REDACTED]. -When informed there was no documentation found in any documents of the facility's fall investigation about the firmness or lack thereof of resident #19's bariatric mattress, the DON agreed the facility had not really addressed the condition of the air alternating mattress although she said CNA #29 had been provided training on these issues at least four times since [DATE]. (11) Nursing Home Administrator (NHA) #43 The NHA was interviewed on [DATE] at 6:29 p.m. He stated he had taken the subject of falls to the facility's family council meetings and that one of the family members mentioned their resident family member was at home, they slept on a larger bed than the facility used. He also said the facility was now looking at important things, such as the settings on a resident's air mattress.

Based on observation, record review, and resident and staff interview, the facility failed to ensure four of six residents reviewed for pressure ulcers (#52, #116, #125, and #66) out of 32 sample residents, received necessary treatment and services, to prevent pressure ulcers from developing, and to promote healing of pressure ulcers. Specifically, the facility failed to: -Consistently and timely assess and document wound conditions; -Follow the physician's orders [REDACTED]. -Ensure dietary measures were provided to promote healing; -Provide dressing changes per nursing standards of practice; -Timely document on newly acquired pressure ulcers; -Update the care plan; and -Provide adequate turning and repositioning to offload pressure. These failures contributed to the development and worsening of pressure ulcers, led to an increase in the number of pressure ulcers, and created the potential for additional skin breakdown. The findings included: 1. Expectations A. References regarding Pressure Ulcers "Perry and Potter Clinical Nursing Skills and Techniques," 8th Edition, Copyright 2014, pages 433 through 452, reads in pertinent part: -Pages 434 - 436: "Ongoing skin assessment is necessary to detect early signs of pressure damage: Skin inspection should include assessment for localized heat, [MEDICAL CONDITION], or indurations ...Document all skin assessments, noting details of any pain possibly related to pressure damage." -Page 437: "Assess and inspect skin at least daily. Note all pressure points; document results. Redistribute the amount and duration of pressure to prevent ischemic tissue injury." -Page 442: "If immobility, inactivity, or poor sensory perception is a risk factor (s) for patient, consider one of the following interventions: ...When needed, use pillow bridging ...Use of pillows prevents direct contact between bony prominences ... Reduces amount of pressure exerted on tissues." According to Stechmiller, The Nutrition in Clinical Practice journal article, "Understanding the Role of Nutrition and Wound Healing," Volume 25, Number 1, (2010), pages 61-68: " ...The recommended range of protein associated with wound healing is between 1.25 and 1.5 grams/kilogram/day for individuals with chronic wounds." B. Facility Policy The facility "Skin and Wound Management Program Overview" dated 9/27/01 and revised on 6/1/07, provided in part the following: "The Skin and Wound Management Program is the responsibility of everyone who provides care to the residents, each with their own set of responsibilities. Ongoing education will be provided to staff, competency will be established and accountability for compliance determined. When a break in skin integrity is identified, the licensed nurse will document a detailed assessment in the medical record including type (pressure ulcer, arterial ulcer, [MEDICAL CONDITION] ulcer/wound, etc.) size, stage, location, drainage, odor of area. Medical nutrition interventions will be recommended by a qualified dietician and implemented in accordance with physician's orders [REDACTED]. 2. Resident #52 Resident #52, an [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident had a brief interview of mental status (BIMS) score of 14 indicating she was cognitively intact. She had no behavioral symptoms. She required extensive assistance of two persons with bed mobility, transfers, dressing, and toilet use. She required limited assistance of one person with personal hygiene. She had balance problems during transfers, moving from seated to standing; she was not steady and was only able to stabilize with human assistance. She was indicated to have one venous/arterial ulcer present, and did not have any pressure ulcers, according to the MDS. The care plan, dated 4/18/14, identified the resident was at risk for pressure ulcers related to [MEDICAL CONDITIONS] [MEDICATION NAME], incontinence, and recent decline. -The goal was, "The resident will maintain current skin integrity over the next 90 days." -Approaches included, "Encourage the resident to change position frequently. Use pressure reduction when resident is in chair or bed." The care plan, dated 6/1/14, identified a "new skin issue ... left ankle skin tear/ulceration." -The goal was, "The resident will show signs of healing over the next 90 days." -Approaches included, "Pressure reduction air mattress applied to the bed. Weekly skin assessments, per facility protocol. Notify physician promptly of change status." (There was no care plan update on 9/9/14 when the physician ordered a "new mattress for pressure relief" - see orders below.) The care plan, dated 11/20/14, identified "skin issue Stage 2 pressure ulcer on the left outer ankle" and an "unstageable pressure ulcer of the left lateral foot." -The goal was, "The resident will show signs of healing and be free of infection over the next 90 days." -Approaches included, "The resident will have a pressure reduction mattress on her bed. The resident's chair and wheelchair will have a pressure reduction cushion. The facility will conduct weekly skin assessments per facility protocol." The care plans were void of documentation related to wearing Ted hose, a Rolyan orthosis boot, the type of mattress on the resident's bed, and when or if the mattress was upgraded (see orders below). Record Review a. Dietary Notes The most current dietary assessment, dated 10/16/14, included documentation that the resident had a wound on the left foot. The registered dietitian (RD) documented the lab results that the resident's BUN (Blood Urea Nitrogen) and Creatinine levels were elevated. No mention of protein levels was documented in the RD notes. The medical record was void of lab results related to protein levels. There was no evidence of nutritional interventions to promote wound healing. There was no evidence the dietitian was notified of the "new skin issue" (see care plan above for 11/20/14), or that nturitional interventions to promote wound healing were initiated after a second wound was discovered. b. Braden Scale The most current Braden Scale, dated 10/15/14, documented the resident's skin risk score was 17, indicating she was "at risk" for skin breakdown. c. Physician clinic appointments, fax notifications, and physician's orders [REDACTED]. On 9/8/14, the nurse sent a FAX to the physician that noted a new pressure ulcer to the left medial foot that measured 0.5 x 0.5 cm of black eschar. On 9/9/14 per physician order, "Provide the resident a new mattress for pressure relief." On 10/9/14, per physician order, "Keep left medial foot wound open to air." On 10/31/14, the nurse requested per fax that the Ted hose be discontinued due to ankle wound. The physician's response, dated 11/10/14, was, "No." On 12/9/14, the physician's note read: "Stage 3 pressure ulcer of the left lateral malleolus, wound continuing to slowly improve. Ordered: Rolyan foot-drop orthosis boot to be worn while in bed to keep pressure off wound. [MEDICAL CONDITION]: unstable - restart Ted hose as per order on 11/20/14, to be worn every day over pressure wound dressing." d. Interdisciplinary Progress Notes/ Nurses' Notes -On 6/1/14, the nurse documented the resident had complaints of pain in the left foot and, upon assessment, an open area of the left ankle was found. The open area was measured to be 1.0 cm x 1.0 cm with yellow sticky drainage. The physician and daughter were notified. -On 11/25/14, "Discontinue Ted hose due to ankle wound." However, review of the medical record did not reveal physician orders [REDACTED]. Initial Wound Evaluation The Initial Wound Evaluation forms, related to the left ankle and the left lateral foot, were requested on 12/18/14 and again on 12/19/14. The facility did not provide the documentation as of 12/22/14. Weekly Wound Progress Note The Weekly Wound Progress Note, dated 10/7/14, documented the resident had two wounds, with wound #1 originally a skin tear on the left outer ankle, now documented as a venous ulcer, void of documented stage of the wound, with measurements documented as 2.0 cm length x 2.5 cm width x <0.1 cm depth, color beefy red and yellow slough. Wound #2 was noted as an abrasion on the left lateral foot, stage was void of documentation, measured 0.75 cm x 1.0 cm, without depth, color brown eschar. -The facility documentation was inconsistent regarding the locations of wounds #1 and #2, per documentation below: -On 10/21/14, wound #1 was documented to be a "hematoma" on the mid lateral left foot acquired in house, stage was documented as "abrasion," size= 0.6 cm x 0.75 cm x <0.1 cm depth, color yellow slough. Wound #2 was documented to be a pressure ulcer, acquired in house, on the left outer ankle, 2.5 cm x 2.75 cm x 0.1 cm, color pink and red with yellow slough. -On 10/28/14, wound #1 was documented as located on the left outer ankle, stage 2, measuring 2.5 cm x 2.4 cm x 0.1 cm, color red with yellow slough. Wound #2 was documented to be on the left lateral foot, stage was void of documentation, measured 1.5 cm x 0.9 cm x no depth documented, wound bed color was rusty brown eschar with white slough. -Review of Weekly Wound Progress Notes revealed no weekly documentation from 10/29/14 through 11/13/14. -On 11/14/14, wound #1, noted on the left outer ankle as a pressure ulcer acquired in house, stage 2, measured 2.2 cm x 2.0 cm x <0.1 cm, color beefy red with yellow slough. Wound #2, left lateral foot, pressure ulcer acquired in house, stage = unstageable, measured 0.7 cm x 0.7 cm x no depth documented, color white slough and brown eschar. -On 11/20/14, wound #1 on the left outer ankle, a stage 2 pressure ulcer, measured 2.2 cm x 2.0 cm x <0.1 cm, wound color with yellow slough. Wound #2 on the left lateral foot, stage = unstageable, measured 0.7 cm x 0.7 cm x no depth documented, wound color black scab eschar. -On 11/28/14, wound #1on the left lateral mid foot, stage = unstageable, measurements 0.9 cm x 0.6 x no depth documented, color black scab eschar. Wound #2 on the left outer ankle, a stage 2 pressure ulcer, measurements 2.2 cm x 2.0 cm x <0.1 cm, color pink with yellow slough. -On 12/8/14, wound #1 on the left outer ankle stage 2 pressure ulcer, measurements 2.0 cm x 1.8 cm x 0.1 cm, color beefy red with yellow slough. Wound #2 on the left lateral foot, stage = unstageable, 0.9 cm x 0.6 cm, color black scab eschar. -On 12/17/14 wound #1 on the left outer ankle stage 2 pressure ulcer, measurements 2.0 cm x 1.8 cm x <0.1 cm, color beefy red with yellow slough. Wound #2 on the left lateral foot, stage = unstageable, 0.9 cm x 0.6 cm, color black scab eschar. Daily Wound Assessments The facility Daily Wound Assessments related to the left ankle wound, dated 9/7/14 through 12/17/14, were reviewed. The assessment dated [DATE] documented the wound had a moderate amount of drainage, the wound bed was yellow, and pain was present. There were multiple days that the facility had missing documentation related to the Daily Wound Assessments of the left ankle wound. The facility Daily Wound Assessments related to the left medial foot wound, dated 9/8/14 through 12/7/14, were reviewed. The assessment dated [DATE] documented the wound did not have drainage, the wound bed was black, and pain was present. There were multiple days that the facility had missing Daily Wound Assessments of the left medial foot wound. Observations / Staff and Resident Interview On the evening of 12/16/14 and the morning of 12/17/14, during observation of the resident's room, the bed did not have an air mattress. On the morning of 12/17/14, the resident was observed to be wearing socks. She was not wearing Ted hose. On the morning of 12/18/14, the resident was again observed to be wearing socks. She was not wearing Ted hose. On the morning of 12/19/14, the resident's bed was observed to have an air mattress. On 12/18/14 at 4:15 p.m., a registered nurse surveyor conducted wound observations with the licensed practical nurse (LPN #27). The Treatment Administration Record (TAR) documented, "Apply [MEDICATION NAME] to the left lateral malleolus wound bed, cover with [MEDICATION NAME] Plus, then hydrofoam, adhere with tape, change on Monday, Wednesday, Friday, Saturday, and as needed." The LPN was observed to remove the old dressing, which was dated 12/16/14, indicating the dressing change had been missed on Wednesday 12/17/14. The nurse agreed the dressing should have been changed on 12/17/14. The old dressing had a moderate amount of old, yellowish-brown drainage. The LPN had a zip lock plastic bag with clean dressings. She had to leave the room to get the paper measuring tape to measure the wounds. The LPN measured the wound to be 2.0 cm x 2.1 cm. She did not measure for depth and said she was not able to stage the wound, as that had to be done by the registered nurse. The nurse did agree that the wound had yellow slough and the skin around the area of the wound was very dry and scaly. The resident was not wearing Ted hose as per the physician's orders [REDACTED]. The LPN was asked if she knew what caused the wound. She said she did not know for sure, but it was possible that the hard shoes the resident wore previously might have rubbed her ankle. She said the resident did not have those shoes anymore. The LPN placed her dressing out on top of the bed. She then removed a pair of scissors from her personal pocket to cut the dressing. The nurse then cleaned around the wound, applied the medication, and applied the cut dressing to cover the wound. The nurse was asked about the bed mattress and the boot for the resident's foot. The nurse said the pressure reduction mattress that was on the bed was replaced with the new air mattress yesterday. The LPN said she did not know about a boot. She said the resident did not have a boot that she was aware of. The resident also said she did not have a boot. The resident said the mattress that was on her bed yesterday, before the air mattress was placed, was not an air mattress, or if it was an air mattress, it did not have any air in it. During the days of 12/16/14 through 12/19/14, the resident was not observed at any time to be in her bed or to be wearing a Rolyan Orthosis Boot. Staff Interviews: On 12/19/14 at 9:45 a.m., LPN #27 was interviewed. She said the staff nurse working on the hall did the daily wound observations, and the unit manager did the weekly wound assessments and staging of pressure ulcers. The LPN said she was a fairly new nurse and had not had special training related to wound care. When asked if she was aware of the physician-ordered Rolyan Orthosis Boot for resident #52, she said she did not know about a boot, but said she would ask the unit manager about it. On 12/19/14 at approximately 2:00 p.m., the Director of Nurses (DON), Unit Manager, and Assistant Director of Nurses were interviewed during a group meeting. The DON said the facility did not have a certified wound nurse. She said the unit managers were responsible to do the weekly wound assessments and staging of wounds. She said she was aware that the wound documentation needed some improvement. She acknowledged that there were too many different forms and places the staff had to document. She said she was in the process of making some changes. -The Unit Manager said she was not aware of physician orders [REDACTED].#52. She then reviewed the medical record, and said the physician had documented the boot had been ordered. She said she did not know if the physician or facility had placed the order, but said she would check on the status of the Rolyan Orthosis Boot. -During a follow-up interview on 12/19/14 at approximately 3:30 p.m., the Unit Manager said the boot had been ordered, and it came in last Monday, 12/15/14. She said she took the boot down to the resident's room "today," 12/19/14 (ten days after the physician order, and four days after it arrived in the facility). On 12/22/14 at 3:50 pm, the resident's physician (who was also the facility medical director) was interviewed by telephone. The physician said she was not aware that the resident was not wearing the Ted hose (ordered 11/20 and 12/9/14) and the Rolyan Orthosis Boot (ordered 12/9/14) as she had previously ordered, or that the air mattress (ordered 9/9/14) had not been changed in a timely manner (see resident interview and observations above). The physician said that she would have expected those things to have been done as ordered. 3. Resident #116 Resident #116, a [AGE] year-old male, was admitted to the facility on [DATE]. According to the face sheet, the resident's [DIAGNOSES REDACTED]. According to the quarterly MDS dated [DATE], the BIMS score was 14, which indicated the resident was cognitively intact. One stage one pressure ulcer was marked. No stage two pressure ulcers, no stage three pressure ulcers, no stage four pressure ulcers, and no unstageable pressure ulcers were marked. The resident's care plan, last revised 7/9/14, identified the problem, "Skin Issue - extensive bruising on admission for right arm, right trunk, right lower abdominal, right knee and right mid buttock." (The care plan was not updated to include additional wounds.) -The goals included, "Skin will show signs of healing x 90 days." -The interventions included, "Monitor skin during ADLs (activities of daily living) and report any changes immediately to supervisor, weekly skin assessment per facility protocol, notify MD (medical doctor) promptly of change status ..." Observations -On 12/18/14 at 12:25 p.m., resident #116 was observed with a white bandage wrapped around his right ankle. He stated that it didn't hurt as much that day. His left ankle was covered. -On 12/18/14 at 2:20 p.m., the resident had a white bandage wrapped around his right ankle. The resident stated that it was wrapped "so the blood doesn't get on the sheets." -On 12/19/14 at 3:30 p.m., the resident's wounds were observed by a registered nurse surveyor, with the licensed practical nurse (#27) who provided care for the resident. The resident's left ankle had a scab in the center. The right great toe had a black scab in the center. The right second toe was reddened. The right ankle wound was nickel-sized with yellow slough in the middle. Record Review According to the data collection tool: -On 7/8/14, wounds were not present. -On 10/11/14, wounds were present - see initial wound evaluation. According to the Initial Wound Evaluation: -On 10/9/14, "Resident was found with multiple bruises and some scabbing to bilateral arms and hands ..." -Undated, " ...Big spot on his right buttock. It looks like the blister area is dry/ healing well." -On 12/3/14, the resident "has 2 open areas on left gluteal. One is 1cm (centimeter) x 1cm and the other is 2cm x 1cm." -On 12/19/14, "The coccyx was acquired in house - hematoma; the left ischium was acquired in house stage 2 with the measurements of 0.5cm x 0.5cm x 0.1cm; the right foot second toe was acquired in house unstageable with the measurements of 0.2cm x 0.1cm; the left lateral ankle was acquired in house stage 2 with the measurements of 0.5cm x 0.3cm; the right lateral ankle was acquired in house stage 3 with the measurements of 0.4cm x 0.8cm x 0.1cm; and the right foot big toe was acquired in house unstageable with the measurements of 0.5cm x 0.7cm." According to the skin risk factors/analysis and interventions: -On 9/13/14, under interventions: "...Turn and reposition. Chair every 2 hrs, bed every 2 hrs ...inspect skin daily with care, weekly skin review by nurse ..." (No dietary referral marked) -On 10/11/14, under risk factors, "Resident currently has wounds present - gluteus." Under interventions: " ...Turn and reposition. Chair every 2 hrs, bed every 2 hrs ...inspect skin daily with care ..." (No dietary referral marked) - On 12/3/14, under interventions: "...Turn and reposition. Chair every 2 hrs, bed every 2 hrs ...inspect skin daily with care, weekly skin review by nurse ..." (No dietary referral marked) According to the nursing summary: -On 09/13/14, " ...wounds present- ST (skin tear)." -On 11/16/14, " ...wounds present- BUE (bilateral upper extremities) bruises ...preventive skin measures: air mattress ..." According to the progress notes: -On 7/9/14, " ...red spot on his right buttock, it looks to be healing well ..." -On 9/6/14, " ...right forearm wound healing. No new areas noted ..." -On 9/21/14, "While toileting resident, a 0.1cm (centimeter) x 0.1cm open area/pressure ulcer was found to right upper medial buttocks ..." -On 10/5/14, " ...resident buttock excoriated ..." -On 11/17/14, "Resident has 5 new scabs to feet, 3 on the left foot, and 2 on the right foot. Resident has been a long time steroid user. Resident frequently picks skin causing new open areas ... All areas to be monitored QD (every day) by nurse ..." -Unreadable date between 11/17/14 at 8 p.m. and 11/19/14 at 4 p.m., "Resident has small ST (skin tear) on gluteal left side. Dr (doctor) and family notified." (Faxed to physician on 11/18, "Resident has skin reddening around coccyx, area on left gluteal is beginning to break down.") -On 11/20/14, "Right inner forearm scab has reopened, 1cm x 1.5cm, area cleansed ..." -On 11/21/14, "New order to apply [MEDICATION NAME] to right upper forearm ..." -On 11/24/14, " ...Assessed resident for scabs on feet that bath aide reported this a.m. (morning). Scabs are healing and have no signs/symptoms of infection. Resident states that 'they ' ve been there for a week or two ...'" -On 12/3/14, " ...Resident has multiple bruises and open areas to both arms. Two open areas on left gluteal - areas were cleansed and dressings applied ..." -On 12/5/14, " ...bruises, open areas to both upper extremities ..." -On 12/10/14, "Resident was found to have 0.5cm x 0.5cm open area to the left lateral ankle, area cleansed, [MEDICATION NAME] applied and wrapped with stretch bandage. Dr (doctor) notified." (Faxed to physician on 12/10/14) According to the quarterly QOL (quality of life) review, dated 10/23/14, the resident was on hospice. "His skin is intact ..." The physician orders [REDACTED]. According to the weekly skin check documentation: -On 9/26/14, "pressure area present: open area right buttock." -On 10/3/14, "pressure area present: right buttock." -On 10/10/14, "pressure area present: right buttock." -On 10/24/14, "pressure area right buttocks." -On 10/31/14, "pressure area right buttocks." -On 11/7/14, "pressure area buttocks." -On 11/14/14, "pressure area buttocks." -On 11/21/14, "pressure area buttocks." According to the weekly wound progress note: -On 10/7/14, "right buttock pressure ulcer stage 2 closed." (Missing measurements for current wounds) According to the daily wound assessment for the right buttocks: -On 10/10/14, "wound all but completely healed-open ..." -On 10/20/14, "area on buttocks closed." (Two of seven daily assessments were not completed for the week of 10/19 through 12/25) -On 10/29/14, "area to buttocks closed." (Two of seven daily assessments were not completed for the week of 10/26 through 11/1) -On 12/8/14, "2 small open areas sacral." (Three of seven daily assessments were not completed for the week of 11/07 through 12/13) -On 12/14/14, "Left ankle-area has scabbed over. No drainage noted." (Three of seven assessments were not completed for the week of 12/14 through 12/20) -On 12/16/14, "buttocks remain open." (Three of seven assessments were not completed for the week of 12/14/ through 12/20) According to the weekly wound tracking form, dated 11/30 through 12/6/14, the only wound documented was the skin tear for the outer lateral left wrist distal. According to the medication record: -On 11/19/14, "barrier cream BID (twice daily) and PRN (as needed) to coccyx area until healed." -On 12/11/14, "Left lateral ankle - cleanse area, apply [MEDICATION NAME] and wrap with roll of stretch bandage." (Started on 12/12 through 12/16) Physician orders: -On 11/19/14, "Barrier cream BID and PRN until healed." -On 12/11/14, "To left lateral ankle - cleanse area, apply [MEDICATION NAME] and wrap with roll of stretch bandage." -On 12/18/14, "Discontinue treatment orders for left ankle and leave open to air." The quarterly nutritional progress note, dated 10/16/14, stated ..."skin condition: zero ...skin: bruises healing ..." The nutritional assessment, dated 7/10/14, stated ..."Nutritional needs: 1747-2271 calories (24-32 calories/ kilogram), 71-85 grams protein (1.0- 1.2 grams/ kilogram)." According to the hospice documentation, dated 11/21/14, "...red angry area on left buttock ..." Incident Reports were provided for 10/9/14 and 11/18/14: -On 10/9/14 at 10:15 a.m., "Resident has multiple bruises on bilateral arms and hands with some scabbing. Resident is on long term steroid therapy. Resident stated he barely touches the table or wheelchair or anything and he bruises..." -On 11/18/14 at 2:00 p.m., "Right gluteal fold - Resident is reddened around the coccyx and skin is beginning to break down. Resident buttocks red, blanchable ...ointment applies. Educated resident on repositioning. He stated he understood." (No incident reports provided for additional wounds present) Resident Interviews -On 12/18/14 at 12:25 p.m., resident #116 stated that his right ankle wound didn't hurt as much that day. -On 12/18/14 at 2:20 p.m., the resident stated that his right ankle was wrapped "so the blood doesn't get on the sheets." He stated could not remember when his ankle wound developed and that it didn't hurt. He also stated that he thought his ischium wound developed two to three weeks ago and that it hurt at times. Staff Interviews On 12/16/14 at 1:00 p.m., LPN #26 was interviewed. She said the resident had two stage two wounds on the buttock. On 12/17/14 at 2:29 p.m., LPN #26 was interviewed again. She stated the resident's ankles rubbed together which created a shear to the left lateral ankle. On 12/19/14 at 9:45 a.m., LPN #27 was interviewed. She stated that the nurses completed a daily wound assessment and that the unit manager completed the measuring and staging of the wounds. She stated the ankle wound was healing and that the buttock wound was the same. She was unable to state what stage the wounds were. She stated that she had not had any previous training on wounds. On 12/19/14 at 10:30 a.m., the RD (registered dietitian) was interviewed. She stated that she was not aware of any wounds this resident had. She said she was told he was primarily comfort care and that no nutritional interventions were used at this time. On 12/19/14 at 12:22 p.m., LPN #27 was interviewed again and she stated that there was no documentation related to turning residents. On 12/19/14 at 1:30 p.m., the RD was interviewed again. She stated that she had not charted on this resident. She stated that she was not notified of any pressure ulcers and that she was told he did not have a pressure ulcer. On 12/19/14 at 2:03 p.m., the unit manager RN #5 (registered nurse) and the DON (director of nurses) were interviewed. The unit manager stated that the procedure when a pressure ulcer or wound was identified included: filling out an incident report, providing immediate first aid, and then it was placed on the 24 hour report. She was unable to describe the left ankle wound because she had not looked at it yet. When asked what treatments were completed for this resident's wounds, she stated that she would have to look at the MAR (medication administration record). She stated that she had no current training in wound care. Her last training was in nursing school approximately four years ago. The DON stated that they completed daily and weekly assessments along with documentation and care plan updates. She stated that she was aware of the missing wound measurement documentation and that the measurements should be documented on a weekly basis. These measurements should be in the chart. She also stated that there should be RD intervention for all wounds of a stage two or higher. The medical director was interviewed on 12/22/14 at 3:34 p.m. She stated it would be good for the registered dietitian to see the residents with wounds to help ensure adequate nutritional status. She stated that this resident had decreased skin integrity due to the long term steroid use, but the wounds should be tracked with measurements taken. 4. Resident #125 Closed record review revealed resident #125, an [AGE] year-old female, was admitted to the facility on [DATE] and discharged on [DATE]. According to the face sheet, the resident's [DIAGNOSES REDACTED]. According to the discharge MDS dated [DATE], the BIMS score was 8, which indicated the resident was moderately impaired. One unstageable pressure ulcer was marked with the measurement of 1.5cm x 1.4cm x 0.2cm. The resident's care plan, last revised on 9/19/14, identified the problem, "Skin Issue - pressure area left forefinger." -The goals included, "Skin will show signs of healing x 90 days." -The interventions included, "Monitor skin during ADLs and report any changes immediately to supervisor ... weekly skin assessment per facility protocol ... notify MD promptly of change status ... check area every day, apply cream and bandaid every day ..." Record Review According to the data collection tool: -On 9/10/14, "wounds present - No" According to the Initial Wound Evaluation: -On 9/18/14, " Left forefinger - in house pressure ulcer - unstageable with measurements: 2cm x 2cm." According to the weekly wound progress note: -On 10/28/14, " ...Left index finger ...slight decrease in length ...measurements: 1.5cm x 1.4cm x 0.1-0.2cm." -On 10/21/14, "Large erosion from abrasion by cast left index finger covered in black eschar... measurements: 1.9cm x 1.4cm x 0.1-0.2cm ..." (No other measurements documented) According to the daily wound assessment for the left forefinger: -On 9/27/14, "Wound bed is purple/red with small white center. Peri wound is pink and red. Area dry. Refuses to leave bandaid on." (Two of seven daily assessments were not completed for the week of 9/21 through 9/27) -On 10/24/14, "Large amount of yellow, foul smelling drainage to left forefinger. Wound bed is yellow/ grey. Peri wound is red." (One of seven daily assessments were not completed for the week of 10/20 through 12/26) -On 11/1/14, "Left forefinger scab fell off. Wound bed white with minimal drainage. Peri wound is dry." (Two of seven daily assessments were not completed for the week of 10/26 through 11/1) -On 11/6/14, "Has dark, hard scab to left forefinger. No drainage. Peri wound is normal, but dry." (Four of seven daily assessments were not completed for the week of 11/2 through 11/8) Physician orders: -On 10/22/14, "Cover scab to left forefinger with clear dressing. Change every 7 days and monitor daily." -On 10/31/14, " ...wound team care consult." -On 11/7/14, "Cancel wound clinic appointment on 11/10." According to the physician progress notes [REDACTED]. The condition is the result of a cast friction injury ... Full thickness scab looks good ..." According to the doctor visit form: -On 9/19/14, "Left forefinger with large dark area under where Coban was tight and had to be cut. Complaint of pain. Findings: pressure wound left index ...." -On 10/16/14, "Pressure sore healing well." The nutritional assessment, dated 9/16/14, stated ..."Nutriti

Based upon staff/resident interviews and record review, the facility failed to ensure one of 40 sample residents (#27) was free from verbal abuse. Specifically, night staff certified nurse aide (CNA) told the resident to "shut up and go back to sleep," after she requested something for her pruritis (itching) during the early morning hours. Staff also did not provide the resident the assistance she requested. Resident #27 waited until the next shift (day shift CNA) arrived to repeat her request, fearful that the night shift would respond if she rang her call light again. The resident expressed fear as well as discomfort from the itching until day shift arrived. Although day shift responded to the resident's pruritis, staff failed to report the resident's allegation of verbal abuse and lack of assistance. The findings include 1. Resident #27 Resident #27, an [AGE] year-old-female, was admitted on [DATE] with diagnoses that included [MEDICAL CONDITION], hypertension, muscle weakness, difficulty walking, [MEDICAL CONDITIONS] reflux, history of coronary bypass graft, hyposmolality, [MEDICAL CONDITION], pathologic fracture humerus and anxiety state. According to the most recent Minimum Data Set (MDS), dated [DATE], resident #27 was cognitively intact with a BIMS (brief interview of mental status) score of 15 of 15. She required extensive assistance of two persons with transfers, was not steady and only able to stabilize with human assistance with moving on and off toilet, walking and moving from seated to standing position. She was not on scheduled pain medication regimen, did receive as needed pain medications and had received 7 days out of the past 7 days medications for antianxiety, antidepressant, and diuretic medications. The resident's care plan, dated 9/10/12 and last updated on 12/3/12, documented in part: -Problem-Self care deficit and needs extensive to total assist with ADLs (activities of daily living) related to decreased mobility due to fractures of right and left humerus and decline in health with recent hospitalization . Resident had orders for anti-anxiety drug/medication on as needed schedule for anxiety. -Goal- Resident will be well groomed. Resident will not experience side effects from medication. -Approaches- Anticipate needs proactive approach to care, pericare with barrier cream, wash folds and keep dry and clean. 2. Resident Status - Complaints of Pruritis (1) On 10/26/12, the resident record documented in part: Per physician notification and new order. Resident complaint of itching in the vaginal area. May apply topical Lotrium cream twice daily and if not improved in 4-5 days call back, Diagnosis: [REDACTED]. Review of the December 2012 Treatment Administration Records documented in part order for Kendall Barrier Cream, apply to affected areas as needed (prn) may keep at bedside for staff use, start date of 6/29/12 (no diagnosis). Although the resident had complaints of discomfort with itching the December 2012, PRN Administration Records were void of documentation the resident received Kendall Cream or [MEDICATION NAME] Powder during the month of December 2012. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].) (2) On 10/27/12, the resident's record documented in part: Per physician notification and new order, resident had red yeasty rash of left axilla, currently receiving antibiotic therapy for urinary tract infection. On 10/29/12, the resident's record revealed a new order: [MEDICATION NAME] powder to affected area till healed as needed (prn). Although there was no documentation in the nurses' notes that the resident's rash had resolved, review of the December 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. (3) On 12/3/12, review of the physician orders [REDACTED]. The MAR indicated [REDACTED]. The first dose administered to the resident was at 8:31 p.m. on 12/4/12. 3. Resident Interview - Verbal Abuse in Response to Complaints of Pruritis On the morning of 1/15/13, resident #27 was interviewed. She said she had a complaint about itching approximately one or two weeks ago. She could not remember the specific date, but that it was during the shut down (when the facility had an outbreak of [MEDICAL CONDITION]). Resident #27 said she rang her call light for help because she was uncomfortable from the pruritis. Two staff, unfamiliar to her and possibly from the unit in shut down, responded. When she told staff her complaint, the night shift CNA told her to 'shut up and go back to sleep' and both CNAs left the room. Resident #27 said she did not receive medication for itching and that she was very upset and uncomfortable all night. Resident #27 said she did not use her call bell again because she feared the CNA that had told her to shut up. The resident said that she waited until the day shift CNA came to work and then she asked for the nurse. She said she told the day shift CNA that she had a very uncomfortable night and was itching all night and that she did not use her call bell again because she was afraid of the same night CNA coming back into her room. 4. Facility Response to Resident #27's Allegation The day shift CNA to whom resident #27 had reported the incident was interviewed, on 1/16/13 at 11:00 a.m., about resident #27 and her complaint. -The day shift CNA said she remembered a morning a few weeks ago (she could not remember the date) when she came to work and the resident told her she had a very bad night. She said the resident told her that she (resident #27) had been itching all night, had reported that to the night CNA, and the resident said the night nurse never came down to treat her itching, staff did not help her and she waited for the day shift to come in. -The CNA said she reported the itching to the day nurse and that the day nurse put some [MEDICATION NAME] powder on the resident and then the resident had a good day. There was no evidence in the resident's record that the resident's allegations of fear of the night staff and that shift's failure to respond to her request for assistance were reported by day shift to administration and no evidence that they were thoroughly investigated. The Director of Nursing (DON) was interviewed on the morning of 1/16/13 related to issues of verbal abuse and the lack of timely response to resident #27's request for assistance during the night shift. The DON said she had not heard about the issues and that she would investigate. On the morning of 1/17/13 the DON said she was still working on the abuse investigation, but she had it narrowed down to around the time of a new order from the physician for [MEDICATION NAME]. The DON said all staff at the time of hire had mandatory training related to abuse prevention and reporting and she did not know why this was not reported to her. Facility Follow-up: On 1/18/13, after survey exit, the facility presented a copy of their investigation. There was no evidence that the day shift nurse was interviewed. While the day shift CNA was interviewed, there was no indication the day shift CNA was questioned about what the resident had reported.

Based on record review, observation and staff interviews, the facility failed to implement appropriate and timely interventions to ensure one (#82) of 40 sample residents received the necessary care and treatment to prevent the development of new pressure ulcers and the decline in their condition. The resident was admitted to the facility without pressure ulcers on his heels. The facility failed to ensure that interventions, including those to promote pressure relief, were timely implemented in order to maintain skin integrity, promote healing, and prevent further skin breakdown. Specifically, the facility failed to place a special mattress on the resident's bed until after a new pressure ulcer had developed on the resident's heel. The Dietary Department did not re-assess and update the dietary interventions for new and worsening pressure ulcers and the Therapy Department was not timely contacted to evaluate the resident's need for pressure relief. The pressure ulcer treatment and dressings had not been provided as per the physician orders; and, the facility did not consistently float the resident's heels to prevent pressure. These failures contributed to the development and worsening of the resident's pressure ulcers. The findings include: A. EXPECTATIONS According to U.S. Department of Health and Human Services, Clinical Practice Guidelines Number 15, pages 3-4, pressure ulcer management should include the development of treatment plans, which are re-evaluated "as soon as any evidence of deterioration is noted" and if there is no evidence of healing within 2-4 weeks. Guideline recommendations for treatment include a complete history and physical examination [REDACTED]'s risks for additional pressure ulcers." B. Resident #82 1. Resident #82, a [AGE] year-old male, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. 1. Resident Status - Decline in Skin Condition After Admission Braden Scale The resident's Braden Scale assessment for predicting pressure ulcer risk, dated 12/24/12, documented the resident had a score of 15 = at risk for skin pressure sores. Minimum Data Set (MDS) According to the admission MDS, dated [DATE], resident #82 had cognitive skills that were severely impaired for decision-making, did not have hallucinations, [MEDICAL CONDITION], or other behavioral symptoms, he required extensive assistance of two persons with bed mobility, transfers, dressing and toilet use, was not steady with moving, transfers, turning around while walking and only able to stabilize with human assistance, had indwelling catheter, was always incontinent of bowel. The MDS documented the resident had two stage II pressure ulcers at the time of the assessment and had eschar (hard crust/scab making ulcer unstageable). On admission, he had one stage II pressure ulcer present upon admission, no stage III, IV or unstageable ulcers. The resident was coded as having pressure reducing devices for the chair and the bed. Care Plans The care plan, dated 12/31/12, documented in part: -Problem- Resident had pressure ulcers related to immobility and decline with prolonged hospitalization . -Goal- Resident's ulcer will heal without complications. -Approach- Assess the pressure ulcer for location, stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization weekly, daily, and prn. Float heels to relieve pressure on the heels. Use pressure reduction when resident is in chair and bed. Skin Assessments Review of the skin and wound Weekly Wound Progress Notes documented new ulcers that worsened. Specifically: -On 12/24/12 (date of admission) - Initial Wound Evaluation, dated 12/24/12, right hip surgical wound, wound #2 skin shear on coccyx. No other pressure ulcers were noted. -On 12/27/12 - Initial wound Evaluation, dated 12/27/12, right heel stage II, length (L) 2.5 x width (W) 3.5 with moderate drainage, left buttocks stage II, L 0.5 x W 0.5 no drainage (no documentation of mm or cm). -On 1/2/13 - Weekly Wound Progress Note: Right heel unstageable, L 3.0 x W 4.5, depth unstageable, left buttocks healed, left heel unstageable L 3.0 x W 4.0 no odor, left 2nd toe unstageable L 0.7 x W 0.7 no odor, no drainage (no documentation of mm or cm). -On 1/9/13 - Weekly Wound Progress Note: Right heel unstageable, L 5.7 cm x W 4.0 cm, depth unstageable, right heel with white wound edge and yellow slough present. Left buttocks healed, left heel unstageable L 4.5 cm x W 2.3 cm depth unstageable, no odors, area of green slough present. -On 1/14/13 - Weekly Wound Progress Note: Right heel unstageable, L 4.2 x W 5.7, depth unstageable, right heel with slight odor, moderate drainage. Left heel unstageable L 2.0 x W 4.0, depth unstageable, slight odor, moderate drainage, (no documentation of mm or cm). Notes: Physician will see resident in her office on 1/22/13 will evaluate to send resident to wound clinic. 2. Failures in Facility Response a. Dietary Notes The Nutritional Assessment, dated 12/27/12, documented in part: Initial Assessment - diet puree/small portions/nectar, supplement-2 cal 120 cc three times per day, documentation of medications and lab results reviewed. Resident required maximum assistance with feeding at meals. Failures: -The assessment was void of documentation related to the surgical wound and pressure ulcers present at the time of the assessment (see above). -There was no new or updated Nutritional Assessment after the resident developed new pressure ulcers that worsened. b. Physician Orders On 12/26/12, the physician order [REDACTED]. Treatment: Allevyn covering/dressing. On 12/27/12, the physician notification/orders documented in part: Resident noted to have an open area to the right heel wound bed is red with moderate amount of serous drainage, tender to touch, left foot 2nd toe has red non-blanchable area at knuckle. On 12/28/12, the FAX Request documented in part; Resident had skin breakdown of the buttocks and the right heel, can the resident have orders for a pressure relief mattress and wheelchair cushion, with request approved on 12/28/12. Failure: The resident was admitted with pressure ulcers and known to be at risk for additional ulcers. The pressure relief devices for bed and wheelchair were not requested until 12/28/12, after the resident had developed additional ulcers. Further review of physician notification/orders revealed: -On 1/2/13, the physician notification/orders documented in part: Resident skin issue: Unstageable ulcer to right heel, unstageable to left heel and left 2nd toe, buttocks wound healed. Treatment: [MEDICATION NAME] border dressing to both heels and change in 2 days and as needed (prn), foam to left 2nd toe change every 3 days and prn. On 1/3/13, the physician order [REDACTED]. -On 1/8/13, the physician order [REDACTED]. -On 1/14/13, the physician orders [REDACTED]. Failures: Observations revealed the facility failed to implement ordered and care planned interventions to promote healing and to prevent further decline. Specifically: On the evening of 1/16/13, resident #82 was observed in bed lying on his back. There were no extra pillows on the bed to float his heels, his feet were not in alignment with his body, but were angled to his right side with the right foot resting against the wall. The certified nurse aide (CNA) on duty was observed in the hallway, documenting in the facility electronic system. When asked to observe the resident's position in bed, the CNA said she had just laid the resident down a little while ago and had not had time to get back to float his heels and would do that now. On the morning of 1/17/13, resident #82 was observed in bed positioned slightly on his left side and his right foot/heel was floated on a pillow. His left foot was near a pillow, but was resting on the bed mattress. The resident's spouse who was present in the room said the resident did not have sores on his heels when he first came in, but the staff had informed her that he now had a sore on the heels. Later on during the morning of 1/17/13, the Wound Nurse (WN) was observed completing the resident's pressure ulcer wound treatment and dressing changes. The dressing on the resident's right heel was dated 1/14/13, three days earlier. See above; dressing changes were ordered every two days. -The resident's right outer ankle was observed to be slightly red over the boney prominence with a very small scab in the center. There also were two small abrasions/blood blisters to the side of the right ankle. The WN, when asked about these findings, stated that findings looked like small abrasion. She said it looked new and was not there when the last dressing change was made. -The WN removed the dressings (dated 1/14/13) and said she had done the last dressing change on 1/14/13. The old dressing when removed by the WN contained a small amount of old dark reddish colored drainage. No odor was noted. The WN said the pressure ulcers present one on each heel were unstageable with 90% eschar. The WN made measurements of the right heel ulcer at 4.7cm wide x 3.2 cm length with depth uncertain due to the eschar. The WN measured the left heel pressure ulcer to be 4.0 cm wide x 2.0 cm length, depth uncertain due to eschar. A small area (less than dime sized) of eschar was observed on the resident's left second toe. The WN said the scab/eschar on the second toe was dry and so it was just left open to air for healing and said it might have been caused by the resident's shoes. 3. Staff Interviews On 1/17/13, the WN was interviewed during observation of the resident's bilateral heels (see above). The WN said the special mattress had been put in place soon after the resident was admitted , but she was not sure what date it was put into place. She said the resident would move his feet around and at times he would get his feet off the pillow used to float his heels. The WN said the facility team reviews and discusses what devices should be used. She said they had discussed Podus Boots and the fact that the boots could have decreased the resident's mobility. The WN said the doctor wanted to see the resident and evaluate sending him to the wound clinic. Failures: On the morning of 1/17/13 the Therapy Department Manager (TDM) was interviewed. She said she had not made an evaluation of pressure ulcer treatment for [REDACTED]. She said about two weeks ago she had placed a wheelchair positioning foot board across the bottom of his wheelchair that can be removed as needed.

Based on observation, resident, family and staff interview, and record review, the facility failed to ensure the resident environment remained as free from accident hazards as possible and that two of 40 sample residents (#26, #27) received adequate supervision and assistive devices to prevent falls with injuries. The facility failure to provide monitoring, supervision, and safe assistance contributed to: -Resident #26 falling from bed while being repositioned, suffering two broken legs, a six-day hospitalization , and pain. -Resident #27 falling while attempting to self-transfer off her bedside commode, injuring her back and impacting the resident's continence status. -The facility further failed to ensure the suction equipment in secure unit was readily accessible in case of an emergency. The findings included: A. Individual Resident Failures 1. Resident #26 Resident #26, an [AGE] year-old female, was readmitted to the facility on [DATE] and 12/21/12. Her diagnoses, per the medical record face sheet dated 12/21/12, included fractured tibia with fibula, late effects of acute polio[DIAGNOSES REDACTED], obesity, hypertension, osteoporosis, and convulsions. Minimum Data Set (MDS): The resident's 12/28/12 MDS, revealed she had a BIMS (cognition) score of 14 indicating she was cognitively intact, and had no delirium or behavioral symptoms. -She needed extensive two-plus-person assistance with bed mobility, dressing, and toilet use (the same since her 6/23/12 MDS). Transfers per the most recent MDS occurred only once or twice within the assessment period. She required extensive one-person assistance with eating and personal hygiene. She had an indwelling catheter (new since her 12/21/12 readmission), and was incontinent of bowel. -She used oxygen, had a [DIAGNOSES REDACTED]. -Pain was noted as present and frequent, at a numerical rating of 6/10, interfering with her sleep and limiting her day to day activities. -The resident had a history of [REDACTED]. Care Plan: The resident's 12/31/12 care plan identified she was "at risk for falling r/t (related to) immobility, with the goal that she would have "less injury associated with falls over next 90 days." Approaches included: "Keep bed in lowest position with brakes locked. Keep call light in reach at all times. Place resident in a fall prevention program if needed and monitor. Two person assist with all cares performed in bed." -The resident's fall prevention care plan did not identify that she had suffered fractures as a result of falls from bed twice within the past year. Her bed was never observed to be kept in the lowest position, and her fall prevention program was not specified. Moreover the resident required positioning assistance from three to four staff, not two as stated in the care plan. See observations, staff interviews and documentation findings below. Hospital Record: Review of an interfacility transfer report from a local hospital revealed the resident was treated for [REDACTED]. Her [DIAGNOSES REDACTED]. The hospital history and physical (H&P) notes on 12/15/12 documented in pertinent part as follows: "Fall from bed with bilateral leg pain ... This evening at (facility name) nursing home rolled out of her bed. She immediately had bilateral leg pain and there was noted to be some deformity in one of her legs. EMS was summoned and the patient was brought in to the emergency department where x-rays revealed bilateral femur fractures. The patient also apparently struck the front of her face and was noted to have some abrasions on the bridge of her right nose as well as over her right eye and on her right forehead. The patient denies loss of consciousness or significant head trauma ... -(Another physician) has recommended Buck traction and pain control. The patient was placed in posterior splints as well in the emergency room . Notably, this patient has a history of postpolio syndrome and is bedbound. She has chronic right-sided weakness which has progressed to the point that she is nonambulatory. She does have a history of severe osteoporosis and has had multiple orthopedic fractures in the past. She did have a left femur fracture in 9/2011, which was treated conservatively with a brace. -Past medical history: Postpolio syndrome with chronic right-sided weakness. The patient is bedbound at this time ... Physical examination: She can use her left arm normally. Her right arm does have some contractures and has really limited use. Assessment and plan: The patient is bedbound and we will need to provide excellent skin care and I will place her on pressure precautions." The summary of the resident's hospital course documented in part: "Bilateral femur fractures: Pt (patient) evaluated by (physician) in orthopedics. The fractures were angulated and displaced. Pt does have severe osteoporosis and nonambulatory. Pt was deemed not a surgical candidate 2/2 (secondary to) osteoporosis. She was placed in bilateral Bucks traction at all times with eventual bracing. Pt is NWB (non weight bearing), she will continue with PT/OT (physical and occupational therapy). She will also continue with Lovenox and TED hose for DVT (deep vein thrombosis, blood clot) prophylaxis." On 12/20/12, the hospital record noted, "Case reviewed ... Nothing more to add at this point. She's doing all right, but if we can't find a SNF (skilled nursing facility) to take her, we may have to adjust our treatment plan. Bilateral immobilizers is an acceptable alternative." Facility Medical Record: According to the resident's MDS assessments since 6/23/12 (see above), the resident had required extensive, two-plus-person assistance for bed mobility and toileting. According to her care plan prior to her 12/14/12 fall, dated 12/27/11 and revised on 5/29/12, the resident was "at risk for falling r/t immobility." Approaches included the same interventions as her current care plan (above) but also the following: "Resident receives teaching r/t safety; instructed to keep bed in lowest position - however R (resident) continues to raise bed to high position, 6/19/12 ... Continue to educate R - Fall mats in place, 5/29/12." Nurses' notes on 12/14/12 at 8:30 p.m. noted, "Res was rolling off her bedpan & cont to roll off the bed onto the fall mat on her hands & knees. Res had an abrasion (illegible) on the side of her nose from her glasses & her R leg at the knee was misaligned. Res was made as comfortable as possible on the floor & 911 ambulance called. (Physician) notified & res husband was made aware." -At 11:30 p.m., the nurse noted, "Res admitted to (local hospital) ortho wing with bil fx (bilateral fractured) femurs." - On 12/15/12 at 2:30 p.m., a nurse noted, "Received fax from (hospital) ortho, X-rays to bilat femurs show comminuted fx to R distal femur & transverse impacted fx to L distal femur..." -On 12/17/12 at 10:30 a.m., "IDT review of fall on 12/14/12 at 8:00 p.m. Resident was rolled off her bed pan, pulled up in bed and 1 of the 2 CNAs left the room to get a bandaid per resident request. Resident asked remaining..." This note was incomplete, marked through with two lines, and initialed and noted as an "error." Below this note was a new note in the same handwriting dated 12/17/12 at 12:45 p.m.: "IDT review of fall on 12/14/12. Resident was rolled off the bed pan on to her R side. While giving peri care resident rolled off the bed onto the floor mat on her hands and knees. resident sustained [REDACTED]. Resident was assessed by RN. It was determined that resident needed to go to the emergency room . Resident was assessed and treated at the hospital. Resident found to have B (bilateral) femoral fractures. Staff education on positioning, turning, cares while in bed & how many staff required began immediately and will continue until nursing staff have been fully educated." After the resident returned from the hospital, on 12/21/12, a pain assessment was documented. The resident's pain was rated a 4/10, had been a problem for a week, the location was in her legs upon repositioning, and the description was "aching" and "miserable." Nonverbal pain indicators were grimacing, groaning and moaning. The resident's acceptable level of pain was noted as 2-3. Treatment was Norco and repositioning every two hours. Nurses' notes on 12/21/12 at 12:30 p.m. noted the resident returned from the hospital in "full leg immobilizers x 2, due to stay in immobilizers for 4-6 weeks, pt received 2 vicodin (at 9 a.m.) ... Multiple staff present with Hoyer lift to transfer pt to bed. Pt in 3 out of 10 pain after transfer to bed. Full skin assessment completed. Immobilizers & ted hose kept in place. Pt repositioned as educated by COTA (certified occupational therapy assistant), wash cloths placed under knees & ankles for support as per nurse on ortho stated being done at (hospital)." -At 3:45 p.m., "R was turned (at 3 p.m. with) oncoming staff, pain a 3 out of 10 before turning, 6 out of 10 after. R requesting pain meds, pharmacy contacted (at 2:45 p.m.) for stat pain meds, pain meds received at (3:45 p.m.) and R given 2 vicodin ... (4:45 p.m.) "R states a 2 out of 10 pain after receiving pain meds." -At 5:30 p.m., "R turned with 5 staff members present including 2 nurses." -At 8:08 p.m., "Day nurses to educate night staff as per SDC (staff development coordinator) to R care & turning schedule. Training completed." Resident Observations and Interviews: The resident was interviewed on 1/4/13 at 3:00 p.m. When asked about her accident, she said, "I was in bed, and they went to turn me over in bed, and I fell out, and broke both my legs. I've got to be in this bed eight more weeks." When asked to describe what happened, she said, "I was on my side (facing the door) and they went to roll me over and I went over the edge ... I don't remember their names. It was just an accident. I've fallen so many times in my life. That concrete don't give!" Asked again for details about her fall, the resident said, "I was in bed on my side. My back itched and a certified nurse aide (CNA) was going to scratch my back. They were going to roll me over so she could scratch my back. Where I was, I didn't think I was as close to the edge as I was and shoo! I went over." The resident said she came back from the hospital with a Foley catheter, and had not had one before. The resident said she was not having any pain. Observation on 1/4/13 at 3 p.m. revealed the resident had fall mats on either side of her bed and bilateral repositioning bars. She said she was able to grab the bars when staff repositioned her in bed. The resident's feet were edematous, her toes on both feet were turned outward, her legs were in immobilizers, her feet resting on a gel pad that looked like a blue waffle, and her bed was in a heightened position. She was not wearing ted hose. When asked if her bed could be lowered, she picked up her bed controls and lowered the bed to the lowest position. As she lowered the bed, her catheter drain bag lay flat on the bare floor. (There was no privacy cover on the catheter bag.) At that time, the resident's nurse entered the room to check her blood pressure, and was notified that the resident's catheter bag was touching the floor when the resident lowered her bed. The nurse said she had been telling the CNAs (certified nurse aides) "her catheter needs to be off the floor in a pouch - the bed doesn't need to be that low because she's not a fall out-of-bed risk." Staff interviews: The charge nurse on duty (above) was interviewed on 1/4/13 at 3:30 p.m. She said she worked the day shift, 6 a.m. to 6 p.m. Regarding the resident's care, she said she was turned every two hours, and added, "We're technically log rolling her so she's a three to four person turn. She's skittish about turning. She fights more than helps. This is my first week down here on my own." Regarding pain management, she said the resident had orders for 1-2 vicodin every six hours as needed. "I gave her two around 11 a.m. so she's almost due again. They're worried about the Tylenol - today she grimaced a little more with movement. That's her normal posture with her feet. Both her legs were broken just above her knee at the growth plate, which is in the knee. We have her on fall precautions. She's still in fear of rolling. She will use the rails if we prompt her for turning." The director of nursing (DON) was interviewed at 4 p.m. on 1/4/13. She said she had received a call (about the events on 12/14/12) while she was on vacation and the Staff Development Coordinator had immediately inserviced staff. Asked what she thought about the resident's fall, she said, "They shouldn't have left the resident alone to go get a bandaid. But accidents do happen." CNA #1, who was present when the resident fell , was interviewed at 4:12 p.m. on 1/4/12. She said she had worked with the resident often on the 2-10 p.m. shift. CNA #1 said, "(CNA #2) came to get me to ask me to get (the resident) off the bedpan. We got her off the bedpan and she wanted to be pulled up in bed, and we pulled her up. When we were getting her off the bedpan, she has a little sore on her hip, so I went to get a bandaid and returned. Then she said she had a sore spot on her back and asked for a bandaid. I left to get a bandaid, I was at the treatment cart, and heard (CNA #2) yell. (The nurse) shut her med cart and went in, and I came running down the hall behind them (CNA #2 and the nurse). (The resident) was on the fall mat on her hands and knees. The fall mat was the puffy one. (CNA #2) was in the room the whole time." CNA #1 said that when she left the room, the resident was in the bed on her back, and the bed was in the high position. -Asked if the resident had experienced any similar falls before, CNA #1 said, "She fell maybe a year ago in the middle of the night. If I remember right, I think she said she had to go to the bathroom, the toilet was right there, and she thought she could get to it. I think she broke her left femur." -When asked if the resident was able to turn herself in bed, she said, "She uses her good arm to grab the bar when you roll her and she'll hold onto that. That bar has been there as long as I've been here. She's able to roll herself over. When (the resident) goes to roll, she needs help - I usually push her elbow toward the bar because she can't get all the way over. I've never known her to roll herself completely over - I've always assisted her." -Asked what precautions they were taking currently with the resident, CNA #1 said, "We usually have three aides and a nurse, we roll her every two hours, and any time we roll her for any reason or try to pull her up in the bed there are three aides and a nurse there, sometimes four. If she says she's having pain we'll go tell the nurse, sometimes it's just a matter of repositioning her. She has a little blister in the groin area, and they're now putting a sponge between her skin and the catheter tubing. (The resident) has complained of pain, maybe from the cast rubbing and it's uncomfortable for her - it's often her back that bothers her - if you go to lay the bed down you have to do it really slow in increments. Her roommate will sometimes remind her when her bed is too high - she needs to keep it low as a fall precaution." The nurse who was working the night of the resident's fall was interviewed at 6 p.m. on 1/4/13. Regarding the resident's fall, she said: -"I was passing meds - I was out in the hall, my cart was across the hall so I was pretty close to her room. I heard my CNA yell something - I'm always listening for alarms, noises, crashes, booms, or whatever. I heard her yell, I locked up my cart, and at that time my CNA was saying 'she fell .' -(The resident) was on the fall mat on her hands and knees, and then from there we got another fall mat, turned her over so I could get her off her hands and knees. It was pretty obvious that one leg was definitely broken, so I told them to keep her warm and comfortable, and went to the phone and called 911, called the RN to come - the RN came in and assessed, too. I had already called 911, got ahold of the doctor too. We got her out. She was talking the whole time. Her glasses hit the (oxygen) concentrator and cut her nose, and I guess there was a spot on her forehead. -As far as I know everybody has been trained. In hindsight? They'd already taken care of her, but both of them should've just stayed in the room... She told me her leg hurt - she was on her hands and knees then, and it was pretty obvious her right leg (was broken). -With her good arm she could reach over with assistance - I've put her on the bedpan and taken her off. She reaches way over and grabs it. We're not allowed to have full or even half rails anymore. About a year ago I guess she had a UTI (urinary tract infection) and thought she could walk, thought the commode was next to her bed, and got herself out of bed. She does raise and lower her bed herself, because she likes it up high to watch TV." -Asked what they were doing for the resident now, she said, "Vicodin for pain, we let her tell us. When she first came back we had to remind her not to let the pain get bad, but she can tell us when she's in pain or not. Always two people or more (to assist), but now we're turning her every two hours, and one has to be a nurse. We premedicated her, for awhile after she first returned from the hospital, before turning her, but now she needs it less." CNA #2 was interviewed at 6:10 p.m. on 1/4/13. She was new to the facility. Asked about her training she said: -She had "about a month for orientation - I was taught how to roll (the resident) and help her out. She helps you if you roll her towards the right because that's her best way - she grabs ahold of the hand rail. -Two people were supposed to be in the room, one on each side of the bed. That night we'd been in there getting her on and off the bedpan. I was getting her cleaned up, we noticed a spot on her back, and had put a bandaid on her leg, and I said, 'Go get me a bandaid to (CNA #1). I had actually finished cleaning her up and everything. Everything was over and done with, and I can't honestly tell you how she went. It was like all of a sudden she had ahold of the rail and she just started going to the right. Short as I am, I tried to reach, but I didn't get her. She was kind of half on her right side and half not. She said her back itched and I was rubbing it lightly with my palm and then she just rolled off the bed. I don't believe she was on her side at the point when (CNA #1) left the room. I helped her up on her side. She helped where she sort of stabilized herself with the rail. We actually have to physically push her. -The rail was near her shoulder, and she just kind of went over it. It happened so fast, it could have been the rail she hit her head on. She still had her glasses on, so I'm thinking it was the concentrator she hit her head on. Then she was on her hands and knees. She was on a pretty thick mat I was standing on a mat myself. I screamed her name, and of course (the nurse) was right outside the door." -When asked what they were doing for the resident now, she said, "To assure we definitely use two people no matter what, that two people stay in the room. The next night (the ADON) came in and oriented us to all the policies and procedures and everything again. She taught us how to move bed rails to where they're in a better spot. We're rolling her every two hours: right side, back, left side, back - there's a gel waffle to protect her heels and we're not supposed to float them. -Two people plus a nurse are supposed to be in the room. If we roll her one way there's two on one side and the nurse is at the foot moving her legs, and then when we get her situated the other person goes around and puts the pillow under her legs - two CNAs pulling her towards us. If she says her legs hurt we just readjust them or whatever, check on her quite frequently, usually hourly checks up and down the hall, and have the bed at the lowest level." Facility response to the resident's fall: The staff development coordinator (SDC) was interviewed at 5:14 p.m. on 1/4/13. -She said that after the resident's fall, the ADON, who was on call, "went in and discussed the need for two-person assist for residents who use a lift and need extreme assist. That training was done Saturday at 5:45 p.m. On Sunday I came in and reviewed with staff also about skin issues. The nurse should look at skin prior to putting a bandaid on it. We have sailboats and tugboats on doors indicating if residents are one or two assist - cardexes were reviewed. -When (the resident) came back (from the hospital), our therapy director and I gathered the staff who were there, showed them how to position, turn, transfer, got a full body pillow to assist with that, talked about doing peri care, how to move, we did that when we were turning her every two hours after pain meds were on board. On next rotation when we needed to turn her, we gathered new staff, had (the therapy manager) post on the closet door how to do it for reference - day nurses taught night nurses and staff. I gathered staff from all areas, we turned, positioned her, and (the therapy manager) came back in on Sunday and hit the Sunday crew. -I've been going in and checking her positioning. It's been good, pain's been controlled, she's been happy, laughing. Information is posted on the inside of bathroom doors on blue and columbine hall. Restorative updates these. (The resident) has always wanted her bed up in the high position. We've encouraged her, she refused, we care planned it last May - we've always had the fall mats in place, she has the halos (transfer bars) in place - she's been able to turn herself over with one assist. We did a falls care plan which was reviewed in September. -We did interviews with staff who were working that night, we had them fill out who was in the room, bed position, what education they've had on transfers and positioning. We wanted to see where they were so we knew how to educate. We did education on the 15th by the ADON. -Yesterday we had our nurse/CNA meeting, went over safety, ensured Cardexes matched what is truly happening with the resident. I've been doing spot checks with those - 90% are in very good shape. The other 10% are corrected right away. Cardexes are posted in rooms now inside the respective closet doors. We went over the extensive assist and whether they are three or four - I have a list of all the residents that she marked who were a three or four and we made sure in the care plans that it states all care to be provided in bed will be a two assist. Three at least are supposed to be in the room with (the resident) - one on each side, one to support the legs. I'm not sure if it's on the care plan and cardex - I will double check." -The SDC followed up a few minutes later to state the care plans and cardexes were in fact updated. When asked if all staff had been trained, the SDC and DON said, "All staff who provide care for (the resident) have been trained." Observation of the resident's room at 6:30 p.m. on 1/4/13 revealed updated staff training regarding transfers and mobility assist were posted inside her closet door. During an interview with the DON on the evening of 1/4/13, she said they could check into lowering the resident's TV so it would be more comfortable for her to watch TV while lying in bed in the lowest, safest position. Incident report and post fall investigation: The time and date of the incident was documented as 8 p.m. on 12/14/12, in the resident's room. -Part of body injured: R leg/knee. "Resident was being rolled over and just kept going. Rolled out of bed on right side on fall mat." To the hospital via ambulance at 8:20 p.m., physician and family notified, final outcome/disposition: "See IDT note, res care plan & staff education." Floor mat and halo 1/4 rails in place, res taking antiseizure & diuretic meds, vitals 99.3, 128/84, pulse 78, resp 20, no changes in mental status." -Post fall investigation forms, dated 12/17/12, documented in pertinent part: "All other fall precautions were in place at the time of incident ... Res should have 2 persons assisting her with cares. Employees are being educated on using 2 persons for care with this resident." CNA #2's written statement dated 12/14/12 said, "Res was getting off bedpan 2000 at time of fall, alert, continent at time, 2000 on bed pan, interventions in place, yes to fall mats, "resident was rolling over to get off bed pan and just kept rolling over out of bed on her knees." Res pain review tool 12/14/12 "Res pain 4/10 - res request 0 at this time transferred to ER to be eval." Nonverbal pain indicators were checked off as follows: distorted expressions, groans, furrowed brow, moaning, avoidance of conversation. "Positioning with pillows & blanket to side to make res comfortable, transfer to ER for evaluation." CNA #1 written statement dated 12/15/12 stated in pertinent part: "(CNA #2 & I had just gotten R off the bed pan, we had pulled her up in the bed & she wanted a bandaid, I left to get a band aid ... Last seen by me, she was laying on her back on bed. Continent & had just voided, on bed pan prior to fall. Fall mats were in place. What could have prevented fall? 2 persons to roll. I had left to get a bandaid from the treatment cart, when I got back in the room R was on the fall mat on hands & knees." CNA #1's drawing indicated the oxygen concentrator was above the resident's head, the resident was on a fall mat with her head on or near the concentrator, the bed was next to the resident. (CNA #2's) drawing showed the bed, with the resident next to the bed on her hands and knees. Family member interview: The resident's family member who visited often was interviewed by phone on the afternoon of 1/4/13. The family member said, "(The resident) can't turn over on her own. Instead of standing and pulling (the resident) toward her, the CNA pushed her to the other side of the bed, and she landed on her face ... " The family member said that this was what the resident told family immediately after the accident. The family member further stated, "She was in the hospital for six days ... It's all she can do to roll onto her side. I doubt she could have rolled over without help. ... She fell out of bed (and broke her leg) about a year and half ago by falling out of bed." Resident roommate interview: Interview with the resident's roommate at 3:00 p.m. on 1/16/13 revealed the roommate was off and on awake that night the resident fell off the bed. She said a CNA was helping the resident off the bedpan, turned her by herself and the resident was too close to the edge and went over. The roommate said staff often did one person assist for turning and bedpan assist. They used to do one person assist until after the resident #26's accident. The roommate said, "They need more CNAs." Cross-reference F 353; nursing staff. Resident observations 1/14/13 - 1/17/13: Resident #26 was observed during the recertification survey, conducted 1/14 through 1/17/13, spending most of her time lying on her back in bed, sleeping or watching television. Specifically: -On 1/15 at 2 p.m. and 3:15 p.m., and on 1/16 at 8:30 a.m., 9 a.m., 10:15 a.m., 11:50 a.m., and 1:30 p.m. the resident was observed lying in bed. -On 1/15/13 from 5:09 to 5:47 p.m., she was observed sitting up in a wheelchair with elevated legs. The DON said she had been given pain meds before she was assisted up in her chair. At 5:47 p.m. she was observed at the dining room table, eating slowly. When the resident was observed lying in bed (see above), her bed was always in the high position. She was often observed watching TV with her roommate. Together they watched one TV located near the center of the room, positioned on a TV stand that was relatively high. -On 1/16/13 from 10:30 to 11:08 a.m., the resident was observed, with her permission, as she was repositioned by staff. The nurse removed the resident's leg immobilizers and assessed her skin. Four staff were in the room, three CNAs and the nurse. At one point a second nurse entered the room and assisted. The nurse who was conducting the assessment said the resident had a "new reddened area on her left ankle, and a reddened area on her knee." The redness was observed near the raised cording on the immobilizer, and the nurse placed foam padding between the resident's reddened skin areas and the immobilizer. When the resident's final turn was done, two nurses and three CNAs were present assisting. The nurses said they would check with therapy about the spots on her immobilizers that were rubbing against her skin, and the new reddened area. "She's due to see her doctor this week, so that is good," they said. The nurses said they removed the immobilizers and looked at her skin three times daily. The resident grimaced while she was on her right side and her legs were immobilized on top of each other with the nurse providing support to her legs. The nurse said she had offered pain medication to the resident before care, but she did not want pain meds. The resident was not grimacing after she was repositioned. When asked if she had pain, the resident said no, and said she did not need pain medication. -The resident was interviewed the morning of 1/17/13 after staff had changed her bed to a wider bariatric bed, with fall mats on either side, and without positioning rails. The resident said she felt safer in a wider bed. When it was observed that the bed was still in the high position, the resident was asked how she felt if her bed was in the lowered position for safety. She said she was fine with her bed being in the low position, and that she thought it was already in the lowest position. She proceeded to lower the bed on her own, and when she did so, her covered catheter drainage bag lay on the floor. There was nothing positioned on the floor to keep her bag from resting on the floor. The DON and nursing home administrator (NHA) were interviewed on the afternoon of 1/17/13. The DON said the resident had repeatedly told them she did not like her bed in the lowered position, and expressed surprise that the resident had stated she did not mind if her bed was in the lowered position. The DON indicated they had not talked to the resident about lowering her TV or exploring other potential options with her. In summary, the facility failed to provide care for resident #26 in a safe manner, although they had knowledge of her risk and prior fracture from a previous fall out of bed. Nursing staff gave conflicting responses to the resident's current fall risk. -Although the resident needed extensive assistance with bed mobility, she was left with only one CNA twice, and the CNA moved the resident unsafely in bed causing her to fall. -The resident's roommate stated that, prior to and during the resident's fall, staff often turned the resident with one staff person although she needed two-plus-person assistance. -Although the resident was care planned to have her bed in the lowest position, staff did not ensure this was done. Although the resident was documented as saying she preferred her bed in the high position, she stated it did not matter to her. There was no evidence the facility explored ways to make a lowered bed more comfortable for the resident. -There was no evidence of staff education for the resident about the risks of having her bed in the highest position. 2. Resident #27 Resident #27, an [AGE] year-old-female, was admitted on [DATE] with [DIAGNOSES REDACTED]. a. Knowledge of Fall Risk According to the most recent MDS dated [DATE],

Based on observation, staff interview and record review, the facility failed to ensure that the resident environment remained free of accident hazards and that four of 32 sample residents (#27, #74, #88, #110) received adequate supervision and assistance devices to prevent accidents. Resident #88 tripped over the raised linoleum/tiles in the threshold between his room and his bathroom and sustained a fractured femur that required surgical intervention in the hospital. The findings include: 1. Resident #88, a [AGE] year-old male, was admitted to the facility from home on 2/21/12 for respite care. He had [DIAGNOSES REDACTED]. He was transported to the hospital on [DATE] and did not return to the facility. a. Resident Status The admission minimum data set (MDS), dated [DATE], assessed that he had minimal cognitive impairment in daily decision-making skills (BIMS score was 12), he required one-person physical assist for bed mobility, personal hygiene and bathing, and supervision for transfers, mobility, eating and toileting. He used a walker for mobility, was occasionally incontinent of urine and continent of bowel. The MDS also reported he was taking both antidepressant and anticoagulant medication. The CAA (care area) summary reported: "Resident has no history of falls and scores low on fall assessment. He is monitored and assisted with transfers due to weakness and gait disturbances." A hospital Progress Note, dated 6/6/11, was in the chart and stated, "He was recently hospitalized following a fall. He was discovered to have lumbar compression fractures . . . He uses a 4-wheeled walker and his care giver reports she has caught him before he fell on multiple occasions . . . He has a history of [DIAGNOSES REDACTED]and pulmonary embolus with infarction. He is chronically anti-coagulated . . . Assessment: Falls, instability . . ." On a Fall Risk Assessment, dated 2/21/12, the resident was scored to be an 8 where "10 or greater represents high risk." The computerized physician's orders [REDACTED]. -Trazodone HCL 50 mg. tablet orally every evening at 5:00 p.m. -Zoloft 50 mg tablet orally every day at 8:00 a.m. -Warfarin Sodium 7.5 mg orally daily every T W F SAT SUN -Warfarin Sodium 5 mg orally every M TH. According to the National Institute of Health's website, <http://www.ncbi.nlm.nih.gov/pubmed>, both Zoloft and Trazodone have side effects that may include "dizziness, light headedness and drowsiness." Warfarin is an anti-coagulant. The care plan for "impaired physical mobility", dated 2/29/12, included goal: "He will transfer with minimal assist of 1-2 staff." Approaches included: -"Assess resident's needs and abilities to transfer. Notify all concerned of changes in status. -Educate family and resident on need for assist with transfers . . . -Resident will be assisted to transfer by staff. Gait belt use if warranted . . ." The care plan for "risk for falling related medications used and gait disturbances" included the following approaches: ". . . Provide resident an environment free of clutter. Keep call light in reach, Keep well used items in reach . . . Provide toileting assistance per scheduled needs. Assist as needed." b. Resident Failures The facility failed to maintain the integrity of the threshold flooring separating the resident's room and bathroom. The resident tripped over the raised linoleum/tiles in the threshold between his room and his bathroom and sustained a fractured femur that required surgical intervention in the hospital. Interdisciplinary Team notes were reviewed and included the following: -3/9/12 Midnight/Nursing: "CNA (certified nurse aide) reported to this nurse that resident was on the floor at 2100 (9:00 p.m.). He was lying on his left side. Stated he "got up to go to the bathroom and his feet got tangled." At first while doing inspection, he denied pain and wanted to get up from the floor. When asked if he could move his leg, it was noted unable to move his left leg. Supported with pillow, instructed CNA not to move him . . . Called son, informed him about the fall. He gave his permission to send him to the hospital. Received order from (physician) to transport him to ER (emergency room ) at (hospital) at 2120 (9:20 p.m.). Non-emergent transported him to the hospital at 2140 (9:40 p.m.)." -3/9/12 - 2:00 a.m./Nursing "Called (hospital) resident sustained [REDACTED]. -3/11/12 - 12:50 p.m./Nursing ". . . Son reports (resident) is not doing so well after surgery. He is having hallucinations and confusion. He is also having oxygen issues." -3/12/12 - 9:45 a.m./IDT (interdisciplinary team) "Falls: Resident tripped on tile in bathroom and fell and broke his left femur. Was sent to the hospital. Surgery planned for Saturday 3/10/12. Observed raised and buckled tiles in the bathroom. Maintenance notified to replace ASAP. Will encourage resident to use call light when he returns. Resident will be assessed for safety precautions when returns." The Patient Transfer Form, dated 3/12/12, stated, "Resident had a fall at 9:00 p.m. He cannot move his left leg." According to the receiving hospital's Discharge Summary, dated 3/26/12, the resident was an "elderly male admitted after falling from chair at nursing home. Found to have left hip fracture." A review of the Incident Report Form, dated 3/12/12 at 9:00 p.m., on Blue Spruce revealed the following documentation: - "Part of Body Injured" Noted unable to move his left lower extremity" - CNA heard him fall on the floor. He was lying on his left side near the bathroom door. - Falls: Found on floor, Un-witnessed fall, from chair, wheelchair/toilet - Injury type: Sent to hospital for eval. - Medical Treatment Rendered - MD called 2110 - to hospital with non-emergent transport. - Final Outcome /Disposition - Resident was transported to the (hospital) for evaluation. admitted for fractured femur and surgery." The Quality Improvement Post-Fall Investigation form, dated 3/12/12, was reviewed and documented the following: - "Physical status - continent - Activity at time of incident - Going to bathroom - Devices - Walker/cane, - Current meds: Hypnotic, Antidepressant, Narcotics, Antihypertensive, Diuretic - Environment Factors - Room was well lit and clean - Last time resident toileted - Resident independent in toileting . . ." Under Environmental Factors on this form was a check box for "Floor Condition - uneven floors." This box was not checked, therefore did not reflect the contributing factor to the resident's fall as determined by the IDT 3/12/12 (see above). The facility's medical director was interviewed at 2:18 p.m. on 6/5/12. He related that he attended the monthly quality assurance meetings and that falls were discussed. The medical director agreed that accurate assessment of residents needs relating for fall prevention was "obviously important," and that the facility was assessing and placing all residents on fall precautions upon admission to the facility. During an interview with the director of nursing (DON) at 10:20 a.m. on 6/5/12, she said, "I think everybody is a fall risk . . . I would hope that staff would report any environmental problems that could cause a resident to trip . . . When asked about the process for reporting maintenance issues, the DON said, "Someone (maintenance) is always on call. We have work orders at every nurses' station. Our maintenance team responds quickly to those reports." The maintenance director was interviewed, at 12:01 p.m. on 6/5/12. He stated, "Usually they (the staff) fill out work orders that are available at all three nurses' stations and other places throughout facility . . . When we get them, we correct whatever the problem is and the date that it is corrected. If we bring a contractor in we note that too. If it is something major, we discuss it in department-head meeting and know that it needs to be corrected immediately . . . In this case, what it was, was (sic) that where tile in the room and the linoleum in bathroom meet, the heat weld between those had actually came out and the linoleum was curled up." c. Policies and Procedures The facility's Resident Fall Management Guidelines, policy number CL-INTER-0104, dated 10/30/01 stated in pertinent part: "1.0 Purpose All resident falls will be assessed, reported, documented and care planned by the interdisciplinary team to prevent repeat falls or falls resulting in a significant injury. 2.0 Fundamental Information The Director of Nursing is responsible for managing the processes for prediction, prevention, treatment, monitoring and calculation of the facility fall rates . . . Objectives: - Prevent injurious resident falls, - Prevent repeat falls, - Analyze trends, patterns of resident falls for implementing process improvement, - Utilize an interdisciplinary approach to fall prevention. 3.0 Procedure 1. A Fall Risk Assessment is completed for each resident on admission, quarterly or when indicated by a designated healthcare professional to determine if there are risk factors that may lead to serious injury to the resident. 2. Include a fall prevention plan and interventions in the plan of care for residents identified as at risk for falling . . . 6. Develop and implement an immediate intervention plan to prevent recurrence . . ." 2. Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. Resident Status MDS: Record review for resident #74 revealed that the 60 day Minimum Data Set (MDS), on 4/14/12, stated the resident's cognitive level (BIMS) score was a 15. Record review revealed that the 60 day Minimum Data Set (MDS) on 4/14/12 coded the resident as needing assistance with transfers, with a 3/3 for extensive 2 person assist. Data Collection Tool: A data collection tool on 4/30/12 stated that the resident's orientation was consistent with person, place, and time. Also, transfers were 2-person assist with mechanical lift (sit to stand)-physical assist. Orders: -A physician order, on 5/15/12, stated the resident was to have physical therapy 5 times a week, up to 7 times a week if needed. -A physician order, on 5/15/12, stated the resident was to have occupational therapy 5 times a week for 4 weeks for ADL (activities of daily living) training, balance, safety with ADLs, and transfers. CNA ADL flow charting: Record review revealed CNA ADL flow chart documentation, from 4/25/12 through 6/24/12, used MDS coding to indicate the level of assistance needed for resident #74's daily transfer needs. The codes documented by the CNAs varied with 8/8, 2/2, 3/2, and 1/1. There was no consistent documentation that matched the daily CNA ADL transfer documentation with that of the MDS assessments, which stated the resident was a 3/3 for transfers (see above). Care Plans: -The resident was care planned for impaired physical mobility, with a start date of 2/21/12 related to a CVA (stroke) and weakness. The resident "needs extensive assistance in bed mobility and transfers." The established approaches included to assess resident's abilities to transfer and needs, to assist resident with wheelchair mobility as needed, communicate with resident during transfers, cue as needed, educate resident and family to transfers needs, mechanical lift, slide board or gait belt as resident needs indicate. This care plan was last reviewed and continued on 5/22/12. -The resident was care planned for extensive to total assist with ADLs related to decreased mobility, with a start date of 2/21/12. The established approaches included to anticipate needs, assist with dressing and grooming every day, encourage resident to participate, assist with oral care, provide bathing to maintain hygiene, toilet per resident's observed schedule, utilize mechanical lift for transfers needing significant weight-bearing assistance. This care plan was last reviewed and continued on 5/22/12. -The resident was care planned for a history of falls, with a start date, of 2/21/12, related to weakness and deficit from distant CVA (stroke). The established approaches included: encourage resident to assume a standing position slowly, monitor medications for side effects that can effect gait and balance, obtain patient consult for (e.g., strength training, toning, positioning, transfer training, gait training, mobility devices), place resident in a fall prevention program, provide resident an environment free of clutter, keep bed in lowest position for use and locked, call light in reach, encourage resident to use call light even when family in the room, education with resident on transfers/call lights and education with staff and transfers, This care plan was last reviewed and updated to include "lowered to floor and gait belt-safety awareness" on 5/30/12 (see below). b. Failure to transfer resident as assessed and care planned (1) Observation On 5/30/12 at approximately 9:45 a.m., a resident was observed in the hallway outside the resident room, stating that resident #74, her roommate, had fallen. The resident, who per her 4/16/12 MDS was cognitively intact, stated that her roommate thought she might have broken her arm. Staff was observed going into the resident room to provide immediate care to resident #74. (2) Interviews An interview on 5/30/12 at 11:35 a.m., with resident #74 confirmed that the resident had fallen earlier in the day. The resident stated that she had "one young girl helping her with a gait belt" and she didn't blame her because she had been getting stronger and planning on leaving. When asked, the resident thought she was a 1-person assist, so she felt it was a simple accident because she "stepped wrong." The resident stated that although she was sore, she was ok. An interview on 5/30/12 at 11:40 a.m., with the resident's roommate, confirmed that the fall had occurred as resident #74 had stated, and that the resident was assisted by only one CNA, and also that the resident had hit the floor hard. Another interview with resident #74's roommate on 5/31/12 at 10:50 a.m., reconfirmed that there was only one CNA in the resident room providing care to resident #74 at the time of the fall. (3) Record Review A faxed communication with the resident's physician on 5/30/12, stated that the "resident had assisted fall with no injury noted. Vss sats 90's on ra (room air). Alert, oriented x 3, neuro's wnl." Nurses' notes, on 5/30/12 at 9:45 a.m., revealed that the resident was on the floor, and the resident was supine and slightly "to the left at her bedside on the floor with feet on the floor and bilateral knees bent." Also documented was that the resident was "verbalizing appropriately and answering questions appropriately." The nurse notes stated that "she was being assisted to bed when her lower left extremities 'gave out' and caused her to fall to the floor." Also, "staff assisted resident to Hoyer sling with no complaint from resident and lifted with 4 staff in room and per Hoyer without incident." Nurses' notes, on 5/30/12 at 6:30 p.m., stated that the resident reported that "she hit the ground hard" today. A further documentation in the nurses' notes indicated that the resident believed "she did not have gait belt on and 'one little girl' with her." The documentation continued, "This nurse informed resident that she was being assisted with 2 staff, and, indeed, had a gait belt . . . as well as being lowered to the floor." Nurses' note, on 5/31/12 at 10:00 a.m., documented that the facility fall committee had a meeting regarding resident #74's fall. It was noted that "resident's behavior and cognition conflict with objective/observed strength with patient. Resident was lowered to the floor with gait belt gently due to 'loss of strength.'" Nurses' note, on 5/31/12 at 4:00 p.m., revealed that "resident's roommate reports 'fall.'" Also, that "CNA reported lowered to floor." Record review of the fall investigation completed by the facility revealed no obvious injuries, and that the resident had been assisted to bed with an aide using a gait belt. The investigation completed by the facility documented the fall as an "assisted fall." Investigation by the facility stated that the resident's physical status was "weak," the resident's ambulatory status was "gait belt, assist of 1," and change in mental status "no." (4) Staff Interview An interview with a CNA on 6/5/12 at 11:05 a.m., revealed that resident #74 was a 2-person assist when transferring from the resident bed. The CNA stated that the resident says that "she's clumsy. She isn't strong enough so we use a gait belt. If she doesn't want to do that, she is a sit to stand, but she doesn't like that." The CNA stated the resident "just isn't very strong." An interview with an Occupational Therapy Assistant (COTA) on 6/5/12 at 1:00 p.m., revealed that resident #74 was a 2-person assist or a Hoyer lift. The COTA stated that residents are only a sit to stand if they have been assessed for that in the therapy department. According to therapy staff member, resident #74 was "not a candidate due to her knee problems, and I've told them that." The COTA confirmed that they had been informed that resident #74 was being assisted by one CNA at the time of the most recent fall, and that a gait belt had been used. The COTA stated that the resident's fall had been discussed in the morning staff meeting related to the resident having only one aide present during transfer. An interview with a Registered Nurse (RN) on 6/5/12 at 1:35 p.m., revealed that they had been told that "there were 2 aides in the room and they assisted her to the floor. From what I understand, she was graduated to a 1-person assist in therapy. I tell the aides that she should still be a 2-person assist with a gait belt or sit to stand if she is too weak. She came here due to a history of falls, so she does have weakness." An interview with the Director of Nursing (DON) on 6/5/12 at 1:45 p.m., revealed that she was not aware of the miscommunication between the therapy department and the nursing staff. The DON confirmed that there was a lack of communication in the charting methods used by the CNAs while using the computer kiosks and those documented in the resident records. The DON agreed that this lack of communication related to resident #74's ADL needs was a current problem. 3. Resident #27, an [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. Resident Status The resident, who was cognitively intact (BIMS score of 14), required frequent help to turn and reposition to prevent pressure ulcers, and offer of toileting, based on her MDS dated [DATE]. -The resident required total assistance of two people with transfers, required extensive assistance of two people with dressing, personal hygiene, toileting and bed mobility. -The resident had one healed pressure ulcer and one current ulcer at stage II. Care Plan: The care plan for resident #27, dated 12/27/11, documented in part as follows: Problem- Resident is at risk for falling related to immobility. Goal- Resident will not have fall/injury over the next 90 days. Approach- Keep bed in lowest position with brakes locked, keep call light within reach, monitor medications and report trends to primary care physician, place resident in a fall prevention program if needed and monitor. b. Record Review Social Services Notes: On 10/4/10 the Social Services Note read in part that the resident was admitted on [DATE] from the hospital with [DIAGNOSES REDACTED]. Annual Progress Note: On 1/6/11 the Social Services Manager documented, in part, per Annual Progress Note: Resident [DIAGNOSES REDACTED]. Resident is total assistance with her activities of daily living. A mechanical lift is used for transfers. Resident is continent of bowel and bladder. On 9/17/11 per Nurses' Notes: Resident continues on increased dose dilantin without headaches but expressed she feels woozy on higher level of dilantin. Resident was educated to let her know, lab would be drawn on Tuesday and resident did understand. Resident required Hoyer mechanical lifting assistance related to right side weakness due to [DIAGNOSES REDACTED] and remained continent of bowel and bladder and able to make needs known. Review of the Nurses Notes read in part; 9/19/11 resident fell out of bed onto her left side at 4:00 a.m. was evaluated and transported to the hospital at 4:20 a.m. and the physician and family was notified. On 9/19/11 at 6:30 a.m., the resident was transported back to the facility with a left leg immobilizer related to a fracture of the left femur. Laboratory Report: On 9/19/11 at 5:14 a.m., the hospital laboratory results documented in part; albumin low=3.2 with reference 3.4-5.0 and phenytoin/dilantin level high=29.0 with reference 10.0-20.0. On 9/20/11 at 7:00 a.m., Nurses Notes/IDT (interdisciplinary team) documented in part, fall precautions in use will mobilize leg and add fall mats to floor. c. Interviews On the afternoon of 6/5/12 the facility CNA working on the Columbine Hallway was interviewed, and asked if she or the other staff provide care to resident #27 on a scheduled routine. The CNA expressed that there was not a routinely scheduled care provided to resident #27 during the day or through the night. She expressed the resident was cognitively intact and could make her needs known, and when she needed assistance, she would use her call light for assistance. On the evening of 6/5/12, during an interview with resident #27, she said she did remember the fall on 9/19/11. She expressed that she remembered she was sleeping and awaken with the thought that she could see the toilet very near her, and in her mind, thought she could reach it but she did not remember anything after hitting the floor. She said after her fall, the facility placed floor mats next to her bed. On the evening of 6/5/12, the Director of Nurses (DON) was interviewed about resident #27 and the fall with femur fracture on 9/19/11. The surveyor requested to see the facility fall investigation, any recommendations to prevent further falls, and neurological checks immediately after the fall and after the resident's return from the hospital later that morning. The DON said she was not the DON at the time of the resident's fall and would try to find information on details of the fall. On 6/8/12 at 11:10 a.m., per phone conversation, the DON expressed she would FAX information to the office. However, no further information has been received as of 6/11/12. 4. Resident #110, an [AGE] year-old male, was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. a. Resident Status Minimum Data Set (MDS): According to the MDS, dated [DATE], resident #110 had moderately impaired-decisions poor, cues/supervision required. Required extensive assistance of one person with bed mobility, transfers, locomotion on unit, dressing, toilet use, personal hygiene. Moving from seated to standing position, the resident was not steady and was only able to stabilize with human assistance. Walking he was not steady and could only stabilize with human assistance. The resident had no limitation in range of motion, and used mobility devices of wheelchair and a walker. Care Plan: The care plan dated 2/20/12 documented in part: Problem- Resident had history of falling related to increased weakness and dementia with poor safety awareness. Goal- Resident will have less injury associated with falls over the next 90 days. Approach- The resident will have equipment device that monitors rising, staff to monitor medications for side effects that affect balance and report trends to physician, observe frequently and place in supervised area when out of bed, place resident in a fall prevention program, provide a clutter free environment, keep call light within easy reach, keep well used items within reach, keep bed in low position, fall mats in place, provide toileting assistance as needed to keep dry and decrease agitations. Dated 4/17/12 - Ensure pressure alarms are functional. Dated 4/19/12 - Wheelchair adjustment related to comfort, new cushion to decrease skin breakdown. Dated 4/22/12 - Educated staff regarding wheelchair position and resident to remain on close monitoring. Dated 5/15/12 - Hold cushion until available. b. Record Review Review of the facility Medication Administration Record, dated 4/1/12 through 4/30/12, revealed resident #110 was on routinely scheduled Lorazepam (benzodiazepine) 0.5 mg at 8:00 a.m. and 4:00 p.m. and Lorazepam 1 mg at 8:00 p.m. Review of the facility fall investigation report, dated 4/16/12 at 7:45 p.m., read in part: Resident standing up out of his wheelchair and fell hitting his head on the hand rail and his back hit the heater vent, wheelchair alarm on but not alarming, resident remained continent. The facility Nurses' Note, dated 4/16/12 at 9:45 p.m., read that the resident transported to hospital related to right upper quadrant pain. The facility Nurses' Note, dated 4/17/12 at 12:45/1:10 a.m., read in part that hospital called and reported resident #110 was positive for urinary tract infection and fractured ribs. Facility Fall Investigation Report, dated 4/19/12 at 3:20 p.m., documented that the CNA witnessed resident #110 fall from his wheelchair in the commons area, resident fell on his right side. New Orders clip alarm and OT (occupational therapy) evaluation and treatment, OT evaluation and implement new wheelchair. Facility Fall Investigation Report, dated 4/20/12 at 9:45 a.m., documented the facility CNA witnessed resident pushing wheelchair back to stand up and fell before CNA could reach him, tab alarm and pressure alarm in place and sounding. The facility Rehabilitation Referral Form, dated 4/19/12, documented in part, on 4/20/12: Resident was seen for fall prevention recommendations for tilt back/high back wheelchair for increased safety and to decrease fall risk. No skilled therapy required at this time, signed by OT Assistant. Facility Fall Investigation Report, dated 4/21/12 at 8:15 a.m., facility staff witnessed resident #110 fall from his wheelchair, tab alarm intact, resident continent, tilt back wheelchair and foot buddy on wheelchair, resident was ambulatory at home prior to admission at the facility. Review of the Nurses' Notes, dated 4/21/12, during night shift read in part; Resident appeared anxious, tried to self transfer multiple times, resident was toileted, alarms were working well, fall mat was in place, resident denies pain. Review of the Nurses' Notes, dated 5/31/12, read in part; Resident ambulated every day and able to reposition self, mucus membranes moist and pink, resident pleasant and cooperative with occasional agitation/anxiety related to wanting to ambulate, wanting to go home and dementia. The Nurses' Note/IDT on 6/1/12 at 11:00 read that the resident had a witnessed fall, he fell in his room, the alarm was sounding but the CNA was unable to reach him before he fell , staff to keep resident in sight. The Nurses' Note dated 6/2/12 at 1:00 p.m. resident was up in wheelchair very restless and agitated. Ativan given with little effect. c. Interviews On 6/5/12 at 3:20 p.m., the Restorative Nurse Manager was interviewed. She expressed that the resident had been on Restorative to maintain strength and ambulation and after his fall with fractured ribs, the resident was not able to do the program related to pain and discomfort and Restorative was placed on hold. On 5/31/12 resident was placed back onto the Restorative Program to maintain ambulation and strengthening. On the morning of 6/5/12, the DON was interviewed about resident #110 and his falls. The DON acknowledge that resident #110 had several falls since his admission and that she was tracking/trending falls and that falls was a part of QA (quality assurance) program. d. Observations and Record Review Multiple days during the facility survey 5/29/12 through 6/4/12, at various times of the day, including meal times, resident #110 was observed sitting in his wheelchair. Staff was not observed to stand or ambulate with resident #110. See care plan above; there was no documentation of interventions to ensure the resident was ambulated regularly with staff, to increase strength and to decrease agitation.

Based on physician and staff interview and record review, the facility failed to ensure that two (#63, #97) of 36 sample residents, who were admitted to the facility with pressure ulcers, received necessary treatment and services to promote healing, prevent infection and prevent the exacerbation/deterioration of their pressure ulcers. Specifically, the facility's failures contributed to the exacerbation/deterioration of resident #63's and #97's pressure ulcers. The findings include: A. Definitions The National Pressure Ulcer Advisory Panel's (NPUAP) February 2007 guidelines found at website http//www.npuap.org, provide the following definitions: Pressure Ulcer Definition: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Pressure Ulcer Stages:Stage I Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Stage II Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Unstagable Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. B. Policies and Procedures Copies of the facility's policy and procedure for pressure ulcer management were submitted by the director of nursing (DON) at 3:32 p.m. on 2/23/11. It was titled, "Pressure Ulcer Risk Reduction Guidelines," CL-WMM-5099 and dated 6/1/07 and stated in pertinent part: 1.0 Purpose To ensure that residents at risk for the development of pressure ulcers (score of 18 or less on the Braden Skin Risk Assessment) receive interventions to reduce the risk of pressure ulcers. 2.0 Procedure 1. Maintain or improve current activity level, mobility, and range of motion. 2. A licensed nurse inspects all resident's skin condition, at minimum on a weekly basis . . . 5. The nurse inspects any reddened areas and/or breaks in the resident's skin and documents the inspection . . . 9. Use care to minimize the force and friction applied to the skin. 10. Minimize skin exposure to moisture due to incontinence, perspiration or wound drainage . . . 12. Obtain a physician's orders [REDACTED]. . . 15. Minimize skin injuries (due to friction and shear) through proper position, transfer and turning techniques. 16. Establish a repositioning schedule; encourage residents, who are able to shift their weight periodically, periodically reposition residents who are unable to shift their weight and position bed and chair-bound residents at least every two hours . . . 18. For residents who are completely immobile and in bed, use devices that totally relieve pressure on the heels, most commonly by raising the heels off the bed. Use pillows under the length of the lower leg, suspending the heels . . . 21. Use lifting devices such as a trapeze or bed linen to move (rather than drag) residents in bed who cannot assist during transfers and position changes . . . 23. Avoid uninterrupted sitting in a chair or wheelchair. Explain to resident the need to reposition. Reposition the resident, shifting the points under pressure every one to two hours depending on the resident's need. Encourage residents who are able to shift weight to do so every one to two hours. 24. Consider seating and positioning devices for chair-bound residents for postural alignment, distribution of weight, balance and stability, and pressure relief. C. Resident Failures 1. Resident #63, a [AGE] year-old female, was originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During her stay in the nursing home, she was admitted to the hospital and had [MEDICAL CONDITION] surgery 10/20/10 after which she returned to the facility. The resident was transferred to another skilled nursing facility on 11/18/10. The resident's re-admission minimum data set (MDS) assessment, dated 9/14/10, revealed that resident #63 had no memory issues, was independent in cognitive skills for daily decision making, required assistance with all activities of daily living except eating, required one-person assist to transfer, was usually continent of bladder and occasionally incontinent of bowel and had moderate back and stomach pain daily. Her height was 5 feet 9 inches and she weighed 109 pounds. a. Status of skin on admission - facility failures The original admission orders [REDACTED]. The Admission/Transfer Form, dated 9/7/10, the date of the resident's re-admission to the facility from the hospital, indicated no skin issues. However, according to the re-admission Data Collection Tool assessment, dated 9/7/10, the Initial Wound Evaluation, dated 9/7/10, reported that she had "red coccyx, shearing Stage I. Allevyn (applied) to coccyx." Notwithstanding the Initial Wound Evaluation above, the 9/14/10 MDS recorded that resident had no pressure ulcers and the resident's re-admission history and physical, dated 9/21/10, documented resident #63 was admitted to the facility for "de-conditioning - needs physical therapy and rehab" and included the assessment by her physician that her skin was "clear." The re-admission Braden Scale score was 18 (where 18 or below are considered at risk). Braden Scale assessments, dated 9/14/10 and 9/21/10 reported scores of 19 and one on 10/5/10 reported a score of 18. Failures on admission: -There was no evidence that the physician was notified of the Stage I pressure ulcer; -There was no evidence that the nurse had obtained an order for [REDACTED]. -There was no evidence that the wound nurse (unit manager) had been notified so as to include specific approaches/interventions, i.e. on the care plan to prevent further skin breakdown; and -There was no documentation on the treatment administration record (TAR ) for 9/10 that the resident was routinely reminded or assisted to reposition every two hours to prevent further skin breakdown. b. Further skin breakdown after admission - facility failures Resident #63 developed a Stage II pressure ulcer on her buttocks and Stage I pressure ulcer on her right heel. Review of faxes to the physician included one relevant fax, dated 9/28/10, "Res has small sheared, open area in gluteal fold. Applied barrier cream mixed with A&D ointment. Also noted 2 small reddish purple non-blanchable areas to back of R heel. Applied a small Allevyn for protection. May we have and order to change dressing to back of R heel Q 72 hours and PRN until it is resolved. Res floating heels while in bed." The area in the gluteal fold was sheared and open, and according to NPUAP (see above) it would be identified as a Stage II, and the areas to the back of the R heel, according to NPUAP (see above)would be identified as Stage I. review of the resident's medical record revealed [REDACTED]. heel. Moreover, there was no documentation in the record (on the TAR) that her heels were always floated while she was lying in bed to prevent further breakdown on her heels. A second Initial Wound Evaluation was initiated on 10/5/10, and reported that resident #63 had a Stage II pressure ulcer to her left buttocks (an area different from gluteal fold) 0.5 X 0.2 X 0, and that it was acquired in-house. This evaluation was completed almost a month after the Stage I pressure ulcer on coccyx was identified on 9/7/10, but not communicated to staff or the physician (see above). The first Daily Wound Assessments began on 10/5/10 and were completed on 11/8/10. However, there was no daily wound assessment performed from 10/12/10 to 10/18/10. On 11/2/10, it was documented that "the wound is healed." The first Weekly Wound Progress Note was not completed on 10/12/10, as scheduled. However, the Weekly Wound Progress Notes that were completed reported the following: -10/18/10 "Left buttocks pressure ulcer, 0.2 cm X 0.2 cm X 0.1 acquired in-house . . . Barrier cream applied to L buttocks per order. Lay down between meals. Has cushion in w/c and air mattress." -10/26/10 "Left buttocks pressure ulcer, 0.1 cm X 0.1 cm X 0 acquired in-house . . . Wound to buttocks improving. Resident states 'feels better.' . . Current tx - barrier cream to L buttock. Encourage res to lay down between meals. Encourage resident to turn side-to-side." Copies of the 10/12/10 Weekly Wound Progress Notes and Daily Wound Assessments from 10/12/10 until 10/18/10 were requested from the Director of Nurses (DON) at 8:30 a.m. on 2/23/11. None were submitted by the facility. Also, requested was an explanation for the almost month's delay in implementing specific approaches to prevent pressure ulcers when, on the resident's admission skin assessment, a Stage I pressure ulcer on the coccyx was identified. The DON stated that she would look into it. No explanation or further documentation for the period of 9/7/10 to 10/5/10 was submitted. The September/October 2010 computerized physician orders [REDACTED]. -9/8/10 "[MEDICATION NAME] powder PRN to rashed (sic) areas under breast and peri-buttock areas." -9/30/10 "Apply barrier cream to gluteal fold." And "As needed for R heel - apply small Allevyn for protection." There was no evidence of a physician's orders [REDACTED].[REDACTED] The Resident Care Plan, dated 9/14/10, included one that identified the problem of "resident is at risk for skin breakdown." The approaches included: 1. Assess resident for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible. 2. Keep clean and dry as possible. Minimize skin exposure to moisture. 3. Conduct a systematic skin inspection weekly by the nurse. Pay particular attention to the bony prominences. Keep physician informed of skin condition. Treatments as ordered. 4. Encourage good food and fluid intake. Supplements as ordered. 5. Encourage physical activity, mobility and range of motion to maximal potential. 6. Use pad for pressure reduction when resident is in chair. Pressure relieving mattress to bed. 7. Assist to turn and reposition routinely, monitor for reddened areas during repositioning. 8. Monitor and report labs as ordered to physician and dietician. 9. Provide incontinence care after each incontinent episode. 10. Use moisture barrier product to perineal area. 11. Monitor skin condition during routine daily care and shower. Report any signs of skin breakdown (sore, tender, red or broken areas. 12. Keep linen clean, dry and wrinkle-free. 13. Avoid shearing resident's skin during positioning, transferring and turning. There was no evidence of an acute care plan to address the reddened area identified 9/7/10. Moreover, the care plan above was not revised and individualized to reflect the various problems and treatments i.e. presence of pressure ulcers first documented on 9/7/10, then on 9/28/10 and again on 10/5/10. Cross-Reference F280; revision/update of care plan. In response to request as to dates the pressure relieving mattress and cushion were placed, on 2/23/11 12:28 p.m., the DON submitted a Roho cushion cardboard-box container with resident's name on it, dated 9/16/10 (nine days after the resident was readmitted to the facility). On 2/24/11 at 10:03 a.m., the DON submitted a delivery ticket for a pressure-relieving (air loss) mattress, dated 9/9/11. 2. Resident #97, an [AGE] year old female, was admitted to facility on 9/7/10 with [DIAGNOSES REDACTED]. The minimum data set (MDS) assessment, dated 9/21/10, revealed resident #97 had both short and long-term memory loss and moderate cognitive impairment in daily decision-making skills, required extensive assistance with turning in bed and with all activities of daily living, was propelled by others in a wheelchair for mobility, was incontinent of both bladder and bowel and had a Stage IV pressure ulcer. The resident's height was 5 feet 7 inches tall and she weighed 128 pounds. The history and physical from the hospital, dated 9/3/10, reported that resident #97 was living in an assisted-living facility where she had a "witnessed mechanical fall with a left [MEDICAL CONDITION]." On 9/7/10, she was admitted from the hospital to the facility for rehabilitation. a. Status of skin on admission - facility failure The admission transfer form from the hospital, dated 9/7/10, documented no skin issues. The transfer form also contained a written order from the resident's attending physician, "Call my office today for appointment 9/15/10 and deliver to my office that day." The only attending physician note in the record was dated 10/11/10. A complete review of the physician's note revealed no mention of the resident's sacral pressure ulcer. There was no evidence in the record that the attending physician's visit ordered on admission for 9/15/10, ever occurred. A copy of the 9/15/10 visit notes was requested from the Director of Nursing on 2/23/10 at 8:30 a.m. None was submitted by the facility. The admission Data Collection Tool assessment, dated 9/7/10, indicated that resident #97 had a wound on her coccyx. The Initial Wound Evaluation, also dated 9/7/10, reported that she had a "Stage II, 2 cm X 2 cm X 1 cm, coccyx ulcer, red wound edges, acquired at (sic)home." Failures: There was no admission/interim care plan in the resident's record that addressed the immediate (from 9/7/ 10 until 9/13/10) pressure ulcer treatment and prevention needs of resident #97 upon admission to the facility even after she was assessed to be admitted with a Stage II pressure ulcer. b. Worsening status of ulcer after admission - facility failures Daily Wound Assessments did not begin until 9/13/10 (six days after admission) and ended on 10/3/10 (12 days prior to resident's discharge). The wound did not heal. The Weekly Wound Progress Notes reported the following: -9/22/10 (two weeks after admission) "Unstagable, sacral pressure ulcer, 4.3 cm X 5.8 cm X? (Sic) 3 cm . . . Summary - Sacrum wound dressing changed. On multivitamin with minerals, Arganaid . . . Resident on air flow mattress, Roho cushion to w/c. Faxed Dr. for orders for pain medication to be given prior to dressing change. Foley cath(eter)placed to promote wound healing d/t (due to)resident's incontinence. Resident to go to wound clinic on 9/23/10." -9/28/10 There were no Weekly Wound Progress Notes in the record. -10/4/10 "Unstagable, sacral pressure ulcer, 4 cm X 3 cm X 2.8 cm, tunneling 1.5 cm, moderate amount exudates, odor - yes . . . Summary - Dressing changed per orders. Cont. on specialty mattress, Arganaid BID, M/V with minerals QD. Has specialty cushion to w/c." Copies of the 9/13/10 and 9/28/10 Weekly Wound Progress Notes and Daily Wound Assessments from 9/30/10 until 10/15/10 were requested from the DON at 8:30 a.m. on 2/23/11. None were submitted by the facility. Faxes from the facility to the physician were reviewed and included the following, in pertinent part: -9/10/10 "Resident has a decub to her coccyx. May we have a referral for the wound clinic?" The physician replied, "Yes." -9/10/10 "Has appointment with wound clinic on 9/14/10 at 1:30 p.m. Until appointment may we apply Allevyn and change QD?" The physician replied, "O.k." -9/15/10 "Res has wound on sacrum area. Is scheduled to go to wound clinic next week. Wound is getting worse. Could we have order to clean wound with wound cleanser, apply Biofine to slough and Calcium Alginate. Cover with foam. Change daily 'til wound clinic appointment?" The physician replied, "O.k." -9/21/10 "Res incontinent of bladder and bowel. Has sacral wound, Unstagable. Could we place Foley cath 'til wound healed? If o.k. need order to change every month until d/c'd." The physician replied, "O.k." -9/22/10 "Res sacrum wound appears to cause res a lot of pain with dressing changes and when up in chair. Could we have the following orders? 1. [MEDICATION NAME] drizzle 2%. Drizzle to wound bed 2 cc with dressing changes. 2. [MEDICATION NAME] 20mg/ml SL 0.5 ml with dressing changes only. 3. Could we schedule [MEDICATION NAME] 7.5/325 instead of PRN? Res yelling out in pain d/t wound." The physician replied, "O.k." Review of the September 2010 Treatment Administration Record (TAR) recorded: -On 9/11/10, four days after admission, the first treatment was documented. The treatment was to the "coccyx - clean with wound cleanser. Apply Allevyn sacral. Change QD." -On 9/16/10, the treatment to the "sacral wound" changed to "Clean with wound cleanser, apply Biofine to slough. Pack with Calcium Alginate. Cover with foam. Change daily." -On 9/24/10, the TAR revealed that the dressing/treatment orders changed again on to "Sacral wound - Clean wound with Normal Saline. Apply [MEDICATION NAME] to peri-wound. Apply Santyl and gauze to wound bed. Cover wound with foam and secure with tape." The September 2010 MAR indicated [REDACTED] -Orders dated 9/22/10, for "Arganaid, one box BID, to aid wound healing increase calories and protein." -Orders on 9/23/10 for "[MEDICATION NAME] 10 mg sol PO QD, for the [DIAGNOSES REDACTED]. -Orders on n 9/24/10, for " [MEDICATION NAME] Cream 4% external one X QD. Place cream to wound bed for 20 minutes then finish wound dressing." The Resident Care Plan, dated 9/13/10, six days after admission, included one that identified the problem of "impaired skin . . . related to admission with pressure ulcer and new incision to hip." The approaches included: 1) monitor wound for changes, i.e. odor, drainage, size and color; assess for signs and symptoms of infection, i.e. increased temp, change in mental status, change in wound appearance, localized [MEDICAL CONDITION], redness pain and heat 2) Dressing change per PCP/protocol; pre-medicate for pain as needed, notify PCP and facility Skin Committee with IDT for monitoring and interventions as scheduled and document findings 3) Assist resident with turn and reposition frequently, monitor skin with baths and ADL care, weekly skin assessments by nurse 4) pressure reducing mattress on bed and cushion on wheelchair as indicated 5) Encourage proper hydration and nutritional intake; incontinent - peri-care with barrier cream to follow each incontinent episode. The facility failed to update and revise this care plan as the resident's risks increased (the resident's Braden Scale skin assessment scores showed on 9/10/10 - score of 16, where "total score of 18 or below are considered at risk;" on 9/14/10 - score of 15, on 9/21/10 - score of 15, and 10/5/10 - score of 13). Moreover, the plan was not revised to reflect the current treatments, approaches and interventions implemented by the facility. Cross-Reference F280; revision/update of care plan. Wound Clinic visit notes included the following: -9/23/10 "Pain scale: 8 (out of 10). Wound location - sacrum, 2.5 cm X 2.5 cm X 2 cm, low drainage, odor none. Sharp excisional debridement of white necrotic tissue." -10/12/10 "Pain scale: 4 (out of 10). Wound location - sacrum. 2.5 cm X 2 cm X 1.5 cm, low drainage, odor none. Undermining from 11 o'clock to 1 o'clock - depth 1.7 cm, 60 % [MEDICATION NAME]. During an interview on 2/23/11 at 8:30 a.m., the DON was asked for documentation from the wound clinic visit on 9/14/10. The DON replied that she would look into it. No documentation of wound clinic visit was submitted. The Medicare Daily Skilled Nurses Notes from admission on 9/7/10 to the resident's discharge on 10/15/10 were reviewed. Documentation revealed, in pertinent part: -9/12/10 (8:55 p.m.) "Sacral wound dressing changed. Purulent drainage with foul odor noted. Tenacious grayish-yellow eschar remains over wound. Unable to ascertain depth. [DIAGNOSES REDACTED] surrounding wound and induration noted. C/O (complaints of) pain with procedure but could have been from rolling . . . " There was no evidence that the nursing staff notified the physician of these findings that could constitute signs of impending infection. -9/18/10 (nights-NOC shift) " . . . Dressing to coccyx changed. Center of wound noted greenish yellow with beefy red tissue surrounding wound. Foul odor noted. Resident medicated prior to wound treatment. Tolerated procedure. Will continue to monitor." Again, there was no evidence that the nursing staff notified the physician of these findings that could constitute signs of impending infection. In conjunction with the Medicare notes, the Daily Wound Assessments dated 9/15, 9/16 (not completed on 9/17 or 9/18) and 9/19/10, all documented that the pressure ulcer had an odor. The physician was not notified of these findings. In response to request as to dates the pressure relieving mattress and cushion were placed, on 2/23/11 at 12:21 p.m., the DON submitted a Roho cushion cardboard-box container with resident's name on it dated 9/17/10 (ten days after the resident was admitted to the facility with an ulcer). On 2/24/11 at 10:03 a.m., the DON submitted a delivery ticket for a pressure-relieving (air loss) mattress, dated 9/13/11 (seven days after resident #97 was admitted to the facility with an ulcer). There was no evidence in the record to indicate that the resident had been consistently turned or repositioned in her wheelchair "frequently" as stated in her care plan until the placement of the mattress and the cushion. 3. Interviews A licensed practical nurse (LPN) was interviewed at 8:08 a.m. on 2/23/11 and said, "Wound Nurse? . . . Usually it's the charge nurses on each side right now. (The corporate clinical consultant) just talked with me yesterday about becoming the wound nurse . . . No, I am not certified but I have read some books to learn more about it (wound care). I'll be checking them (the pressure ulcers) and doing the paper work and measuring them . . . We haven't had a designated wound nurse since last (2010) July or August. Wounds are supposed to be assessed daily by the nurse assigned to them. Then the initial wound eval(uation) is done when they come in. And then, if there is a wound, write general description, then do daily wound assessment. The weekly assessment should be done by the wound manager and so that's what I'll be doing. We're hoping to have (the medical director) come - so we can make wound rounds every week." The Director of Nursing (DON) was interviewed at 8:30 a.m. on 2/23/11. -She said, "We don't have a specific designated wound nurse . . . Usually it is our unit managers and within the last three weeks we have been going through a change on that. Our Assistant DON unit manager on Blue Spruce hall just stepped down so the floor nurses have been doing it (pressure ulcer assessments and providing dressing changes). Apparently there was a wound nurse before I came . . . the third week in August last year (2010) but we did position shifting and hired an ADON unit manager and an RN as SDC(staff development coordinator) but she's no longer here . . . right now, I have a LPN (as SDC) . . ." -She said, "No, none of our nurses are certified in wound care management. Our corporation would only cover about 20% of the cost. I looked into it. I think the cheapest one I found was about $7-8,000.00 . . ." -She further stated, "Wound rounds are made on Thursdays . . .No he (medical director) doesn't (make rounds with the team) yet; he's just getting on board and about 2 weeks ago we started talking about it . . ." -She said, in response to a question on how are treatments communicated to the unit managers and floor nurses, "On any of the bigger wounds, I usually go with them to the wound clinic and come back and teach the nurses. I am not familiar with them (residents #63 and #97). I think they were here when I first came. . . ." -She said in response to a question about the process of documentation, "What happens is, on admission once we have found wounds, the Initial Wound form is done. After that is done, we will do daily observations and dressing changes according to doctor's orders. Then we have weekly wound progress notes, I fax to (corporate clinical consultant), go through them with her. There is also a tracking form that I keep. Weekly is when we do the staging." An LPN who was unit manager on one of the halls and the DON were interviewed at 9:02 a.m. on 2/23/11. -The LPN said, "No, I have not taken a special class (in pressure ulcer/wound care). I was trained here on wound care . . . The nurses get the incident reports (regarding wounds) and I get the reports and follow it from there. CNAs (certified nurse aides) will ask me to look at them (the residents) if they think there is an issue. -The LPN further stated, "When we have a new admission, we do their first assessment and then if we find something we will write it on 24 hour report and/or give the wound assessment to us (the unit managers.) . . . " -The LPN, in response to a question about the procedure if a wound gets worse, said, "I would measure it, contact the MD and tell him and ask if they would like new dressing orders. When we call or fax the doctors, we should include measurements, the dressing, how often we're changing the dressings, if and when they want us to report back to them. -The DON added, "It also depends on if it's being followed at the wound clinic . . . Yes, there should be an order from the doctor for referral to wound clinic." -The DON continued, " If we are admitting someone with a wound present, we will make sure to have to some sort of wound orders to take care of them . . . The nurses are notified of new wounds on the 24-hour report, the unit manager and I will look at the pressure ulcer and we call the PCP (personal care provider) for treatment orders. -The DON said she had never made wound rounds with the Medical Director, stating, "We're just setting it up for every Thursday . . . That's why I pulled him in - he needs to be onboard." -The DON related, "Currently we do not have a (dedicated) wound nurse, the floor nurses do the daily treatments . . . they (the pressure ulcers) are assessed and staged at least once a week . . . Yes, the goal of our change is to have one person doing the weekly (assessment) - to do the measuring, it's really a must. Apparently before I came that was one of the system changes - the wound manager. I will be directing it (the skin/wound team) and my two unit managers and the doctor and nurse practitioner at the wound clinic are good resources for me." The facility's Medical Director was interviewed at 9:31 a.m. on 2/24/11. He said, "We have QA meeting every month . . . They (the facility QA team) have a list of things we cover; each department is represented . . . Yes, we do discuss pressure ulcer. . . We do pressure ulcer rounds on my patients . . . they will call me with wound issues. I know that they are rounding on them (residents who have pressure ulcers) . . . The obvious thing is we want to know about new ones, why or what happened with that patient. We want to make sure that we don't contribute to any problem . . . When I get a fax regarding a pressure ulcer, it depends on the wound but I would want to know the location, the size and depth and any signs of infection and anything else that would help make a decision . . . Yes it would be beneficial to have the same person assessing the wounds each week for consistency."

Based on record review and resident, staff and family interview, the facility failed to ensure two of 15 residents (#1 and #2) were free from abuse. Certified nurse aide (CNA #1) was observed telling resident #2 she wished she could "break (the resident's) neck." That same morning, CNA #1 was observed lifting and "slamming" resident #1 into his wheelchair. Both residents were cognitively impaired and dependent on staff for assistance. The findings included: A. Facility Abuse Prevention Policy/Procedure The facility's corporate policy and procedure manual provided in pertinent part as follows: - "Every resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, neglectful acts, and involuntary seclusion." - "All potential employees will be screened for history of abuse or mistreatment of [REDACTED]. - "All residents and employees will be encouraged to report concerns, incidents and grievances without fear of retribution." - "Corrective actions of incident reports will be reviewed for patterns/trends of events that could constitute abuse and determine if investigation is warranted." - "Administrator and Director of Nursing are to monitor and assess staff for signs of burnout, frustration or stress." B. Resident Failures 1. Resident #2 - Verbal Abuse Resident #2, an [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. Minimum Data Set (MDS) According to her 8/26/10 MDS, resident #2 had short-term and long-term memory problems and moderate cognitive impairment. She exhibited persistent anger with self or others, but no other mood or behavioral symptoms. She required extensive, one-person physical assistance with transfers, dressing and toilet use; and needed partial physical support while standing. She had limited range of motion and partial loss to both hands and both feet. She had shortness of breath; frequent mild pain; fell in the past 31-180 days; and had abrasions, bruises and skin tears. Her condition was noted as unstable. She was 60 inches tall and weighed 79 pounds. b. Care Plan The resident's care plan, in pertinent part, included the following: - "Explain all cares prior to starting and converse with resident while providing cares" (9/30/10). - An undated, pre-printed "behavior symptoms" care plan had "verbal abuse" and "resists care" checked off, but no approaches were documented. The page was otherwise blank. - An undated, handwritten entry read, "Mood: Res easily embarrassed by physical limitations (hands deformed by RA, pain, weakness) becomes angry & has verbal outbursts." Pertinent approaches read, "When she becomes angry at you, simply leave when safe & return after she calms down. Address her in a polite adult manner." - "Alteration in comfort related to pain due to severe OA ([MEDICAL CONDITION]) to both hands, compression fx (fracture) lower back" (3/16/10). Approaches included pain assessments, medications and non-pharmaceutical interventions, but nothing regarding transfers or care provision in a manner to minimize discomfort. c. Nursing Note documentation of verbal abuse by CNA #1 A nurse's note, dated 9/25/10 at 3:44 p.m., read, "R (resident) being assisted out of bed this morning by CNA. R told CNA her arm was stuck behind head & stated 'Are you trying to break my neck?' CNA (#1) allegedly responded 'I wish I could.' The other CNA (#2) in room stepped in & took over care of R. CNA was immediately removed from floor. DON (Director of Nursing) & Admin(istrator) notified, who notified State & Police. MD also sent notification. I left msg (with) an ans. mach of son/POA (power of attorney) @ 1000 (10 a.m.) to please call facility back. Attempted to reach POA again @ 1550 (3:50 p.m.) (with no) contact. R denies pain. (No) visible skin tears or bruises." A note by the Social Services Assistant dated two days after the above incident (9/27/10), read, "Visited with resident after a report came in of verbal abuse with a staff member. Resident stated she knows her feelings (were) hurt. She doesn't remember what happen(ed)." d. Resident Interview Resident #2 was interviewed on 10/6/10 at 2:20 p.m. She did not seem to remember the 9/25/10 incident. She was observed with a dressing on her right arm, and when asked what happened, she said, "She works here. She squeezed my arm and I told her she was hurting me and she kept doing it. She is not a very pleasant person." (Cross-refer to F323, failure to provide safe transfer assistance.) e. Staff Interview CNA #2, who was present during the incident above, was interviewed the morning of 10/5/10. CNA #2 said she recalled CNA #1 "made mean comments" about residents at break time, using terms like "f---ing retard" and "[***] " to describe residents. Regarding what occurred on 9/25/10, CNA #2 said she was getting ready to transfer resident #2. CNA #1 had her hand on the back of resident #2's head; resident #2 was slapping at CNA #1, and said it felt like she was "breaking her neck." CNA #1 said, "I wish I could break your neck." CNA #2 told CNA #1 that she would finish the transfer, so CNA #1 moved to the sink, turned on the water, and said she couldn't stand resident #2 that she "f---ing hated her" and that "she (resident #2) is a [***] ." Both CNAs left the room together and CNA #2 went to the Unit Manager to report the incident. 2. Resident #1 - Physical Abuse by CNA #1 Resident #1, an [AGE] year-old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. MDS According to his 9/10/10 MDS, resident #1 had short-term and long-term memory problems, and moderate cognitive impairment. He exhibited repetitive physical movements, was verbally and physically abusive, and resisted care. He needed extensive, two-person assistance with bed mobility, transfer, ambulation, and toilet use. He was unable to stand without physical help, and his balance was unsteady while sitting. He had range of motion limitations and partial loss to both hands and arms, frequent mild pain, was 68 inches tall, and weighed 155 pounds. He was receiving hospice care. b. Care Plan The resident's care plan, in pertinent part, included the following: - "Explain all cares prior to starting and converse with resident while providing cares" (undated). - "Comfort measures only: Keep resident comfortable" (4/6/10). - "Pain/Discomfort: Actual, related to recent fall, joint pain, musculoskeletal...Provide positioning/support, assistive devices/braces, relaxation/meditation" (4/6/10). - "ADL (activities of daily living) - dependent. He needs extensive to total assist w/ ADLs related to decreased mobility and cognitive deficits. Utilize mechanical lift for transfers needing significant weight-bearing assistance" (9/9/10). c. Nursing note documentation of physical abuse by CNA #1 A nurse's note dated 9/25/10 at 3:32 p.m. read, "R (resident) was being assisted from bed to w/c (wheelchair) by two CNAs. CNA (#3) alleges that other CNA (#1) 'slammed' R into chair. CNA removed from floor by DON & Unit Manager. CNA relieved of duty pending investigation. Administrator notified, police notified, State notified. I spoke (with) daughter regarding incident. Expressed that R was not harmed, (no) skin tears or bruising visible. R denies pain & also (no) non-verbal s/s (signs/symptoms) pain. Daughter stated she does not want this CNA working (with) her father anymore." d. Interviews CNA #3 was interviewed on the morning of 10/5/10. She said on 9/25/10 at about 6 a.m. they went to resident #1's room. CNA #1 got his clothes and "put the bed in the high position. CNA #3 asked her to lower the bed a little bit and CNA #1 at first said, 'If you don't like the way I do it go get someone else to help you' with attitude and an unpleasant tone. She looked mad when she first got to work that morning." CNA #3 said they finished dressing the resident and went to put him in his chair. CNA #1 did not lower the bed; with a swinging/slinging motion, she "slammed (resident #1) into the chair and his eyes went wide open. She did not apologize or anything to the resident." At that point CNA #3 walked out and went directly to the unit manager to report the incident. The unit manager (UM) was interviewed on the morning of 10/5/10. - The UM said she had heard reports from other employees that CNA #1 was "short and rude with both employees and residents," but she did not hear any of that prior to 9/25/10. She said at 6 a.m. she got report from the night nurse, checked staffing and was short one CNA on the other hall. The hall CNA #1 was working on was not short staffed. - The UM said she said "good morning" to CNA #1 and she did not answer, had her head down and kept walking. At 6:30 a.m., "I heard (CNA #1) call a (female) resident fat," said it behind her back, and she wasn't sure if the resident heard her or not. The UM said she pulled CNA #1 aside and asked her if she was ill or in a bad mood. CNA #1 said she would be okay, she was just under a lot of stress. She thought she was going to have a full time position and the Director of Nursing (DON) told her she was still looking into it. She was PRN (as needed). Then they both went back to work; the UM said she was keeping an eye on CNA #1. - The UM said that at approximately 7 or 7:30 a.m., CNA #3 approached her and said CNA #1 had been rough with resident #1. The UM said she would find CNA #1 and talk to her, but said she didn't see CNA #1 until after breakfast, and by then had been approached by another CNA (#2). The UM said CNA #2, who was the hall monitor and was assigned to the floor during breakfast, asked to talk with her in private. At this time, CNA #1 was in the dining room assisting residents. - The UM said that after breakfast, at approximately 8:30 a.m., she and CNA #2 went outside and CNA #2 told the UM what CNA #1 had said to resident #2. CNA #2 was in the room because CNA #1 had asked her to come in with her and said, 'I don't want to get fired today.' CNA #2 said resident #2 said she doesn't like CNA #1. CNA #2 said she then took over the care of resident #2 and CNA #1 went to the sink and was making comments and cursing. - The UM said she then called the DON, who had since gone home, and said she was pulling CNA #1 off the floor and the DON said she would come in to help. The UM said she told CNA #1 she was pulled off the floor for allegations of abuse and she was to be off until the incident was investigated. CNA #1 then denied the allegation and said CNA #2 would back her up. CNA #1 wrote a statement denying the allegations, made no other comment, and was escorted out of the building. Resident #1's family member was interviewed on 10/6/10 at 4 p.m. She said the facility called her at about 2 p.m. after the early morning incident of CNA #1 lifting and slamming the resident into a chair. The facility told her that the incident had occurred at about 6:30 a.m. She said the family did get a copy of the police report and wanted to know if CNA #1 had been reported to the licensure board (Board of Nursing). She said she was told CNA #1 had verbally abused a resident and then been rough and flung her dad into his wheelchair. The family member said she didn't think resident #1 remembered the incident, and "even if he did, he probably could not find the words to express that." During interviews on 10/5/10, 10/6/10 and 10/27/10, the DON and Nursing Home Administrator (NHA) said CNA #1 was terminated effective 9/25/10, and would not be rehired. However, record review and interviews revealed the facility had knowledge upon hiring CNA #1 that she had been accused of abusing a nursing home resident at the facility where she worked before. Cross-refer to F225, failure to adequately screen employees prior to hire, failure to report and thoroughly investigate abuse allegations, and failure to protect residents from abuse.

Based on resident and staff interview and record review, the facility failed to adequately screen staff prior to hire, provide monitoring and supervision to protect residents when staff were hired with problematic backgrounds, failed to thoroughly investigate abuse allegations, failed to report abuse allegations to appropriate state agencies, and failed to investigate misappropriation of property allegations. Four of 15 sample residents (#1, #2, #3, #4) and several additional residents who participated in group interviews and investigative interviews were subjected to inappropriate and/or abusive behavior by facility staff, and/or misappropriation of property. The facility failures in screening staff and investigating allegations of alleged mistreatment contributed to incidents of abuse involving two of 15 sample residents (#1, #2) on 9/25/10. Cross-reference F223; abuse. The findings included: A. Facility Policies and Procedures 1. "According to the (corporate) policy and procedure manual (in pertinent part): - Every resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, neglectful acts, and involuntary seclusion. - All potential employees will be screened for history of abuse or mistreatment of [REDACTED]. - All residents and employees will be encouraged to report concerns, incidents and grievances without fear of retribution. - Corrective actions of incident reports will be reviewed for patterns/trends of events that could constitute abuse and determine if investigation is warranted. - Administrator and Director of Nursing are to monitor and assess staff for signs of burnout, frustration or stress." 2. The Hiring Process Policy, dated 2/15/09, provided in pertinent part: - "(The corporation) will participate in obtaining background and criminal record checks for all new hires...The information will be analyzed to determine whether any past offenses could legitimately endanger our residents. This information will be strictly confidential and won't be used against a potential applicant other than for the protection of the residents and in compliance with state and federal law." - "Background and criminal record information on applicants is used as a critical step in the employment process. Employment of an individual is contingent upon the result of the background check." 3. The Abuse Prohibition and Prevention policy in pertinent part defined abuse as follows: - "Verbal Abuse: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Examples of verbal abuse include, but are not limited to threats of harm; saying things to frighten a resident, or conversation that would make the resident uncomfortable." - "Neglect: Means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." - "Physical Abuse: Includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment." 4. Employee Screening: All potential employees will be screened for history of abuse, neglect or mistreatment of [REDACTED]. - "The Administrator will review the results." - "All prospective employees will be checked for a history of abuse through the state nurse aide registry or (blank)." - "The Department Manager and Administrator will be immediately notified of all reports indicating a previous history of abuse." B. Facility Failures 1. Inadequate staff screening contributing to resident abuse a. Cross-refer F223; Abuse. - Record review and interviews revealed on 9/25/10, CNA #1 verbally abused resident #2, an [AGE] year-old female; and physically abused resident #1, an [AGE] year-old male. Review of resident #2's record revealed a nurse's note on 9/25/10 at 3:44 p.m. that read in pertinent part, "R (resident #2) being assisted out of bed this morning by CNA. R told CNA her arm was stuck behind head & stated 'Are you trying to break my neck?' CNA (#1) allegedly responded 'I wish I could.'" - Review of resident #1's record revealed a nurse's note on 9/25/10 at 3:32 p.m. that read in pertinent part, "R (resident) was being assisted from bed to w/c (wheelchair) by two CNAs. CNA (#3) alleges that other CNA (#1) 'slammed' R into chair." b. Record review and Nursing Home Administrator (NHA) interview revealed the facility had knowledge upon CNA #1's hire that she had been "terminated pending investigation" from her previous employment at another nursing home for investigation of abuse. However, CNA #1 was hired without monitoring and supervision, worked PRN (as needed) on day shifts and night shifts. Specifically: (1) Record review - Review of CNA #1's employee record revealed she noted on her application, dated 3/15/10, that she had worked at another nursing home from 1/03 to 8/09, and was "terminated pending investigation." She noted she was eligible for rehire. - A copy of CNA #1's Board of Nursing (BON) verification revealed her license was active. A letter from the BON, dated 3/11/10, noted a case against CNA #1 had been dismissed "finding there was no reasonable cause to warrant further action on the complaint." - An undated, unsigned note in CNA #1's record read, "Under investigation by State for attempted smothering resident - criminal investigation dismissed." - The human resources department from her previous employer, on 4/9/10, was noted to respond to a reference request as follows: "Per company policy - I can confirm dates of employment, title and salary. Thank you." The question, "Would you rehire?" was not answered by the previous employer. There was no evidence the former Director of Nursing (DON), who documented the reference checks, called the DON at the resident's former place of employment. (2) Interview The NHA, interviewed on 10/27/10 at 9:30 a.m., said the former DON brought to his attention that he might hear some things about CNA #1, but they were not true. He said he left the nursing department hiring decisions up to the DON and did not review each and every new hire. He did not review the background information on CNA #1. The current DON stated during the interview with the NHA, "I don't think the application was reviewed appropriately or thoroughly - the proof is in the pudding." The DON said CNA #1 was in their database as non-rehireable. "She was verbally disgusting...She got so audacious, she got bolder and bolder. The aides reported her - they did the right thing." The DON said some of the CNAs came forward after the 9/25/10 incident and said they had observed some inappropriate staff treatment of [REDACTED]. 2. Inadequate monitoring and supervision a. Review of CNA #1's timesheets, from her hire on 4/26/10 until her termination on 9/25/10 at 8:57 a.m., revealed she worked day, evening and night shifts. In fact, on her second day of employment, 4/28/10, she worked the night shift from 10 p.m. to 6 a.m. She worked that same night shift on 4/29, 4/30, and 5/3/10, and several times throughout her employment. b. During an interview on 10/27/10, the NHA and current DON said CNA #1 was not under a supervision plan during her employment at the facility. The DON said she herself had not worked in the facility very long, and when she was notified fairly recently who CNA #1 was, and the CNA's history, she began positioning herself where she could observe CNA #1's interactions with residents. However, she said there was no formal monitoring and supervision for CNA #1 beyond the typical staff supervision. c. Unit Manager (UM) interview on 10/5/10 (see below) revealed she and the DON were aware CNA #1 was angry and had called a resident "fat" the morning of 9/25/10, before verbally abusing resident #2 and physically abusing resident #1. In the interview on 10/5/10, the UM said she said "good morning" to CNA #1 early the morning of 9/25/10 and CNA #1 did not answer, had her head down and kept walking. At 6:30 a.m., "I heard (CNA #1) call a (female) resident fat." CNA #1 said it behind the resident's back, and the UM said she wasn't sure if the resident heard her or not. The UM said she pulled CNA #1 aside and spoke to her with the Director of Nursing (DON). The DON asked her if she was ill or in a bad mood. CNA #1 "said she would be okay, she was just under a lot of stress. She said she thought she was going to have a full-time position; the DON told her she was still looking into it." The UM said CNA #1 was PRN. Although the UM said she was "keeping an eye on CNA #1," about an hour later, she received reports from CNAs #2 and #3 that resident #1 had abused two residents. 3. Inadequate response to inappropriate and abusive behavior by CNA #1 before and after incidents on 9/25/10. a. Prior knowledge of CNA #1 inappropriate and abusive behavior CNA #2, who was present during the 9/25/10 verbal abuse incident involving resident #2 was interviewed the morning of 10/5/10. CNA #2 said she recalled CNA #1 "made mean comments" about residents at break time, using terms like "f---ing retard" and "[***] " to describe residents. Regarding what occurred on 9/25/10, CNA #2 said she was getting ready to transfer resident #2. CNA #1 had her hand on the back of resident #2's head; resident #2 was slapping at CNA #1, and said it felt like she was "breaking her neck." CNA #1 said, "I wish I could break your neck." CNA #2 told CNA #1 that she would finish the transfer, so CNA #1 moved to the sink, turned on the water, and said she couldn't stand resident #2, that she "f---ing hated her" and that "she (resident #2) is a [***] ." CNA #3 was interviewed on the morning of 10/5/10. - CNA #3 said on 9/25/10 at about 6 a.m., she and CNA #1 were assisting resident #1. When CNA #3 asked CNA #1 to lower the bed a little bit, CNA #3 said "CNA #1 at first said, 'If you don't like the way I do it go get someone else to help you' with attitude and an unpleasant tone. She looked mad when she first got to work that morning." - CNA #3 said they finished dressing the resident and went to put him in his chair. CNA #3 said that CNA #1 did not lower the bed; but with a swinging/slinging motion, she "slammed (resident #1) into the chair and his eyes went wide open. She did not apologize or anything to the resident." The UM was interviewed on the morning of 10/5/10. She said she had heard reports from other employees that CNA #1 was "short and rude with both employees and residents," but she did not hear any of that prior to 9/25/10. However, the UM further went on to state during the interview: - The UM said she said "good morning" to CNA #1 early the morning of 9/25/10 and CNA #1 did not answer, had her head down and kept walking. At 6:30 a.m., "I heard (CNA #1) call a (female) resident fat." CNA #1 said it behind the resident's back, and the UM said she wasn't sure if the resident heard her or not. The UM said she pulled CNA #1 aside and spoke to her with the Director of Nursing (DON). The DON asked her if she was ill or in a bad mood. CNA #1 "said she would be okay, she was just under a lot of stress. She said she thought she was going to have a full time position; the DON told her she was still looking into it." The UM said CNA #1 was PRN." - The UM said they went back to work, and she was keeping an eye on CNA #1. About an hour later, she received reports from CNAs #2 and #3 that resident #1 had abused two residents. Additional CNAs who worked with CNA #1 were interviewed on 10/5/10 at approximately 10:45 a.m. They made the following comments, in pertinent part: - "Yes, I worked the floor with (CNA #1) maybe two or three times. She was bubbly and upbeat, but in a sarcastic way. She was quick and to the point with resident care - it was just a job. I never did observe any inappropriate care or comments to residents; only her sarcasm." - "(CNA #1) and I worked together once in awhile, but not very often. She just wanted to hurry and get things done and didn't take time to do all the care that needed to be done. She'd make comments like, 'That resident is such a pain in the ass,' but she made the comments out of the room and residents did not overhear her say those things." - "Yes, I saw it in the paper (CNA #1's abuse incident at a facility where she worked before), and knew about the issues. We didn't talk about it. I worked on the same hall as (CNA #1) a few times." The CNA said she did not observe any inappropriate behavior from CNA #1. - "Yes, I worked with (CNA #1). She picked up (residents) by their arms & swung them. In the dining room one time (CNA #1) told a resident you might as well be quiet. (She was) rude to co-workers, (we) couldn't find her at times during work. Yes, I heard about her when she first came to work here. I couldn't believe they even let her work here. I don't care if the charges were even dropped, if she was working here I wouldn't put my grandparent in here." b. Inadequate monitoring and reporting of CNA #1's resident abuse on 9/25/10. (1) Monitoring See above; failure of UM to monitor CNA #1 on 9/25/10 after observing the CNA's inappropriate behavior. (2) Reporting Interviews with the state ombudsman and county adult protective services (APS) on 10/5/10 revealed they were informed of the abuse incidents by the police department, not by the facility. During an interview on 10/27/10, the NHA said notification of the ombudsman and APS was not included in their facility policy for reporting. He said he did report CNA #1 to the police, state occurrences department and the board of nursing (BON). However, review of prior occurrences and facility investigations revealed inadequate investigations, resident protection and reporting (see below). Moreover, review of the facility's BON report on CNA #1 by the NHA revealed it was not filed until 10/5/10, ten days after the 9/25/10 abuse incidents, and not until health department onsite investigation began. 4. Inadequate report of previous abusive incident Resident #3, a [AGE] year-old woman with [DIAGNOSES REDACTED]. She had short-term and long-term memory problems and modified cognitive independence. According to occurrence report review and nurses' notes in her medical record, resident #3 was found by a CNA on 12/22/09 at her bedside "sitting in shower chair - bed sheet across her lap & tied to shower chair, 2nd sheet across her forehead & tied to back of shower chair. Bath blanket covering resident. Call light (not) within reach. CNA reports resident was transferred from shower room to room by bath CNA. Floor CNAs assisting resident. This writer reported situation to DON." The occurrence report dated 12/22/09 read, "Bath aide returned resident to her room and left her unattended for about 20 minutes. No injuries." The bath CNA (CNA #4) was reported to the state occurrence department for neglect, but there was no evidence CNA #4 was reported to the BON. The report noted the physician, ombudsman and family/guardian were notified, but not the BON. Under follow-up reports, the facility was noted to state on 12/30/09, they were "awaiting to hear from Dept of Health. Bath aide remains suspended." On 1/6/10, the facility reported to state occurrences, "We have this position in limbo. We have the bath aide on suspension pending the outcome and response from the state. Please advise. We need to bring aide back or terminate her and hire someone for this position." The state occurrences response on 1/6/10 was, "Please clarify what response you are waiting for? We do not determine the outcome for the employee. It is the facility's responsibility to conduct an investigation and when it is concluded, to determine appropriate personnel action." On 1/19/10, the facility responded, "No problem. We took care of it ourselves." On 1/28/10, state occurrences emailed, "What did you do regarding the bath aide - bring her back or terminate? Is she returned, what training/supervision is being provided?" There was no evidence of a response from the facility. Resident #3 was interviewed on 10/6/10 at 2:40 p.m. She said she remembered the incident above, and stated she was "naked, in a sheet, wet" and the "sheet around my waist was tied." She said the CNA had tied her to the shower chair and said she would be back, and never came back. "Two others" found her and assisted her, she said. Asked how that made her feel, she said, "Mad, and no control." During an interview with the NHA on 10/27/10 at 1:45 p.m., he said CNA #4 had been terminated. Asked if she was reported to the BON, he said she was not. Asked why, he said he was not directed to by the state occurrences department, and the allegation was neglect, not abuse. 5. Failure to thoroughly investigate, follow up on resident statements, and report allegations of mistreatment. Further review of occurrence reports revealed CNA #5, a bath aide, was reported for physical abuse on 5/5/10 against three residents: a [AGE] year-old female, a [AGE] year-old female, and an [AGE] year-old male. At the time of the complaint investigation, two of the residents no longer resided in the facility and one resident was not interviewable. The allegations were as follows: a. One resident, when a nurse asked about the "ecchymotic sites from knees to ankles, anteriorly," said, "I don't move my legs fast enough in the bath. I have to hit my legs to get them to move." b. Regarding the second resident, a nurse reported she witnessed CNA #5 "attempt an unsafe transfer (no footwear) with this resident...and used an inappropriate tone of voice with the resident. The resident's family has complained that (CNA #5) uses water temps that are too hot and scrubs too hard." c. The third resident "complained to the visiting hospice CNA that her bath aide was very rough on her skin and put hot water on her." The first and third residents did not recall the incidents, and the second resident was "angry at (the) bath aide." Resident interviews included in the facility investigation revealed the following comments: - A staff person (first name listed only, no title) "is rude." - "Bath person won't give her a shower - she puts her in the tub. She just drops me in the chair and it hurts my back. She's mad cause I want a shower not a bath. She sets me down real hard. My back and bottom hurts. She is rude. Resident stated I will not take a bath, I want a shower." - "Scared when bath is given but aid is caring. I don't like the chair, going up in the air." - "Baths are neglectful. Have not had a bath at all this week. I had one last Thursday the 6th (5/11). Baths will go good for a week or two then none for a week or so." - "Bath - I never had a bath like that before. The bath aid scares me. Rushes me. I am slow, she rushes me. I don't move fast, enough time to move." There was no evidence the facility further investigated the residents' statements about feeling fearful, or about staff rudeness, mistreatment, roughness, and neglect. The facility's conclusion was that the allegation was "unsubstantiated." No plan for monitoring and supervision of CNA #5 was documented. The BON was not notified of the allegations of physical abuse and neglect. There was insufficient evidence of follow-up to ensure residents were protected. The DON was interviewed at 9:30 a.m. on 10/27/10 regarding CNA #5. She said she was not aware of any monitoring and supervision plan for her, but she had not had one complaint about her. She said she had been watching her because of some personnel issues, but added that once the expectations were set out, "She's absolutely been an all star employee." However, at the time the incidents occurred, the facility did not ensure proper investigation, resident safety, and reporting. d. Current Resident Statements - Resident-Staff Interactions A resident group interview was conducted on 10/6/10 with five residents chosen by the facility. When asked if staff treated them well, residents responded, "Depends on who is working." All the residents agreed with this statement. Residents made no specific comments about CNA #1; however, they made the following pertinent comments regarding staff treatment: - "The lunch room lady is not very nice. Very short in tone, and (will say) 'Can't you see I am busy?' or she will ignore you, or throw your plate on the table." - "Some (staff) are excellent and some are not. I was stuck for an hour the other day. If you use the mechanical lift they will leave you sitting too long." - "Staff? Not enough. We need more CNAs. An older lady on the night shift will throw the covers back and say, "Are you wet?!" - "It takes a long time for help during the night shift." - "The CNAs tell you they are real busy and you can hear all the lights going off." - "I have to wait for an hour on the night shift to get a nurse for my medications." - "I can't find my call light at times - it's out of reach." The residents said they had shared the issues on call lights and dietary staff with the facility. They did not say the other concerns had been reported. Review of Resident Council Minutes revealed the following: - On 10/13/10, minutes included a complaint about problems with a dietary aide who the resident stated "doesn't like them." The documented follow-up, dated 10/19/10, read, "We have changed the way we serve food. (Dietary aide) only works three days plus she doesn't really serve the food any more. Interview resident 10/19, stated that the dietary aid has not worked here for awhile and everyone else was real nice." There was no evidence of further investigation. - On 9/1/10, minutes included a complaint about "not enough CNAs after 10 p.m. There was no evidence of a follow-up investigation. - On 7/1/10, minutes included a complaint that "aides are slow answering call lights." There was no evidence of a follow-up investigation. - On 6/3/10, minutes included a complaint about inappropriate staff behavior. The documented follow-up on 6/7/10 was a plan to conduct a "total staff in-service...on 6/21/10." 6. Misappropriation of Resident Property The facility failed to document and protect resident possessions thoroughly and timely investigate when possessions were reported missing, report investigative findings to residents and families, identify patterns by tracking and trending, and reimburse or replace items as appropriate. The surveyor requested written evidence of thorough investigations into the allegations and occurrences above. The SSD, during an interview at 2:55 p.m. on 10/27/10, said she would need to check with the NHA for this documentation. At approximately 4 p.m. on 10/27/10, the NHA said he would need to continue going through those records with the SSD. He was asked to fax copies of those investigations by the following day, 10/28/10, and he agreed. However, on 10/28/10 at 2:40 p.m., he sent an email stating in pertinent part that the records were part of the facility's quality assurance process and he could not provide copies. Cross-reference F166; failure to timely respond to resident grievances, for detailed findings.