Every finding on record at Lakeside Post Acute

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen.Specifically, the facility failed to: -Ensure kitchen equipment was clean (microwave and blenders), and; -Store food items under sanitary conditions.Findings include:I. Failure to ensure kitchen equipment was clean (microwave and blenders)A. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 6/30/26. It revealed in pertinent part, Equipment food-contact surfaces and utensils shall be clean to sight and touch. The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. (4-601.11)B. Facility policy and procedureThe Sanitization policy, revised November 2022, was provided by the nursing home administrator (NHA) on 6/25/26 at 4:00 p.m. The policy read in pertinent part, All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. When cleaning fixed equipment (mixers, slicers, and other equipment that cannot readily be immersed in water), the removable parts are:-Washed and sanitized and non-removable parts cleaned with detergent and hot water, rinsed, air-dried and sprayed with a sanitizing solution (at the effective concentration); and,-The equipment is reassembled and any food contact surfaces that may have been contaminated during the process are re-sanitized (according to the manufacturer's instructions).C. ObservationsThe initial kitchen tour was conducted on 6/22/26 at 8:53 a.m. and the following was observed:-The blender located next to the microwave had food debris that was yellow and sticky on the motor base of the blender. -The microwave located by the steam table had sticky food debris on the interior walls and the ceiling of the cooking cavity.-The blender located near the spice jars shelves had thick, sticky accumulation of food residue built up on the motor base of the blender.A follow-up kitchen tour was conducted on 6/23/26 at 8:51 a.m. and the following was observed:-The blender located next to the microwave remained soiled with food debris on the motor base. -The microwave located by the steam table remained soiled inside.-The blender located near the spice jars shelves remained soiled with food debris on the motor base. D. Staff interviewsDietary aide #1 was interviewed on 6/25/26 at 9:44 a.m. Dietary aide #1 said kitchen staff were responsible for cleaning any equipment they used. He said kitchen staff should clean the entire equipment after use including the blender because sometimes spills could occur. Dietary aide #1 said the cook was primarily responsible for cleaning the blender since the cook used it most frequently. He said failure to properly clean kitchen equipment could result in contamination with germs. Dietary aide #2 was interviewed on 6/25/26 at 10:14 a.m. Dietary aide #2 said there was a kitchen cleaning schedule with assigned responsibilities for kitchen staff. She said the cook was responsible for cleaning the blender after use. Dietary aide #2 said other staff could clean the kitchen equipment when requested. She said having dirty kitchen equipment was not sanitary.Cook #1 was interviewed on 6/24/25 at 8:50 a.m. [NAME] #1 said kitchen staff should clean the kitchen equipment after each use. He said the blender was used to prepare ingredients and the removable components were cleaned after use. [NAME] #1 said the microwave was cleaned twice a day or whenever it became dirty after use. He said the kitchen night crew was responsible for cleaning the kitchen equipment; however, all kitchen staff were expected to clean any equipment after use.The NHA was interviewed 6/25/26 at 1:54 p.m. The NHA said there was a cleaning kitchen schedule with assigned responsibilities for kitchen staff. He said staff were expected to adhere to it. He said he was unsure why there were two blenders in the kitchen because it created unnecessary cleaning responsibilities. The NHA said he would provide in-service training to dietary aides, cooks, and all kitchen staff on proper cleaning of kitchen equipment.II. Failure to store food items under sanitary conditionsA. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 6/30/26. It revealed in pertinent part, Food shall be protected from contamination by storing the food in a clean, dry location where it is not exposed to splash, dust, or other contamination and at least six inches above the floor. (3-305.11)B. Facility policy and procedureThe Food Receiving and Storage policy, revised November 2022, was provided by the NHA on 6/25/26 at 4:00 p.m. The policy read in pertinent part, Foods shall be received and stored in a manner that complies with safe food handling practices. Food in designated dry storage areas are kept at least six inches off the floor (unless packaged for case lot handling, for example, dollies, pallets, racks and skids) and clear of sprinkler heads, sewage/waste disposal pipes and vents.C. ObservationsThe initial kitchen tour was conducted on 6/22/26 at 8:53 a.m. and the following was observed:- One box containing cans of tomato sauce was on the floor in the dry storage room.- Three packages of tortillas were on the floor underneath a shelf in the corner of the dry storage room.A follow-up kitchen tour was conducted on 6/23/26 at 8:51 a.m. and the following was observed:- The box containing cans of tomato sauce remained on the floor in the dry storage room.- The three packages of tortillas remained on the floor underneath a shelf in the corner of the dry storage room.D. Staff interviewsDietary aide #1 was interviewed on 6/25/26 at 9:44 a.m. Dietary aide #1 said all kitchen staff were responsible for placing food items on the shelves after deliveries including the dietary manager. He said if food items were observed on the floor and the packaging were opened, they would throw them away. Dietary aide #1 said if boxes were found on the floor, they should be removed off the floor and placed on the shelves. He said he picked up the three packages of tortillas observed on the floor and threw them away. Dietary aide #1 said storing food items on the floor was not sanitary.Cook #1 was interviewed on 6/25/26 at 10:10 a.m. [NAME] #1 said every kitchen staff member was responsible for ensuring food items in the dry storage room were stored off the floor. He said if he noticed an opened food item on the floor, he would throw it away. [NAME] #1 said he did not pay attention to the three packages of tortillas or the box containing cans of tomato sauce being on the floor in the dry storage room.The NHA was interviewed 6/25/26 at 1:54 p.m. The NHA said kitchen staff should check the dry storage room daily to ensure food items and boxes were stored off the floor. He said he would provide an in-service training to dietary aides, cooks, and all kitchen staff on proper food storage.

Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life, and resident safety.Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to its infection prevention program.Findings include:I. Cross-referenced citationsCross-reference F880: 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. The facility failed to ensure housekeeping staff followed appropriate infection control procedures when cleaning and disinfecting residents' rooms and high frequency touched areas (call lights, door handles and handrails), ensure housekeeping staff followed disinfectant dwell times (amount of time required to ensure germs are eliminated) when cleaning residents' rooms, ensure housekeeping staff performed appropriate hand hygiene between glove changes and after cleaning residents' toilets and ensure housekeeping cleaned only the toilet bowl with the toilet brush. The facility failed to ensure staff wore the appropriate personal protective equipment (PPE) when providing care for residents requiring device care who were on enhanced barrier precautions (EBP). The facility failed to ensure staff performed appropriate hand hygiene when moving from dirty to a clean task. Cross-reference F945: The facility failed to provide annual infection prevention and control training to staff members. A total of 36 out of 77 staff members did not receive annual training required for infection prevention and control. Infection prevention failures existed throughout the facility including cleaning of resident rooms inappropriately, failing to wear appropriate personal protective equipment (PPE) for residents on EBP, and appropriately completing hand hygiene. II. Facility policy and procedureThe Quality Assurance and Performance Improvement policy and procedure, revised February 2020, was received from the regional director of clinical services #2 on 6/23/26 at 11:24 a.m. It read in pertinent part, This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include tracking and measuring performance, establishing goals and thresholds for performance measurement, identifying and prioritizing quality deficiencies, systemically analyzing underlying causes of systemic quality deficiencies, developing and implementing corrective action and monitoring the effectiveness of corrective action.III. Staff interviewsThe nursing home administrator (NHA) and regional director for clinical services #2 were interviewed on 6/25/26 at 12:30 p.m. The NHA said infection control was identified during QAPI as an area in need of improvement in April 2026. The NHA said there was a performance improvement plan (PIP) started, but not followed through with. The NHA said there were supposed to be weekly infection prevention audits but they were not being completed. The NHA said there was not a root cause identified for the infection prevention deficiencies. The NHA said the staff training for infection prevention was not identified in QAPI.

Based on record review and interviews, the facility failed to provide infection prevention and control program mandatory training for all staff, which included, training on the standards, policies, and procedures for the infection prevention and control program that was appropriate and effective, and as determined by staff need.Specifically the facility failed to provide annual infection control training to 36 out of 77 staff members.Findings include:I. Training record reviewA request was made for the facility's annual infection control training records for all active staff members on 6/24/26.On 6/24/26 at approximately 10:00 a.m. the nursing home administrator (NHA) provided the records for all active staff members who had completed annual infection control training. The records revealed 36 out of 77 staff members had not completed the facility's annual infection control training.-The facility failed to ensure all active staff members completed the annual training for infection control.Cross-reference F880: failure to use the correct disinfect, the proper cleaning technique, and proper hand hygiene during the resident room cleaning.II. Staff interviewsDietary aide #1 was interviewed on 6/25/26 at 9:52 a.m. Dietary aide #1 said he completed required training on an online training platform, which included abuse and neglect training, but could not recall whether he had completed the infection control training. Dietary aide #1 said he attended an all-staff meeting that included a demonstration on the proper use of personal protective equipment (PPE).Certified nurse aid (CNA) #6 was interviewed on 6/25/26 at 10:53 a.m. CNA #6 said she received a PPE training during an all-staff meeting. She said she had completed some training on an online platform, but she was unsure whether infection control training was among them. CNA #6 said she was unable to locate documentation verifying completion of infection control training.The human resources director was interviewed on 6/25/26 at 1:20 p.m. The human resources director said she was responsible for tracking staff training completion on the online platform. She said she pulled out a report monthly throughout the year to identify staff with incomplete training. The human resources director said she forwarded those reports to the department managers for follow up with staff. She said she reminded staff through a group messaging system to complete all assigned and required training including the infection control training. The human resources director said she was unsure identifying the failure leading staff not to complete their infection control training. She said the infection control training was a requirement for both the company and state regulations to ensure staff were competent to perform their jobs. The human resources director said, going forward, she would recommend pulling staff off the schedule until they completed all required training.The NHA and the director of nursing (DON) were interviewed together on 6/25/26 at 1:54 p.m. The NHA said the human resources director was responsible for tracking staff training completion on the online platform. He said the human resources director would report incomplete training to the NHA. The NHA said the failure to ensure completion of infection control training was a poor follow up from the management team. He said to address the issues, the human resources director should generate reports more frequently, such as weekly or daily if needed until back in compliance. The NHA said they should continue to follow up staff on a daily basis until the training got completed. The NHA said they would text, email, and call staff to remind them completing the training, if necessary taking them off the schedule until completion of the required training. The DON said she was not aware of so many staff missed the infection control training. She said she would get the assistant director of nursing to follow up with staff to ensure completion.

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 on one of three units.Specifically, the facility failed to:-Ensure housekeeping staff followed appropriate infection control procedures when cleaning and disinfecting residents' rooms and high frequency touched areas (call lights, door handles and handrails);-Ensure housekeeping staff followed disinfectant dwell times (amount of time required to ensure germs are eliminated) when cleaning residents' rooms;-Ensure housekeeping staff performed appropriate hand hygiene between glove changes and after cleaning residents' toilets; -Ensure housekeeping cleaned only the toilet bowl with the toilet brush; -Ensure staff performed appropriate hand hygiene when moving from dirty to a clean task; and, -Ensure staff wore the appropriate personal protective equipment (PPE) when providing care for a resident requiring device care who was on Enhanced Barrier Precautions (EBP). Findings include: I. Housekeeping failures A. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, was retrieved on 6/28/26 from https.//pubmed.ncbi.nlm.nih.gov. It revealed in pertinent part, High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease). Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stays, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 6/29/26 from https://www.cdc.gov/healthcare-associated- infections/hcp/cleaning-global/procedures.html?CDC_AAref_Val=https://www.cdc.gov/hai/pre ent/resource-limited/cleaning-procedures.html#cdc_generic_section_2-4-1-general-environmental-cleaning-techniques. It read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs. Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. B. Facility policy and procedure The Cleaning and Disinfecting Residents' Rooms policy, revised August 2013, was provided by the regional director of clinical services on 6/25/26 at 4:00 p.m. It read in pertinent part, Manufacturers' instructions will be followed for proper use of disinfecting (or detergent) products. Disinfecting (or detergent) solutions will be prepared as needed and replaced with fresh solution frequently. Perform hand hygiene after removing gloves. Clean horizontal surfaces (bedside tables, overbed tables, and chairs) daily with a cloth moistened with disinfectant solution. Do not use feather dusters. C. Observations On 6/24/26 at 10:41 a.m. housekeeper (HK) #1 was observed exiting room [ROOM NUMBER]. She did not perform hand hygiene after exiting the room. At 10:46 a.m. HK #1 unlocked the cleaning cart and removed a cleaning tray which contained a mold and mildew spray bottle, a scrubbing pad, a toilet brush and three rags. Without performing hand hygiene, she donned gloves and entered room [ROOM NUMBER] (a double occupancy room) and placed the three rags on the window sill. She placed the cleaning tray on the sink. She emptied the trash next to the sink and placed a new trash bag in it. She then placed the cleaning tray on the top of the trash can. HK #1 sprayed the mold and mildew cleaner into the sink and scrubbed it with the scrubbing pad. She turned on the water and used her gloved hand to rinse the sink with water. She wiped it dry with the first rag. She then used her gloved hand to splash water onto the mirror and wiped it with a paper towel. She dried the sink with a second rag and wiped down the paper towel dispenser and the soap dispenser. She used the first rag to wipe off bed A's overbed table and night stand. She used the second rag to dry them. HK #1 wet the third rag with water and wiped off bed B's overbed table and dropped some of the resident's antacids on the floor. She used her gloved hands and picked the antacids up and placed them back into the medicine cup and placed the medicine cup back onto the overbed table. HK #1 then returned to the cleaning cart to remove the broom and dust pan. She swept the room and picked up the debris and removed her gloves. -HK #1 did not use a disinfectant while cleaning the room or disinfect high touch areas such as the door knobs, light switches, call light and bed controller. HK #1 did not change her gloves and perform hand hygiene after touching the dirty floor with her gloved hands and failed to use a clean rag on each side of the double occupant room. HK #1 removed two mops pads from the mop bucket and rang them out with her bare unwashed hands and dropped them on the floor. Without performing hand hygiene, she donned gloves, placed the mop handle on the first mop pad and mop bed B side of the room and removed the mop pad with her gloved hands. She then placed the mop handle onto the second mop pad and mopped bed A side of the room. She removed her gloves and donned clean ones. -HK #1 did not wash her hands or don gloves when removing the mop pads from the mop bucket solution, after removing the first mop pad from the handle or after removing her gloves. HK #1 removed the mold and mildew cleaner from the tray and emptied the trash. She then sprayed the mold and mildew cleaner on the toilet and the floor around the toilet. She then placed the spray bottle back into the cleaning tray. She removed the toilet brush and scrubbed the toilet bowl, the rim, under the seat, the container used to collect urine that was sitting on the toilet tank, the back of the toilet tank, the back of the toilet lid and the top of the toilet lid. She then used the toilet brush to clean the floor around the toilet. HK #1 used a clean dry rag to wipe off the toilet rim, under the seat, the seat, under the lid, the top of the lid, the tank, the grab bars, the window sill and the handle to open the window. She returned to the cleaning cart, removed two mop pads from the mop bucket and rang them out. -HK #1 did not clean the bathroom from top to bottom/clean to dirty, did not use the toilet brush only for the toilet bowl, did not use a disinfectant while cleaning the bathroom, failed to perform hand hygiene after cleaning the bathroom and failed to remove her dirty gloves before ringing out the mop pads. HK #1 dropped the three mop pads onto the floor and placed the mop handle on the first mop pad and mopped the bathroom. She used her gloved hands to remove the soiled mop pad and placed it into the cleaning tray. She used a second mop pad to mop the bathroom floor a second time and used her gloved hands to remove the mop pad and placed it in the cleaning tray. She removed her gloves and placed the cleaning tray on the cleaning cart. She removed the soiled mop pads from the tray and placed them into a plastic bag. Using her unwashed bare hands she removed a mop pad from the mop bucket and rang it out. She then mopped from the sink to the door. She used her bare hands to remove the mop pad and placed it in the trash bag. She donned gloves and cleaned the bottom of the broom. She removed her gloves and entered room [ROOM NUMBER]. -HK #1 failed to perform hand hygiene after removing her gloves, after touching the soiled mop pads with her bare hands, before removing a new mop pad, after cleaning room [ROOM NUMBER] and prior to entering room [ROOM NUMBER]. -Cross reference F945: failure to provide infection control training. D. Staff interviews HK #1 was interviewed on 6/24/26 at 1:34 p.m. HK #1 said the mold and mildew cleaner had a one minute kill time. She said the mop water contained a cleaner, but she was not sure what the cleaner was. She said she should have performed hand hygiene between glove changes and every chance she had. She said she was nervous and forgot to perform hand hygiene. She said the bathroom should be cleaned last. She said she cleaned the toilet first and then the grab bars. She said the toilet brush should be used for the toilet bowl and the rim. She said she did not know what high touch surfaces were. She said she did not receive infection control training at the facility and went by her previous experience. The maintenance director was interviewed on 6/24/26 at 4:11 p.m. The maintenance director said normally the housekeeping supervisor provided the infection control training to the housekeeping staff; however, the housekeeping supervisor no longer worked at the facility. He said he provided one-to-one education with the HK's individually on hand hygiene and the proper cleaning process. He said the resident rooms should be cleaned from top to bottom and clean to dirty. He said higher areas should be cleaned first down to the floor. He said a clean rag should be used to clean each side of a double occupancy room, the sink and the bathroom. He said he was not sure if the bathroom should be cleaned first or last. He said the toilet brush should only be used to clean the toilet bowl, not the entire toilet or the floor. He said high touch surfaces should be cleaned daily. He said he provided education to HK #1 the prior day on disinfecting high touch surfaces. He said HK #1 should have performed hand hygiene after each glove change and after cleaning the toilet. He said acid bathroom and shower disinfectant should have been used for the bathroom. He said the hydrogen peroxide disinfectant, with a one minute kill time, should have been used to disinfect the room and high touch surfaces. The maintenance director said the facility was short a HK and he instructed HK #1 to just concentrate on the sink, toilet and floors the day of the observation. The director of nursing (DON) was interviewed on 6/25/26 at 9:25 a.m. The DON said hand hygiene should be performed before entering a resident room, upon exiting a resident room, between glove changes and after cleaning the bathroom. She said the toilet brush should only be used inside the toilet bowl and should not be used for cleaning anything else. She said if a rag was used to clean the toilet it should not be used to clean any other surfaces. She said the correct chemicals should be used to ensure the resident rooms were disinfected properly to prevent the spread of infection. She said a different rag should be used to clean each side of a double occupancy room, the sink and the bathroom. She said the room should be cleaned from top to bottom or clean to dirty and the high touch surfaces should be disinfected daily. The infection preventionist (IP) was interviewed on 6/25/26 at 11:46 a.m. The IP said hand hygiene should be done between everything including glove changes and before and after exiting a resident room to avoid cross contamination. She said she had only been the IP for two weeks. She said it was important to use the correct disinfectants as well as kill time or the areas would not be disinfected properly. She said high touch surfaces should be disinfected daily and the room should be cleaned top to bottom and clean to dirty to prevent cross contamination. She said the antacids that fell to the floor should have been thrown away. She said the toilet brush should only be used inside the toilet bowl. She said she would provide education to all staff regarding infection control. II. Ensure staff wore the appropriate personal protective equipment (PPE) when providing care for a resident requiring device care who was on Enhanced Barrier Precautions (EBP) A. Professional reference According to the Center for Disease Control (CDC), Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (4/2/25), retrieved on 6/30/26 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for EBP include device care and use of central lines, urinary catheters, feeding tubes and tracheostomy/ventilator use. B. Facility policy and procedure The EBP policy and procedure, revised December 2024, was received from regional director of clinical services #2 on 6/25/26 at 4:00 p.m. It documented in pertinent part, EBPs are utilized to prevent the spread of MDROs to residents. EBP apply when a resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical device and does not have secretions or excretions that are unable to be covered or contained. Indwelling medical devices include central lines, urinary catheters, feeding tubes and tracheostomies. Examples of high-contact resident care activities requiring the use of gown and gloves for EBP include device care or use. C. Observations During a continuous observation on 6/23/26, from 2:02 p.m. to 2:22 p.m., the following was observed: At 2:02 p.m. registered nurse (RN) #1 was providing care to observed working with Resident #62. RN #1 gathered supplies, entered Resident #62's room, washed her hands, donned (put on) clean gloves and hooked up a syringe to Resident #62's gastrostomy tube (G-tube). RN #1 flushed the tube with water, administered medication and flushed the tube with water. RN #1 administered Resident #62's tube feeding formula and flushed with water. RN #1 plugged Resident #62's G-tube to close it. -RN #1 did not don a gown for high-contact care activities while working with Resident #62's G-tube. III. Ensure staff performed appropriate hand hygiene when moving from dirty to a clean task A. Facility policy and procedure The Hand Washing/Hand Hygiene policy and procedure, revised October 2023, was received from regional director of clinical services #1 on 6/25/26 at 4:00 p.m. It documented in pertinent part, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Hand hygiene is indicated before moving from work on a soiled body site to a clean body site on the same resident. During a continuous observations on 6/24/26, from 11:58 a.m. to 12:16 p.m., the following was observed: Certified nursing aides (CNA) #1 and CNA #2 entered Resident #62's room to provide care and get her up for lunch. CNA #1 washed her hands and donned clean gloves and a gown. CNA #1 entered Resident #62's room and began to provide perineal care. CNA #1 cleaned Resident #62 as she had urine in her brief and a bowel movement in her brief. CNA #2 entered the room and assisted CNA #1 with rolling Resident #62 to get a clean brief under her. CNA #1 secured the clean brief and began to put on Resident #62's pants. CNA #1 and CNA #2 rolled Resident #62 to get her pants pulled up and place a Hoyer (mechanical lift device) sling underneath her bottom. CNA #1 hooked the sling up to the lift device. CNA #1 lifted Resident #62 in the air and CNA #2 guided the wheelchair in place for Resident #62 to sit in. Once Resident #62 was securely in the wheelchair, CNA #1 and CNA #2 removed the Hoyer sling from the lift device and CNA #2 removed the sling from under Resident #62. CNA #1 and CNA #2 changed Resident #62's shirt. CNA #1 cleaned Resident #62's face with a clean washcloth. CNA #1 removed the gloves and gown, washed her hands and stepped out of the room. -CNA #1 did not change her gloves or complete hand hygiene after cleaning Resident #62's perineal area after she had an incontinent episode of urine and bowel movement. D. Staff interviews CNA #1 was interviewed on 6/24/26 at 12:16 p.m. She said she was supposed to change her gloves and wash her hands after completing perineal care on a resident. She said she forgot to do this during the observation. RN #2 was interviewed on 6/24/26 at 1:25 p.m. She said residents with a G-tube should be on EBP. She said a gown and gloves should be worn during device care including administering medications and tube feeding. She said this was important because any access from outside to the inside of someone's body increased the risk of transmitting bacteria into the body. The director of nursing (DON) was interviewed on 6/24/26 at 3:25 p.m. She said EBP were important to protect residents and staff from infections. The DON said staff should wear gloves and a gown when providing high contact care including G-tube device care. The DON said gloves should always be changed after completing a dirty task such as perineal care and hands should be washed. She said this was to prevent cross contamination from bacteria in a dirty task to the next task. The IP was interviewed on 6/25/26 at 11:45 a.m. The IP said hand hygiene was important to be completed after completing a dirty task for basic infection control measures and to prevent cross contamination. The IP said gloves and gowns should be worn when working with residents on EBP. She said residents on EBP were more susceptible to antibiotic resistant bacteria and it was for their protection. She said a gown and gloves should be worn during G-tube care including tube feeding and medication administration. E. Additional observations On 6/24/26 at 9:59 a.m. Resident #6's coccyx wound was observed with LPN #1. There was a sign on Resident #6's door that indicated the resident was on EBP. The sign on the resident's door indicated gloves and a gown must be worn for resident care activities, including dressing, bathing/showering, transferring, linen changes, providing hygiene, changing briefs or assisting with toileting and device care or use, such as central lines, urinary catheters, feeding tubes, tracheostomies and wound care. Gowns and gloves were located in a storage bin outside of the residence room. LPN #1 donned gloves before removing Resident #6 wound dressing. -LPN #1 failed to put on a gown before providing Resident #6 with direct care. On 6/25/26 at 10:08 a.m. LPN #2 was assisting Resident #9 with rolling to his left side, and then to a sitting position on his bed. LPN #2 assisted Resident # 9 with removing his sweater. LPN #2 used his stethoscope to auscultate the resident's left upper arm to check his AV fistula (a surgically created connection between an artery and a vein, used for hemodialysis access). -LPN #2 failed to put on a gown before providing Resident #9 with direct care. F. Additional staff interviews LPN #2 was interviewed on 6/25/26 at 10:10 a.m. LPN #2 said he was unsure if Resident #9 was on precaution. LPN #2 said he checked Resident #9's chart and discovered the resident was on EBP. He said the resident did have a physician's order for EBP. He said he should have worn a gown when providing care and assessing the resident's AV fistula. He said he did not do that because the resident did not have signage on his door indicating he was on EBP. He said the IP was responsible for placing signage on the resident's door and obtaining PPE to be placed outside of the resident's door. The IP was interviewed on 6/25/26 at 11:46 a.m. The IP said any resident who had a wound and/or an implanted medical device would be placed on EBP. The IP said she was responsible for placing EBP signage on the resident's door, placing a storage bin containing PPE outside the resident's room, and ensuring the resident had a physician in the medical records. Said this was important because residents who meet the criteria for EBP were more susceptible to contracting bacteria and developing an infection. She said it was the facility's responsibility to ensure facility staff were following EBP recommendations with all high-contact care. She said LPN #1 and LPN #2 should have donned a gown in addition to donning gloves before providing direct care.

Based on observations and interviews, the facility failed to ensure all drugs and biologics used in the facility were properly stored and labeled for three of four medication carts. Specifically, the facility failed to:-Ensure prescription medications were discarded after the expiration date and after they were discontinued; and,-Ensure personal beverage containers were not stored in resident medication drawers.Findings include:I. Professional referencesThe United States Food and Drug Administration (USFDA) Don't Be Tempted to Use Expired Medicines (revised 10/31/24) was retrieved on 6/26/26 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It read in pertinent part, Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth, and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed, there is no guarantee that the medicine will be safe and effective. If your medicine has expired, do not use it.The PharMerica (1/12/25) abridged list of medications with shortened expirations dates, was retrieved on 6/30/26 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://pharmerica.com/wp-content/uploads/2025/01/PMC-[NAME]-Meds-with-Shortened-Expiration-Dates_012025_FINAL.pdf. It read in pertinent part, Once certain products are opened and in use, they must be used within a specific timeframe to avoid reduced stability, sterility and potentially reduced efficacy. Product-specific storage and expiration details can be found in the drug product's package insert under the 'How Supplied/Storage & Handling' section. A drug product's beyond use date (BUD) is the manufacturer supplied expiration date or the shortened date after opening, whichever comes first. These in-use medications should be labeled such that the date opened is noted, clearly visible and securely attached to a part of the package to not be discarded. This date is to be referenced when auditing to clear medications prior to expiration. The Pharmcare USA's (4/9/23) Medication Disposal Practices in Assisted Living and Long Term Care, was retrieved on 6/30/26 from https://pharmcareusa.com/education/medication-disposal-practices-in-assisted-living-ltc/. It read in pertinent part, When medications are not disposed of correctly, they can pose serious threats to both human health and the environment. Improper disposal can lead to accidental ingestions, overdose and even death. The Highlights of Prescribing Information for Symbicort (budesonide and formoterol fumarate dihydrate) Inhalation Aerosol, for oral inhalation use, was retrieved on 6/30/26 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/205382s013lbl.pdf. It read in pertinent part, Throw away Symbicort when the counter reaches zero ('0') or three months after you take Symbicort out of its foil pouch, whichever comes first.The Highlights of Prescribing Information for Fluticasone propionate, revised January 2019, was retrieved on 6/30/26 fromchrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/020121s045lbl.pdf It read in pertinent part, Do not use your FLONASE nasal spray after the date shown as EXP on the label or box.II. Facility policy and procedureThe Medication labeling and Storage policy, revised February 2023, was provided by regional director of clinical services #1 on 6/25/26 at 4:00 p.m. It read in pertinent part, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The medication label includes, at a minimum: medication name (generic and/or brand); prescribed dose; strength; expiration date; resident's name; route of administration; and appropriate instructions and precautions.III. ObservationsOn 6/23/26 at 12:30 p.m., medication cart #1 on the west unit was observed with licensed practical nurse (LPN) #3.The drawer for Resident #29 contained the following:-Symbicort (budesonide-formoterol) 80-4.5 micrograms (mcg), (a corticosteroid medication used to reduce airway inflammation). The medication was ordered for two puffs twice a day, with 85 doses remaining. The medication did not have an expiration date.On 6/23/26 at 2:58 p.m. medication cart #1 on the north unit was observed with registered nurse (RN) #1. There was a beverage container next to the resident's medication in the second-level drawer. RN #1 removed the beverage container from the medication cart and walked into the medication room. RN #1 left the medication cart unlocked and unattended.On 6/23/26 at 3:10 p.m.medication cart #2 on the north unit was observed with LPN #4. The drawer for Resident #10 contained the following:-Methocarbamol (a medication used to treat muscle pain, spasms, and stiffness) oral tablet 500 milligrams (mg) that had an expiration date of 5/31/26. The expired medication was given to the resident four times on 6/2/26, 6/5/26, 6/6/26 and 6/15/26. The drawer for Resident #5 contained the following:-Fluticasone propionate nasal suspension (a medication used to treat allergies and nasal congestion) 50 micrograms (mcg) over-the-counter medication. The medication did not have an expiration date.IV. Staff interviewsLPN #3 was interviewed on 6/23/26 at 12:33 p.m. She said she always checked the expiration date on all medication before she administered it to a resident. She said she did not notice the inhaler did not have an expiration date on the medication before she gave it to the resident. RN #1 was interviewed on 6/23/26 at 3:02 p.m. She said she was advised to store all personal beverage containers behind the nurses' station. She said she should not store her personal beverage container in the medication drawer to maintain sanitary conditions for the stored medications.LPN #4 was interviewed on 6/23/26 at 3:10 p.m. She said she worked at the facility as an agency nurse. She said she did not know who was responsible for checking the medication carts for expired medications. She said she did not remember checking the medication expiration dates during her shift.The director of nursing (DON) was interviewed on 6/24/26 at 2:23 p.m.: The DON said the facility nursing staff and agency nurses were expected to check the medication storage rooms and the medication carts regularly for expired and discontinued medications. She said the facility pharmacy consultant would come to the facility once a month to audit the medication carts and the medication rooms for expired medication. The DON said in order to ensure the medication drawers were kept clean and sanitary, nursing staff should not store personal beverage containers in the resident medication drawers. She said the facility would conduct an in-service for all facility staff trained to administer medication to check expiration dates.

Based on record review and interviews, the facility failed to provide and document sufficient discharge preparation for two (#57 and #59) of two residents reviewed for a safe and orderly discharge out of 35 sample residents. Specifically, the facility failed to ensure a written discharge bed hold notice was provided to Resident #57 and Resident #59 or their representative at the time Resident #57 and Resident #59 were transferred to the hospital.Findings include:I. Facility policy and procedureThe Bed Hold Notice policy, undated, was provided by the regional director of clinical services on 6/24/26 at 9:59 a.m. It read in pertinent part, It is the policy of the facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave.Bed hold means holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. To include the duration of the State bed hold policy, if any, during which the resident is permitted to return and resume residence in the facility.In the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/or the resident representative within 24 hours. The facility will document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative.II. Resident #57A. Resident statusResident #57, age [AGE], was admitted on [DATE] and discharged to the hospital on 6/12/26. According to the June 2026 computerized physician orders (CPO), diagnoses included chronic kidney disease, hypertension, repeated falls, anxiety disorder and muscle weakness.The 3/26/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. B. Record reviewA nursing progress note, dated 6/12/26 at 9:35 p.m., revealed Resident #57 had an unwitnessed fall in the bathroom with injury to his left middle finger with pain and discomfort. The resident was transferred to the emergency department for evaluation and treatment of the dislocated middle finger. -Review of Resident #57's electronic medical record (EMR) revealed no documentation to indicate Resident #57 and/or his representative were provided with a written bed hold notice at the time of the resident's transfer to the hospital on 6/12/26. III. Resident #59A. Resident statusResident #59, age [AGE], was admitted on [DATE] and discharged [DATE]. According to the March 2026 CPO, diagnoses included chronic respiratory failure, end stage renal disease, heart failure and muscle weakness. The 3/16/26 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 10 out of 15.B. Record reviewA nursing progress note, dated 3/31/26 at 4:21 p.m., revealed the resident was working with restorative therapy in the gym. Resident #59 had appeared to have seizure type activity. A call was placed to the provider and the resident was sent to the emergency room for evaluation and treatment. -Review of Resident #59's EMR revealed no documentation to indicate Resident #59 and/or her representative were provided with a written bed hold notice at the time of the resident's transfer to the hospital on 3/31/26. III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 6/24/26 at 3:07 p.m. LPN #1 said when a resident was transferred to the hospital they should be provided with a bed hold notice. She said if the resident was not able to sign the notice the nurse would document the verbal acceptance of the bed hold notice. She said it was important to provide the resident with the bed hold to ensure the resident's bed was secure for their return. The unit manager was interviewed on 6/24/26 at 3:11 p.m. The unit manager said a resident should be provided with a bed hold notice if they were transported to the hospital. He said the bed hold policy was provided to ensure the resident's bed was held for their return to the facility.The director of nursing (DON) was interviewed on 6/24/26 at 93:15 p.m. The DON said a bed hold notice should be provided to a resident when sent to the emergency department to ensure the bed would be held for them upon return. She said if the resident was not able to sign the form they would notify the responsible party and receive verbal confirmation that the bed hold notification was provided. She said she was not sure why Resident #57 and Resident #59 were not provided with a bed hold notice.

Based on record review, observations, and interviews, the facility failed to ensure residents unable to carry out activities of daily living (ADLs) received necessary services for one (#1) of three residents reviewed for ADLs out of 35 sample residents. Specifically, the facility failed to ensure Resident #1 received scheduled showers.Findings include:I. Facility policy and procedureThe Bath, Shower/Tub policy, undated, revised February 2018, was provided by the regional director of clinical services #2 on 6/25/26 at 4:33 p.m., The policy read in pertinent part, The purposes of this procedure are to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin. Be sure that the bath area is at a comfortable temperature for the resident. Stay with the resident throughout the bath. Never leave the resident unattended in the tub or shower. Use the emergency call signal for assistance, if needed. When transporting the resident to and from the bath area, make sure that the resident is covered and his or her privacy is maintained. Document the date and time the shower/tub bath was performed. The name and title of the individual who assisted the resident with the shower/tub bath. All assessment data (any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath. How the resident tolerated the shower/tub bath. If the resident refused the shower/tub bath, the reason(s). Reporting: Notify the supervisor if the resident refuses the shower/tub bath. Notify the physician of any skin areas that may require treatment. Report other information in accordance with facility policy and professional standards of practice.II. Resident #1A. Resident statusResident #1, age [AGE], was admitted to the facility on [DATE], sent to the emergency room on 5/21/26, and readmitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included traumatic brain injury, cognitive communication deficit, difficulty walking, unsteadiness on feet, obesity, dependence on wheelchair, need for assistance with personal care, cardiovascular accident (stroke), and multiple sclerosis.The 5/31/26 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. He needed substantial to maximal assistance with toileting hygiene, showers and bathing, upper body dressing, sitting to standing, and chair to chair/bed transfer. He was dependent on staff for lower body dressing and putting on and taking off footwear. B. Resident observations and interview Resident #1 was interviewed on 6/23/26 at 11:00 a.m. During the interview, Resident #1 was sitting in his wheelchair in his room, positioned next to his bed. There was an adult brief unfolded, lying on the resident's bed. The resident smelled of urine and stool. The resident had food stains on his shirt. Resident #1 said he received a shower yesterday (6/22/26) for the first time in two weeks. He said he would often go up to two weeks without getting a shower.D. Record reviewThe ADL care plan, initiated 5/19/22 and revised on 7/14/22, revealed the resident had an ADL self-care performance deficit related to CVA with right-sided neglect and multiple sclerosis. Pertinent interventions included scheduling bathing per resident's preferences. Requires extensive physical assistance. Encourage showers at least twice weekly, and if the resident refuses, encourage an alternative time or next shower day. The resident requires one staff maximum assistance with bathing. Offer to clean and trim nails as needed. The resident requires extensive-total assistance with toileting tasks (revised on 6/2/26). Encourage the resident to use the bell to call for assistance as needed.A review of the bathing documentation for May 2026 and June 2026 revealed a preference for showers on Monday and Thursday evenings. Review of the May 2026 bathing documentation indicated the resident received a shower on 5/25/26 and 5/28/26. -It indicated the resident received a shower on two of seven opportunities.Review of the June 2026 (6/1/26 to 6/15/26) bathing documentation indicated the resident received a shower on 6/9/26.-It indicated the resident received a shower on one of five opportunities. -The resident did not receive a shower or bath from 5/29/26 to 6/8/26 (10 days) and from 6/10/26 to 6/21/26 (11 days).-A review of Resident #1's electronic medical record (EMR) revealed no documentation to indicate why Resident #1 did not receive his showers as scheduled.E. Staff interviewsCertified nurse aide (CNA) #7 was interviewed on 6/23/26 at 3:10 p.m. She said if a resident refused a shower, she would have another staff member offer the resident a shower a second time. She said she would document the refusal in the resident point of care section in the EMR. She said the facility had a shower refusal binder. She said if a resident refused a shower, the staff would have the resident sign a refusal sheet and place it in the binder. She said she had not recalled the resident refusing his showers in the past. She said Resident #1 did not refuse showers.CNA #6 was interviewed on 6/24/25 at 11:20 a.m. CNA #6 said Resident #1 required assistance for going to the bathroom and taking his showers. She said Resident #1 was scheduled for showers twice a week. She said if Resident #1 refused a shower, the nursing staff were required to document the refusal in the facility shower refusal binder. She said she was unsure if the resident refused his showers.The director of nursing (DON) and regional director of clinical services #2 were interviewed together on 6/24/26 at 2:42 p.m.The DON said the staff were provided training for bathing hygiene upon hire. She said Resident #1's shower days were Mondays and Thursdays. She said if a resident refused an offer of a shower or a bath, the staff were expected to reapproach the resident and offer the shower a second time. Resident #1 should have received his showers on his scheduled preferred shower days. Regional director of clinical services #2 said she would provide an in-service immediately to the nursing staff to educate them on the facility policy regarding providing resident showers and providing residents prompt incontinence care.

Based on observations, record review and interviews, the facility failed to provide written notification of room changes and roommate changes for one (#18) of four residents reviewed for notifications out of 35 sample residents.Specifically, the facility failed to provide timely written and/or verbal notification of room and/or roommate changes to Resident #18 and/or the resident's representatives.Findings include:I. Facility policy and procedureThe Change of Room or Roommate policy, undated, was provided by regional director of clinical services #2 on 6/25/26 at 4:33 p.m., The policy read in pertinent part, It was the policy of the facility to conduct room and roommate changes in a manner that protects resident rights, dignity, choice, privacy, and safety. Room changes shall occur only when requested by the resident or when clinically, operationally, or environmentally necessary to meet resident care needs or ensure the health and safety of residents. Residents have the right to receive advance notice of involuntary room changes and the opportunity to appeal such changes in accordance with state and federal regulations.II. Resident #18A. Resident statusResident #18, age [AGE], was admitted to the facility on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included cognitive function and awareness deficit, adult failure to thrive, weakness, and a vitamin D deficiency. The 4/16/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was independent with eating, oral hygiene, toileting hygiene, and chair-to-bed transfers. He required set-up or clean up assistance with showers and bathing, upper body dressing, and lower body dressing B. Resident interviewResident #18 was interviewed on 6/24/26 at 1:26 p.m. He said the staff had not come in to talk to him about the room change. He said none of the facility staff had come to explain the room change appeals process. He said he felt like he was forced to change his room because of his insurance status. He said she was not provided anything in writing regarding his room change. The resident said he was already settled into his new room. C. Record reviewThe notice of room change notification form, dated 6/8/26, revealed a verbal okay was obtained from Resident #18 to change rooms for bed management. The form documented consent was given verbally and was signed by the social services director (SSD).-However, there was no documentation in Resident #18's electronic medical record (EMR) to indicate the facility provided the resident with written notification of the room change.D. Staff interviewThe SSD was interviewed on 6/23/26 at 3:12 p.m. The SSD said Resident #18 changed rooms because he was not getting along with his roommate at the time. She said room moves were discussed in the interdisciplinary team (IDT). She said a room change authorization form should be filled out for each resident room change or when a resident got a new roommate. She said residents were informed of the move. She said she was responsible for completing room change forms. She said she would give the resident and the roommate a five-day notice of the room change. She said she told the resident to notify her if he would like to appeal the room change. She said she did not document the appeal details in the resident's chart, or that she told the resident that he had an opportunity to appeal. She said she filled out the notice of room change one day later because she wants to get her documentation done ahead of time. -However, the room change form did not indicate a 5-day notice of appeals was given to Resident #18. The director of nursing (DON) was interviewed on 6/24/26 at 2:53 p.m. The DON said the SSD would notify a resident of the room change. She said if a resident disagreed with the room change, the resident had the opportunity to appeal. The DON said Resident #18 was told about the room change on Monday, 6/8/26. She said the resident was moved to his new room on 6/9/26. She said she updated their room change policy to notify the resident of the five-day appeal option in the event of a room change. She said the reason for giving residents a five-day appeal option was to give the resident a chance to adapt to the room change. She said she would ensure residents received the details of the five-day appeal option in writing regarding room changes.

Based on record review, and interview, the facility failed to provide choices for preference for one (#5) of two residents reviewed for self-determination out of 35 sample residents.Specifically, the facility failed to provide Resident #5 showers per her preference.Findings include:I. Resident #5A. Resident statusResident #5, age under 65, was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included paraplegia and end stage renal disease. The 6/10/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status score of 15 out of 15. The resident required substantial to maximal assistance from staff for personal hygiene and showers. B. Resident interviewResident #5 was interviewed on 6/22/26 at 1:02 p.m. Resident #5 said she missed showers recently. She said she had dialysis on Mondays, Wednesdays and Fridays, so she preferred her showers on Tuesdays and Saturdays. She said she had talked to staff about this, but was not receiving showers per her preference. C. Record reviewReview of the resident's comprehensive care plan did not include preferences or specific days for showers. Review of the resident's electronic medical record (EMR) revealed the resident's shower preferences were obtained, undated, and revealed the resident preferred her showers twice weekly on Monday and Thursday afternoons. Shower records for the last three months, from 3/24/26 to 6/23/26 revealed the resident received showers on 16 occasions out of a possible 35 opportunities (if offered twice weekly per her preference). D. Staff interviewsCertified nurse aide (CNA) #1 and CNA #2 were interviewed on 6/24/26 at 9:50 a.m. CNA #1 said Resident #5 had dialysis on Mondays, Wednesdays and Fridays and always refused showers on the days she went out to dialysis. CNA #1 said the EMR prompted the shower schedule. CNA #1 said Resident #5's shower days were on Tuesdays and Saturdays and she preferred them in the evening time. Registered nurse (RN) #2 was interviewed on 6/24/26 at 1:25 p.m. She said she did not know the shower schedules and would defer to the CNA caring for Resident #5. RN #2 said she was not aware of Resident #5 refusing showers. RN #2 said if a resident refused a shower, the CNA should let the nurse know so the nurse could talk to the resident about it. RN #2 said the nurse should document a progress note in addition to filling out a shower refusals sheet that the resident signed. The director of nursing (DON) was interviewed on 6/24/26 at 3:25 p.m. She said she was not aware of Resident #5 missing any showers. The DON said Resident #5's current shower schedule was on Tuesdays and Fridays. The DON said she was not aware of Resident #5's preference for showers on Tuesdays and Saturdays due to dialysis on Fridays. The DON said if a resident refused a shower, it should be documented in a progress note and on a shower refusal sheet.

Based on observations, record review and interviews, the facility failed to ensure the medication error rate was not greater than five percent (%).Specifically, the facility's medication error rate was 8.57%, or three errors out of 35 opportunities for error.Findings include:I. Facility policy and procedureThe Administration of Medication policy and procedure, revised April, 2019 was provided by the regional director of clinical services on 6/25/26 at 4:33 p.m., The policy read in pertinent part, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: enhancing optimal therapeutic effect of the medication; preventing potential medication or food interactions; and honoring resident choices and preferences, consistent with his or her care plan. Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: the date and time the medication was administered; the dosage; the route of administration; the injection site (if applicable); any complaints or symptoms for which the drug was administered; any results achieved and when those results were observed; and, the signature and title of the person administering the drug.II. Medication administration observations On 6/24/26 at 9:21 a.m. licensed practical nurse (LPN) #4 prepared to administer medications to Resident #41. LPN #4 checked Resident #41's blood sugar. The blood sugar was 160 milligrams per deciliter (mg/dl). LPN #4 went back to the medication cart and retrieved Resident #41's medications. On 6/24/26 at 9:30 a.m. LPN #4 retrieved the NovoLog insulin pen and the Lantus insulin pen. Both pens were labeled with Resident #41's name on them. LPN #4 administered 20 units of NovoLog insulin into the resident's left arm and 32 units of Lantus insulin into the resident's right arm. Review of Resident #41's June 2026 computerized physician's orders (CPO) revealed the following physician's orders: Lantus (insulin glargine) given once a day, subcutaneously at 8:00 a.m.; and,NovoLog (insulin aspart) given once a day, subcutaneously at 8:00 a.m.-Both insulin doses were ordered to be given at 8:00 a.m. LPN #4 administered both insulin doses were 30 minutes late.On 6/24/26 at 10:23 a.m., registered nurse (RN) #2 prepared to administer medications to Resident #13. RN #2 dispensed the resident's medications into a medication cup, including one 75-milligram (mg) oral tablet of Lyrica (medication used to treat nerve pain). She administered the medication to the resident.Review of Resident #13's June 2026 CPO revealed the following physician's order:-Lyrica oral capsule 100 mg (pregabalin). Give one capsule by mouth three times a day for neuropathic pain, ordered 6/24/26.-However, Resident #13 was to receive one tablet of Lyrica 100 mg. IV. Staff interviews LPN #4 was interviewed on 6/24/26 at 9:40 a.m. LPN #4 said the insulin doses were administered late because she was waiting for Resident #41 to return from the dining room. RN #2 was interviewed on 6/24/26 at 10:30 a.m. RN #2 said she looked at the resident's orders in the medication administration record (MAR) while dispensing medications to make sure she followed the five rights of medication administration: right name, right time, right dosage, right route and accurate documentation. RN #2 said she did not realize it was the wrong dose when she administered it to the resident. She said she noticed the Lyrica dose had changed in the MAR, but did not check the dose on the medication card as she was dispensing it. RN #2 said she should not have given the Lyrica to the resident, and instead, should have called the pharmacy to get an order to access the lock box for the correct dose. She said she would report the medication error to the doctor and to her director of nursing (DON). The director of nursing (DON) was interviewed on 6/24/26 at 2:38 p.m. The DON said she was notified by RN #2 of the medication error for Resident #13. The DON said she called the provider to report the medication error. She said she obtained a physician's order to continue to administer the 75 mg of Lyrica until the 100 mg of Lyrica could be delivered from the pharmacy. She said Resident #31's pain level was assessed and did not increase. She said if the resident did not have the accurate dosage of pain medication, the nurses could call the pharmacy to access the facility's emergency kit and look for the medications there. She said it was important to receive pain medications promptly so residents did not have pain. The DON said LPN #4 was an agency staff member. She said agency staff and facility staff received education on policies and procedures for medication administration before working at the facility. The DON said she would provide re-education to nursing staff who were responsible for administering medications to facility residents. She said this re-education would include the importance of reviewing medication dosage and administering medications on time.

Based on observations, record review and interviews, the facility failed to provide necessary services consistent with professional standards of practice to promote healing of pressure injuries and prevent additional pressure injuries for one (#6) of two residents out of 35 sample residents. Specifically, the facility failed to ensure thorough documentation of weekly wound assessments to track the progression of a chronic pressure injury for Resident #6.Findings include:I. Professional referenceAccording to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA (2019), retrieved on 6/26/26 from https://www.internatinoalguidline.com/2019 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 LossPartial 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 LossFull thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle were not exposed. Slough may be present but did 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 LossFull 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 UnknownFull 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 UnknownPurple 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. Pressure injury assessment includes an evaluation of the pressure injury size and physical characteristics Assess and document physical characteristics of the pressure injury, including: Anatomical location, category/stage, size and surface area, tissue type(s), color, periwound condition, wound edges, sinus tracts, undermining and tunneling, exudate and odorII. Facility policy and procedureThe Pressure Injury Risk Assessment policy and procedure, revised April 2026, was provided by regional director of clinical services #2 on 6/25/26 at 4:00 p.m. It read in pertinent part, The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries. The purpose of a pressure injury risk assessment is to identify resident risk factors for pressure injury. Risk factors that increase a resident's susceptibility to develop or not heal pressure injuries include, but are not limited to; prolonged mechanical load on the skin and underlying soft tissue, under nutrition, malnutrition, and hydration deficits, impaired/decreased mobility and decreased functional ability, and the presence of previously healed pressure injuries. Document the following in the resident's medical record. The date and time assessment is conducted. Findings of the pressure injury risk assessment and skin assessment. The date and time and type of skin care provided, if appropriate. The name and title (or initials) of the individual who conducted the assessment. Any change in the resident's condition, if identified. How the resident tolerated the procedure or their ability to participate in the procedure. Any problems or complaints made by the resident related to the procedure. If the resident refused the treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting, and available alternatives.III. Resident #6A. Resident statusResident #6, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included demyelinating diseases of the central nervous system, paraplegia, chronic obstructive pulmonary disease, congestive heart failure, protein calorie malnutrition, and artificial opening of the urinary tract. The 2/4/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #6 was independent with eating and with the use of a motorized scooter. Resident #6 required partial to moderate assistance with oral hygiene, personal hygiene, toileting hygiene, rolling left to right, chair and bed to chair transfers and tub and shower transfer. Resident #6 required substantial to maximal assistance with showering and bathing himself, upper and lower body dressing. The MDS assessment revealed the resident did not have any unhealed pressure injuries. B. Resident interview Resident #6 was interviewed on 6/23/26 at 10:26 a.m. Resident #6 said he had had a wound on his coccyx for a long time. He said his wound completely healed, then reopened because he liked to sit in his motorized wheelchair. He said the nurses were treating his wound with a dressing that was changed every other day. He said the staff offered to reposition him but he was more comfortable not moving in bed and lying on his back. He said he was not able to reposition himself in bed because of his arm strength. He said he was unsure how big his wound was because the nurses never told him what it looked like. He said the wound did not hurt. C. Observation On 6/24/26 at 9:59 a.m. Resident #6's coccyx wound was observed with licensed practical nurse (LPN) #1. A quarter-size wound was noted on the resident's coccyx area with loss of skin and red tissue at the center of the wound that was exposed. The wound had a crater-like opening with a scant amount of reddish drainage. No exposure of bone was visualized. The resident did not demonstrate signs of any pain or discomfort during this observation. D. Record reviewResident #6's care plan, initiated 7/8/24 and revised 2/3/26, documented Resident #6 was admitted with stage four pressure ulcers to his sacrum and the wounds were resolved on 1/15/26. The resident was at risk for further skin breakdown and/or slow and delayed healing related to paraplegia, edema, heart failure, and bowel incontinence. Interventions included administering medications as ordered, administered treatment as ordered, nutrition or hydration interventions to manage skin problems, pressure reduction cushion for chair and pressure reduction mattress for bed. -However, the care plan for Resident #6 failed to include interventions for skin assessments and documentation. A review of Resident #6's June 2026 CPO revealed the following physician's orders related to Resident #6's sacral wound: admitted to hospice for demyelinating disease of the central nervous system, ordered 10/24/25.Barrier ointment to coccyx area twice daily and PRN (as needed) with incontinence, ordered 2/26/26.Please open and complete the nursing weekly summary note every night shift on Fridays, ordered 4/24/26.-However, the nursing weekly summary failed to include wound assessments.Monitor chronic wound to the coccyx. Notify hospice of any signs and symptoms of worsening of the wound, ordered 5/28/26.-However, there was no documentation in the resident's electronic medical record (EMR) to indicate the facility was consistently monitoring the resident's wound.Wound care to the coccyx: cleanse with sterile water, pat dry, skin prep to the periwound only place on intact skin. Cut to fit wound bed (CollagenSilver), cover with silicone superabsorbent dressing, ordered 5/28/26 and discontinued 6/23/26.Cleanse the pressure area to the sacrum with Dakin's solution (topical antiseptic), apply skin prep to the peri-wound area, apply calcium alginate with silver to the wound bed, and cover with a soft foam dressing. Change every other day and as needed (PRN), ordered 6/23/26.Wound measurements and skin issue evaluations to be completed weekly by nurse and PRN, ordered 6/25/26 (during the survey).-The physician's orders for wound measurements and skin issue evaluation to be completed weekly were not initiated until after the start of the survey.The nursing change of condition note, dated 5/28/28 at 4:44 p.m., revealed the resident had a new pressure ulcer. The note documented the primary care provider feedback noted that hospice recommended to consult with wound care providers to advise on best treatment options.-However, there was no documentation in the resident's EMR to indicate the facility consulted with a wound care provider regarding the resident's wound. A skin issues nursing note, dated 6/25/26 at 8:57 a.m., revealed Resident #6 had a new pressure injury located at his coccyx. The note revealed the wound was acquired in-house. The note documented the following measurements for the wound:. length in centimeters (cm): 1.6, width (cm): 0.2, and depth (cm): 0.2. The wound was 20% epithelial tissue (new tissue forming over skin injury) and . 80% granulated tissue (beefy red new connective tissue in a wound). The wound had a moderate amount of exudate (fluid leaking from tissue) that was serous fluid (clear watery fluid). The wound had a faint odor after cleansing. There was no swelling or edema and normal tissue surrounded the wound. -However, the wound skin evaluation not with wound measurements was not completed until after the concern was brought to the attention of the facility during the survey. IV. Staff interviewsLPN #1 was interviewed on 6/24/26 at 10:10 a.m. LPN #1 said the main goal was to maintain Resident #6's comfort because he was receiving hospice care services. She said the facility had a wound care nurse who was responsible for conducting wound assessments and documenting wound measurements. She said the resident's wound was not getting better or worse and did not look to be infected. She said the drainage had not increased and the wound did not look inflamed. She said she thought the wound reopened because the resident liked to sit in his motorized wheelchair and refused repositioning when offered by facility staff.LPN #2 was interviewed on 6/24/26 at 1:10 p.m. LPN #2 said he was recently hired as the wound care nurse for the facility. He said Resident #6 had a wound on his coccyx that reopened last month (May 2026). He said the wound started because the resident was noncompliant with limiting his time in his motorized wheelchair. He said the resident had a chair cushion and a bed cushion. He said he was responsible for measuring and documenting wounds, however he did not think it needed to be done for Resident #6 because the resident was receiving hospice care services. The director of nursing (DON) and regional director of clinical services #2 were interviewed together on 6/24/26 at 1:53 p.m. The DON said she had worked as the facility's DON since August 2025. She said the facility's nurses would assess any newly developed wounds, document a skin assessment, and also document any change of condition in the resident's EMR. The DON said the nursing staff should notify the facility's physician of the presence of a new pressure injury. The DON said that depending on what a wound looked like, the facility would initiate a referral for the resident to see a wound care physician. The DON said the facility's nurses were expected to assess, measure, and document new pressure injuries and continue with wound measurement weekly to establish a baseline and monitor the progression of the wound. The DON said Resident #6 was not referred to see a wound care physician because he was receiving hospice care services. The DON said Resident #6's stage 3 wound was present upon the resident's admission to the facility. She said the wound was healed in January 2026. She said the wound reopened on 5/28/26. She said the facility staff completed a change of condition note in the residents EMR. She said the change of condition note did not include a detailed description of the resident's wound. She said the wound started because of the resident's comorbidities and his nutritional decline. She said the primary care physician was advised of the reopened wound. The DON said the physician advised the facility to call and notify the hospice care services provider for treatment orders. The DON said hospice provided treatment orders for Resident #6's wound on 5/28/26. She said she was not aware that hospice recommended having the resident follow up with a wound care provider.Regional director of clinical services #2 said she would start a re-education and training for the nursing staff immediately. She said the training would include how and when to perform wound assessments. She said the training would have a focus on how to actually measure and document any new pressure injuries. The infection preventionist (IP) was interviewed on 6/24/26 at 4:54 p.m. The IP said she was not involved in wound management for facility residents or for Resident #6. She said she was unaware of when the wound started or the description of the wound. She said symptoms of an infection of a wound would include warmth, redness, fever, increased drainage and pain at the site of the wound. She said if a resident had multiple symptoms, she would be concerned of the resident possibly having an infection.The DON was interviewed again on 6/25/26 at 9:05 a.m. The DON said she did not believe Resident #6's sacral wound was infected because the resident presented no additional signs and symptoms of infection. The DON said that when the wound was noted to have an odor on 6/21/26, the hospice care services provider was notified and new treatment orders were obtained. The DON said the hospice care services provider wanted to see if the new treatment orders were effective before moving to additional treatment options. She said Resident #6 would be followed by the wound care physician starting 6/30/26. She said the former wound care nurse did not document the wound measurements for Resident #6 because it was assumed the hospice nurses were doing the wound documentation. The DON said moving forward, the facility nurses would be responsible for wound care documentation, even if the resident was receiving hospice care services. -However, the appointment for Resident #6 to see a wound care physician was not made until the concern was brought to the facility's attention during the survey (see record review above).

Based on record review and interviews, the facility failed to fully investigate and document incidents of sexual abuse involving one (#2) of one resident reviewed out of seven sample residents. Specifically, the facility failed to: -Conduct and document a thorough investigation of an allegation of sexual abuse involving Resident #2 as the victim of sexual abuse by staff members;-Interview the resident's roommate for what he might have heard or seen during the time of the alleged abuse incident;-Pursue the resident's ongoing allegations that staff were rough and abusive towards him during the provision of personal care; and, -Investigate why staff did not stop care when the resident made the allegation of abuse and have other staff take over care. Findings include: I. Facility policy and procedureThe Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, revised September 2022, was received from the nursing home administrator (NHA) on 3/26/26 at 12:30 p.m. The policy documented in pertinent part, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of property are reported to the local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.II. Allegation of sexual abuse of Resident #2 by a nursing staff member on 2/18/26A. Facility investigationThe facility investigation, dated 2/24/26, documented Resident #2 told the investigator he was yelling for help so he could be changed after having a bowel movement. The nurse on duty, licensed practical nurse (LPN) #1, entered his room and shortly after, certified nurse aide (CNA) #1, entered the room and told the nurse he could assist with changing the resident. The investigation documented the resident refused the CNA #1's offer to get him changed but CNA #1 proceeded to change him anyway. The resident alleged that CNA #1 grabbed his hands and began to wipe his backside and clean him up. The resident said while being wiped and cleaned, CNA #1 then put his fingers into his rectum. He stated that he yelled out telling him to stop but CNA #1 did not stop and continued to wipe his rectum. Resident #2 said CNA #1 finished cleaning him and left the room.The investigation report documented that Resident #2 alleged that during nighttime care interaction, while being assisted with changing, the LPN (LPN #1) on duty inserted his finger into his anus four times. Resident #2's documented statement, dated 2/19/26, revealed the resident said he was yelling for help with incontinence care during the night shift on 2/18/26 when CNA #1 entered his room. The resident said he was not sure what time this occurred. The resident said CNA #1 started to provide care, but LPN #1 entered and told CNA #1 he would take over. -However, LPN #1 and CNA #1's statements contradicted the resident's statement regarding who provided the incontinence care (see staff member's statements below).Resident #2 said he did not want LPN #1 to provide his care and he tried to swat LPN #1 away. He said it was no use because LPN #1 grabbed his hands and turned him aggressively, causing him to hit his head against the wall. LPN #1 continued to provide care. The resident said LPN #1 proceeded to change his brief and while wiping his buttocks, the nurse put his finger into his anus repeatedly four times. LPN #1 finished his care and left the room. The resident said no one checked on him for the rest of the night. The investigation report documented that the resident was distressed and agitated during the investigative interview, which was his normal baseline.-However, this was not Resident #2's demeanor during the interview during the survey on 3/26/26 (see the interview below). During the interview, the resident was very clear about his allegation and was not emotional or exaggerating the initial allegation he made about the staff's behavior, which he described as abusive behavior directed towards himself. In addition, the resident very clearly repeated his initial allegation that it was the LPN not the CNA, who abused him. The investigation documented LPN #1 was off for the next couple of days after the incident, while the investigation occurred and was interviewed by phone by the facility investigator. LPN #1's statement, dated 2/19/26, documented Resident #2 was yelling while CNA #1 was providing incontinence care from a bowel movement. He said the resident was yelling that CNA #1 was touching his anus and that was not what was happening. CNA #1's statement, dated 2/20/26, documented Resident #2 was yelling out to be changed and he and LPN #1 entered the resident's room. CNA #1 said he proceeded to clean Resident #2. During care, the resident said stop putting your finger in my anus. CNA #1 said he told the resident he was not putting his finger in his anus and continued to clean feces off the resident's buttocks and when finished, he left the room. -The facility failed to interview the resident's roommate to see if he saw or heard what occurred.The investigation documented that following the investigation, the facility determined the allegation was unsubstantiated based on the evidence and interviews conducted. There was no evidence or signs of trauma to the resident's rectal area and CNA #1 and LPN #1's interviews both corroborated their stories on what happened during the brief change. The resident also has a cognitive decline and terminal agitation, resulting in false allegations.The facility investigation documented Resident #2's care plan was updated to include a care focus for false allegations and care in pairs to ensure the safety of the resident and accuracy of care and treatment that was provided to the resident. -The facility failed to add a care plan focus to address Resident #2's allegation of rough care or method of incontinence care when a bowel movement occurred to ensure the resident did not feel like staff was being unnecessarily rough or abusive towards him. III. Resident #2A. Resident statusResident #2, age less than 65, was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included bipolar disorder, anxiety, depression, post-traumatic stress disorder and traumatic brain injury. The 3/23/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident had aggressive behavior towards others and experienced delusions. He was dependent on staff for toileting and transfers and bed mobility. The resident used a manual wheelchair and was dependent on staff for mobility. B. Resident interview and observationResident #2 was interviewed on 3/26/26 at 1:28 p.m. Resident #2 said the care he had been receiving was terrible. He said the staff did not listen to him and were rough with care. He said he felt the staff's approach to his care was abusive. He said the nighttime nurse, LPN #1 was very rough towards him when providing his care. Resident #2 said on the night that he alleged he was abused (2/18/26), he tried to push LPN #1 away but he was weak and did not have enough strength to stop LPN #1 from rolling him over and wiping him. Resident #2 said he had limited mobility in both arms and could not reposition himself in bed without assistance from another person. Resident #2 said LPN #1 had rolled him over onto his side so aggressively his head hit the wall beside his bed. He said once he was on his side, LPN #1 began to wipe him so hard that he felt it was aggressive and abusive. He told LPN #1 to stop but he would not stop. Resident #2 said he did not want LPN #1 to provide his care but LPN #1 still provided his care, despite his request to leadership to prevent LPN #1 from taking care of him. Resident #2 said no one listened to him or believed him. Resident #2 said this was not the only time LPN #1 had been rough towards him. He said a few weeks prior, LPN #1 transferred him to bed in a rough manner, which caused him pain. He said in addition to LPN #1 providing rough care, Resident #2 said there were other staff members who failed to reposition him properly in his wheelchair, which caused him pain and bruising in his arms. Resident #2 said he had asked staff to assist him to sit up straight this morning (3/26/26) for breakfast so he could feed himself but staff did not assist him as he requested. Resident #2 said he had trouble eating when he was sitting up straight. He said this morning he was not able to eat much and he spilled a lot of food on his shirt. The resident pointed to the spilled oatmeal that was still on his shirt from his morning meal. The resident was observed during the interview with an oatmeal soiled shirt and he was slouched down and slumped over to the left in the wheelchair. His left arm was hanging over the side of the wheelchair and he had a bruise on his upper arm where the armrest was poking into his arm that was hanging over the side of the wheelchair. He said his arm was sore from hanging over the side of the wheelchair. C. Record reviewResident #2's care plan, dated 2/6/26, revealed the resident had the potential to display behaviors that included verbal aggression towards others, delusions and hallucinations. The care plan documented the resident had a history of making false allegations. He had a history of reporting decreased interest in things with displayed tearfulness, sleep disturbance, worry, anxiety, and obsessive thoughts. The care plan documented the resident sometimes declined medications prescribed to treat related symptoms. Pertinent interventions included providing care in pairs (two staff members) at all times, documenting and recording behavioral episodes, investigating all concerns voiced, maintaining a calm, slow, understandable approach and providing the PASRR (Preadmission Screening and Resident Review) Level II recommendations, which included individual therapy due to the resident's diagnosis of post-traumatic stress disorder (PTSD).-However, there was no related care plan focus to address the resident's PTSD and interventions to help the resident manage PTSD symptoms. IV. Staff interviews LPN #2 was interviewed on 3/26/26 at 10:56 a.m. LPN #2 said Resident #2 was to receive care in pairs and they were to take extra time to have a conversation explaining each step of care with Resident #2 before starting and during care in order to increase comfort and trust. LPN #2 said he had not had a problem with implementing this approach with the resident.CNA #2 was interviewed on 3/26/26 at 10:59 a.m. CNA #2 said he always provided Resident #2 care with another staff person and always took extra time to make sure to be attentive and let the resident know what was occurring. He said he always made sure to tell Resident #2 thank you after care to make the resident feel respected. CNA #2 said when wiping the resident during a brief change, he was careful to provide more of dabbing motion than a wiping because that was more acceptable and comfortable for the resident. The director of nursing (DON) and the NHA were interviewed on 3/26/26 at 1:38 p.m. The NHA said the facility investigation revealed the resident had misinterpreted the staff's actions during incontinence care. The DON said the nurse witnessed the care and reported that CNA #1 had not inserted his finger into the resident's anus. The DON said the resident had a large bowel movement and CNA #1 had to wipe the resident several times to remove all of the feces from his buttocks and anal area. The DON said CNA #1 had wiped the resident's rectal area over and over again to properly clean him.

Based on observations, record review and interviews, the facility failed to ensure one (#3) of four residents were kept free from physical abuse out of six sample residents.Specifically, the facility failed to protect Resident #3 from physical abuse by Resident #4.Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, was provided by the nursing home administrator (NHA) on 10/9/25 at 10:05 a.m. It read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support protecting residents from abuse, neglect, exploitation or misappropriation of property by anyone; developing and implementing policies and protocols to prevent and identify abuse or mistreatment of residents neglect of residents and/or theft, exploitation or misappropriation of resident property; provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management and handling verbally or physically aggressive resident behavior; implementing measures to address factors that may lead to abusive situations; identifying and investigating all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and protecting residents from any further harm during investigations.II. Incident of physical abuse between Resident #3 and Resident #4 on 6/21/25A. Facility investigationThe facility's abuse investigation, dated 6/21/25, documented that at approximately 8:15 p.m. Resident #3 and Resident #4 were in the smoking patio area when a verbal altercation occurred. Resident #3 told Resident #4 to smell his feet and called him names. Resident #3 then moved his electric wheelchair toward Resident #4 in an aggressive manner. Resident #4 flicked a lit cigarette at Resident #3 and spit at Resident #3, grabbed Resident #3's arm and dug his fingernails into his skin, and struck Resident #3 in the face, which caused Resident #3's glasses to fall to the ground.Resident #3 left the patio and notified staff. Staff ensured both residents were kept apart and remained on opposite sides of the hallway for the rest of the evening. The facility initiated 15-minute checks for both residents. A registered nurse (RN) assessed Resident #3 after the incident and documented minor scratches on the resident's arm and a small burn on his chest. Resident #3 denied pain. The RN offered wound treatment and Resident #3 declined. Resident #3 declined to discuss the incident further but appeared angry and frustrated. A physician's assistant offered counseling and therapy and Resident #3 declined.Resident #4 was interviewed after the incident and he said that Resident #3 made inappropriate comments and moved his wheelchair toward him. Resident #4 said he reacted by striking Resident #3 in the face.The investigation documented that staff and residents were interviewed and they did not report any ongoing safety concerns. Documentation confirmed that physical contact occurred and that treatment was offered and declined. The interventions implemented after the incident for both residents included continued 15-minute checks, behavior monitoring and review of the residents' care plans. Resident #3's care plan directed staff to provide redirection, offer preferred activities and monitor mood and behavior. Resident #4's care plan directed staff to maintain a calm environment, encourage expression of feelings and documented behavioral episodes with triggers. The investigation documented that the facility substantiated that the allegation of resident-to-resident physical abuse occurred.B. Resident #3 - victim1. Resident statusResident #3, age less than 65, was initially admitted on [DATE], readmitted [DATE] and discharged [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included paraplegia, depression and anxiety. The 9/2/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required substantial assistance with toileting, bathing, and moderate assistance with dressing. The MDS assessment did not indicate that the resident had any behaviors.2. Resident #3 interviewResident #3 was interviewed on 10/8/25 at 5:43 p.m. Resident #3 said that on the day of the incident (6/21/25) he was in the smoking area in his wheelchair when Resident #4 made verbal and racial remarks toward him, including comments about him being crippled. He said that when he moved his wheelchair toward Resident #4, his intention was not aggressive but to respond to what was being said. He said there were no staff members present during the altercation and that his roommate ran inside to get help. Resident #3 said that before staff arrived, Resident #4 hit him twice in the face which caused his glasses to fall and break. He said Resident #4 also flicked a lit cigarette that caused a burn between his chest and stomach. He said the cigarette landed on his stomach and he did not feel it immediately because he was paraplegic and had limited sensation. He said he later noticed burn marks on his chest and stomach area. He said he declined an assessment at the time but continued to have a visible mark afterward. Resident #3 said the situation ended once staff arrived. 3. Record review The behavioral care plan, initiated 2/7/25 and revised 9/23/25, documented that Resident #3 had diagnoses of depression and anxiety and exhibited verbal aggression toward others. The care plan described a history of racist or derogatory comments, unfounded accusations and easy agitation. Resident #3 sometimes made jokes or comments that he found humorous but that could irritate others and that he could speed in his electric wheelchair when agitated. Pertinent interventions included redirecting the resident to a quiet area, encouraging the use of games on his cell phone, offering arts and crafts supplies, providing brain teaser puzzles, offering preferred music or television, offering snacks or drinks, and encouraging calm expression of feelings. Additional interventions included observing and documenting behavioral episodes, notifying the physician and responsible party of aggression or significant changes, obtaining a psychological consultation if indicated, and educating staff to provide care in pairs for safety when the resident exhibited aggressive behavior.The 6/21/25 nurse progress note revealed that Resident #3 had a verbal altercation with another resident in the smoking area and the other resident became physical with Resident #3. The 6/26/25 nurse progress note documented that a skin assessment was completed at the time of the incident on 6/21/25 and no burns or open sores were observed. The note revealed that the other resident flicked a lit cigarette at him, but no burn was noted during the assessment. The note documented that the resident was scratched by the other resident, but there was no bleeding or skin tear observed.A subsequent nurse progress note dated 6/26/25 at 6:17 p.m. revealed that Resident #3 reported an open area on his chest that appeared to be a cigarette burn. The note documented that there were no signs or symptoms of infection and that wound care orders were received. The note further documented that the open area was not present during the initial assessment on 6/21/25 and that the physician was notified.C. Resident #4 - assailant1. Resident statusResident #4, age less than 65, was admitted on [DATE]. According to the October CPO, diagnoses included dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety.The 8/21/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He was independent with completing his activities of daily living (ADL).The MDS assessment did not indicate that the resident had any behaviors.2. Resident #4's interviewResident #4 was interviewed on 10/8/25 at 11:08 a.m. Resident #4 said his stay at the facility had been all right. He said he usually got along with the other residents and talked with them without any problems. He said he often went to the smoking area and did not have a preference whether other residents were present or not. He said he became angry and had a fight with Resident #3 in June 2025 and he did not know what was wrong with Resident #3. He said he had never had disagreements with any other residents. He said the police investigated the incident and that he now had to go to court. He said it helped him calm down when other residents did not talk to him when he felt frustrated. He said he did not want to discuss the incident further.3. Record reviewThe behavioral care plan, initiated 12/4/24 and revised on 7/3/25, documented that Resident #4 could become angry if he perceived that he was being disrespected or teased. It documented that he could become verbally or physically abusive toward others if provoked. Pertinent interventions included observing and documenting changes in behavior, including frequency and potential triggers, encouraging the resident to verbalize feelings, redirecting to a quiet area if agitated, encouraging physical activity, offering preferred activities, music, television programs, snacks or drinks and encouraging calm expression of feelings. Additional interventions included maintaining a calm and slow approach, obtaining a psychological consultation as indicated, notifying the physician and responsible party of episodes of aggression and documenting all behavioral episodes.The 6/21/25 nurse progress note documented that Resident #4 was involved in a physical altercation with another resident (Resident #3) in the smoking area. The note indicated that a verbal disagreement occurred and escalated when Resident #4 scratched, spit, and struck the other resident in the face, knocking the resident's glasses off. Staff separated the residents and placed both residents on frequent checks.The 6/25/25 nurse progress note documented that the frequent checks were discontinued.III. Additional resident interviewResident #6 was interviewed on 10/9/25 at 8:43 am. Resident #6 said he used a vaporizing device in the smoking area that evening on 6/21/25 and Resident #3 joked with Resident #4 to come smell his fee. Resident #6 said Resident #4 responded to Resident #3 to smell his own feet and Resident #4 approached and got in Resident #3's face. Resident #6 said he left the smoking area to get help. Resident #6 said he informed RN #1 and RN #1 immediately ran into the smoking area and Resident #6 went to his room. Resident #6 said he did not see Resident #4 throwing a lit cigarette at Resident #3 or punching him, but he said Resident #3 told him that Resident #4 punched him and flicked a lit cigarette at him when Resident #6 left to get help. Resident #6 said the facility did not obtain a witness statement from him or talk to him afterward. IV. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 10/8/25 at 12:55 p.m. LPN #1 said he had worked at the facility for three years, first as an agency staff member and more recently as a full-time employee. He said he worked on the hall where Resident #4 resided, and that Resident #3 lived in a different area of the facility. He said there was an assigned team responsible for supervising residents who required supervision. He said the facility kept residents' cigarettes and lighters secured. LPN #1 said staff reviewed the electronic treatment administration record (eTAR) and psychological monitoring documentation for residents who required closer observation. He said he had not seen Resident #4 display aggression or assault anyone and that he was shocked when he heard about the incident that occurred on 6/21/25 between Resident #3 and Resident #4. He said he watched for body language, nonverbal cues, agitation and anything out of the ordinary to recognize early signs that a resident was becoming agitated or aggressive so he could intervene appropriately.LPN #1 said that if one resident became physically aggressive toward another resident, he would speak to them in a calm tone, remain neutral, step between the residents if there was physical contact, separate them and call for assistance. He said he stayed with the residents until help arrived and then notified the abuse coordinator, the NHA and the director of nursing (DON). He said he had not been aware of Resident #4's previous aggressive incidents before the 6/21/25 event and that the behavior was unexpected. He said he would review the resident's care plan for behavioral interventions in place and that following an incident, staff typically increased monitoring until the resident returned to baseline.Certified nurse aide (CNA) #1 was interviewed on 10/8/25 at 2:07 p.m. CNA #1 said residents who were not independent had designated times for supervised smoking and that staff kept the residents' cigarettes and lighters. She said she heard about the altercation between Resident #3 and Resident #4 from the charge nurse, who instructed staff to increase observation and monitoring of Resident #4, watch for any signs of verbal or physical aggression toward other residents and ensure that other residents were kept safe. CNA #1 said if Resident #4 became upset, the interventions were to talk to him, de-escalate the situation and notify the charge nurse if his behaviors were out of control. She said she made sure other residents were safe and kept away from Resident #4. CNA #1 said she was usually informed by the charge nurse when increased monitoring was needed for a specific resident. She said she also reviewed the Kardex (tool utilized for providing consistent care for residents) for interventions and documented her observations and interactions immediately.CNA #1 said Resident #3 occasionally made comments to staff, such as calling them lazy or using profane language when his medications were given late, but that he was redirected verbally and would apologize afterward. She said it was not typical for Resident #4 to be physically aggressive because he was very social, joked with others and often helped the activities director with setting-up activities. CNA #1 said she recognized early signs of aggression by closely monitoring changes in tone of voice, yelling, or screaming and that she would run to investigate and de-escalate the situation. She said she stayed with the residents involved to ensure safety and obtained assistance as needed. She said she reported information to the abuse coordinator and that after an incident and staff ensured resident safety. RN #1 was interviewed on 10/9/25 at 11:23 a.m. RN #1 said she could not recall who came to get her to assist the residents in the smoking area on the day of the incident between Resident #3 and Resident #4. She said Resident #3 had been talking about his showers and mentioned that his feet were smelly, then asked Resident #4 to smell his feet. She said Resident #3 also said Can you help a brother out and smell my feet, which offended Resident #4. RN #1 said Resident #4 began yelling at Resident #3. RN #1 said that during her assessment and observation immediately after the incident, there were no burn marks noted on Resident #3's chest or stomach area and no burn marks observed on his shirt. She said that a day or two later, burn marks consistent with a cigarette burn appeared on Resident #3's chest. She said the area was round, approximately 1 centimeter (cm) by 1 cm in size, irritated and raw. RN #1 said it was possible she did not see burn marks initially because the injury was fresh and had not yet fully developed.The social services director (SSD) was interviewed on 10/9/25 at 11:52 a.m. The SSD said she had not been at the facility on the day of the incident between Resident #3 and Resident #4, but she said she would normally begin the investigation when such an event occurred. She said her responsibilities included separating the residents, contacting the police if the incident involved physical abuse, notifying the ombudsman and the (interdisciplinary team (IDT) and documenting the occurrence.The SSD said that to ensure the victim was monitored for emotional trauma, staff made sure the resident was in a safe location, spoke with the resident, offered behavioral health services, provided ombudsman contact information, and offered a room change if needed. She said the facility did whatever was necessary to prevent the situation from escalating.The SSD said that once interventions were in place, the residents' care plans were updated and staff were educated regarding behavioral interventions. She said the facility monitored whether the aggressor's behavior improved or worsened after new interventions were implemented. She said nurses completed behavior monitoring and checked the eTAR and electronic medication administration record (eMAR) for any behaviors noted during their shifts. She said if psychotropic medications were prescribed, the facility completed psychopharmacological monitoring and gradual dose reduction (GDR) reviews.The SSD said she coordinated with nursing leadership, including the DON and the assistant director of nursing (ADON), to ensure that behavioral interventions and supervision changes were implemented and documented. She said she reviewed the records to verify that behavioral monitoring and physician orders were entered and followed.The social services assistant (SSA) was interviewed on 10/9/25 at 12:16 p.m. The SSA said she did not remember the details of the incident that occurred on 6/21/25 between Resident #3 and Resident #4 and she could not recall when she was first notified. She said she remembered obtaining statements from both residents. The SSA said she did not recall that the victim developed burn marks on his chest or stomach.The SSA said that if she identified a resident with cigarette burns or observed an altercation, she would separate the residents, redirect them and contact the police and the ombudsman. She said she would offer or provide medical attention for the victim, notify the nurse if emergency services were needed, and escort the assailant to his room or another area of the building to ensure the safety of all residents.The DON was interviewed on 10/9/25 at 1:16 p.m. The DON said she ensured that all staff understood and followed behavior management interventions in the residents' care plans. She said the staff completed crisis prevention intervention (CPI) training annually and they provided additional education when the residents argued. She said staff were reminded to separate the residents and report the incident to management.The DON said she monitored staff compliance with behavior-related documentation and interventions by educating staff, reviewing the Kardex for interventions, confirming that nurses checked the care plans, and ensuring that behavior tracking was completed. She said she reviewed the behavior monitoring dashboard each morning and reminded staff to complete documentation if it was missing. The NHA was interviewed again on 10/9/25 at 1:00 p.m. The NHA said the facility was in the process of upgrading their cameras and that the camera in the smoking area was not functioning on 6/21/25. He said his expectation for staff during abuse incidents was to intervene, de-escalate verbal or physical behavior, notify the NHA, and for the DON to initiate risk management, place the resident on behavior tracking, interview witnesses, implement interventions and update the care plan. He said they would also notify the ombudsman. He said if 15-minute checks were initiated, then nursing staff would follow up to ensure they monitored the residents. He said the facility ensured the accuracy of an occurrence by considering every perspective, interviewing witnesses as soon as possible, obtaining multiple points of view and requiring the SSD to investigate thoroughly.The NHA was interviewed a second time on 10/9/25 at 2:31 p.m. The NHA said the nurse progress note documented that RN #1 completed a head to toe assessment on 6/21/25 and did not observe burn marks at that time. He said the facility did not believe the chest burn came from the 6/21/25 incident although he initially had said the chest burn was caused during the incident on 6/21/25.

Based on record review and interviews, the facility failed to ensure that one (#1) of four residents out of eight sample residents received adequate supervision and facility-assisted devices to prevent elopement. Specifically, the facility failed to provide Resident #1 the supervision necessary to prevent elopements. These facility failures created a situation with the likelihood of serious harm to the resident's health and safety if not immediately corrected. Resident #1 was admitted to the facility on [DATE] with a diagnosis of bipolar disorder (major mental illness), adult failure to thrive, cocaine dependence and alcohol dependence. A wander/elopement risk evaluation was completed upon the resident's admission on 4/9/24 and revealed Resident #1 had no previous elopement attempts and was not at risk for eloping or wandering. However, Resident #1 had an emergency court-appointed guardian who requested the resident not leave the facility without supervision due to her mental illness and substance-seeking behaviors. On 1/10/25 at approximately 10:25 a.m. Resident #1 left the facility unsupervised when the receptionist buzzed someone out the front door and failed to see Resident #1 following behind the other person leaving the facility. After actively searching for the resident and notifying the resident's guardian about the resident's elopement, Resident #1 was located by the resident's guardian at 12:45 p.m. near a homeless shelter approximately five miles from the facility and the facility's driver picked up the resident and returned her to the facility. -The facility placed Resident #1 on 15-minute checks upon her return to the facility, however, this intervention proved to be ineffective as Resident #1 eloped a second time, four hours after returning to the facility. On 1/10/25 at 5:17 p.m., despite the facility initiating and conducting 15-minute checks on Resident #1, the resident eloped from the facility a second time when a nurse buzzed the resident out the facility door after failing to check the camera to see who was being buzzed out the door. The facility again began a search for Resident #1 and notified the police and the resident's guardian. On 1/11/25 at 10:15 p.m. (almost 29 hours after the resident eloped from the facility the second time) a staff member saw Resident #1 on the side of the road in a downtown area approximately five miles from the facility and notified the nursing home administrator (NHA) and the police. When the police arrived, Resident #1 was transported to the hospital, per the guardian's request. Findings include: Observations, interviews and record review confirmed the facility corrected the deficient practice prior to the onsite investigation on 2/10/25 to 2/12/25, resulting in the deficiency being cited as past noncompliance with a correction date of 1/14/25. I. Situation of serious harm The facility failed to ensure facility staff were aware of which residents were able to leave the facility without supervision and which residents needed to have supervision when leaving the facility. This resulted in a staff member buzzing Resident #1 out the front door when another person left the faciity on [DATE]. The resident was located approximately five miles from the facility over two hours later. Following Resident #1's first elopement on 1/10/25 at 10:25 a.m., the facility failed to put effective interventions and systems in place to ensure Resident #1 was unable to elope again. This resulted in Resident #1 being buzzed out the front door a second time on 1/10/25 and being located approximately five miles from the facility almost 29 hours later. II. Facility plan of correction The corrective action plan the facility implemented in response to Resident #1's elopement incidents on 1/10/25 was provided by the NHA on 2/11/25 at 1:00 p.m. The correction plan revealed the following: A. Immediate action Resident #1 had an elopement and community safety assessment completed on 1/10/25. Resident #1 was found by the police on 1/11/25 and taken to the hospital per the guardian's request until a locked unit was found for Resident #1. A sister facility with a locked unit accepted the resident. B. Identification of others affected The facility determined six other residents were at risk for eloping from the facility. C. Systemic changes -On 1/13/25 all residents were educated via individual letters regarding not assisting other residents to leave the facility and the process for signing in and out when leaving the facility by the NHA or designee. -On 1/13/25 all receptionists were educated to not leave the front desk unattended for breaks. -On 1/14/25 the interdisciplinary team (IDT) members reassessed all residents for elopement risk and community safety. -On 1/14/25 the IDT created an elopement binder, with a list of all residents at risk, their face sheets and photos, if allowed. The binder was placed at the front desk and the nurses' station. -On 1/14/25 staff on all shifts received education on the process for the front doors, residents at risk for eloping, notifying the nurse with concerns, location of the list of residents at risk of eloping, assisting residents to sign out and leave or redirection, elopement policy and elopement binder from the director of nursing (DON) or designee. Any staff members who were not on duty or were on leave, received education on their next scheduled work day. Agency staff were educated before the start of their shift. On 1/14/25 all residents' cell phone numbers were updated in the electronic medical records (EMR) by the IDT members. D. Preventing elopements The facility took the following actions to prevent elopement from reoccurring. The front desk will be staffed from 8:00 a.m. to 5:00 p.m., seven days per week and assist with helping residents sign in and out. Elopement risk assessments were to be completed on admission, with a change of condition, and quarterly by the IDT. Residents determined at risk by the IDT will have a care plan in place to prevent elopement. The DON will audit potential new admissions for elopement risk, determine if the facility can meet the resident's needs and ensure a care plan with appropriate interventions is in place if appropriate. New hires will receive education on wander, elopement and elopement binder and resident safety by the DON, the social services director (SSD) or designees. The NHA will ensure the elopement binders are kept up to date with any resident change in assessment or new admission. E. Monitoring The DON will track/audit all resident elopement assessments monthly to ensure they are completed on admission and quarterly. A quality assurance and performance improvement (QAPI) committee performance improvement plan (PIP) was implemented to review and interpret all audit findings. All findings will be discussed at the monthly QAPI committed meeting for a minimum of three months, or until the pattern of compliance is maintained. III. Facility policy and procedure The Elopements and Wandering Residents policy, undated, was provided by the NHA on 2/12/25 at 9:00 a.m. It read in pertinent part, The facility is equipped with door locks or alarms to help avoid elopements. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. IV. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE] and discharged to the hospital on 1/11/25. According to the January 2025 computerized physician orders (CPO), diagnoses included bipolar disorder, adult failure to thrive, cocaine dependence, alcohol dependence and acquired absence of left toes. The 10/10/24 minimum data set (MDS) assessment revealed Resident #1 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. Resident #1 had no documented behaviors. Resident #1 had no impairment to her extremities and used a walker or wheelchair. B. Record review The elopement evaluation, dated 4/9/24, revealed Resident #1 had a diagnosis of bipolar disorder. Resident #1 ambulated independently with or without the use of an assistive device or wheelchair. The resident did not have any hearing, vision or communication problems. Resident #1 had no previous elopements or wandering behaviors. The elopement care plan, initiated on 1/10/25 (following the residents elopements) revealed Resident #1 was at risk for wandering, eloping and exit-seeking related to agitation, difficulty redirecting, poor safety awareness and impulsivity. The resident had left the facility without notifying staff and demonstrated poor safety awareness in the community. Pertinent interventions were documented as 15-minute checks of the resident's location for safety, allowing the resident to wander in safe areas within the facility and notifying the resident's guardian and the police if Resident #1 successfully eloped. The NHA provided the timeline of Resident #1's 1/10/25 elopement incidents on 2/11/25 at 9:00 a.m. The timeline revealed the following: Resident #1 eloped from the facility on 1/10/25 at approximately 10:25 a.m. when the receptionist buzzed someone out the front door and failed to see the resident following behind the other person. At 11:00 a.m. the nursing staff were unable to locate Resident #1 in the facility's common areas or the resident's room. The staff initiated a full facility sweep. At 11:20 a.m. the NHA and the DON were notified Resident #1 had eloped. The IDT members searched known areas for the resident, which included gas stations, bus stops and downtown areas. At 12:00 p.m. Resident #1's guardian was notified the resident eloped. The facility's driver was asked to help search locations based on the guardian's recommendations. At 12:45 p.m. Resident #1's guardian located the resident near a homeless shelter approximately five miles from the facility and the facility's driver picked up the resident and returned her to the facility. At 1:15 p.m. Resident #1 returned to the facility, was assessed by nursing staff and placed on 15-minute checks. At 5:15 p.m. Resident #1 was seen in the dining room for her 15-minute check. At 5:17 p.m. Resident #1 was buzzed out by a nurse at the nurses' station who failed to check the camera to see who was being buzzed out the door. At 5:30 p.m. Resident #1 was unable to be located for her 15-minute check. At 5:37 p.m. the nurse notified the DON, the NHA, the police and the resident's guardian. At 6:10 p.m. the police and the DON arrived at the facility. The police were given the resident's face sheet and a description of the resident. On 1/11/25 at 10:15 p.m. a staff member saw Resident #1 on the side of the road in a downtown area approximately five miles from the facility and notified the NHA and the police. At 10:30 p.m. the police arrived and spoke with Resident #1 and the staff member. The guardian's number was provided and the staff member told the police the guardian wanted Resident #1 to be taken to a hospital once she was found. The facility began investigating the situation on 1/11/25 and developed a QAPI plan which included a PIP on 1/13/25. V. Staff interviews The NHA, the SSD and the corporate consultant (CC) were interviewed together on 2/11/25 at 11:40 a.m. The SSD said the staff were doing their normal rounds on 1/10/25 and were unable to locate Resident #1. She said the staff searched the facility and expanded the search to the community. She said Resident #1 was located and the facility's driver returned the resident to the facility. The SSD said the resident was assessed by the provider and placed on 15-minute checks. The NHA said he received a phone call on the same day, but later in the evening, that the staff were unable to locate Resident #1 when the staff were completing their 15-minute checks. He said the resident's guardian and the police were notified that Resident #1 was unable to be located on 1/10/25. The NHA said on 1/11/25 he received a phone call from a staff member who was driving home and spotted Resident #1 on the side of the road in a downtown area. He said the staff member stayed with Resident #1 until the police arrived and then asked the police to take the resident to the emergency room , per the resident guardian's request. The NHA said Resident #1 did not return to the facility after the resident's guardian requested she be taken to the hospital on 1/11/25 and was placed in a sister facility with a secured unit per the guardian's request. The NHA said Resident #1 had never left the facility prior to 1/10/25 and did not have a history of eloping. He said the first time Resident #1 left the facility was because a staff member was buzzed out and Resident #1 followed behind the staff member. He said the second time Resident #1 left the facility, the nurse failed to look at the camera to see who was trying to be buzzed out and just opened the door.

Based on interviews and record review, the facility failed to ensure residents were permitted to remain in the facility and not transfer or discharge for one (#1) of three residents reviewed for discharge planning out of eight sample residents. Specifically, the facility failed to provide Resident #1 with an appropriate discharge process. Findings include: I. Facility policy and procedure The Transfer or Discharge, Facility-Initiated policy, revised October 2022, was provided by the nursing home administrator (NHA) on 10/21/24 at 1:15 p.m. It read in pertinent part, If the facility does not permit a resident's return to the facility (initiates a discharge) based on inability to meet the resident's needs, the facility will notify the resident, and/or his or her representative in writing of the discharge, including notification of appeal rights. A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident's discharge or transfer from the facility. Sufficient preparation and orientation for the resident prior to an immediate facility-oriented transfer or discharge includes explaining to the resident where he/she is going and why, and taking steps to minimize his/her anxiety or depression (working with the resident, representative, or family to ensure that the resident's belongings will be taken care of and transferred to the new location as needed/requested, and ensuring that staff recognize characteristic resident reactions identified during assessment and care planning). Documentation of Facility-Initiated Transfer or Discharge When a resident is transferred or discharged from the facility, the following information is documented in the medical record: -The basis for the transfer or discharge; and, -If the resident is being transferred or discharged because his or her needs cannot be met at the facility, documentation will include the specific resident needs that cannot be met and the facility's attempt to meet those needs. Should the resident be transferred or discharged for any of the following reasons, the basis for the transfer or discharge is documented in the resident's clinical record by the resident's attending physician. The Transfer and Discharge policy, dated 2024, was provided by the NHA on 10/21/24 at 2:59 p.m. It read in pertinent part, It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances. Discharge Against Medical Advice (AMA): The resident and family/legal representative should be informed of the risks involved, the benefits of staying at the facility, and the alternatives to both. Under no circumstances will the facility force, pressure, or intimidate a resident into leaving AMA. The physician should be notified of the intended AMA discharge and be encouraged to speak with the resident to encourage them to stay at the facility. Documentation of this notification should be entered in the nurses' notes by the nursing department. The social service designee should document any discussions held with the resident/family in the social service progress notes, if present. Notify Adult Protection Services, or other entities, as appropriate if self-neglect is suspected. Document accordingly. III. Resident #1 A. Resident status Resident #1, age less than 65, was admitted on [DATE], readmitted on [DATE] and discharged on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included end stage renal disease, peripheral vascular disease, chronic viral hepatitis C, opioid abuse, dependence on renal dialysis, polyneuropathy (nerve damage) and hypertension (high blood pressure). The 5/10/24 quarterly minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. He was independent with eating, oral hygiene, toileting, and showering. He used a front wheel walker to ambulate. He experienced frequent pain, and received scheduled pain medication. He did not reject care from staff. He did not wander. B. Family interview A family member was interviewed on 10/21/24 at 2:45 p.m. The family member said Resident #1 was homeless before he was admitted to the facility and he was again homeless after the facility discharged him AMA. The family member said no one from the facility called the family member about the discharge even though they were the legal representative for Resident #1 and were listed as the contact person for the resident. The family member said Resident #1 did not receive his medications from the facility when he was discharged and the family member did not know why. C. Record review The comprehensive care plan, initiated on 1/9/24 and revised on 5/5/24, revealed Resident #1 was to have his medication administered as ordered by the physician, had a diagnosis of hypertension and was at risk for chest pain and dizziness. Resident #1 was at high nutritional risk related to dialysis and wounds, fluid overload with swelling. The resident had a history of dialysis refusals due to not feeling well. Pertinent interventions included providing a diet, supplements and vitamins/minerals per physician order and the facility was to coordinate care with the dialysis center's dietitian. The 5/31/24 nursing elopement risk assessment tool revealed the resident was not cognitively impaired with poor decision making skills, did not wander, did not leave the facility without notifying staff and was not at risk for elopement. The July 2024 CPO revealed Resident #1 was to receive scheduled dialysis every Tuesday, Thursday, and Saturday. -However, according to the resident's care plan, he frequently refused dialysis due to not feeling well (see care plan above). A behavioral contract, signed by Resident #1 on 7/12/24, documented in pertinent part, Resident #1 must adhere to the following expectations to remain a resident at (facility name): -Communicate with the nursing department prior to going out on pass and, -Take enough medication for the scheduled number of days you will be out. I read and understand the above-listed behavioral expectations. I understand if I choose to leave, without my prescribed medications, and do not return to (facility name) at the agreed upon time, I will be considered out AMA and immediately discharged from the facility. A 7/21/24 nurse progress note revealed, Resident #1 left (the facility) for an overnight pass with his medications. Resident #1 was expected to return on Monday 7/22/24 by 5:00 p.m. -However, according to the NHA, Resident #1 was not expected to return to the facility until 7/23/24 (see NHA interview below). The 7/21/24, 7/22/24 and 7/23/24 nursing progress notes documented Resident #1 was out of the facility on pass. A nurse progress note dated 7/23/24 at 10:38 a.m. documented Resident #1 did not show up for his dialysis appointment. -However, according to the resident's care plan, he frequently refused dialysis due to not feeling well (see care plan above). An interdisciplinary team (IDT) progress noted, dated 7/23/24 at 3:53 p.m., revealed Resident #1 went out on pass and said he would return by 7/23/24 at 5:00 p.m. The facility attempted to reach him by phone and a message was left reminding him of the agreement he signed regarding if he did not return to the facility at an agreed upon time he would be discharged per the agreement. A nurse progress note, dated 7/23/24 at 6:06 p.m., documented Resident #1 would be back from being out on pass that evening at 5:00 p.m. Several phone calls were made to the resident's voicemail with no return call. As per facility contract, if he had not returned as agreed upon, he would be considered an AMA discharge. Resident #1 did not go to his dialysis appointment today (7/23/24) which he needed three times per week. The NHA informed (via voicemail) Resident #1 of his choices and the outcome. A physician's assistant progress note dated 7/25/24 (two days after the discharge) documented Resident #1 was doing overall well and tolerating his dialysis well. He went out on pass on 7/21/2024, did not return as he agreed to on 7/23/24 and was then discharged per policy. The note documented to refer to the nursing notes for attempts to contact the patient/family. -There was no documentation in Resident #1's electronic medical record (EMR) which revealed the resident's needs that could not be met by the facility or the attempts made by the facility to meet the resident's needs. IV. Staff interviews The NHA was interviewed on 10/21/24 at 2:20 p.m. The NHA said Resident #1 sometimes left the facility and did not return when he said he would. The NHA said Resident #1 signed a behavioral contract on 7/12/24 which read if Resident #1 did not return when he said he was going to return to the facility, the facility would discharge him AMA (see record review above). The NHA said she thought Resident #1 agreed to return in two days on 7/23/24, not in one day (on 7/22/24) as the nurse documented. The NHA said he did sign out of the facility and take one day of medications with him. The NHA said when she reached Resident #1 at night (on 7/23/24) via telephone the NHA thought he was safe because he told her he was sleeping on someone's couch. The NHA said she did not document that information. The NHA said she did not document anything about Resident #1's medications. The NHA said she thought she finally spoke to Resident #1 at 8:00 p.m. that night, however, she said the only documentation of Resident #1 being told he was discharged AMA was on 7/23/24 at 6:06 p.m. The NHA said she told Resident #1 over the phone he had signed a contract and because he did not keep it, he was declared AMA. The NHA said, had Resident #1 returned at 5:00 p.m like he said he would, she would have let him continue to live at the facility. The NHA said Resident #1 asked how he would get his belongings. The NHA said she told him she would box up his belongings and his bike for someone to come and get. The NHA said about a month later, someone did come in to get his belongings but she did not recall who the person was. The NHA said she was unaware a facility behavioral contract was not an acceptable reason for a resident to be discharged AMA. The NHA said Resident #1 did not come to get his medications and the facility did not arrange to give his medications to him. The NHA said the facility did not offer to go and pick Resident #1 up from wherever he was on 7/23/24. The NHA said Resident #1 was not evaluated by the physician prior to the discharge. The NHA said, because she thought Resident #1's discharge was considered AMA, the facility did not need to notify the ombudsman or any state agencies. The NHA was interviewed a second time on 10/21/24 at 4:00 p.m. The NHA said she should have begun a facility initiated transfer for Resident #1 and had the medical director sign the necessary paperwork for an appropriate discharge. The NHA said Resident #1 was discharged from the facility because he did not return when he said he would. The NHA said she documented he was one hour and six minutes late therefore she discharged him from the facility.

Based on interviews and record review, the facility failed to ensure residents were free from significant medication errors for two (#4 and #38) of seven residents reviewed for medication errors out of 32 sample residents. Resident #4, who had diagnoses of schizoaffective disorder (mental health condition that causes people to experience symptoms of schizophrenia and mood disorders) and bipolar, had a physician'sorder for clozapine (an antipsychotic medication). The medication required a complete blood count (CBC) laboratory result to be sent on a monthly basis to the pharmacy in order for the pharmacy to refill the medication. On 6/11/24, Resident #4 was administered her last available dose of clozapine, however, the results of the monthly CBC had not been obtained from the laboratory and faxed to the pharmacy in order for the pharmacy to refill the medication. Due to the facility's failure to send the CBC laboratory results to the pharmacy, Resident #4 did not receive her clozapine on 6/12/24 and 6/13/24. The facility failed to contact the resident's physician in order to inform the physician the medication was unavailable and obtain further orders. Due to the facility's failures to obtain the antipsychotic medication timely, Resident #4 missed two doses of the medication and self harmed herself on 6/13/24 by burning her left forearm with a cigarette, causing a cluster of five blisters. Additionally, the facility failed to: -Ensure Resident #38 received antibiotic medication according to the physician's orders; and, -Complete a medication review and reconciliation of medications prescribed for Resident #38. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607, retrieved on 7/15/24, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication. II. Antipsychotic medication error A. Facility policy and procedure The Adverse Consequences and Medication Errors policy, revised April 2014, was provided by the nursing home administrator (NHA) on 7/1/24 at 9:46 a.m. It read in pertinent part, A medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of professionals providing services. Examples of medication errors include the omission of drugs (medication not administered). The Medication Shortages/Unavailable Medication policy, revised 1/1/22, was provided by the director of nursing (DON) on 7/1/24 at 10:25 a.m. It read in pertinent part, This policy set forth procedures relating to medication shortages and unavailable medications. Upon discovery that the facility has an inadequate supply of medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from the pharmacy. If a medication is unavailable during normal pharmacy hours, the facility nurse should call the pharmacy to determine the status of the order. If the next available delivery causes a delay or a missed dose in the resident'smedication schedule, the facility nurse should obtain the medication from the emergency medication supply kit to administer the dose. If the medication is not available in the facility'semergency supply kit, the licensed facility nurse should call the pharmacy emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. If emergency delivery is unavailable, the facility nurse should contact the attending physician to obtain orders and directions. If the facility nurse is unable to obtain a response from the attending physician in a timely manner, the facility nurse should notify the nursing supervisor and contact the facility's medical director for orders and directions, making sure to explain the circumstances of the medication shortage. When the missed dose is unavoidable, the facility nurse should document the missed dose and the explanation for such missed dose on the MAR and TAR and in the nursing progress notes. The documentation should include a description of the circumstances of the medication shortage, a description of the pharmacy response upon notification, and actions taken. B. Resident #4 1. Resident status Resident #4, age less than 65, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included schizoaffective disorder, bipolar, chronic obstructive pulmonary disease (COPD), depression and muscle weakness. The 5/16/24 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The assessment revealed the resident was on routine antipsychotic medications and it had been documented by a physician that a gradual dose reduction (GDR) was contraindicated. 2. Resident interview Resident #4 was interviewed on 6/26/24 at 10:33 a.m. Resident #4 said the facility told her they ran out of her clozapine. She said she became anxious and was feeling distressed about not receiving her routine clozapine medication for two consecutive days. Resident #4 said on 6/13/24, due to the anxiety she was feeling about not receiving the medication, she used a cigarette to burn her left forearm which caused five blisters on her arm that required medical attention 3. Record review A review of Resident #4's behavior care plan revealed the resident was on an antipsychotic medication for schizoaffective disorder related to unprovoked verbal aggressive behavior. Interventions included monitoring behavior episodes and attempting to determine the underlying cause. -The care plan did not include an intervention for ensuring CBC laboratory results were faxed to the pharmacy in order to obtain refills of the medication. Review of Resident #4's June 2024 CPO, revealed the following physician's orders: Clozapine oral tablet 100 milligrams (mg). Give three tablets by mouth at bedtime related to schizoaffective and bipolar disorder, ordered 6/15/23. Monthly CBC for clozapine monitoring every day shift every month for clozapine use. Fax results to pharmacy for refill on medication clozapine, ordered 8/28/23. Review of Resident #4's June 2024 medication administration record (MAR) revealed the resident received her last dose of clozapine on 6/11/24. -Further review of the June 2024 MAR revealed the resident's clozapine was not administered on 6/12/24 and 6/13/24. -A review of the resident's progress notes on 6/12/24 revealed no documentation to indicate why Resident #4 did not receive her clozapine. On 6/13/24 at 11:39 p.m. registered nurse (RN) #2 documented the medication was unavailable. RN #2 documented the pharmacy required an updated CBC laboratory result in order to refill the medication. -The facility failed to send Resident #4's CBC laboratory results to the pharmacy prior to the resident's last dose of the medication on 6/11/24 in order to receive the next refill of the medication in a timely manner (see progress note above and interviews below). A 6/14/24 progress note documented Resident #4 reported to an occupational therapist that, due to feelings of distress and not receiving her medication, she self harmed by burning herself with a cigarette on the evening of 6/13/24. A wound care progress note dated 6/24/24 revealed Resident #4's blisters on her left forearm had developed into wounds and had received a status of not healed. The initial wound encounter measurements were 3.2 centimeters (cm) length by 3.7 cm width. An education for medication unavailability and shortages, dated 6/18/24, was provided by the NHA on 7/2/24 at 12:13 p.m. It read in pertinent part, Education completed with the primary nurse (RN #4) regarding how to access needed laboratory information for follow up, notifying the provider and the need to document steps taken to resolve issues as they arise. Licensed practical nurse supervisor educated on the need to follow up on information reported from floor staff. All nursing administration was educated regarding the above. C. Staff interviews RN #4 was interviewed on 7/2/24 at 11:02 a.m. RN #4 said she discovered, during medication administration on her shift on 6/12/24, that Resident #4 did not have clozapine available for administration. RN #4 said she contacted the pharmacy and was told the medication would be delivered with the next delivery. RN #4 said she did not administer the medication on her shift because the clozapine was unavailable and therefore Resident #4 missed a dose of the medication on 6/12/24. RN #4 said she passed the information on to the next shift's nurse but did not inform the charge nurse or the nurse manager about the missed dose due to the unavailability of Resident #4's clozapine. RN #4 said she failed to document her actions in the nurse progress notes. RN #4 said missing the doses of clozapine could have caused Resident #4 to inflict the injuries to her forearm with a cigarette on 6/13/24. RN # 4 said she had been educated by the director of nursing (DON) on the proper procedures to follow when medications were unavailable. RN #2 was interviewed on 7/2/24 at 11:40 a.m. RN #2 said she contacted the pharmacy on 6/13/24 during her nighttime medication administration when she discovered Resident #4's clozapine was not available. RN #2 said the pharmacy requested an updated CBC laboratory result before the medication could be refilled. RN #2 said she faxed the most current CBC laboratory test result to the pharmacy, however, she said she still did not receive the clozapine. RN #2 said she contacted the pharmacy again and was informed that the clozapine was not filled because the CBC laboratory test result was not current and, as a result, Resident #4 missed a second dose of the medication on 6/13/24. RN #2 said she informed the oncoming nurse about the unavailable medication, however, she said she did not notify the attending physician to obtain further orders and/or directions. RN #2 said she was unable to obtain the updated CBC laboratory test result for the pharmacy because the laboratory's website did not communicate with the facility's electronic medical record system RN #2 said Resident #4 received clozapine for her diagnosis of schizoaffective and bipolar disorder and missing two consecutive days of her medication could result in extreme behaviors, such as self-harm. RN #2 said she did not recall why she did not inform the nursing supervisor and the attending physician about the missed doses of the medication. RN #2 said she had received education on the proper procedures to follow when there were instances of medication shortage/unavailability and to document her actions per the facility's protocol. The DON was interviewed on 7/2/24 at 12:10 p.m. The DON said the staff should have followed the facility's protocol for medication shortages and unavailability by notifying the nurse supervisor and the attending physician about the circumstances of the medication and the missed doses. The DON said she believed the lack of awareness of staff led to the significant medication error and she had completed training for all nursing staff about the facility's policy regarding medication unavailability and medication errors. -A voicemail was left for the pharmacist during the survey, however, the phone call was not returned by the survey exit on 7/2/24. 47536 III. Antibiotic medication error A. Professional reference [NAME] A, Triantafylidis L, O ' [NAME] N, et al. Improving Medication Reconciliation With Comprehensive Evaluation At A Veterans Affairs Skilled Nursing Facility: The Joint Commision Journal on Quality and Patient Safety (2021), was retrieved on 7/1/24 from https://www.jointcommissionjournal.com/article/S1553-7250(21)00153-7/fulltext. It read in pertinent part, Unintentional medication discrepancies due to inadequate medication reconciliation pose a threat to patient safety. Skilled nursing facilities (SNFs) are an important care setting where patients are vulnerable to unintentional medication discrepancies due to increased medical complexity and care transitions. SNFs represent a critical setting for medication reconciliation efforts due to challenges completing the reconciliation process and the concomitant high risk of adverse drug events in this population. Ineffective medication reconciliation continues to threaten patient safety across health care systems around the world. Best-practice guidelines outline the need for high-quality medication reconciliation in all care settings, including skilled nursing facilities (SNFs). Patients in SNFs are at heightened risk for medication reconciliation errors due to increased care transitions (for example, home to hospital to SNF to home) and medical complexity. Improving medication reconciliation in the SNF setting is challenging due to resource constraints, complex workflows, and variation in the capabilities of electronic medical records (EMRs). B. Facility policy The Documentation of Medication Administration policy, revised November 2022, was received from the nursing home administrator (NHA) on 7/1/24 at 3:35 p.m. The policy read in pertinent part, A medication administration record is used to document all medications administered. A nurse documents all medication administered to each resident on the resident's medication administration record (MAR). Administration of medication is documented immediately after it is given. Documentation of medication administration includes, at a minimum, the resident's name, name and strength of the drug, dosage, route of administration, date and time of administration, initials, signature and title of the person administering the medication, and the resident response to the medication. C. Resident #38 1. Resident status Resident #38, age greater than 65, was admitted on [DATE]. According to the July 2024 CPO, diagnoses included neuromuscular bladder dysfunction and history of methicillin-susceptible staphylococcus aureus (MSSA) bacteremia staphylococcus infection (MSSA BSI). The 5/15/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident was independent with his activities of daily living. 2. Resident interview Resident #38 was interviewed on 7/1/24 at 1:14 p.m. Resident #38 said he took antibiotic medications three times a day. He said he took the medication to prevent an infection from returning to his spine. 3. Record review Review of Resident #38's July 2024 CPO revealed the following physician's order: Cephalexin 500 milligram (mg) tablets, give 500 mg orally (by mouth) three times a day, ordered 5/25/22. A 8/1/23 infectious disease (ID) physician note revealed Resident #38 was evaluated by the ID physician. The ID physician ordered a decrease in the resident's Cephalexin. The new order was for Cephalexin 500 mg tablets, two times a day. A 4/2/24 ID physician note revealed Resident #38 was evaluated by the ID physician. The note documented the resident had a history of MSSA BSI from an infection in his spine in 2020. The note documented the resident was to continue on Cephalexin 500 mg twice a day for infection prevention. The facility failed to change Resident #38's Cephalexin order on 8/1/23. From 8/1/23 to 7/2/24, the resident was administered the Cephalexin medication three times a day instead of two times a day. -There was no documentation in Resident #38's electronic medical record (EMR) to indicate a medication review and reconciliation had occurred following the resident's appointment with the ID physician in order to ensure the resident was receiving the correct dose of the Cephalexin antibiotic -Review of Resident #38's comprehensive care plan revealed the facility failed to develop an individualized care plan focus for Resident #38 for antibiotic stewardship and infection monitoring. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 7/1/24 at 1:05 p.m. LPN #1 said when any resident returned from outside appointments, the facility nurse should review the clinical documentation from the outside provider, which included a review and reconciliation of medication. She said when the nurse completed her review, it was the nurse's responsibility to contact the physician to discuss new or changed treatment orders. The DON was interviewed on 7/2/24 at 8:50 a.m. The DON said when residents returned to the facility from outside appointments, the nurse should review the clinical documentation from the outside provider. The DON said when changes to care were identified, the nurse should contact the physician for clarification and new facility orders if indicated. The DON said she was unable to locate documentation in Resident #38's EMR to indicate the nurse, the interdisciplinary team or the facility physician had completed a review of the ID physician's treatment plan. The DON said the facility had an antibiotic stewardship program. She said the antibiotic stewardship program was responsible for reviewing all antibiotic orders to ensure antibiotics were used effectively. The DON said she was unable to locate documentation to indicate the facility reviewed Resident 38's prescribed antibiotic medication. The DON said she would contact the ID physician and ensure Resident #38 received the prescribed dose of Cephalexin going forward.

Based on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to: -Ensure the main entrance walkway was smooth without holes and gaps in the concrete surface; -Ensure the sidewalks and the common space areas were clear of debris, hoses and other equipment; -Ensure the residents had unrestricted access to hallway safety rails; -Ensure the common area recreational spaces were clear of extension cords; -Ensure the residents' hallway flooring was even without open gaps/spaces in the flooring surface; -Ensure the handicapped door opener was functioning and operational; -Ensure broken and damaged medical equipment, discarded resident belongings, folding chairs, large metal drums, hoses and maintenance items were disposed of and not left piled up in the parking lot behind the facility; -Ensure the landscaping was tidy and free from large areas covered with weeds and overgrown grass, empty cardboard boxes and piles of wood; and, -Ensure missing light covers were replaced when missing or broken. Findings include: I. Facility policy and procedure The Maintenance Manual policy, dated 12/31/15, was provided by the nursing home administrator (NHA) on 7/4/24 at 9:46 a.m. It read in pertinent part, Maintenance activities include, providing a functional, sanitary, and comfortable environment, controlling or eliminating nuisances and pollutants within the immediate environment and ensuring that all equipment, buildings, spaces, and fixtures are kept in operable condition. This facility shall properly maintain the exterior of the building, the grounds, and the parking lot to ensure that they are clean, well-kept, and as free as possible of environmental pollutants. This facility shall employ safe and proper methods in maintaining the facility to protect against injury to our residents, staff, or visitors. Exterior general maintenance: Inspect the exterior of the building weekly for needed repair. Check the exterior of doors and windows, including handles, knobs and locks, sills. Grounds, sidewalks, patios, and parking lot: Cut all lawns on a regular basis (weekly during summer). Keep shrubs neatly trimmed. Sweep sidewalks and patios daily during warm months when they are in constant use and weekly during cool months. Clean up any debris, especially broken glass, on sidewalks and patios immediately. All debris is a potential hazard to our residents. Maintain the facility, its fixtures, and equipment in safe and good repair. Repair, or have repaired, any defect in the facility's structure, fixtures, or equipment as soon as possible. By periodic inspection (at least weekly), he/she shall check the condition of special equipment and fixtures for the blind and otherwise physically handicapped residents, and all other required safety equipment and fixtures. Should any of the above be inoperable, defective, or not securely installed, the administrator will have them immediately repaired by the maintenance supervisor or appropriate servicing company. Inspect all areas in the building and grounds under the control of the license that are used to provide the care and services required to obtain and retain a license, including storage areas. Determine that no condition exists that presents a potential hazard to residents, clients, employees, or visitors. Check bulb guards around exposed light bulbs to make sure they are securely fastened. Install new fluorescent lights as necessary. Replace light covers and glass when broken or cracked. II. Observations Two environmental tours of the facility were conducted on 6/26/24 at 10:10 a.m. and on 7/2/24 at 12:22 p.m. Observations revealed the following: -The front concrete sidewalk at the bottom of the ramp leading to the front door was cracked and had a large hole the width of the sidewalk at the point where two pieces of the sidewalk met. The gap in the sidewalk spanned the entire width of the sidewalk and was four to five inches wide and a couple of inches deep. -Visitors and residents were observed having to make a deliberate step over the hole in the sidewalk or step or roll around to an area of the sidewalk that was not as badly gouged. A couple of visitors got stuck in the hole and one vendor bringing in supplies struggled to get the cart full of supplies over the gouged sidewalk. The facility had several patios for resident use. The patio off the activities room had raised garden beds where residents assisted in the gardening process. -The sidewalks on the activities room patio had gardening supplies, a cardboard box and a garden hose on the surface, which were likely to cause a trip hazard for residents using the patio. -Additionally, there were pieces of a disassembled plastic shed leaning up against the building. -The smoking patio had uneven sidewalks and several gouged areas on the surface of the walkway at the entrance to the patio area. -The unit hallways were cluttered with unused resident beds, wheelchairs, a recliner chair and mechanical lifts that were blocking resident access to the hallway safety rails. -The hallway lights outside the resident rooms were missing their covers and the bulbs were exposed. The facility recreation room had a large pool table, television and several bookshelves containing books and other recreation items for the residents. -The televisions and bookshelves in the room were inaccessible to residents because the walkway was blocked by a large coiled-up extension cord used to power a swamp cooler, which was a potential tripping hazard. -The hallway floor outside the rehabilitation gym was in a state of disrepair. The tiles were missing and a new plywood floor was placed. The floor, however, had a large gap where the flooring did not meet, causing an uneven surface that a resident with unsteady balance or using a walker assistive device could get stuck in causing a likely trip hazard. -There was a large pile of trash in the back parking lot visible from inside the facility. The unorganized pile of trash spanned several parking spaces and consisted of three hospital beds, several folding chairs, hoses, a large metal drums, a weed eater, a grass spreader, open and filled cardboard boxes, folding tables, metal buckets, walkers, wheelchairs, discarded resident belongings and other miscellaneous items. The pile was dumped in place in a disorganized manner and the items left in the elements were starting to rust. -The outside landscaping was overgrown with weeds. III. Resident interviews Resident #25 was interviewed on 6/26/24 at 9:33 a.m. Resident #25 said the front entrance sidewalk was a problem that had been in its current state of disrepair for at least the past two years. He said it needed to be fixed because he and the other residents and visitors would be caught up in the hole. He said he saw several residents in manual wheelchairs struggle to get past the hole and up the ramp. Resident #25 said the handicapped door opener at the front door when exiting the building had also been broken for at least two years. He said it caused an accessibility issue and was a problem because residents who used wheelchairs had to position themselves correctly to be able to push the door with their footrests and if they did not have proper shoes on it could be problematic to the person. Resident #25 said he was bothered by the pile of trash in the back parking lot. He said the trash was building up and the facility was not taking care of it. He said the weeds were growing around the trash and it could possibly attract rodents. A resident group interview was conducted on 7/1/24 at 10:30 a.m. with four alert and oriented residents (#65, #20, #42 and #46). The residents said they thought the area in the back parking lot was a storage area for broken equipment that needed to be repaired. The residents said the area was a space for staff parking and they had occasional cookouts for residents and staff in the back during warm weather. The residents said the handicapped door opener had been broken for at least three years and they just got used to it. One resident said it needed to be fixed. The residents said the cracked sidewalk at the bottom of the front entrance ramp had been that way forever. One resident said he hated that crack and they all said staff had to help them up the ramp because of the crack and hole in the surface of the sidewalk. IV. Staff interviews The maintenance director (MTD) was interviewed on 7/2/24 at 3:35 p.m. The MTD said there was a lot to keep up with in the building. He said the facility had contractors in the building doing structural repairs and it took his time away from his regular duties. He said the floor outside of the rehabilitation gym was sagging and he was having a hard time repairing it. He said he would replace more of the flooring to eliminate the gap in the floor. The MTD said the facility had a routine schedule for landscaping the grounds every Friday but got delayed when the building had plumbing issues that needed to be addressed. The MTD said the junk out back had been there for some time and they just needed to get a dumpster to get rid of all of the unused items. The MTD said the facility had plans to remodel the building and would begin that work as soon as they cleared the list of urgent repairs. The MTD said the handicapped door opener needed to be fixed. He said he had a door technician scheduled and would have him look at the handicapped door opener to see if he could repair it during the repair visit. The NHA was interviewed on 7/2/24 at 3:48 p.m. The NHA said the MTD had a lot of projects but she would talk to him about the issues discussed.

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 on two of four units. Specifically, the facility failed to: -Ensure housekeeping staff followed proper cleaning techniques for cleaning and disinfecting resident rooms and high frequency touch areas (call lights, bed controls and light switches); -Ensure infection control protocols were followed during and after wound care provided to a resident in the facility's shower room; and, -Ensure staff performed hand hygiene appropriately during wound care. Findings include: I. Housekeeping failures A. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, was retrieved on 7/10/24 from https://www.journalofhospitalinfection.com/article/S0195-6701(21)00105-5/fulltext. It revealed in pertinent part, High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 7/10/24 from https://www.cdc.gov/healthcare-associated- infections/hcp/cleaning-global/procedures.html?CDC_AAref_Val=https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html#cdc_generic_section_2-4-1-general-environmental-cleaning-techniques. It read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include bed rails, IV (intravenous) poles, sink knobs, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs. Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. B. Facility policy and procedure The Cleaning and Disinfecting Residents' Rooms policy and procedure, revised August 2013, was received from the nursing home administrator (NHA) on 7/1/24 at 2:49 p.m. It revealed in pertinent part, The purpose of this procedure is to provide guidance for cleaning and disinfecting residents' rooms. Clean horizontal surfaces (for example, bedside tables, over bed tables, and chairs) daily with a cloth moistened with disinfectant solution. Do not use feather dusters. Clean all high touch furniture items with disinfectant solution. Clean all high touch personal use items (for example, lights, phones, call bells and bed rails) with disinfecting solutions. C. Observations On 6/27/24 at 8:52 a.m. housekeeper (HSKP) #1 was observed cleaning resident room [ROOM NUMBER], a double occupancy room. HSKP #1 used a Swiffer duster to dust the B side of the room, including the lamp, ceiling, walls, television, bedside table, night stand, headboard/footboard of the bed, dresser and the window sill. After dusting, HSKP #1 removed her gloves, performed hand hygiene and applied new clean gloves. HSKP #1 proceeded to take the same Swiffer duster to the A side of the room and dust the lamp, ceiling, television, door frame, closet doors and the light above the sink. -HSKP #1 failed to wipe any high touch surfaces in the residents' room with a disinfectant. On 6/27/24 at 9:12 a.m. HSKP #1 was observed cleaning resident room [ROOM NUMBER], a double occupancy room. HSKP #1 collected the Swiffer duster and dusted the B side of the room, including the light over the sink, blinds, television, the light over the bed, headboard, footboard and the walls. HSKP #1 removed her gloves, performed hand hygiene and applied new clean gloves. HSKP #1 took the Swiffer duster again and dusted the A side of the room, including the night stand, walls, ceiling, television, dresser, door frame and the closet door. -HSKP #1 failed to wipe any high touch surfaces in the residents' room with a disinfectant. HSKP #1 proceeded to sprayed the toilet in room [ROOM NUMBER] with disinfectant and waited for the appropriate dwell time before wiping down the toilet. HSKP #1 wiped the toilet with a dry cloth starting with the toilet seat, then the outside of the toilet down to the floor. HSKP #1 proceeded to use a toilet brush to scrub the toilet bowl and flushed the toilet. While HSKP #1 was scrubbing the toilet bowl, water splashed onto the seat and the outside of the toilet. -HSKP #1 failed to clean the toilet from cleanest to dirtiest. -HSKP #1 failed to reclean the toilet seat and outside of the toilet after water from inside the toilet bowl splashed on the areas while the toilet bowl was being scrubbed. On 6/27/24 at 9:57 a.m. HSKP #2 was observed cleaning resident room [ROOM NUMBER], a double occupancy room. HSKP #2 sprayed the sink and toilet with disinfectant, waited the appropriate dwell time and began wiping the sink faucet handles, the toilet rim and the toilet bowl. Using the same rag she used to wipe the toilet rim and toilet bowl, HSKP #2 wiped down the handrails in the bathroom and the knob to the bathroom door. -HSKP #2 failed to clean surfaces from cleanest to dirtiest when she wiped the toilet bowl and then the handrails and bathroom door knob. HSKP #2 retrieved a new rag, sprayed the rag with disinfectant and wiped down the door knob to the main door of the room and the dresser for bed B. HSKP #2 then took a new rag, sprayed disinfectant on it and wiped down the dresser and nightstand for bed A. -HSKP #2 failed to disinfect any high touch surfaces in the residents' room. D. Staff interviews HSKP #1 was interviewed on 6/27/24 at 9:38 p.m. HSKP #1 said resident rooms were cleaned daily. HSKP #1 identified high touch areas/surfaces as light switches, blinds and walls. HSKP #1 said call lights and door knobs should be cleaned daily, however she did not clean them in either room (see observations above). HSKP #1 said bedside tables were cleaned when the residents asked for them to be cleaned. HSKP #1 said high touch areas should be cleaned to prevent bacteria build up. HSKP #2 was interviewed on 6/27/24 at 10:16 a.m. HSKP #2 said high touch areas in a resident room were call lights and should be disinfected daily. HSKP #2 said she did not clean the call lights or bedside tables in the room because the facility had a housekeeper (HSKP #3) on light duty and it was that person's responsibility to clean the high touch areas in the residents' rooms and common areas. HSKP #2 said she did not scrub the toilet in room [ROOM NUMBER] because she only scrubbed toilets as needed, based on their appearance. HSKP #3 was interviewed on 6/27/24 at 10:29 a.m. HSKP #3 said she was responsible for disinfecting/cleaning common areas in the building along with door knobs, sinks, mirrors and grab bars in residents' rooms while she was on light duty. HSKP #3 said she did not clean residents' bedside tables or call lights unless they appeared dirty. HSKP #3 said she did not get to every resident's room every day and she was assigned to different halls every day. The maintenance director (MTD) was interviewed on 7/2/24 at 11:57 a.m. The MTD said he was responsible for checking on housekeepers for audit purposes, such as checking that trash had been collected, rooms were cleaned and ensuring staff schedules were completed. The MTD said high touch areas in residents' rooms were door knobs, call lights, light switches and television remote controls. The MTD said high touch areas should be cleaned daily with a disinfectant to prevent the spread of infection. The MTD said HSKP #3 was on light duty and was responsible for cleaning all high touch surfaces in residents' rooms. The MTD said he left the training of the housekeepers to his housekeeping supervisor (HSKS). The HSKS was interviewed on 7/2/24 at 12:12 p.m. The HSKS said high touch surfaces in the residents' rooms were call lights, bed controls, television remote controls, the sink, door knobs and light switches. The HSKS said high touch surfaces should be cleaned daily to prevent infection. Infection preventionist (IP) #1 was interviewed on 7/2/24 at 11:52 a.m. IP#1 said high touch areas were sinks, bedside tables, door knobs, light switches and call lights. IP #1 said high touch areas were to be cleaned/disinfected daily to prevent infection. II. Wound care failures A. Professional reference The Clean and Aseptic Technique: Cleaning a Wound, undated, was retrieved on 7/15/24 from: https://www.healewoundcare.com/clean-aseptic. It revealed in pertinent part, Organize supplies onto a clean surface, wash hands and open up items to be used. A clean, non-porous material needs to catch and run-off from the wound during cleaning and should be replaced with a clean, dry field before dressing placement. B. Facility policy and procedure The Handwashing/Hand Hygiene policy and procedure, revised August 2019, was received from the NHA on 6/26/24 at 9:00 a.m. It revealed in pertinent part, The facility considers hand hygiene the primary means to prevent spread of infection. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents and visitors. Use an alcohol-based hand rub containing at least 62% alcohol, or alternatively, soap (antimicrobial or non antimicrobial) and water for the following situations: before and after direct contact with residents,before performing any mom-surgical invasive procedures, before handling clean or soiled dressings and gauze pads, before moving from a contaminated body site to a clean body site during resident care, after contact with blood or bodily fluids, after contact with objects in the immediate vicinity of the resident and after removing gloves. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Applying and removing gloves perform hand hygiene before applying non sterile gloves. Perform hand hygiene after removing gloves. The Dressing-Clean Technique policy and procedure, undated, was received from the NHA on 7/4/24 at 9:46 a.m . It revealed in pertinent part, A clean dressing technique is used to provide a conduit to wound healing. All dressings are performed using clean technique, unless otherwise specified by the physician. Wash hands before and after the procedure and wear gloves. Remove gloves. Open packages and remove dressing, observing aseptic technique. C. Observations On 7/1/24 at 12:43 p.m. licensed practical nurse (LPN) #1 was observed providing wound care to Resident #10. Wound care was provided in the shower room. LPN #1 set all of the clean wound care supplies directly on the counter around the sink. Resident #10 remained sitting in a wheelchair for treatment with the resident's right foot resting on the foot pedal with no barrier pad between the surface of the foot pedal and the bottom of the resident's foot. -LPN #1 failed to provide a clean working area for the clean wound care supplies and the treatment of the wound. LPN #1 applied gloves and removed the old dressing from the resident's right foot. LPN #1 had to moisten the bandage with normal saline to remove the dressing. After removing the old dressing from the wound, LPN #1 removed her soiled gloves and applied new gloves. -LPN #1 failed to perform hand hygiene after removing her soiled gloves and before putting on new gloves. LPN #1 applied normal saline to two pieces of gauze. Taking one piece of gauze at a time, she pressed the wound twice with the gauze and then wiped the wound four times. Wound drainage and saline solution was observed to be dripping down the resident's leg onto his foot pedals and onto the shower room floor. LPN #1 opened sterile gauze pad packets and then opened a bottle of iodine and poured it over the gauze. LPN #1 proceeded to wring out the excess iodine over the trash can and placed the iodine soaked gauze pads on the resident's wound. LPN #1 secured gauze pads to the resident's leg with rolled gauze. Resident #10 left the shower room via wheelchair. -The resident's wheelchair pedals were not cleaned after the wound care was provided. LPN#1 removed her gloves after disposing of the unused supplies. LPN #1 applied one glove to one hand and carried the trash across the hallway from the shower room to the soiled utility room for disposal into a biohazard trash receptacle. LPN #1 returned to the nurses station, collected a computer and placed it onto her medication cart. The shower room door was closed and the floor was not cleaned. -LPN #1 failed to change her gloves after cleaning the wound, prior to opening the sterile packaging and failed to perform hand hygiene after wound care was complete. -LPN #1 failed to place a barrier pad under the resident's leg to contain the wound drainage. -LPN#1 did not clean the shower room floor or the resident's foot pedals after wound care. On 7/1/24 at 3:40 p.m. registered nurse (RN) #1 was observed on 7/1/24 at 3:40 p.m. providing wound care to a Resident #28 in his room. Resident #28 was lying on his right side for treatment and the resident's incontinence brief was pulled away from the site of the wound. The resident was lying on a chucks barrier pad. The incontinence brief and the chucks pad were observed with bloody wound drainage on them prior to RN #1 changing the wound dressing. -RN #1 did not place a clean chucks pad or incontinence brief under the resident prior to changing the wound dressing. Following the wound dressing change, RN #1 changed the resident's incontinence brief, however, she did not replace the soiled chucks barrier pad. -RN #1 failed to provide a clean working area under the resident for wound care. D. Staff interviews LPN #1 was interviewed on 7/1/24 at 12:49 p.m. LPN #1 said she did not sanitize between gloves changes and it was best practice to apply a sanitizer or wash hands with soap and water between glove changes. LPN #1 said the Resident #10 preferred not to complete wound care in his room if his roommate was present, which was why she completed the wound care in the shower room. LPN #1 said the shower room was cleaned by the certified nurse aides (CNA) after each use and once daily by housekeeping. LPN #1 said she did not observe any fluids drip onto the resident's foot pedals or floor during wound care and so she did not clean the shower room floor or the foot pedals (see observations above). LPN #1 said sometimes a barrier pad could be placed under the wound if a resident was receiving treatment in bed. LPN #1 said a barrier pad could prevent cross contamination or soiling of areas below the wound during treatment. LPN #1 said when cleaning the wound, she should have only wiped the wound once with each piece of gauze to prevent potential contamination of the wound. RN #1 was interviewed on 7/1/24 at 4:58 p.m. RN #1 said placing a new chucks barrier pad under the resident for wound care could help prevent infection. IP #1 was interviewed on 7/2/24 at 11:52 a.m. IP #1 said a wound should be cleaned with what the physician order instructed. IP #1 said the wound should only be wiped once with each piece of gauze to prevent infection. IP #1 said chucks barrier pads should be used under the residents' wounds to absorb drainage and prevent infection. IP #1 said setting up dressing supplies should be done on a clean surface, such as a barrier pad, to prevent infection. IP #1 said the nurse should have cleaned the shower room and foot pedals after wound care was provided. IP #1 said nursing staff should perform hand hygiene when changing gloves to prevent the spread of infection. IP #1 said housekeeping cleaned shower rooms and CNAs also cleaned shower rooms between residents. She said the nursing staff should have cleaned the shower room floor and Resident #10's foot pedals after performing wound care

Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the facility's main kitchen and two out of four unit refrigerators. Specifically, the facility failed to: -Ensure beverages in the unit refrigerators were dated and labeled; -Ensure stacked pans were dried appropriately; -Ensure dented food cans were not used; and, -Ensure an appropriate test strip was used for the sanitizing bucket. Findings include: I. Ensure beverages in the unit refrigerators were dated and labeled A. Professional reference The Colorado Department of Public Health and Environment (3/16/24) The Colorado Retail Food Establishment Rules and Regulations, were retrieved on 7/10/24 from https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_RFE_Reg_6 CCR 1010-2_2024_EN.pdf. It read in pertinent part, Time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations. A date marking system may include using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine, marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded and/or marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded. The Hormel Code Date and Handling Information 2022, retrieved on 7/15/24 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.hormelhealthlabs.com/wp-content/uploaDM/HHL-Code-Date_Handling-Sheet-04_2024.pdf It revealed in pertinent part, Hormel Thick & Easy Clear Thickened Beverages shelf life: refrigerated up to ten days. B. Observation On 6/26/24 at 10:22 a.m., the following was observed in the east nursing station nourishment refrigerator: -There was one opened gallon of milk with no open date . On 6/27/24 at 3:14 p.m., the following was observed in the west nursing station nourishment refrigerator: -There were two bottles of juice, an opened bottle of sparkling water and an opened container of thickened beverage with no labels or dates on them. C. Staff interviews The dietary manager (DM) was interviewed on 6/27/24 at 3:45 p.m. The DM said nursing staff were responsible for ensuring all opened items in the unit refrigerator were properly labeled and dated. He said all opened and undated items should be discarded since no one knows how long they have been opened. He said undated beverages could cause food-borne illness. Licensed practical nurse (LPN) #2 was interviewed on 6/27/24 at 4:00 p.m. LPN #2 said opened beverages needed to be dated and labeled to ensure every staff member knew when the drink should be discarded. She said the gallon of milk in the refrigerator had no open date and needed to be thrown away. LPN #2 said residents could become sick from drinking milk products that were past the date they should be discarded. LPN #2 said all unlabeled and undated items in the refrigerator would be discarded. The NHA was interviewed on 7/1/24 at 1:00 p.m. She said the unit refrigerators should be monitored by nursing staff to ensure items were dated and labeled when opened. II. Ensure stacked pans were dried appropriately A. Professional reference The Colorado Department of Public Health and Environment (3/16/24) The Colorado Retail Food Establishment Rules and Regulations, was retrieved on 7/10/24 from https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_RFE_Reg_6 CCR 1010-2_2024_EN.pdf. It read in pertinent part, Equipment and Utensils, Air-drying required. After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food and may not be cloth dried. B. Facility policy The Kitchen Sanitation policy, revised November 2022, was provided by the nursing home administrator (NHA) on 7/2/24 at 6:25 p.m. It read in pertinent part, The food service area is maintained in a clean and sanitary manner. Food preparation equipment is allowed to be air dried. Drying food preparation equipment and utensils with a towel or cloth may increase risks for cross contamination. C. Observations On 7/1/24 at 10:40 a.m. there were metal pans that were stacked on a storage shelf in the main kitchen. The metal pans had moisture between them. D. Staff interviews Dietary aide (DA) #2 was interviewed on 7/1/24 at 11:00 a.m. DA #2 said cooking utensils and pans needed to be air-dried before they were stacked together to prevent moisture buildup. DA #2 said sometimes they stacked the pans together to make room for additional dishes. The DM was interviewed on 7/1/24 at 11:10 a.m. The DM said the pans should not have moisture between them and should be air-dried. The DM said the excess moisture could attract harmful bacteria and had higher chances of cross contamination. The DM separated the pans and placed them individually to be air-dried. He said he would provide education to all of the kitchen staff on the proper process of drying kitchen pans before they were stacked together. III. Ensure dented cans were discarded A. Professional reference According to the United States Department of Agriculture (USDA), retrieved on 7/10/24 from https://ask.usda.gov/s/article/Is-food-in-damaged-cans-dangerous, Never use food from cans that are leaking, bulging, or badly dented, cracked jars or jars with loose or bulging liDM, canned food with a foul odor or any container that spurts liquid when opening. Such cans could contain clostridium botulinum. A deep dent is one that you can lay your finger into. Deep dents often have sharp points. A sharp dent on either the top or side seam can damage the seam and allow bacteria to enter the can. Discard any can with a deep dent on any seam. While extremely rare, a toxin produced by it is the worst danger in canned gooDM. Don' t taste such fooDM. Even a minuscule amount of botulinum toxin can be deadly. B. Observations On 6/26/24 at 10:14 a.m., during the initial kitchen tour, there was one dented can of ready-to-use roasted chicken gravy, one dented can of mandarin oranges and one dented can of apples that were on the rack for storing canned fooDM in the kitchen. C. Staff interviews The DM was interviewed on 6/27/24 at 4:30 p.m. The DM said dented canned food needed to be stored separated from the other cans and should not be used. The DM said dented canned food could grow bacteria that could cause food-borne illness to the residents. The DM said he believed a lack of awareness from the kitchen staff resulted in having dented canned fooDM on the kitchen rack. He said all of the kitchen staff received training and were aware not to place dented food cans on the rack to be used. The DM said he had removed the dented cans and would provide education to the kitchen staff immediately to avoid staff using any dented food cans. The nursing home administrator (NHA) was interviewed on 7/1/24 at 1:00 p.m. The NHA said dented canned fooDM should be separated and were not to be used. IV. Ensure the correct sanitizing stripes were used for sanitizing buckets A. Professional reference The Colorado Department of Public Health and Environment (2024) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 7/10/24 from: https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view read in pertinent part, Chemical sanitizers that are used to sanitize equipment and utensils shall be provided and available for use during all hours of operation. A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times and be used in accordance with the EPA registered label use instructions. Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. B. Observations and interviews On 6/26/24 at 10:11 a.m., DA #1 went to the dishwashing area and filled a red bucket with a broad range quaternary sanitizer solution and headed to the dining room. DA #1 said the solution was used to clean equipment and surfaces in the food preparation area. She said she did not check the chemical concentration of the sanitizer when she filled the bucket with the sanitizer solution. The DM said the kitchen had an automatic solution dispenser that mixed the solution with water. The DM said the staff used the machine to fill the red sanitizer buckets. He said the staff needed to test the solution each time they filled the bucket to ensure the strength of the solution was correct by testing the parts per million (PPM). He said the kitchen staff needed to document that they tested the solution on a log. He said the solution should also be tested in the morning and in the evening to ensure it was the correct strength. The solution was tested with a test strip by the DM. The solution registered 10 ppm on the strip. -The DM dumped out the solution and tested another bucket of sanitizer solution with a new test strip. The new test strip read 10 ppm. The DM told DA #1 to stop using the solution until the proper sanitizing solution was attained. On 6/27/24 at 8:50 a.m. the DM tested the sanitizer with a new test strip and tested the chemical solution and it measured 200 ppm. C. Record review A review of the June 2024 (6/1/24 to 6/27/24) sanitizing test strip log on 6/27/24 at 9:50 a.m. revealed the log was missing documentation for nine days out of 27 days. -The test logs for 6/1/ 24 to 6/18/24 documented the quat solution tested at 200 ppm each shift (see interview below). C. Staff interviews The DM was interviewed on 6/27/24 at 2:25 p.m. The DM said the facility had been using the wrong test strips to test the ppm of sanitizing solution. The DM said the correct test strips had been obtained and the quat solution was now testing at 200 ppm, which was the proper ppm. The DM said the test logs could not be accurate given the facility had the wrong test strips (see record review above). The DM said he would educate the kitchen staff on how to test the quat solution correctly. The DM said he did not know how long the facility had been using the wrong test strips. He said all the old test strips had been discarded. The nursing home administrator (NHA) was interviewed on 7/1/24 at 1:00 p.m. The NHA said the kitchen staff should ensure the sanitizing solution measures 200 ppm before using it on equipment and surfaces in the food preparation area and in the dining room where residents eat. The NHA said she was unsure why the policies and procedures were not being followed by facility staff. She said she would provide education immediately and monitor for compliance.

Based on observations, record review and interviews, the facility failed to ensure one (#8) of one resident reviewed out of 32 sample residents was provided personal privacy in her room. Specifically, the facility staff failed to knock before entering Resident #8's room while the resident was being provided with personal care. Findings include: I. Facility policy and procedure The Resident Rights policy, revised August 2009, was provided by the nursing home administrator (NHA) on 7/4/24 at 9:46 a.m. It read in pertinent part, Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to privacy and confidentiality and voice grievances and have the facility respond to those grievances. II. Resident status Resident #8, age less than 65, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included chronic respiratory failure, chronic pain syndrome, bipolar disorder, major depressive disorder, and diabetes mellitus. The 4/15/24 minimum data set (MDS) assessment revealed Resident #8 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #8 required moderate assistance of one person with bed mobility, toileting and maximum assistance with lower body dressing. The assessment documented Resident #8 had no behaviors. III. Resident interview and observations Resident #8 was interviewed on 6/26/24 at 3:19 p.m. Resident #8 said most of the facility staff did not respect her privacy. Resident #8 said staff would frequently enter her room when she was receiving personal care which bothered her. On 6/27/24 at 1:51 p.m. Resident #8 was lying in her bed waiting for staff assistance to get ready for an outside appointment. At 1:55 p.m. certified nurse aide (CNA) #2 arrived to assist the resident. CNA #2 knocked on the door and entered the resident's room. CNA #2 closed the resident's door before she started providing personal care. At 2:02 p.m. activities assistant (AA) #1 arrived at Resident #8's room. AA #1 proceeded to enter Resident #8's room without knocking. -AA #1 exited the room quickly after realizing Resident #8 was being provided with personal care, however, AA #1 failed to initially knock before entering the room At 2:10 p.m. Resident #8 came out of her room in a power wheelchair and said there was no privacy in the facility. IV. Staff interviews CNA #2 was interviewed on 6/27/24 at 2:15 p.m. CNA #2 said she always knocked before entering a resident's room. She said AA #1 did not knock before she opened Resident #8's bedroom door. CNA #2 said she was providing personal care to Resident #8 when AA #1 entered the room without knocking. She said Resident #8 was upset about the incident. CNA #2 said she asked AA #1 to knock and wait for a response before entering a resident's room because residents' private areas were often exposed when they were receiving personal care. AA #1 was interviewed on 6/27/24 at 2:45 p.m. AA #1 said she was trained to run special activities groups, one-on-one activities and outings. AA #1 said she had been in her current position for two months and had no prior experience with the activity department. AA #1 said Resident #8 had previously complained that her knocking was too loud, which disturbed her afternoon sleep, therefore she tried to knock gently. AA #1 said she did not document or report the resident's concern about her knocking too loudly to disturb the resident's afternoon sleep to anyone. AA #1 said she would be mindful of knocking. -However, despite AA #1 saying she knocked gently on Resident #8's door, AA #1 was observed entering the resident's room without knocking (see observation above). The NHA was interviewed on 7/1/24 at 1:00 p.m. The NHA said it was the facility's policy for every resident to be treated with respect and dignity. The NHA said every staff member should knock before entering a resident's room. The NHA said resident's rights should be respected and followed. The NHA said she had initiated education on 7/1/24 for AA#1 and would continue to educate all the facility's staff regarding knocking on resident's doors before entering their rooms.

Based on resident observation, record review and interviews, the facility failed to ensure one (#46) of three residents reviewed for pressure ulcers out of 27 total sample residents, received care consistent with professional standards of practice to prevent pressure injuries. Resident #46 was at high risk for developing pressure injuries due to being admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #46 was admitted to the facility on [DATE] and was admitted with intact skin to both heels. The facility developed a care plan for the resident which did not include initial interventions for protecting the resident's heels from pressure injury development. On 6/29/21, the resident developed a deep tissue injury (DTI) to his left heel that was a stage 3 pressure wound following surgical debridement (removal of dead tissue) of the wound by the wound physician on 9/1/21. The facility failed to develop, document, and implement appropriate interventions for Resident #46 to prevent the resident from developing an avoidable left heel pressure injury. Findings include: I. Professional reference According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .), Cambridge Media: Osborne Park, Western Australia; 2014, from http://www.npuap.org (10/18/21): Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [CONDITION(S)] of intact skin. Intact skin with a localized area of non-blanchable [CONDITION(S)], which may appear differently in darkly pigmented skin. Presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], abrasions). Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .), Cambridge Media: Osborne Park, Western Australia; 2014, from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf (10/18/21), Repositioning to prevent and treat heel pressure ulcers: The reduction of pressure and shear at the heel is an important point of interest in clinical practice. The posterior prominence of the heel sustains intense pressure, even when a pressure redistribution surface is used. Because the heel is covered with a small volume of subcutaneous tissue, mechanical loads are transmitted directly angular to the bone. Given the small surface area of the heel, it is challenging to try to redistribute load from the heel through the use of pressure redistributing devices. Inspect the skin of the heels regularly. Ensure that the heels are free of the surface of the bed. Ideally, heels should be free of all pressure - a state sometimes called floating heels ' . Pressure can be relieved by elevating the lower leg and calf from the mattress by placing a pillow under the lower legs, or by using a heel suspension device that floats the heel. Consequently, the pressure will instead spread to the lower legs, and the heels will no longer be subjected to pressure. II. Facility policy and procedure The Pressure Injury policy, last revised 12/18/18, was provided by the nursing home administrator (NHA) on 10/12/21 at 3:08 p.m. It read in pertinent part, Purpose: To ensure that a resident who is admitted to the facility without a pressure injury does not develop a pressure injury unless clinically unavoidable and that a resident who has an injury receives appropriate care and services to promote healing and to prevent additional injuries. Reduce pressure over bony prominences by offloading and positioning. Develop turning and repositioning plans for residents in bed or chair. Provide special attention to suspending (offloading) heels. Evaluate the need for a pressure-reducing mattress or overlay. III. Air mattress product guide The product owner's manual for the alternating pressure mattress, obtained on 10/14/21 from https://www.smpcares.com/wp-content/uploads/2017/05/P -APM2-SS-OM-with-5900-Control.pdf, read in pertinent part, Indications for use: The alternating pressure (APM) models are powered, flotation therapy mattresses providing a pressure management surface for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . IV. Resident status Resident #46, age younger than 70, was admitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/14/21 minimum data set (MDS) assessment revealed that the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) of nine out of 15. He required two-person limited assistance for bed mobility, dressing, toilet use, and personal hygiene. He required two-person extensive assistance for transfers. He was at risk for developing pressure ulcers/injuries and had a Stage 3 pressure ulcer which was not present upon admission. The resident was on hospice. V. Wound observation On 10/11/21 at 1:33 p.m., Resident #46's left heel Stage 3 pressure ulcer was observed during the wound dressing change performed by licensed practical nurse (LPN) #2. Certified nurse aide (CNA) #1 was also present during the dressing change to assist LPN #2 with positioning the resident's leg so LPN #2 could change the dressing. Resident #46 had an alternating pressure mattress to his bed. Resident #46 was sitting up in his wheelchair in his room. He was wearing foam heel protectors on both feet. LPN #2 removed the foam heel protector and sock from the resident's left foot. LPN #2 removed the previous dressing from the resident's left heel. There was minimal drainage observed on the old dressing. The wound was observed to be a penny-sized open area to the back of the resident's left heel. The open area of the wound presented with red granulation (healthy) tissue over the entire surface. There was no eschar (dead) tissue observed inside the wound. The skin surrounding the wound was intact with some small areas of dry, flaky skin. LPN #2 cleaned the wound with normal saline. She then removed her gloves, washed her hands, and re-gloved prior to applying a clean dressing to the wound. She reapplied the resident's sock and foam heel protector to his left foot. LPN #2 then cleaned up her wound supplies, washed her hands and exited the resident's room. Resident #46 tolerated the wound dressing change well and said that the wound only hurt when he bumped it. VI. Record review The 5/4/21 Braden Scale assessment (a guide utilized for assistance with predicting pressure ulcer risk) documented Resident #46 was at high risk for developing pressure ulcers based on a score of 11 out of 23 (a lower score indicates higher risk of developing pressure ulcers). The assessment documented the resident had slightly limited sensory perception, was bedfast, had very limited mobility, his food intake was probably inadequate, and his potential for friction (the force of rubbing two surfaces against one another) and shear (gravity force pushing down on the resident's body with resistance between the resident and the chair or bed) was a problem. Review of the Skilled Nursing Documentation assessment completed upon Resident #46's admission to the facility on [DATE] revealed the resident was admitted with a perineal area that was reddened and irritated from constant bowel movements. There were no other skin concerns and no wounds documented on the assessment. Review of the Weekly Nursing Documentation (weekly skin) assessments from 5/11 through 6/22/21 revealed the only skin concerns identified for Resident #46 were redness from his scrotum to the top of his coccyx and swelling in his right knee. There were no concerns documented regarding the resident's heels. The Weekly Nursing Documentation (weekly skin) assessment dated [DATE] documented Resident #46 had redness from his scrotum to the top of his coccyx, swelling in his right knee, and a right heel DTI. -The assessment documented incorrectly that the DTI was on the resident's right heel, however the DTI was actually on Resident #46's left heel. Review of Resident #46's comprehensive care plan, initiated 5/7/21 and last revised 9/29/21, revealed the resident was at risk and/or had the presence of skin breakdown related to incontinence and decreased mobility. He had [CONDITION(S)] (redness) to his scrotum and coccyx, and an improving stage 3 left heel wound. Further review of Resident #46's at risk for skin breakdown care plan revealed the initial interventions put into place on 5/7/21 to prevent further skin breakdown included applying barrier cream to the resident's buttocks, coccyx, perineal area, and groin, encouraging and assisting the resident with positioning, monitoring/documenting/reporting as needed any changes in skin status, providing incontinence care as needed, and weekly skin checks performed by a licensed nurse. -Despite the resident's admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The following pertinent interventions were added to Resident #46's skin breakdown care plan after the discovery of the left heel DTI on 6/29/21: administering supplements as ordered, administering treatments as ordered and monitoring for effectiveness, assessing/recording/monitoring wound healing weekly, measuring length, width and depth where possible, assessing and documenting the status of the wound perimeter, wound bed and healing progress, reporting improvements and declines to the medical doctor, resident is anxious at times and repeatedly removes his Prevalon boots, continuing to encourage the resident to wear boots related to the wound, and the use of a pressure relieving air mattress. -The foam heel protectors which Resident #46 was observed wearing multiple times during the survey were not included in the interventions on the care plan. -Despite the care plan indicating the resident repeatedly removed his Prevalon boots (which are different from the foam heel protectors the resident was observed wearing), review of progress notes revealed only one note dated 7/14/21 regarding the resident's refusal to wear the Prevalon boots. The note read in pertinent part, Refuses to keep boots on for a prolonged period. reapplying boots as needed (PRN), but the patient takes them off within the hour. Multiple attempts at education and application of boots. A skin/wound note documented on 6/29/21 read in pertinent part, Right heel wound, unopened. Discolored and hardened in areas.Wound measuring 1.5 inches by 2 inches in diameter. Director of nursing (DON), hospice and wound doctor (WD) were notified. -The 6/29/21 skin/wound note incorrectly documented the pressure wound was on Resident #46's right heel, however, the wound was on the resident's left heel. A Risk Management Review note dated 6/30/21 documented the following: Type of incident: New pressure injury Root Cause: friction from moving heels on mattress Treatment required : [MEDICATION(S)] Interventions put into place: Prevalon boot applied Referrals made: Wound physician to see Medical doctor notified/response: Medical doctor will be in to look at tomorrow Resident/Responsible Party communication: Hospice Notified. Review of the wound doctor (WD) progress notes revealed the following wound notes, in pertinent part: 7/1/21: Wound #1 left heel is a deep tissue pressure injury. Persistent non-blanchable (discoloration of the skin that does not turn white when pressed) deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 6 centimeters (cm) in length by 4 cm in width with no measurable depth. Wound bed has 100% epithelialization (the process of covering denuded (loss of the outer layer of skin caused by prolonged moisture and/or friction) epithelium, which is the layers of cells that make up the outer surface of the body). Cleanse the wound with normal saline and apply [MEDICATION(S)] to the area two times per day (BID) and as needed (PRN). 7/8/21: Wound #1 left heel is a deep tissue pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. ISubsequent wound encounter measurements are 3.5 cm in length by 4 cm in width with no measurable depth. Wound bed has 100% epithelialization. The wound is improving. Cleanse the wound with normal saline and apply [MEDICATION(S)] to the area BID. 7/14/21: Wound #1 left heel is a deep tissue pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 3.5 cm in length by 4 cm in width with no measurable depth. Wound bed has 100% eschar (dead tissue). There is no change noted in the wound progression. Cleanse the wound with normal saline and apply [MEDICATION(S)] to the area BID. 7/22/21: Wound #1 left heel is a deep tissue pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 3.5 cm in length by 3.5 cm in width with no measurable depth. Wound bed has 100% eschar. The wound is improving. Cleanse the wound with normal saline and apply [MEDICATION(S)] to the area BID. 7/29/21: Wound #1 left heel is a deep tissue pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 1.5 cm in length by 1.8 cm in width with no measurable depth. Wound bed has 100% eschar. The wound is improving. A skin/subcutaneous (layer between the skin and muscle) level surgical debridement was performed. Subcutaneous tissue was removed along with devitalized tissue: necrotic/eschar. Post debridement measurements: 1.5 cm length by 1.8 cm width by 0.1cm depth. Cleanse the wound with normal saline and apply [MEDICATION(S)] to the area BID. 8/4/21: Wound #1 left heel is a deep tissue pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 1 cm length by 1 cm width with no measurable depth. Wound bed has 100% epithelialization. The wound is improving. Cleanse the wound with normal saline and apply [MEDICATION(S)] to the area BID. 8/11/21: Wound #1 left heel is a deep tissue pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 1 cm length by 1 cm width with no measurable depth. Wound bed has 100% epithelialization. There is no change noted in the wound progression. Cleanse the wound with normal saline and apply [MEDICATION(S)] to the area BID. 8/18/21: Wound #1 left heel is a deep tissue pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 1.2 cm length by 0.8 cm width with no measurable depth. Wound bed has 100% eschar. There is no change noted in the wound progression. Cleanse the wound with normal saline and apply [MEDICATION(S)] to the area BID. Leave open to air. 8/25/21: Wound #1 left heel is a deep tissue pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 1 cm length by 0.7 cm width with no measurable depth. Wound bed has 100% eschar. The wound is improving. Cleanse the wound with normal saline and apply [MEDICATION(S)] to the area BID. 9/1/21: Wound #1 left heel is a deep tissue pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 0.7 cm length by 0.7 cm width with no measurable depth. There is a moderate amount of drainage noted. Wound bed has 100% eschar. The wound is deteriorating. A skin/subcutaneous level surgical debridement was performed. Subcutaneous tissue was removed along with devitalized tissue: necrotic/eschar. Post debridement measurements: 0.7 cm length by 0.7 cm width by 0.1cm depth. Cleanse the wound with wound cleanser. Apply Alginate with silver and cover with foam dressing. Change dressing every other day. 9/8/21: (Wound documented now as a stage 3 wound) Wound #1 left heel is a stage 3 pressure ulcer pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 0.7 cm length by 0.5 cm width with no measurable depth. There is a small amount of drainage noted. Wound bed has 100% epithelialization. The wound is improving. Cleanse the wound with wound cleanser and apply [MEDICATION(S)] to the area BID. Leave open to air. 9/15/22: Wound #1 left heel is a stage 3 pressure ulcer pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 1.0 cm length by 0.5 cm width by 0.2 cm depth. There is a moderate amount of drainage noted. Wound bed has 100% granulation (healthy tissue). The wound is deteriorating. Cleanse the wound with wound cleanser. Apply Alginate and cover with foam dressing. Change dressing every other day. 9/22/21: Wound #1 left heel is a stage 3 pressure ulcer pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 1.0 cm length by 0.5 cm width by 0.1 cm depth. There is a small amount of drainage noted. Wound bed has 100% granulation (healthy tissue). There is no change noted in the wound progression. Cleanse the wound with wound cleanser and apply [MEDICATION(S)] to the area BID. 9/29/21: Wound #1 left heel is a stage 3 pressure ulcer pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 1.0 cm length by 0.5 cm width by 0.1 cm depth. There is a moderate amount of drainage noted. Wound bed has 100% granulation (healthy tissue). There is no change noted in the wound progression. Apply Alginate and cover with foam dressing. Change dressing daily. Review of the October 2021 CPO revealed Resident #46 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The start date of the order was 9/29/21. VII. Interviews LPN #2 was interviewed on 10/11/21 at 1:53 p.m. She said Resident #46 acquired his left heel wound at the facility. She said he was seen weekly by the WD. She said his wound had gotten a lot better. LPN #2 said Resident #46 was not compliant with the Prevalon boots. However, she said he would wear the foam heel protectors without taking them off. The DON and quality improvement specialist (QIS) #2 were interviewed together on 10/12/21 at 10:53 a.m. The DON said Resident #46's left heel wound was discovered on 6/29/21. She said the WD assessed the wound on 7/1/21 and said it was a DTI. She said the WD debrided the wound on 9/1/21 and classified it as a stage 3 pressure injury after the debridement. The DON confirmed that Resident #46's care plan documented that the alternating pressure mattress was initiated as an intervention on 7/1/21. However, she thought he had been utilizing the mattress since his admission to the facility. She said they did not float heels because that could frequently lead to pressure injuries on the back of the calf where the floating device was in place. The DON agreed the care plan did not document any other interventions in place to prevent heel pressure injuries prior to Resident #46 developing his left heel wound. She said he was participating in a restorative program three to six times per week effective 5/11/21. She said the program was put in place to assist him with bed mobility, which also would have improved his blood circulation to his heels. QIS #2 said Resident #46 was significantly debilitated when he was first admitted to the facility. She said he was non-compliant with wearing Prevalon boots. QIS #2 said the resident would wear the foam heel protectors. She confirmed that the foam heel protectors were not documented as an intervention in the care plan. QIS #2 said she thought the WD said Resident #46's left heel wound was unavoidable, but she did not think that was documented. -There was no documentation to indicate the resident refused to wear the Prevalon boots except for the progress note dated 7/14/21 (see above). QIS #2 said the alternating pressure mattresses the facility used were set based on height and weight of the resident. She said they were also set up to allow for the comfort of the residents. She said the nurses were to monitor the mattresses to ensure they were functioning properly and were inflated effectively. QIS #2 said restorative nurse aide (RNA) #1 was in charge of setting up the alternating pressure mattresses for residents. She said RNA #1 remembered setting up an alternating pressure mattress for Resident #46 upon his admission to the facility. The WD was interviewed on 10/12/21 at 11:59 a.m. The WD said when he first assessed Resident #46's left heel wound it was a DTI with necrotic tissue covering the wound. He said he debrided the necrotic tissue after the necrotic tissue began to slough (non-viable fibrous yellow tissue damaged tissue in the wound) because slough contributes to delayed wound healing. The WD said the wound was determined to be a stage 3 pressure injury after the debridement. The WD said he had not deemed the wound to have been an unavoidable wound. He said when residents are determined to be a high risk for pressure injuries, prevention of wound development should be top priority. He said if a resident was considered a high risk for pressure injury development, Prevalon boots would be the best intervention. The WD said if a resident was non-compliant with the Prevalon boots, foam heel protectors should be put in place to protect the heels and prevent the potential development of heel pressure injuries. Restorative nurse aide (RNA) #1 was interviewed on 10/12/21 at 1:04 p.m. RNA #1 said she had been trained how to set up the alternating pressure mattresses by the vendor who supplied the mattresses for the facility. She said she remembered setting up a mattress for Resident #46 when he was admitted he was very thin and weak. RNA #1 said she did not document or keep a list of which residents had alternating pressure mattresses. She said she just knew who had them. The facility's wound nurse was out of the country during the survey, and was unable to be interviewed regarding Resident #46's wound.

Based on record review and interviews, the facility failed to take steps to protect one (#4) resident of five residents reviewed in a sample of eight residents from abuse. Cross-reference: F609 failure to report allegations of physical abuse and F744 failure to provide services and support to the resident with dementia after an incident of sexual abuse. Specifically, the facility failed to protect Resident #4 from sexual abuse from Resident #5. The facility failed to have in place specific measures to protect vulnerable and at risk residents from more functional and independent residents. Independent residents were allowed to take/assist dependent and cognitively impaired residents outside of the building without staff supervision. The facilities failure to identify risks associated with such activities contributed to a sexual assault on 12/21/19. In addition, the facility's failure to monitor and to take steps to address residents with known history of [MEDICAL CONDITION] contributed to the incident on 12/21/19. Resident #5, who was an alert, oriented, independent and ambulatory resident with known, prior to admission, habitual use of alcohol, took Resident #4 (who had severe cognitive impairment) in her wheelchair outside of the building to the parking lot where he sexually assaulted her behind one of the parked cars. Resident #4's physician reported that in the immediate aftermath (resident) felt guilty and felt she did something wrong. She said she talked to the resident and reassured her that it was not her fault and she did nothing wrong. She said the resident still felt bad and it caused her certain distress. The patient health questionnaire (PHQ-9) conducted by social services assistant (SSA) #3 on 12/25/19 identified that Resident #4 went from minimal to moderate depression. Findings include: I. Facility policy and procedure A copy of the facility's Abuse Policy reviewed 11/15/19 was provided by the clinical nurse consultant (CNC) on 2/12/2020 at 10:37 a.m. The policy read in part, that facility does not condone resident abuse by anyone, including staff members, other residents, volunteers . and other individuals. Every resident has the right to be free from verbal, sexual, physical and mental abuse. II. Incident of sexual abuse on 12/21/19 between Resident #4 and Resident #5 [NAME] Resident #4 1. Resident status Resident #4, age 84, was admitted on [DATE]. According to the (MONTH) 2020 computerized physician orders [REDACTED]. The 12/25/19 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with the brief interview for mental status score (BIMS) of three out of 15. The resident required supervision with bed mobility, transfers, walking in the room, locomotion on and off the unit, eating, toilet use, and personal hygiene. The resident had no symptoms of [MEDICAL CONDITION], she had difficulty focusing attention, was easily distracted, had difficulty keeping track of what was said, and had disorganized thinking. The MDS did not identify any verbal or physical behaviors directed toward other residents. 2. Record review The care plan last revised on 8/4/17, identified the resident had delusions related to dementia. Specifically, she may believe that her roommate's items are hers (and) may rummage through (her) roommate's belongings (as well as her own). She may hide items (and) then forget where she put them (and) report them missing. She may also believe delusional things regarding other residents. She may believe that her roommate's items are hers (and) may rummage through roommate's belongings (as well as her own). She may hide items (and) then forget where she put them (and) report them missing. She may also believe delusional things regarding other residents. She may believe that male residents want to go to bed with her, even if they have never approached her or said anything to her or are significantly impaired (i.e. cannot talk or walk). When having distress (related to) a delusion, she usually is redirectable through reassurance (and) conversation. Pertinent interventions included to monitor behavior and provide opportunity for positive interactions. The note by SSA #3 on 12/24/19 documented overheard resident with (registered nurse) for medications. (Registered nurse) greeted resident and resident did not greet back. (Registered nurse) asked what was wrong. (Resident) stated I have tears in my eyes. SSA opened the door to intervene on conversation with a smile and cheerful tone. Resident reciprocated social cues and smiling back. Resident also held SSA's hand and started to sing rock a bye baby. SSA and (social worker) are observing resident due to recent incident. Resident does not seem as engaged, evident by appearing to zone out while making art projects yesterday and not being responsive to staff prompts to greeting today. The patient health questionnaire (PHQ-9) conducted by social services assistant (SSA) #3 on 12/25/19 identified that Resident #4 went from minimal to moderate depression. There were no further notes from social services or nursing staff regarding psychosocial wellbeing of the resident. B. Resident #5 1. Resident status Resident #5, under the age of 70, was admitted on [DATE], and discharged [DATE]. According to the (MONTH) 2020 CPO, [DIAGNOSES REDACTED]. The 12/26/19 MDS assessment documented the resident was cognitive intact with the BIMS of 15 out of 15. The resident required minimal assistance with most activities of daily living (ADLs). He did not require any assistive devices for ambulation. The resident had no symptoms of [MEDICAL CONDITION], or short term memory problems. The MDS did not identify any verbal or physical behaviors directed toward other residents. 2. Record review According to the hospital's history and physical on 11/20/19, the resident was admitted to the emergency room intoxicated with blood alcohol level (BAC) over 300 milligram per deciliter (mg/dl). The urine test was positive for alcohol and cannabinoids. During his stay he was monitored for the severity of [MEDICATION NAME] withdrawal. resident underwent [REDACTED]. The care plan initiated on 11/28/19, did not identify the history of [MEDICAL CONDITION]. It did not include monitoring resident's behavior related to the history of alcohol and cannabinoids use. According to the admission note by physician on 11/29/19, the resident reported that he drinks a pint of vodka most days. According to the nurse progress note, on 12/2/19 the resident was nowhere to be found and returned to the facility later that day. Resident was educated on proper sign out processes when leaving the building. The social services note on 12/18/19, revealed that social services director (SSD) reported to SSA #1 there was a concern that Resident #5 had alcohol in his possession. The SSA #1 confronted the resident who denied having or drinking alcohol. SSA #1 reviewed with the resident protocol on alcohol use and he verbalized understanding. There were no further notes describing the resident's condition and/or note that concern was communicated to nursing staff for further evaluation and monitoring. C. Summary of investigation The Investigation was provided by clinical regional consultant (CRC) on 2/10/2020 at 12:30 p.m. The 12/21/19 investigation documented, Resident #5 took Resident #4 in her wheelchair outside of the building and sexually assaulted her in the parking lot behind a van. The incident was witnessed by certified nurse aide (CNA) #1 who reported the incident to the management. The plan of action revealed the facility took the following actions: - Contacted the police department and reported the incident. - Investigated events of the incident. - discharged Resident #5 into the police custody. The CNA #1 provided her perspective on just having (Resident #4) be monitored since she is not independent with activities of daily living. There were no changes made to Resident #4's care plan. The summary of the investigation revealed the facility substantiated the allegation of sexual abuse based on the witness statement. D. Police report The police report summary was obtained on 2/12/2020. In pertinent part read, that Resident #5 was taken into the police custody on 12/21/19 after he left facility premises and was hiding in a nearby bus stop. The details of the investigation revealed that Resident #5 was on parole for murder in the second degree, he had been drinking and was living in the homeless shelter prior to his admission to the long term care facility. During the interview the resident admitted that on the day of the assault he had a beer earlier. Resident #4 shared with the police that man who took her out the other day wanted something and he was up to no good. When she was asked by a police officer what the man wanted, her face turned red and she told me that she couldn't say. She said she told him, No, no, no but he did it. E. Staff interviews CNA #2 was interviewed on 2/11/2020 at 3:20 p.m. She said Resident #4 required minimal assistance with activities of daily living, she was able to ambulate independently in her wheelchair around the building. She said the resident required the supervision of one person when she went outside on the patio. The resident was confused but able to maintain simple conversation and say what she wants. She said independent residents were not allowed to assist dependent residents to outside patio. Housekeeper (HK) #1 was interviewed on 2/11/2020 at 12:03 p.m. She said the Resident #4 was pleasant, and would smile and say hi to her every time they meet, but she mostly kept to herself. She said she observed resident crying at times when she could not locate the picture of her husband, which was actually a picture of a celebrity, but the resident thought it was a picture of her husband. She said resident liked holding hands and at times would joke about her breast. She said she did not observe resident walking into other rooms. RN #1 was interviewed on 2/11/20 at 2:30 p.m. She said Resident #4 was alert and oriented to self only. She said she recognized faces but did not recall the names. She said the resident was very polite and at times would become teary when she spoke about her husband. She said resident had a baseline behavior of touching other people, usually it was holding hands, touching hands or shoulders, or rubbing back. She said at times resident would make jokes about her breasts. She said she did not observe residents in other rooms. She said she did not recall Resident #4 making false allegations about other residents. RN #2 was interviewed on 2/11/20 at 3:10 p.m. She said the resident was pleasant, confused and very touchy. She would touch hands, shoulders and was very hands on on the unit with other residents and staff members. She said independent residents were not allowed to assist dependent residents with tasks. She said it used to be that some other residents would help Resident #4 to cut her meal and take her to the dining room, but such practice was no longer acceptable. She said independent residents were not allowed to take dependent residents outside of the building. Receptionist #1 was interviewed on 2/12/2020 at 3:40 p.m. She said she worked in the building some days as receptionist and some days as a CN[NAME] She said she knew the resident well and she was a friendly lady who hung out a lot in a TV room. She said on the day of the incident, 12/21/19 she was not working in the building. She said there always was a receptionist at the desk during business hours and residents were not allowed to take other residents outside of the building. The former director of nursing (DON) was interviewed on 2/12/2020 at 3:25 p.m. She said she was not in the facility when the incident took place. She said the investigation was completed by social services. She said it was not a common practice for independent residents to take dependent residents outside of the building. She said Resident #4 had dementia but was able to answer simple questions, and made her wishes known. The resident did not have any negative behaviors, was pleasant and liked to hold hands. She said there were no inappropriate sexual behaviors but she was overly friendly with male population. The current DON was interviewed on 2/12/2020 at 4:45 p.m. She said it was her second day in the DON position. She said the facility did not initiate behavior tracking specific to [MEDICAL CONDITION] for residents with known history of [MEDICAL CONDITION]. She said behavior tracking will only be initiated if a resident was caught using alcohol in the building. Resident #4's primary care physician was interviewed on 2/12/2020 at 3:10 p.m. She said the resident had advanced dementia, but was able to maintain simple conversation. She said she had poor short term memory and steadily declined over the past year. The resident was pleasant and cooperative, she did not have any inappropriate behaviors that she was aware of, and did not have continuous delusions or hallucinations. She said resident had behaviors that were consistent with her [DIAGNOSES REDACTED]. She said the resident was agitated at times when her roommate would occupy a bathroom for too long and she would get upset and start telling that someone was in the bathroom. She said it was reported to her that the resident was sexually assaulted on 12/21/19. She said she had a chance to talk to the resident after the incident but she has not yet documented that in her notes. She said she did not ask resident any direct questions about the incident as she did not want to cause more trauma. She said in the immediate aftermath (resident) felt guilty and felt she did something wrong. She said she talked to the resident and reassured her that it wasn't her fault and she did nothing wrong. She said the resident still felt bad and it caused her certain distress. SSA #1 and SSD were not available for an interview due to the training outside of the facility. SSA #3 was no longer working in the facility. SSC was interviewed on 2/12/2020 at 3:50 p.m. She said she was a consultant for the building and came to the building weekly. She said she worked with SSD and SSAs, but she did not know residents well. She reviewed the record for Resident #4 and stated she was not able to locate any additional notes besides those that document changes in resident's level of depression. She said she would expect SSA to report to her significant changes in resident's depression. She said she recall receiving text messages from SSA #3 around Christmas time but she did not recall what messages were about. She said she did not recall discussing Resident #4's condition with SSAs or SSD. She said after incidents of sexual or any kind of abuse the role of SSA was to monitor resident to make sure they receive needed support and to provide comfort and reassurance. She said she did not locate any evidence that it was done for Resident #4. The notes by SSA #3 documented that resident had a spike in her depression which later went down. In addition, she said it was unclear if the resident's tearfulness and zoning out related to the incident. She said around the same time the resident's family member passed away. She said she did not know if the resident knew about the death of the family member. She said it could have been just a holiday blues as well. The NHA was interviewed on 2/12/2020 at 4:30 p.m. He said the investigation was completed and it determined the abuse had occurred. Facility follow up: On 2/10/2020 around 6:00 p.m. CRC stated that they are implementing new measures to protect vulnerable residents in the building, effective immediately. Specifically that they are conducting an audit to identify all vulnerable residents and re-educating staff on associated risks. In addition, the lock time on the front entrance door was reset to make sure doors were locked after the receptionist on duty left. On 2/11/20 at 10:27 a.m. CRC provided an action plan that revealed that the facility conducted an audit to identify residents at risk. The binders were created to list at risk residents and to assist staff members in identifying residents that require additional monitoring. Staff were educated on the risk when some residents choose to go outside with another resident and ability to consent for such choices. The lock time on the front door was set between 6:00 p.m and 8:00 a.m., and the receptionist was to notify the interdisciplinary team (IDT) member if a resident is observed to attempt to take an at risk resident out of the building.

Based on record review and staff interviews the facility failed to ensure a resident with pressure injuries (ulcers) received the necessary treatment and services to prevent new pressure ulcers from developing for one (#1) resident out of three sampled residents for pressure ulcers. Specifically, the facility failed to ensure: -This resident's air mattress was monitored daily as ordered by the physician; -The mattress for this resident was functioning properly after a room change to prevent the development of a new pressure injury; -The documentation on the treatment administration record (TAR) was accurate from the nursing staff that provided care; and -Notification to the resident's primary care provider was done in a timely manner. This resident sustained [REDACTED]. mattress was not plugged in after a room change resulting in the resident laying on a non functioning air mattress for approximately four days and experiencing pain during that time and after I. Professional reference According to the National Pressure Ulcer Advisory Panel (NPUAP), NPUAP Pressure Injury Stages, 4/16, http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdf, (12/16), interventions for prevention and treatment of [REDACTED]. Except some signs of pressure ulcer healing within two weeks. -'If progress toward healing is not seen within two weeks, the individual, the pressure ulcer, and the plan of care should be re-evaluated. -Screen nutritional status for each individual at risk of or with a pressure ulcer .when progress toward ulcer closure is not observed. -Wherever possible, do not position an individual on an existing pressure ulcer. -When pressure ulcers deteriorate or fail to heal, the clinician should consider replacing the existing support surface with one that will provide a properly matched support surface environment in terms of pressure, shear, and microclimate for the individual. Changing the support surface is only one of several strategies to consider. More frequent repositioning, preventive interventions and local wound care should also be intensified as needed. II. Information provided from the manufacturer of the air mattress On 8/16/17 at 6:30 a.m. the clinical support manager (CSM) provided the statement from the owner's manual of the air mattress, which documented the following information, Power loss: if power is lost, DO NOT UNPLUG the control unit and DO NOT DISCONNECT the air lines from the control unit. The air-cylinder will equalize pressure in the support cylinders, and maintain inflation for days or weeks, functioning as a non-powered air flotation mattress. Additional information from the owner's manual, documented the following pertinent information, Troubleshooting guide, Problem; system will not power up. Possible cause: The system is not plugged in. Solution: Plug power cord into wall receptacle. Problem: Patient not turning/alternating properly. Possible cause: System is not turned ON. Solution: Plug power cord into wall receptacle. III. Policy and procedure On 8/14/17, the facility provided a copy of the pressure ulcer management policy, revised on 2/18/16, which documented the following pertinent information, The purpose of this policy is to establish protocols for care of residents who have admitted to the facility with pressure ulcer or who have developed a pressure ulcer while residing in the facility. The charge nurse will be responsible to assess the pressure ulcer, notify the physician, complete a narrative note, care plan will be initiated to identify actual skin breakdown; pressure relieving surfaces will be re-evaluated. Daily documentation by nursing for any resident with a stage III (3) or IV (4) pressure ulcer, weekly wound rounds, and the interdisciplinary team to review treatment plans and initiate any revisions/changes to the plan of care as indicated. IV. Resident #1 status Resident #1, age over 60, was admitted on [DATE]. According to the June 2017, computerized physician orders [REDACTED]. According to the May 2017 minimum data set (MDS) assessment, the resident had minimal to no cognitive deficit with a brief interview for mental status (BIMS) of 14 out of 15. Her mood score was three out of 27. She required extensive assistance for all her activities of daily living with one to two-person assist except for eating which she was supervision. 1. Record review According to the primary physician's admission progress note January 2016, Chief complaint: Patient is being seen for an annual history and physical. Patient admitted to facility 1/2016 after having a FLAP surgery for [REDACTED]. (FLAP- is a surgery technique in plastic and reconstructive surgery where any type of tissue is lifted from a donor site and move to a recipient site with an intact blood supply.) Past surgical history of: open reduction internal fixation of right femur, FLAP for sacral wound, hamstring myoplasty FLAP, and ischial bursectomy and debridement. According to the vendor invoice provided by the NHA, the resident had the same mattress since their admission of 1/5/16 to the facility. According to the 4/26/17 MDS assessment, the resident's skin was intact. According to the 5/10/17 nursing weekly skin documentation revealed,Skin warm and dry, mucous membranes moist and pink, turgor within normal limits, scalp clear, nails clean and trim, open areas to bilateral lower extremities, posterior/lateral legs, treatment as per physician's orders [REDACTED]. No noted [MEDICAL CONDITION]. Turned and repositioned every two hours. According to the 5/12/17 nursing notation documented, Elder had a room change today due to an accident and her room doesn't have water or electricity, now on (name of hall). According to the incident report filed by the director of nursing (DON) at 3:30 p.m. on 5/16/17, (four days after the resident was moved) During the emergency evacuation of the elder's room, elder was moved on her bed from room (rooms named). The cord for the air pump for the bed was not moved during the emergency. Elder presents today with wound on sacrum. The pump for air mattress plugged back in. Wound treated by floor nurse. Orders entered for wound care and will be assessed and followed by wound team. No complaints of pain to the sacrum pressure area. Environmental factors furniture re-arranged or added the last two day. Predisposing condition-recent room change. No witness found. MD (physician) notified on 5/17/17 at 9:30 a.m. According to the May 2017, Medication Administration Record [REDACTED]. According to the May 2017 TAR, the resident was ordered, Air mattress on medium soft therapeutic setting, monitor for placement and function every shift. The TAR indicated from 5/12/17 through 5/16/17 the nurses had initialed the bed was functioning properly. (See incident report above noting the resident's bed did not have the cord and could not be functioning during this timeframe.) According to the May 2017 CPOs, an order was written to monitor the resident's pain every shift using a one-ten pain scale (zero being no pain and 10 being the highest pain level). It noted the resident's acceptable level of pain was one out of 10. The MAR indicated [REDACTED] -Non-pharmacological interventions were not documented from 5/12/17-5/16/17 regarding the resident's increase in pain, nor did she receive as needed (PRN) medications to help with her pain level that she reported above her tolerable level. According to the May 2017 certified nurse aide (CNA) look back report, the CNAs had a minimum of three (shifts) missed opportunities to indicate the resident was assisted with bed mobility from 5/12/17 to 5/15/17. According to the last revised care plan of 5/18/17, This resident has potential for pressure ulcer development related to immobility, [MEDICAL CONDITION] and incontinence. Elder has pressure ulcer to her sacrum. Interventions that were documented included, Assess/record/monitor wound healing measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the physician, educate the resident as to causes of skin breakdown, follow facility policies for prevention/treatment of [REDACTED]. Document alternative methods. This resident requires air mattress on bed and custom cushion on power chair and weekly skin check by licensed nurse. According to the pressure injury and weekly monitoring documents that followed the initial assessment: The onset of the pressure injury to the sacrum was 5/16/17. Measurements noted: 5/18/17- wound unstageable, 9.1cm(Length x Width x Depth- cm-centimeters) x 6.1cm x 0cm , 5/25/17- wound unstageable, 9.9cm x 4.7cm x .1cm, 6/1/17- wound unstageable, 8cm x 5.4cm x 1.1cm, 6/8/17- wound stage IV, 7cm x 5cm x 1cm. According to the physician's assistant (PA) progress note dated 6/1/17, documented the reason for the visit was, Patient is being seen for monthly regulatory visit. Filling out transportation company paperwork. There was no metion of the sacrum wound. According to the physician assistant (PA) progress note dated 6/13/17, the reason for the visit was, Patient is being seen for acute visit, and patient has a new decubitus to sacrum and is stage IV. Will be seeing plastics on 6/22/17 for FLAP? Followed by wound doc as well. A report dated 6/22/17 from a local wound clinic noted, The patient was seen today for follow up and management of difficult to heal wound(s). Huge stage IV, but relatively clean, sacral pressure ulcer. Initial wound encounter measurements are 8.5 cm x 6.5cm x 2.1cm, with an area of 55.25 sq cm (square centimeters) and a volume of 116.025 cubic cm. Muscle, bone, and necrotic adipose are exposed. There is a large amount of serosanguineous drainage noted. The patient report (sic) wound pain of five out of 10. The wound margin is well defined. Wound bed is 1.25% slough, 51-75% bright red, pink, firm granulation, no [MEDICATION NAME], eschar present. Bone exposed in undermining. The patient appears to have good judgement and insight. Memory is grossly intact. Treatment will require FLAP closure with pre-hospital stay nutritional labs. V. Staff interviews The maintenance director (MD) was interviewed on 8/14/17 at 1:20 p.m. He said he was not notified during the period of 5/12/17-5/16/17 regarding any issues with this resident's air mattress. He said he was not sure who did the training for the staff regarding air mattresses in the facility. He said he had not requested a vendor to come in and train the staff on air mattresses. He said the restorative department mostly worked with the settings of the air mattresses. The restorative aide (RA) was interviewed on 8/14/17 at 1:44 p.m. She said the vendors who came into the building normally set the air mattresses according to the height and weight of the resident. She said she learned how to operate the air mattresses from a peer staff member. She said she had not had any formal training from a vendor or the management team regarding equipment settings. She said she was unaware of how the settings from the vendors were communicated to the nursing staff, and who currently monitored the air mattresses. She said she did know how to turn off the alarms on the air mattresses. She said the resident was dependent on staff for bed mobility. When she would work with residents who had air mattresses she would make sure the pump was on, had no blinking alarm lights, and was plugged in and functioning properly. CNA #4 was interviewed on 8/14/17 at 2:45 p.m. She said she had been working in the facility for a year and a half. She said she had not received any training since she was hired for air mattresses. She said she would check the air mattress when she cared for the residents. She was familiar with resident #1 who. was dependent on staff for bed mobility and had to be turned frequently. She said when she worked with the resident, the resident did not refuse care. CNA #6 was interviewed on 8/14/17 at 3:05 p.m. She said this resident was dependent on staff for bed mobility. The resident was able to make her needs known to staff. She said the resident would even tell staff what setting to put her bed on. The resident would request the level of five. She had not received any training on appropriate settings of air mattresses.She said the air mattress needed to stay plugged in to work properly. The director of therapy services (DTS) was interviewed on 8/14/17 at 2:05 p.m. She said the purpose of the air mattresses would be to redistribute the resident's weight, help with off loading, and add additional support for those residents who could not turn themselves. She said most of the time the residents who had air mattresses were high risk for developing pressure ulcers, had a history of [REDACTED]. She said one could tell if the air mattress was on because the pump lights would be lit. The assistant director of nursing (ADON) who also functioned as the staff development coordinator and restorative director, was interviewed on 8/14/17 at 2:20 p.m. She said she had not provided any training to her restorative aides or any other staff in the facility regarding the air mattress settings. She said restorative aides did not do anything with the air mattresses. She said adjusting the air mattress would be out of their scope of practice, and if the RAs needed assistance with the air mattresses they needed to get the nurse. She said as the ADON, she would expect all residents who had an air mattress to have a physician's orders [REDACTED]. She said she was unsure of how the information was gathered from the vendors regarding the settings for the air mattress, or trouble shooting different mattresses. She said the purpose of the air mattresses was to help the resident with repositioning, reduce skin breakdown, and redistribution of pressure. The DON was interviewed on 8/14/17 at 4:50 p.m. She said she was the ADON for the facility before she became the DON in July 2017. She said she expected her nurses to check the function and placement of the air mattresses every shift and document the information on the TAR. She said if they had any concerns or issues she would expect them to notify her immediately. She said she was made aware the resident had been moved and had been moved to a different room without the power source to her air mattress. She said the alternating pressure function would not be able to function without the bed being plugged in. She said she was unaware of any training being provide to the staff regarding air mattress and what to check during emergencies regarding air mattresses. She said if a resident needed to be moved during an emergency and required power for any device that the mattresses needed to be checked after moving the resident for function. The DON was interviewed on 8/14/17 at 5:30 p.m. regarding the incident report on 5/16/17. She said a CNA walked past her office on 5/16/17 with the plug to the resident's air mattress in her hand. She said she was unaware the resident's air mattress had not be plugged in since her move on 5/12/17. She said she could not remember how the CNA found the plug, but told her it was the plug for this resident's mattress. She said she had felt the resident's mattress and it felt like it had air in it on 5/16/17. The Licensed practical nurse #1 was interviewed on 8/14/17 at 5:40 p.m. She said she used to take care of resident #1 and remembered her moving to the other side of the building at one time. She said the resident was only on the other side of the building for a few days and returned to her normal room with a large pressure ulcer. She said she remembered a CNA finding the cord to the resident's mattress days after the resident was moved. She said she had not received any training for air mattress maintenance in the facility. The representative (RP) from the mattress vendor was interviewed on 8/15/17 at 4:45 p.m. he said if this specific air mattress was unplugged it would lose the ability to redistribute air flow and assist with offloading. The frequent visitor was interviewed on 8/16/17 at 2:52 p.m. This person said they were made aware of this resident's situation from a hospital this resident had go to for a different procedure. This person remembers being told a car hit the facility and knocked out the power to this resident's room and allegedly, nobody noticed that the air mattress had deflated. This person also indicated the uncertainty of, How none of the staff notices an air mattress that was so critical to her care being was deflated so long. The CSM was interviewed on 8/16/17 at 6:30 a.m. she said if a power failure were to occur (or unplug the control unit from the wall) the mattress will hold air for at least a couple of days . The primary care physician was interviewed on 8/16/17 at 8:21 a.m. She said she had last seen this resident on 5/15/17, just the day prior to when she acquired her wound. She said she was not aware the resident had a wound on her sacrum and was not notified until the middle of June 2017 when her assistant did an acute visit for the newly acquired wound.

Based on observations, record review and interviews, the facility failed to ensure one (#102) of two out of 35 total sampled residents received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, the facility failed to timely provide care and services to improve and/or maintain the resident's range of motion (ROM). On 1/13/17, the resident was assessed with [REDACTED]. The findings included: 1. Resident status Resident #102, age 63, was admitted on [DATE]. According to the 1/17 computerized physician orders [REDACTED]. According to the 12/28/16 minimum data set (MDS) assessment, the resident was cognitively impaired, as evidenced by a brief interview for mental status (BIMS) score six out of 15. The resident did not exhibit any behaviors or resist care.The resident required extensive assistance of one with meals. The resident required total assistance of one with dressing, toileting and transfers. 2. Observations 1/12/17 -At 5:15 p.m., the resident was observed sitting up in wheelchair at the dining table occasionally independently feeding herself with using her left upper extremity. Her right upper extremity was in a flexed position and her right hand was in a fist position. 1/13/17 -At 2:30 p.m., the resident was observed in bed with her hands clasped together and her arms in a flexed position. 1/18/17 -At 3:50 p.m., the resident was observed in bed with her right upper extremity in a flexed position and her right hand in a fist position. 3. Record review Although there was no information documented on the 12/28/16 MDS assessment indicating the resident had range of motion (ROM) limitations, therapy evaluations identified the resident had impaired mobility and strength in her right upper extremity, right hand and right wrist. -The occupational therapy (OT) evaluation dated 9/3/16 documented in the assessment summary that the resident had impaired range of motion and strength. The OT noted, Due to the documentation physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for: Pressure sores, further decline in function and decreased participation with functional tasks. -The OT initial evaluation dated 9/3/16-9/5/16 documented in part: Gross strength right upper extremity (RUE) function impaired, pt (patient) demonstrates significant muscle impairments. pt had right sided weakness status [REDACTED]. -Therapy documentation dated 9/5/16 revealed the resident had decreased range of motion to her right upper extremity, right hand and right wrist. There was no reference to flexion or extension. 4. Facility failures a. Although the resident was noted to be at risk for decline in function without skilled therapeutic intervention, an order was not entered for therapeutic intervention until three months later. Specifically, an order was written 12/12/16, for nursing/rehab/restorative-passive ROM (range of motion) program to strengthen muscular coordination. Will participate at least 15 minutes each day, 6 days a week. b. The resident's care plan was reviewed. There was no reference to the resident's ROM status until the care plan was updated on 12/12/16. The care plan was updated at this time to include ROM. However, the care plan did not reference the findings from the therapy evaluations in September 2016, or instruct staff how often, how long, and for which extremities ROM was to be conducted. 5. Evaluations during survey (1/11 and 1/13/17) and staff interviews confirmed declines in the resident's ROM since her admission as well as lack of timely implementation of care and services to prevent decline. a. Evaluations A physician order [REDACTED]. The OT evaluation, ordered 1/11/17 and dated 1/13/17, documented, in pertinent part: Gross strength (RUE) = impaired (pt. demonstrates severe impairment of strength in RUE). AROM (active range of motion) right wrist extension=0 degrees, PROM right wrist flexion=80 degrees, AROM right thumb CM flexion=0 degrees, right thumb CM extension AROM=O degrees. In the assessment summary it read, the resident had severe impairment indicating a need for contracture management . The OT evaluation further documented, in pertinent part: Reason for skilled services-pt. had been referred to skilled OT due to new onset of right upper extremity decreased active range of motion and right hand contracture indicating a need for contracture mgmt (management), passive range of motion and prolonged stretch, manual techniques, and education on positioning to increase range of motion and functional use of right upper extremity. Pt demonstrates severe gross and fine motor coordination impairments of the right hand and shoulder. b. Staff interviews A registered nurse (RN #1) was interviewed on 1/12/17 at 9:59 a.m. The RN said the resident had a contracture (a condition of fixed high resistance to passive stretch of muscle). The RN further stated the resident was on a restorative program in the morning; however, he was not aware if the resident had any equipment such as a brace to maintain or improve mobility. CNA #4 was interviewed on 1/18/17 at 11:15 a.m. He said the resident had received restorative therapy for 2-3 weeks. He said that he provided passive ROM to the resident's arms, legs, hands and wrist. He said the restorative nurse informed him that the resident needed ROM. CNA #1 was interviewed on 1/18/17 at 11:45 a.m. CNA #1 said the resident had received restorative therapy for about 3-4 weeks. She said the restorative therapy program usually distinguishes what extremities are to receive ROM but thought in this case, the nurse just forgot to put what extremity to provide range of motion to in the order. CNA #5 was interviewed on 1/18/17 at 1:25 p.m. CNA #5 said she believed the resident had been on restorative therapy since November, 2016. She said she provided ROM to all of the resident's extremities. She said if it is not specified in the order, she will complete ROM to all extremities. The rehabilitation manager (RM) was interviewed on 1/18/17 at 1:30 p.m. She said that residents were reviewed on admission during a morning clinical meeting. She said if a resident had a ROM impairment, the resident would be screened. -She said resident #102 was evaluated from 9/3/16 to 9/5/16 and therapy recommended a restorative program for decreased ROM to right wrist and right thumb. She said this recommendation was given to the restorative nurse. -She said that typically, she would not follow up on restorative programs as the restorative nurse was responsible to follow up. She said nursing would be responsible to obtain an order to start restorative therapy and that the restorative certified nurse aide would provide care. -She said that delay in the start of resident's restorative program could have contributed to resident's decline in ROM to her right wrist and right thumb. She said the resident would be assessed 1/19/17 for a possible splint or brace. RN #3 was interviewed on 1/18/17 at 1:50 p.m. -The RN said she was the restorative nurse. She said she would be notified if a resident had a ROM impairment in a restorative huddle. She said the restorative certified nurse aides would give updates on residents' care. She said at times therapy would give recommendations and then nursing would be responsible for writing an order for [REDACTED]. -She said the resident's family had expressed concerns about the resident's inactivity 12/5/16 and agreed at that time that the resident could benefit from a restorative program. However, she also felt the resident was at her baseline mobility.

Based on observations, record review, and staff interviews the facility failed to prevent a significant weight loss of five percent or greater due to inconsistent provisions of nutritional supplements for one (#39) of six out of 35 sampled residents. The findings include: I. Professional Reference According to Gaddey, Heidi L., and Holder, Kathryn. Unintentional Weight Loss in Older Adults, American Family Physician. 2014 May 1, 718-722, in pertinent part, Unintentional weight loss (i.e. more than a 5% reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality. In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of [MEDICAL CONDITION] in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments. II. Facility's Policies and Procedures (P&P) On 11/24/15 a copy of the Weight Management P&P was provided by the director of nursing (DON). The facility's weight management policy developed on 10/1/13, documented, in pertinent part, .Residents identified with significant weight change will be assessed by the IDT (interdisciplinary team) team; and further interventions will be implemented to minimize the risk for further weight change where possible and promote weight stability . Residents identified at risk for weight change will have interventions implemented to minimize the risk for additional weight change included in their plan of care. This may include supplements, RD (registered dietitian) evaluation, assisted dining, etc. III. Resident Status Resident #39, [AGE] years old was admitted on [DATE]. According to the face sheet she was diagnosed with [REDACTED]. According to the Minimum Data Set ((MDS) dated [DATE] she required limited assistance for eating. The 10/13/15 MDS indicated she was not assessed for cognition or mood. The quarterly MDS dated [DATE] indicated she had moderate cognitive impairment and no depressive symptoms. The resident appeared petite in stature and was often slumped down in her wheelchair with hunched shoulders. She had short white hair that at times went uncombed. Her eyes were sunken in and she was missing several upper and lower teeth. According to the initial nutritional assessment, dated 5/20/15, she was 49 inches in height and weighed 99 lbs. A. Record Review According to the weight loss summary the weights were measured in pounds as follows: 5/20/15 - 99 5/28/15 - 98 6/4/15 - 97.4 6/10/15 - 99 6/18/15 - 98.8 7/2/15 - 97.2 8/7/15 - 96.8 9/11/15 - 97.6 10/8/15 - 91.8 10/16/15 - 92.6 10/21/15 - 91.6 10/29/15 - 91.6 11/5/15 - 89.4 (a 9.7% weight loss from 5/20/15) The weight summary indicated that the resident had a 7.5% weight loss from 8/7/15 to 11/5/15. The nutrition care plan last revised on 10/28/15, documented the following, Focus: BMI reflects overwt (overweight status); advanced age may result in compromised nutritional status; increased need for staff cueing to swallow; [MEDICATION NAME]; recent significant rate of wt (weight) loss. The goal read, Goal: Rate of wt loss will slow down, although gradual rate of wt loss would be OK; will consume estimated nutritional needs; [MEDICATION NAME] will improve; will receive staff cueing to swallow if needed per SLP (speech language pathologist). The interventions were, -regular/regular/thin liquids diet as ordered -staff to cue/assist resident at meals if needed -staff to monitor trends in wts, po (daily) intakes -skin integrity, and labs as available -Mighty Shakes at meals as ordered -Med Pass as ordered between meals, - Vit (Vitamin) D, Vit B as ordered. On 7/21/15 a telephone order was written for 4oz of Mighty Shakes (nutritional supplement) twice a day with lunch and dinner. Laboratory results with a completion time of 5/24/15 documented the resident ' s [MEDICATION NAME] level was at 3.4 grams per deciliter. According to the laboratory report the normal range was 3.5-5.7 grams per deciliter which indicated that she had low protein levels. The nutrition re-assessment/CAA (care area assessment) review, effective date 9/30/15, documented, in pertinent part, the following: -Regular/regular/thin liquids - Mighty Shake 4oz BID (twice a day) at L (lunch) and D (dinner) meals (400kcal, 12gm pro daily) -Meal intake: breakfast - 25-50%; lunch - 25-75%; supper - 50-75% -Fluid intake - breakfast - 140-360ml; lunch - 240-480ml; dinner - 240-360m -Weight- 97.6lbs Current Condition: Resident has had no significant rate of wt change over the past 6 mo (months). Current BMI of 28.6 reflects overwt status. Note 9/18/15 MD (medical doctor) order for Vit D changes. Per 9/28/15 Nursing Notes, resident's skin remains intact. Resident continues to receive: Vit B12, Vit D, [MEDICATION NAME], Senna. -Comments: Resident is not a nutritional concern at this time. RDN (Registered Dietitian Nutritionist) rcmds (recommends) no changes. RDN will continue to f/u at least quarterly. The nutrition/dietary note, dated10/28/15, documented the following, in pertinent part, Note the following wt trends: 9/11- 97.6 # (pounds), 10/16 - 92.6 #. Resident has had a significant rate of wt loss (-5%) within this time frame. Resident continues to receive a Reg (regular)/Reg/Thin liquids diet that includes a Mighty Shake BID at L and D .Goal: To slow the rate of wt loss. RDN rcmds the initiation of 60cc Med Pass (nutritional supplement) TID (three times a day) between meals . On 11/24/15 the food service director (FSD) provided a copy of the resident ' s meal ticket for breakfast, lunch, and dinner. Her food preferences were not indicated on the meal ticket, and no supplements were listed on the ticket for all three meals. See the above listed physicians ' telephone order for Mighty Shakes that should have been provided during lunch and dinner meals. On 11/24/15 the Medication Administration Records (MARs) documented that on 10/5/15, 10/6/15, 10/9/15, 10/17/15, 10/18/15, 10/23/15, 11/3/15, 11/5/15, 11/14/15, and 11/20/15 the administration of the Mighty Shakes at lunch was not signed off by the nurse. On 10/30/15, 11/2/15, 11/3/15, 11/4/15, 11/8/15, 11/12/15, 11/18/15, and 11/20/15 the administration of the Mighty Shakes at dinner was not signed off by a nurse. B. Observations On 11/18/15 at 4:57 p.m. the resident was observed sitting in the dining room drinking coffee in her wheelchair. At 5:08 p.m. she was given two pieces of toast, two packets of jelly, two packets of butter, and a cup of ice cream. At 5:10 p.m. she requested potato chips from the staff, which was provided. She left the dining room at 5:58 p.m. She ate two pieces of toast with jelly and three-fourths a bowl of potato chips. She was not provided or offered a Mighty Shake during the meal. On 11/19/15 at 4:46 p.m. the resident was observed sitting in the dining room. She was provided two pieces of toast and ate half a piece of toast. No Mighty Shake was provided. At 4:50 p.m. a nurse asked her if she wanted to leave the dining room and assisted her back to her room. On 11/20/15 at 4:53 p.m. the resident was given peanut butter and jelly on toast. She told the nurse delivering the food she did not want peanut butter and jelly, just jelly toast. She was delivered ice cream and a scone and asked staff to take it back; staff removed the ice cream. At 4:55 p.m. the peanut butter and jelly toast was replaced with two pieces of toast with jelly on it. The Director of Nursing (DON) offered her another piece of toast, which she declined at 5:15 p.m. At 5:28 p.m. the nurse offered her more coffee and asked if she wanted to return to her room. She left the dining room at 5:30 p.m. having eaten one and a half pieces of jelly toast. She was not provided or offered a Mighty Shake during the meal. C. Staff Interviews On 11/24/15 at 11:23 a.m. the RD stated that the normal process was she completed nutritional assessments quarterly and as needed and created the nutritional care plans for the residents. She then notified the nurses and/or certified nursing assistants (CNAs) of the interventions, including recommended supplements. The nursing staff was responsible for writing a communication form to the dietary department to inform them of the order. The RD stated that the rest of the staff provided the nutritional interventions since she was only there a couple of times a week. RD reported that she wanted the resident to receive the Mighty Shakes at meals and the Med Pass between meals due to the resident's weight loss. She said the Mighty Shakes were ordered by the doctor. On 11/24/15 at 1:43 p.m. the FSD was interviewed. He stated that he was responsible for reviewing the telephone orders that were put in his mail box and then updating the meal tickets from the telephone orders. He said the dietary department was in charge of providing the Mighty Shakes at each meal and putting the Mighty Shakes on the meal trays delivered to the resident. He stated that he and the dietary staff would know if a resident was supposed to receive a Mighty Shake by looking at their meal ticket. He said it would be documented under the supplements section of the form. He reviewed the resident ' s meal ticket and agreed that there was nothing documented under supplements. He stated he was unaware if the Mighty Shakes order for the resident was new or if it had been ordered prior to his start date in September, 2015. He stated that the resident had not been getting the Mighty Shakes since it was not documented on the meal ticket. On 11/24/15 at 2:50 p.m. the DON was interviewed. She stated that Mighty Shakes come from the dietary department. She stated that CNAs could give it but dietary usually gave them. The DON stated that Resident #39 should have been receiving Mighty Shakes. On 11/24/15 at 2:31 p.m. LPN #2 was interviewed. She stated that the kitchen gave Mighty Shakes. She said she would go in the dining room to see if Resident #39 had consumed the Mighty Shake before she signed the MAR. She stated she was not aware that Resident #39 had not been receiving the Mighty Shakes from the dietary department and said she was signing off on the MAR because she provided Med Pass. The MAR indicated [REDACTED]. K. Changes Made During Survey On 11/23/15, during the survey process, the RD revised the care plan as follows: Focus: .need for staff cueing/encouragement at times . replaced .increased need for staff cueing to swallow . Goal: .will receive staff cueing/encouragement if needed . replaced will receive staff cueing to swallow if needed per SLP . On 11/24/15 interventions were added to the care plan as follows: -8oz whole milk at (breakfast) and 1 strip of bacon at B (breakfast) -resident refuses a diet texture change or a table change -weekly wts as ordered. On 11/24/15 the RD documented in a nutrition/dietary note, in pertinent part, Wt loss continues despite current nutritional interventions .In addition to diet, resident receives 60cc Med Pass BID between meals (240kcal, 10gm pro daily). Resident also receives Mighty Shakes at L and D meals to boost nutrition . RD was unable to accurately assess Resident #39's nutrition and meal intake due to inaccurate documentation of provision of Mighty Shakes on the MAR.

Based on record review and interview, the facility failed to ensure two of of 40 sample residents (#76 and #64) received the care and services necessary to attain and/or maintain their highest level of physical well-being. Specifically: -Resident #76 failed to receive cardiopulmonary resuscitation (CPR) when she was found without "signs of life," although it had been specifically requested by the resident on her Medical Orders for Scope of Treatment (MOST) form executed on admission. -Resident #64 failed to receive neurological assessments following a fall, as expected. The finding include: I. Implementation of Advance Directive A. Expectations According to the Colorado Advance Directive Consortium, with regard to the medical orders scope of treatment (MOST) form, "If "Yes CPR" is checked, call [DATE] and/or initiate emergency resuscitation." See: Colorado Advance Directives Consortium, "Getting the MOST out of the Medical Orders for Scope of Treatment Process and Form, Guidance for Healthcare Professionals," [DATE], www.coloradoadvancedirectives.com [DATE]. B. Resident #76 1. Resident #76, a [AGE] year old female, was admitted on [DATE], and according to her resident face sheet, her [DIAGNOSES REDACTED]. Additionally, her client [DIAGNOSES REDACTED]. According to an OBRA assessment [DATE], the resident was cognitively intact. 2. Record Review According to her Colorado medical orders for scope of treatment (MOST) dated [DATE], she requested to have cardio [MEDICAL CONDITION] resuscitation (CPR) performed if she had no pulse and was not breathing, as well as comfort measures, antibiotics, and long-term artificial nutrition /hydration by tube if necessary to sustain life. According to nurses notes on [DATE] at 0115 (1:15 a.m.), resident #76 was found having difficulty breathing. According to the nurses notes, the resident was found ten minutes later at 0125 (1:25 a.m.) and, "life signs absent." At the same time, it was noted that the registered nurse (RN) on duty was notified and assessed the resident, and the doctor was called to pronounce death. According to the notes, no CPR was attempted. 3. Staff Interviews On [DATE] at 8:16 a.m., the licensed practical nurse (LPN) on duty the night of [DATE] and assigned to resident #76 that night was interviewed. He reported the following: -On the night of the 18th of June he was informed by a certified nurse aide (CNA) that the resident was having problems with breathing, and at that point he went and assessed the patient and started a nebulizer treatment (a medication that assists with lung function). -About a half hour later, he went to check on the resident and she appeared to have passed away. -He went to the chart and saw a hospital order that stated that the resident was a do not resuscitate (DNR) so he treated her as a DNR and did not perform cardio [MEDICAL CONDITION] resuscitation (CPR). -He said he saw the resident's MOST form in front of the chart, but he did not know what it was. On [DATE] at 1:28 p.m., an interview with the Nursing Home Administrator (NHA) and Nurse consultant (NC) revealed the following: -When NHA was asked if she was aware that the resident had requested CPR be performed, she stated that she was aware. When asked what her understanding was of the occurrences surrounding the death of resident #76, she stated that she believed that the LPN went to the resident's room and the resident was complaining of shortness of breath, and he offered a breathing treatment. She stated that she believed the nurse checked on the resident shortly after that and she was not breathing, and, "she looked dead according to nurse." The NHA stated that the nurse did not follow protocol, but called the registered nurse (RN) over to do an assessment, then called the physician. -When the NHA was asked what the RN did at that point she stated," her interaction was minimal." -When asked what action was taken as a result of the resident not receiving CPR, the NHA stated that they identified issues with the process being followed, and did extensive education about responding appropriately. She stated that the facility reported the RN to the agency as she was not a facility employee and that the LPN was written up and began receiving one on one counseling. She said she had not reported the LPN to the Board of Nursing. On [DATE] at 1:28 p.m., the Nursing Home Administrator (NHA) provided a sign in list of nurses that were educated on the MOST form. The form was dated [DATE], and only had 12 of 23 nurses' signatures indicating they had received the MOST education. C. Cross-reference F155; failure to protect the right of residents to exercise their right to determine end of life care. II. Implementation of Fall Management Program A. Facility Policy The facility fall management program read in pertinent part, " ...Following a resident fall, the assigned nurse will do the following: ...Glasgow Coma Scale/neurological assessment with all un-witnessed fall or known head injury ..." The assistant director of nurses (ADON), and the minimum data set coordinator (MDSC) was interviewed on [DATE] at 9:30 a.m. The ADON stated neurological assessments needed to be completed for 72 hours after a fall. The MDSC stated the interdisciplinary team reviews all the paperwork after a fall to ensure the interventions were adequate. The ADON stated neurological assessments were completed on all falls, whether or not the fall was witnessed or un-witnessed. B. Resident #64 1. Resident #64, age 92, was admitted to the facility on [DATE]. According to the ,[DATE] Computerized Physician order [REDACTED]. The most recent Minimum Data Set, dated dated [DATE], documented the resident had cognitive impairments. The resident required extensive assistance with activities of daily living. The resident was coded as walking independently. 2. Fall [DATE] Review of the documentation from the resident's daughter, dated [DATE], revealed the resident fell with walker on the right side. The daughter thought the resident caught herself with her right hand which was bleeding. The resident complained of hurting her back, arm and hand. The nurses notes, dated [DATE], documented the resident had a fall while at the high rise building across the street. The resident was complaining of back pain, knee pain, and right wrist pain. The nurses note, dated [DATE] at 6:00 p.m., documented the resident had complained of nausea. The nurses note, dated [DATE] at 1:00 a.m., documented the resident was complaining of fell ing sick. 3. Neurological Assessments following [DATE] fall The ,[DATE] Glasgow coma scale/pupil response evaluation (GCSPR) beginning on [DATE] failed to show neurological assessments were completed as scheduled following the resident's reported fall. The neurological assessment was to be completed every 15 minutes for the first hour, then every 30 minutes for 3 hours, then every hour for four hours, every four hours for 16 hours, then every 8 hours for the next 48 hours. Review of the nurses notes failed to show the neurological assessment was completed. The GCSPR was incomplete for the neurological response from 12 hours after the fall throughout the remainder of the evaluation period. 4. Interview The ADON and the MDSC reviewed the resident's neurological assessments and confirmed they were not complete and had missing entries throughout the entire 72 hour period. The MDSC stated the resident's [MEDICATION NAME] was causing the nausea; however, the resident should have been evaluated neurologically for a possible head injury.

Based on record review and interviews, the facility failed to protect the right of four of 40 sample residents (#76, #99, #78 and #87) to exercise their right to determine end of life care. Cross-reference F309; care and services. The findings include: A. Expectations Reference: According to the Colorado Advance Directive Consortium, with regard to the Medical Orders for Scope of Treatment (MOST) form, "If" Yes CPR" is checked, call [DATE] and/or initiate emergency resuscitation." See: Colorado Advance Directives Consortium, "Getting the MOST out of the Medical Orders for Scope of Treatment Process and Form, Guidance for Healthcare Professionals," [DATE], www.coloradoadvancedirectives.com [DATE]. Interviews: An interview conducted, on [DATE] at 10:20 a.m. with two certified nurse aides (CNAs) revealed that when asked what they would do if they walked into a room and the resident looked like he/she were not breathing, one CNA stated she would check the resident's oxygen and then get the nurse. The other CNA stated she would check the resident's oxygen and call for help. The CNA added she would not know whether or not to perform cardiopulmonary resuscitation if she did not call the nurse. An interview, at 10:23 a.m. on [DATE], with a licensed practical nurse (LPN) revealed that if a resident looked void of vital signs, she would check the resident's pulse, and call a cor and check the resident's cor status. When asked if there would be any reason not to perform CPR on a resident who had an order for [REDACTED]." An interview, on [DATE] at 10:26 a.m., with a LPN revealed that if she discovered a resident without vitals, "I would find out the code status. If they were a full cor, I would have to follow that because I am not qualified to disobey the directive." B. Failure to protect residents' decisions regarding end of life Record review and interviews revealed staff failed to implement resident #76's request for end of life support and failed to clarify resident #99, #78 and #87's decisions regarding end of life care. 1. Resident #76 - Cross reference F309 Resident #76, a [AGE] year old female, was admitted on [DATE], and according to her resident face sheet, her [DIAGNOSES REDACTED]. Additionally, her client [DIAGNOSES REDACTED]. According to an OBRA assessment [DATE], the resident was cognitively intact. According to her Colorado medical orders for scope of treatment (MOST), dated [DATE], the resident requested to have cardio [MEDICAL CONDITION] resuscitation (CPR) performed if she had no pulse and was not breathing, as well as comfort measures, antibiotics, and long-term artificial nutrition/hydration by tube if necessary to sustain life. According to nurses notes, on [DATE] at 0115 (1:15 a.m.), resident #76 was found having difficulty breathing. According to the nurses notes, the resident was found ten minutes later at 0125 (1:25 a.m.) and, "life signs absent." At the same time, it was noted that the registered nurse (RN) on duty was notified and assessed the resident, and the doctor was called to pronounce death. According to the notes, no CPR was attempted. On [DATE] at 8:16 a.m., the licensed practical nurse (LPN) on duty the night, of [DATE], and assigned to resident #76 that night was interviewed. He reported the following: -On the night of the 18th of June he was informed by a certified nurse aide (CNA) that the resident was having problems with breathing, and at that point he went and assessed the patient and started a nebulizer treatment (a medication that assists with lung function). -About a half hour later, he went to check on the resident and she appeared to have passed away. -He went to the chart and saw a hospital order that stated that the resident was a do not resuscitate (DNR) so he treated her as a DNR and did not perform CPR. -He said he saw the resident's MOST form in the front of the chart, but he did not know what it was. On [DATE] at 12:37 p.m., interview with the nursing home administrator (NHA) revealed that the team had met and discussed the death of resident #76 and had found that it was an issue with the LPN not following policy. On [DATE] at 1:28 p.m. the nursing home administrator (NHA) provided a sign in list of nurses that were educated on the MOST form. The form was dated [DATE], and only had 12 of 23 nurses' signatures indicating they had received the MOST education. 2. Resident #99 Resident #99, age 76, was admitted to the facility on [DATE]. According to the Record of Admission, [DIAGNOSES REDACTED]. According to the resident's [DATE] MOST form, the resident desired cardiopulmonary resuscitation (CPR) if his pulse was absent and he was not breathing. According to the [DATE] physician orders, and the ,[DATE] computerized physician orders [REDACTED]. Review of the telephone orders from admission through his discharge, on [DATE], revealed there was no clarification order to reflect the resident's declared wish for the initiation of CPR if needed. Review of the closed record, on [DATE] revealed a [DATE] telephone clarification order that read: "Effective [DATE], cor status is full cor per MOST form." This brought the physician's orders [REDACTED]. This order was obtained five days after the resident was discharged . In an interview, on [DATE] at approximately 9:45 a.m., the MDS coordinator confirmed this order was obtained, on [DATE], (after the resident's discharge) from the physician. 3. Resident #78 Resident #78, [AGE] years old, was admitted to the facility on [DATE]. According to the face sheet, his [DIAGNOSES REDACTED]. Review of social worker progress notes revealed a note, dated [DATE], in which the social worker documented the resident scored a ,[DATE] on his brief interview for mental status (BIMS) indicating the resident's cognition was intact. The resident signed an Advance Directive treatment of [REDACTED]. The resident signed he wanted cardiopulmonary resuscitation (CPR) followed by advance cardiac life support. This revealed the resident's COR status (resuscitation status) as a Full Cor. No other forms had been signed by the resident to change his current COR status. Review of the physician orders, from ,[DATE] to ,[DATE], had the resident's COR status as a No Cor. On [DATE] at 9:30 a.m., (during survey) a new telephone physician order [REDACTED]. 4. Resident #87 Resident #87, [AGE] years old, was originally admitted [DATE]. According to the face sheet, her [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS), dated [DATE], revealed the resident's brief interview for mental status (BIMS) indicated the resident's cognition was intact. The resident scored a ,[DATE]. Review of the physician orders [REDACTED]. During an interview, on [DATE] at 10:30 a.m., with resident #87, she stated "as far as I know I have always been a full cor." "I have never signed anything else since admission stating I did not want CPR." During an interview, on [DATE] at 4:30 p.m., with one of the resident's registered nurses (RN), the nurse was asked how she would determine a resident's COR status. She stated, "I would look at their current physician's orders [REDACTED].