Every finding on record at Lamar Estates Nursing Center

Based on record review and interviews, the facility failed to ensure one (#6) of 12 residents reviewed for abuse out of 14 sample residents were kept free from abuse.Specifically, the facility failed to protect Resident #6 from verbal abuse by the facility's dietary manager (DM).Findings include:I. Facility policy and procedureThe Abuse Investigation and Reporting policy and procedure, undated, was received from the business office manager on 8/27/26 at 6:51 p.m. It read in pertinent part, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown origin shall be promptly reported and thoroughly investigated by facility management.II. Resident #6 (victim)A. Resident statusResident #6, age [AGE], was admitted on [DATE]. According to the August 2026 computerized physician orders (CPO), diagnoses included cardiomegaly (enlargement of the heart), chronic obstructive pulmonary disease, anxiety disorder and major depressive disorder.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 15 out of 15. The MDS assessment documented the resident did not have any physical or verbal behaviors or other behavioral symptoms not directed towards others.B. Resident interviewResident #6 was interviewed on 8/26/26 at 4:57 p.m. Resident #6 said she had an issue with the DM raising her voice at her approximately two weeks prior. Resident #6 said the DM started yelling at her, and said she yelled right back at the DM. Resident #6 said the incident was a knock-down, drag-out fight. Resident #6 said she thought the DM was reprimanded for the incident. Resident #6 said the nursing home administrator (NHA) came to her afterward and said Resident #6 would never have to deal with that again. C. Record reviewThe psychosocial care plan, revised 10/1/25, revealed Resident #6 had a psychosocial wellbeing problem resulting from little interest in doing things and social isolation. Pertinent interventions included encouraging visits from family and friends, and staff engaging Resident #6 in facility life, including encouraging activities of choice, meals in the dining room and interactions with peers.-Review of Resident #6's electronic medical record (EMR) did not reveal any documentation of the incident between the resident and the DM, an assessment of the resident following the incident or subsequent psychosocial monitoring of the resident following the incident.III. Staff interviewsHousekeeper (HK) #1 was interviewed on 8/27/26 at 12:06 p.m. HK #1 said she had heard about an incident where something broke out between a resident and the DM over a slice of bread. HK #1 said she heard the resident and the DM had argued, but said she had not witnessed the incident.Certified nurse aide (CNA) #1 was interviewed on 8/27/26 at 12:48 p.m. CNA #1 said she had seen Resident #6 and the DM get into it the other day in the dining room over a piece of bread. CNA #1 said Resident #6 had asked the social services director (SSD) for a piece of bread when the DM came out of the kitchen and told Resident #6 to ask the dietary aides for food, not other staff members. CNA #1 said all the staff present in the dining room saw Resident #6 and the DM raise their voices at each other. CNA #1 said she was not able to intervene during the incident as she was providing meal assistance to another resident at the time. CNA #1 said the incident ended when the DM left the dining room and Resident #6 eventually got her piece of bread.The SSD was interviewed on 8/27/26 at 1:49 p.m. The SSD said the other day, Resident #6 asked the DM to get her a piece of bread. The SSD said the DM was being suspended by the NHA at the time for something unrelated, so the SSD stepped in to get Resident #6 a piece of bread. The SSD said Resident #6 was yelling and the SSD tried to get her to calm down. The SSD said she brought Resident #6 a piece of bread but the resident was still crying and upset at the DM for not bringing her bread.The business office manager was interviewed on 8/27/26 at 2:04 p.m. The business office manager said she had not heard about any incidents between the DM and any residents. She said no incidents had been reported to her. The business office manager said she recalled seeing Resident #6 upset and seeing a few staff members comforting her the other day and said it may have occurred that Monday or Tuesday (8/24/26 or 8/25/26). The business office manager said she did not know why Resident #6 had been upset or any details of the situation. The business office manager said there were a few staff members comforting Resident #6, but the situation appeared to be under control so she did not approach them. The business office manager said Resident #6 was visibly upset and appeared to be crying. The business office manager said she thought the NHA was in her office at the time.The business office manager said if she saw a staff member raising their voice at a resident, she would separate the resident and the staff member, remove the resident from the situation and report the incident to the NHA. The NHA was interviewed on 8/27/26 at 3:50 p.m. The NHA said she was present (in the kitchen) for the incident between the DM and Resident #6. The NHA said Resident #6 had asked for a slice of bread and a conversation transpired with the DM. The NHA said she was in the kitchen and came out to the dining room to talk to the DM. The NHA said she did not hear either Resident #6 or the DM raise their voices at the time. The NHA said she saw Resident #6 crying later because she did not get a slice of toast. The NHA said no staff members had approached her with any concerns about staff raising their voices at residents. The NHA said Resident #6 and the DM did not get along, but said she had not heard of any concerns about an incident between the DM and Resident #6.The NHA said after hearing the concerns regarding the exchange between the DM and Resident #6, she would report the incident to the State Agency (as it was not reported at the time of the incident). She said she would speak to Resident #6 and talk to the staff members who witnessed the incident. She said she would provide education to the staff about abuse reporting. The NHA said the incident likely happened on 8/19/26, when she was escorting the DM out of the facility.-However, interviews with other facility staff revealed the NHA had been been present for or was made aware of the incident of verbal abuse between the DM and Resident #6 (see other staff interviews) at the time of the incident. Cross-reference F609: for failure to report an alleged violation.The NHA was interviewed a second time on 8/27/26 at approximately 6:52 p.m. During the interview, a police officer came and spoke with the NHA regarding the incident between the DM and Resident #6. The police officer asked the NHA if she had been aware of the incident at the time it occurred and the NHA responded that she had been.The NHA was interviewed a third time on 8/27/26 at approximately 7:15 p.m., after the police officer left. The facility's investigation of the incident between Resident #6 and the DM was requested at the time of the interview. The NHA said she did not have any documentation related to the investigation as she had not been aware of the incident prior to her interview earlier that day (see interview with NHA on 8/27/26 at 3:50 p.m. above).-However, the NHA reported to the police officer (on 8/27/26 at 6:52 p.m.) that she had been aware of the incident at the time it occurred (see above).CNA #2 was interviewed on 8/27/26 at 6:09 p.m. CNA #2 said she was in the dining room providing residents with meal assistance with CNA #1 and two other CNAs when the incident between Resident #6 and the DM occurred. CNA #2 said Resident #6 had asked the SSD for a piece of bread. She said the DM came out and began yelling at Resident #6 and asked the resident why she did not ask the CNAs for the bread. CNA #2 said Resident #6 was upset and was crying after the interaction with the DM. CNA #2 said she approached the resident to try to comfort her. CNA #2 said she ended up getting Resident #6 food from a local restaurant to try to cheer her up. CNA #2 said the NHA entered the dining room when she heard Resident #6 and the DM yelling. She said the activity director (AD) had informed the NHA about the incident.The AD was interviewed on 8/27/26 at 6:15 p.m. The AD said she had received training on abuse reporting and prevention when she first began working at the facility. The AD said she knew if there was anything she thought could even remotely be considered abuse or mistreatment, she would report it to the NHA immediately. The AD said she had seen the incident between Resident #6 and the DM the Thursday or Friday prior (8/20/26 or 8/21/26). The AD said she had been in her office near the dining room with the door closed when she heard Resident #6 yelling. The AD said she left her office and approached Resident #6. She said she saw the DM was standing close to Resident #6 facing her. The AD said she spoke with Resident #6 to see what the problem was, and the resident said she had just asked for a piece of bread. The AD said after some back and forth between herself, the resident and the DM, Resident #6 said all she wanted was a piece of bread. The AD said the DM then yelled at Resident #6 and asked her why she did not just ask the CNAs in the dining room for bread. The AD said Resident #6 was emotional from the incident but did not cry. The AD said the incident eventually ended when the DM entered the kitchen, grabbed a piece of bread on a plate, then approached Resident #6 and shoved it toward the resident before leaving. The AD said she comforted Resident #6 after the incident and said the resident did not appear to be in any fear or distress after the incident.The AD said after the incident, she returned to her office and did not initially follow-up with the NHA, because the NHA was nearby in the kitchen at the time and was present for the situation. The AD said the NHA approached her later on in the day on the day of the incident. She said the NHA told her she had heard about the interaction between Resident #6 and the DM from several staff members. The AD said the NHA then asked her if the DM had been really out of control during the incident with Resident #6, and the AD responded that she had been.-However, the NHA did not document any information related to the incident (see record review above).

Based on record review and interviews, the facility failed to report alleged violations of potentialabuse to the State Survey and Certification Agency in accordance with state law for three (#6, #1 and #3) of 12 residents reviewed for abuse out of 14 sample residents.Specifically, the facility failed to:-Report an incident of potential verbal abuse towards Resident #6 by the dietary manager (DM) to the State Agency; and,-Report allegations of verbal abuse towards Resident #1 and Resident #3 by the nursing home administrator (NHA) within two hours of being notified of the allegations. Findings include: I. Facility policy and procedure The Abuse Investigation and Reporting policy and procedure, undated, was received from the business office manager on 8/27/26 at 6:51 p.m. It read in pertinent part, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown origin shall be promptly reported and thoroughly investigated by facility management. II. Allegation of verbal abuse towards Resident #6 by the DM A. Resident interview Resident #6 was interviewed on 8/26/26 at 4:57 p.m. Resident #6 said she had an issue with the DM raising her voice at her approximately two weeks prior. Resident #6 said the DM started yelling at her, and said she yelled right back at the DM. Resident #6 said the incident was a knock-down, drag-out fight. Resident #6 said she thought the DM was punished for the incident. Resident #6 said the nursing home administrator (NHA) came to her afterward and said Resident #6 would never have to deal with that again. Cross-reference F600 for failure to keep residents free from abuse. B. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 8/27/26 at 12:48 p.m. CNA #1 said she had seen Resident #6 and the DM get into it the other day in the dining room over a piece of bread. CNA #1 said Resident #6 had asked the social services director (SSD) for a piece of bread when the DM came out of the kitchen and told Resident #6 to ask the dietary aides for food, not other staff. CNA #1 said all the staff present in the dining room saw Resident #6 and the DM raise their voices at each other. CNA #1 said she was not able to intervene during the incident as she was providing meal assistance to another resident at the time. CNA #1 said the incident ended when the DM left the dining room and Resident #6 eventually got her piece of bread. The SSD was interviewed on 8/27/26 at 1:49 p.m. The SSD said the other day Resident #6 asked the DM to get her a piece of bread. The SSD said the DM was being suspended by the NHA at the time for something unrelated, so the SSD stepped in to get Resident #6 a piece of bread. The SSD said Resident #6 was yelling and the SSD tried to get her to calm down. The SSD said she brought Resident #6 a piece of bread but the resident was still crying and upset at the DM for not bringing her bread. The NHA was interviewed on 8/27/26 at 3:50 p.m. The NHA said she was present (in the kitchen) for the incident between the DM and Resident #6. The NHA said Resident #6 had asked for a slice of bread and a conversation transpired with the DM. The NHA said she was in the kitchen and came out to the dining room to talk to the DM. The NHA said she did not hear either Resident #6 or the DM raise their voices at the time. The NHA said she saw Resident #6 crying later because she did not get a slice of toast. The NHA said no staff members had approached her with any concerns about staff raising their voices at residents. The NHA said Resident #6 and the DM did not get along but said she had not heard of any concerns about an incident between the DM and Resident #6. The NHA said after hearing these concerns regarding the exchange between the DM and Resident #6, she would report the incident to the State Agency (as it was not reported at the time of the incident), speak to Resident #6 and talk to staff who witnessed the incident, and provide education to the staff about abuse reporting. The NHA said the incident likely happened on 8/19/26 when she was escorting the DM out of the facility. -However, interviews with other facility staff revealed the NHA had been been present for or made aware of the incident of verbal abuse between the DM and Resident #6 at the time of the incident. CNA #2 was interviewed on 8/27/26 at 6:09 p.m. CNA #2 said she was in the dining room providing residents with meal assistance with CNA #1 and two other CNAs when the incident between Resident #6 and the DM occurred. CNA #2 said Resident #6 had asked the SSD for a piece of bread when the DM came out and began yelling at Resident #6 and asked the resident why she did not ask the CNAs for the bread. CNA #2 said Resident #6 was upset and was crying after the interaction with the DM, and CNA #2 said she approached the resident to try to comfort her. CNA #2 said she ended up getting Resident #6 food from a local restaurant to try to cheer her up. CNA #2 said the NHA entered the dining room when she heard Resident #6 and the DM yelling, and said the activities director (AD) had informed the NHA about the incident. The AD was interviewed on 8/27/26 at 6:15 p.m. The AD said she had received training on abuse reporting and prevention when she first began working at the facility. The AD said she knew if there was anything she thought could even remotely be considered abuse or mistreatment she would report it to the NHA immediately. The AD said she had seen the incident between Resident #6 and the AD the Thursday or Friday prior (8/20/26 or 8/21/26). The AD said she had been in her office near the dining room with the door closed when she heard Resident #6 yelling. The AD said she left her office and approached Resident #6, and saw the DM was standing close to Resident #6 facing her. The AD said she spoke with Resident #6 to see what the problem was, and the resident said she had just asked for a piece of bread. The AD said after some back and forth between herself, the resident and the DM, Resident #6 said all she wanted was a piece of bread. The AD said the DM then yelled at Resident #6 and asked her why she did not just ask the CNAs in the dining room for bread. The AD said Resident #6 was emotional from the incident but did not cry. The AD said the incident eventually ended when the DM entered the kitchen, grabbed a piece of bread on a plate, then approached Resident #6 and shoved it toward the resident before leaving. The AD said she comforted Resident #6 after the incident and said the resident did not appear to be in any fear or distress after the incident. The AD said after the incident, she returned to her office and did not initially follow-up with the NHA, because the NHA was nearby and present for the situation as she was in the kitchen at the time. The AD said the NHA approached her later on in the day on the day of the incident, and the NHA said she had heard about the interaction between Resident #6 and the DM from several staff members. The AD said the NHA then asked her if the DM had been really out of control during the incident with Resident #6, and the AD responded that she had been. -However, the NHA failed to report the incident to the State Agency. II. Allegations of verbal abuse towards Resident #1 and Resident #3 by the NHA A. Allegation of abuse On 8/26/26 at 9:15 a.m. allegations of physical abuse against NHA were reported to NHA. The allegations alleged the NHA verbally abused Resident #1 and Resident #3. -However, the facility was unable to provide documentation that the allegations of verbal abuse were reported to the State Agency within two hours of notification (see interviews below). B. Staff interviews The NHA was interviewed on 8/26/26 at 1:14 p.m. (approximately after the allegations were reported). The NHA said she did not know what to report when she was notified of the allegations earlier that morning (8/26/26). The NHA said the facility was now past the two-hour reporting deadline for the allegations because the facility was notified of the allegation in the morning. The NHA said she would suspend herself because it was the facility's policy. The NHA was interviewed a second time on 8/27/26 at 10:45 a.m. The NHA said the facility had reported the allegations to the State Agency and completed the investigations for the allegations of verbal abuse by the NHA toward Resident #1 and Resident #3. The social services director (SSD) and the business office manager were interviewed on 8/27/26 at 12:41 p.m. The SSD said she usually completed facility abuse investigations at the facility, unless she was involved in the allegation and then the investigation would be assigned to another leadership team member. The business office manager said if there was a situation that could be considered abuse, the staff would report it to the NHA within two hours and then if the NHA had to report the situation, the facility would report it within the two hour deadline.

Based on observations, record review and interviews, the facility failed to have a system in place to ensure all residents were offered and received an updated COVID-19 vaccination which matched the current variants.Record review revealed the facility was in outbreak status when nine residents tested positive for COVID-19 on 1/13/26. Within the next 14 days, an additional seven residents tested positive for COVID-19. Record review revealed the residents' electronic medical records (EMR) did not include documentation prior to the outbreak on 1/13/26 that indicated that residents or their representatives were provided education regarding the potential benefits and potential risks associated with the updated COVID-19 vaccine and there was no documentation of the COVID-19 vaccine being administered to residents or if residents did not receive the vaccine due to medical contraindication or refusal. Specifically, the facility failed to:-Document in the EMRs of 10 current residents (#2, #6, #7, #10, #12, #13, #15, #17, #21 and #23) that the residents had been provided education on 5/6/25 after the residents' said they wanted to receive the updated COVID-19 vaccine; -The facility failed to administer the COVID-19 vaccine to residents who consented to have the vaccine in May 2025 for Resident #2, Resident #6, Resident #7, Resident #10, Resident #12, Resident #13, Resident #15, Resident #17, Resident #21 and Resident #23 prior to the COVID-19 outbreak on 1/13/26; and, -The facility failed to document in the residents' EMRs whether education had been provided prior to the outbreak about the updated COVID-19 vaccine to the remaining residents (14) at the facility. Findings include:I. The facility's COVID-19 statusThe facility confirmed a positive case of COVID-19 on 1/13/26 when Resident #8 was hospitalized with altered mental status and diagnosed with COVID-19. All of the residents were tested and an additional eight residents tested positive on 1/13/26. By 1/14/26, an additional five residents tested positive for COVID-19 and one resident tested positive on 1/16/26. The facility was still following outbreak guidance when an additional resident tested positive for COVID-19 on 1/28/26. By 1/28/26, 16 of 24 residents and nine staff members had tested positive for COVID-19.II. Immediate jeopardyA. Findings of immediate jeopardyObservations, record review and resident and staff interviews from 1/26/26 to 1/29/26 revealed multiple failures in the facility's vaccine administration section of the infection control program, including failure to document in the residents' EMRs if/when the facility offered the COVID-19 vaccination to the residents, if the residents consented or refused the vaccination and if the facility provided education to the residents' who refused the COVID-19 vaccination on the risks versus benefits. On 5/6/25 15 residents consented to receive the updated COVID-19 vaccination when it became available. The vaccine was available for administration to facility residents by October 2025. The facility's plan was to provide a list to the pharmacist of all residents who wanted to receive the updated COVID-19 vaccine, in order for the vaccine to be administered when the pharmacist was at the facility. The facility had not provided the vaccination list to the pharmacist by the time the COVID-19 outbreak began on 1/13/26. All of the residents who had indicated on 5/6/25 that they wanted the updated COVID-19 vaccination when it was available had not received the vaccine by the onset of the outbreak on 1/13/26. Six of the 10 residents who still resided at the facility and wanted the COVID-19 vaccination tested positive for COVID-19 during the outbreak.The above failures created an immediate jeopardy situation that placed all facility residents at risk due to the likely transmission of highly infectious COVID-19.B. Facility notice of immediate jeopardyOn 1/28/26 at 7:00 p.m. the nursing home administrator (NHA) was notified that the failures in the facility's infection control program related to COVID-19 vaccination created an immediate jeopardy situation that placed all residents in the facility at risk for serious harm (COVID-19).C. Facility plan to remove immediate jeopardyOn 1/29/26 at 6:38 p.m. the NHA provided a plan to remove immediate jeopardy. The plan read:The alleged non-compliance has the potential to affect all residents.Corrective Action:-On 12/11/25 the facility held a QAPI (quality assurance performance improvement) committee meeting and a plan to audit vaccinations in December 2025 to include an audit of vaccination status and hold a vaccine clinic.-On 12/11/25 the medical director and the pharmacist were informed that a list would be provided by the infection preventionist to the pharmacist and proceed with a vaccine clinic.-On 1/13/26 an ad hoc (as needed) meeting was held to revise the vaccination plan based on an outbreak. -The plan developed on 1/13/26 included a revised vaccine audit and clinical directions including but not limited to, oxygen, antipyretics, or other alternative orders.-On 1/13/26 the outbreak protocol began, which included increased surveillance, education and training on PPE (personal protective equipment/donning and doffing (application and removal of the PPE), hand hygiene and reporting of symptoms.-On 1/13/26 the medical director guidance included directions to conduct a COVID-19 vaccine clinic following the resolution of COVID-19 positive residents.-On 1/13/26 medical records were audited by the infection preventionist (IP) for COVID-19 vaccinations. The audit included the following criteria: active residents as of 1/13/26; a review of previous consents; and were updated to include COVID-19 vaccination status based on resident consent and/or declination.-On 1/27/26 all residents were provided with education on COVID-19 vaccinations and consents/declinations were obtained.-On 1/27/26 the IP identified 11 out of 24 residents who were not eligible to receive the vaccine due to recent COVID-19 infection.-On 1/27/26 the IP identified four residents who were eligible and agreed to have the COVID-19 vaccine. The four residents received the COVID-19 vaccine on 1/27/26. -Two out of 24 residents were not eligible for the vaccine due to recent vaccine administration. -Seven out of 24 residents declined the vaccine administration.-On 1/27/26 the IP identified no additional residents requiring consent and/or declination.-On 1/28/26 interdisciplinary team (IDT) members to include the NHA, the director of nursing (DON), the IP and the medical director staff were provided guidance and education on an improved process for identifying vaccine status by the following practice change: daily review of new admissions or readmissions for historical vaccine status via state vaccination portal, hospital records, and/or resident and/or representative recollection during daily clinical meeting. Findings will be entered into the medical record by the IP/designee. -Ongoing compliance will be reviewed during QAPI committee meetings. The IP will present data regarding vaccine status by providing consent and/or declination documentation.-On 1/26/26 a COVID-19 vaccine consent form was implemented to improve the information and documentation of residents who consent and/or decline the vaccine.-On 1/29/26 the morning meeting tool was updated to probe for new admission/readmission. -Education was provided to the IDT by the nurse consultant on compliance with the regulation on 1/28/26.-The QAPI meeting tool was revised and updated on 1/13/26 to include information related to vaccine status to include consent and/or declination. The medical director will visually review consent forms with a QAPI report to ensure ongoing compliance with admission/readmission and annual vaccinations.D. Removal of immediate jeopardyOn 1/29/26 at 7:10 p.m. the NHA was notified the immediate jeopardy was removed based on evidence of the facility's implementation of the above plan. However, deficient practice remained at an F level, no actual harm with potential for more than minimal harm that is not immediate jeopardy. III. Professional referenceAccording to the Centers for Disease Control's (CDC) Staying Up to Date with COVID-19 Vaccines, updated 11/19/25, retrieved on 2/2/26 from https://www.cdc.gov.covid/vaccines/stay-up-to-date.html, read in pertinent part, Getting the 2025-2026 COVID-19 vaccine is important because:-Protection from the COVID-19 vaccine decreases with time;-Immunity after COVID-19 infection decreases with time; and,-COVID-19 vaccines are updated to give you the best protection from the currently circulating strains. Getting the 2025-2026 COVID-19 vaccine is especially important if you:-Never received a COVID-19 vaccine;-Are ages 65 years and older;-Are at high risk for severe COVID-19; and,-Are living in a long-term care facility.IV. Facility policy and procedureThe Coronavirus Disease (COVID-19), Vaccination of Residents policy, revised August 2025, was provided by the NHA on 1/27/26 at 2:54 p.m. It read in pertinent part, Residents who are eligible to receive the COVID-19 vaccine are offered the vaccine. The resident's medical record includes documentation that indicates , at a minimum, the following: the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine; each dose of COVID-19 vaccine administered to the resident (or if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal; signed consent, date of administration.V. Record review and staff interviewAn untitled document containing a list of residents' names, dated 5/6/25, was provided by the NHA and the IP on 1/28/26 at 12:30 p.m. The list contained all of the residents who resided at the facility at that time. The names of residents who were at the facility at the time of the January 2026 COVID-19 outbreak were highlighted on the list, including Residents #2, #3, # 6, #7, #9, #10, #12, #13, #15, #17, #21 and #23. The IP said the highlighted residents' names represented the residents who were offered and consented to receive the updated COVID-19 vaccine on 5/6/25. The IP said Resident #3 later declined the vaccine and Resident #9 received the updated COVID-19 vaccine outside of the facility. The IP said she began compiling a new list of residents who wanted the vaccine in the fall of 2025.-The facility did not provide an updated list during the survey from fall 2025 of residents who wanted the vaccine.An email documented by the pharmacist to the facility social services director (SSD) was provided by the NHA on 1/28/26 at 7:30 p.m. The email was dated 1/28/26 at 6:04 p.m. (during the survey). The email revealed an influenza and pneumococcal vaccination clinic occurred at the facility on 11/10/25 and residents who requested the COVID-19 vaccines were informed that the COVID-19 vaccines would be administered at a future vaccination clinic.A document titled Quality Improvement Data Collection form was provided by the IP on 1/29/26 at 12:45 p.m. It documented a COVID-19 vaccination audit, which included documentation of 16 residents' consents for the COVID-19 vaccination, dated 1/27/26 (during the survey). It documented 10 of the residents would not be eligible to receive the vaccine until April 2026 due to COVID-19 infection in January 2026. It documented the updated COVID-19 vaccination was administered to Residents #6, #12, #17 and #21 on 1/27/26.-Resident #6, #12, #17 and #21 had wanted to receive the updated COVID-19 vaccine as of 5/6/25 (see above).VI. Resident #15A. Resident statusResident #15, age [AGE], was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included osteoarthritis, high blood pressure and Wernicke's disease (a neurologic disorder).The 11/26/25 minimum data set (MDS) assessment revealed Resident #15 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment indicated the resident was independent with eating, personal hygiene, dressing and transferring. The MDS assessment indicated the resident was not up to date on the COVID-19 vaccination. B. Record reviewResident #15's EMR vaccination record revealed his last COVID-19 vaccination was on 11/26/24. Resident #15's name was highlighted on the 5/6/25 document provided by the IP as he wanted to receive the updated COVID-19 vaccination when it was available (see above).Resident #15 EMR revealed he tested positive for COVID-19 on 1/14/26.C. Staff interviewThe DON was interviewed on 1/29/26 at 1:30 p.m. The DON said Resident #15 required supplemental oxygen while he was sick with COVID-19 in January 2026.VII. Resident # 10A. Resident statusResident #10, age greater than 65, was admitted on [DATE]. According to the January 2026 CPO, diagnoses included dementia, low back pain and pneumonia.The 11/10/25 MDS assessment identified Resident #10 had severe cognitive impairment with a BIMS score of six out of 15. The MDS assessment revealed the resident required set-up assistance with eating, moderate assistance for toileting and showering and supervision for dressing and transfers. The MDS assessment indicated the resident was not up to date on the COVID-19 vaccination. B. Record reviewResident #10's EMR vaccination record revealed her last COVID-19 vaccination was on 11/18/24. Resident #10's name was highlighted on the 5/6/25 document provided by the IP as she wanted to receive the updated COVID-19 vaccination when it was available (see above).Resident #10's EMR revealed she tested positive for COVID-19 on 1/13/26.VIII. Resident #7A. Resident statusResident #7, age less than 65, was admitted on [DATE]. According to the January 2026 CPO, diagnoses included cerebral palsy, high blood pressure, renal insufficiency and stroke.The 12/16/25 MDS assessment identified Resident #7 had severe cognitive impairment with a BIMS score of two out of 15. The MDS assessment revealed the resident required set-up assistance with eating, and was dependent on staff for toileting, showering, dressing and transferring. The MDS assessment indicated the resident was not up to date on the COVID-19 vaccination.B. Record reviewResident #7's EMR vaccination record revealed her last COVID-19 vaccination was on 11/26/24. Resident #7's name was highlighted on the 5/6/25 document that was provided by the IP as she wanted to receive the updated COVID-19 vaccination when it was available (see above).Resident #7's EMR revealed she tested positive for COVID-19 on 1/13/26.IX. Resident # 23A. Resident statusResident #23, age greater than 65, was admitted on [DATE]. According to the January 2026 CPO, diagnoses included high blood pressure, stage one pressure ulcer and heart failure.The 12/16/25 MDS assessment identified Resident #23 had moderate cognitive impairment with a BIMS score of 10 out of 15. The MDS assessment revealed the resident required set-up assistance with eating, and required moderate assistance with hygiene, showering, dressing and transferring. The MDS assessment indicated the resident was not up to date on the COVID-19 vaccination. B. Record reviewResident #23's EMR vaccination record revealed her last COVID-19 vaccination was on 10/14/24. Resident #23's name was highlighted on the 5/6/25 document that was provided by the IP as she wanted to receive the updated COVID-19 vaccination when it was available (see above).Resident #23's EMR revealed she tested positive for COVID-19 on 1/13/26.X. Resident #13A. Resident statusResident #13, age greater than 65, was admitted on [DATE]. According to the January 2026 CPO, diagnoses included high blood pressure, dementia, heart disease, renal insufficiency and diabetes.The 12/21/25 MDS assessment identified Resident #13 had moderate cognitive impairment with a BIMS score of nine out of 15. The MDS assessment revealed the resident was independent with eating, dressing and transferring, required set-up assistance with toileting, and supervision with hygiene and showering. The MDS assessment indicated the resident was not up to date with the COVID-19 vaccination. B. Record reviewResident #13's EMR vaccination record revealed her last COVID-19 vaccination was on 11/26/24. Resident #13's name was highlighted on the 5/6/25 document that was provided by the IP as she wanted to receive the updated COVID-19 vaccination when it was available (see above).Resident #23's EMR revealed she tested positive for COVID-19 on 1/14/26.XI. Resident #2A. Resident statusResident #2, age greater than 65, was admitted on [DATE]. According to the January 2026 CPO, diagnoses included heart disease, kidney disease, diabetes and septicemia (blood infection).The 1/10/26 MDS assessment identified Resident #2 had severe cognitive impairment with a BIMS score of four out of 15. The MDS assessment revealed the resident required set-up assistance with eating and was dependent on staff for hygiene, toileting, showering, dressing and transferring. The MDS assessment indicated the resident was not up to date on the COVID-19 vaccination. B. Record reviewResident #2's EMR vaccination record revealed her last COVID-19 vaccination was on 9/30/24. Resident #2's name was highlighted on the 5/6/25 document that was provided by the IP as she wanted to receive the updated COVID-19 vaccination when it was available (see above).Resident #2's EMR revealed she tested positive for COVID-19 on 1/14/26.XII. Resident #6A. Resident statusResident #6, age greater than 65, was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included high blood pressure, kidney disease, diabetes and respiratory failure. The 12/16/25 MDS assessment identified Resident #6 was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment revealed the resident was independent with eating, hygiene, toileting, dressing and transferring and required set-up assistance for showering. The MDS assessment indicated the resident was not up to date on the COVID-19 vaccination.B. Resident interviewResident #6 was interviewed on 1/28/26 at 4:45 p.m. Resident #6 said she would have received the COVID-19 vaccine in November 2025 if she could have. Resident #6 said she was initially told by someone at the facility that her insurance did not cover the vaccine. Resident #6 said she finally received the vaccine yesterday (1/27/26).C. Record reviewResident #6's name was highlighted on the 5/6/25 document provided by the IP as she wanted to receive the updated COVID-19 vaccination when it was available (see above).According to Resident #6's EMR, when the COVID-19 outbreak began at the facility on 1/13/26, the facility had not yet administered the updated COVID-19 vaccine (her previous COVID-19 vaccine was on 11/26/24).Resident #6's EMR vaccination record revealed the facility administered the COVID-19 vaccine to Resident #6 on 1/27/26 (after the COVID-19 outbreak).XIII. Resident #17A. Resident statusResident #17, age greater than 65, was admitted on [DATE]. According to the January 2026 CPO, diagnoses included respiratory failure, anxiety and depression. The 10/29/25 MDS assessment identified Resident #17 had severe cognitive impairment with a BIMS score of six out of 15. The MDS assessment revealed the resident required set-up assistance with eating and moderate assistance with hygiene, toileting, showering and dressing and required supervision with transfers. The MDS assessment indicated the resident was not up to date on the COVID-19 vaccination. B. Record reviewResident #17's name was highlighted on the 5/6/25 document provided by the IP as she wanted to receive the updated COVID-19 vaccination when it was available (see above).According to Resident #17's EMR, when the COVID-19 outbreak began at the facility on 1/13/26, the facility had not yet administered the updated COVID-19 vaccine (her previous COVID-19 vaccine was on 11/26/24).C. Staff interviewThe IP was interviewed on 1/29/26 at 1:38 p.m. The IP said Resident #17 received the COVID-19 vaccine on 1/27/26 and then tested positive for COVID-19 on 1/28/26.XIV. Resident #21A. Resident statusResident #21, age greater than 65, was admitted on [DATE]. According to the January 2026 CPO, diagnoses included cerebrovascular disease (disorder of blood vessels in the brain), right knee pain and muscle weakness.The 11/10/25 MDS assessment identified Resident #21 had moderate cognitive impairment with a BIMS score of nine out of 15. The MDS assessment revealed the resident required set-up assistance with eating, was independent with hygiene, dressing, toileting and transfer and required supervision with showering. The MDS assessment indicated the resident was not up to date on the COVID-19 vaccination. B. Record reviewResident #21's name was highlighted on the 5/6/25 document provided by the IP as he wanted to receive the updated COVID-19 vaccination when it was available (see above).According to Resident #21's EMR, when the COVID-19 outbreak began at the facility on 1/13/26, the facility had not yet administered the updated COVID-19 vaccine (his previous COVID-19 vaccine was on 11/26/24).Resident #21's EMR vaccination record revealed the facility administered the COVID-19 vaccine to Resident #21 on 1/27/26 (after the COVID-19 outbreak).XV. Resident #12A. Resident statusResident #12, age greater than 65, was admitted on [DATE]. According to the January 2026 CPO, diagnoses included high blood pressure, diabetes and depression.The 11/10/25 MDS assessment identified Resident #12 was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment revealed the resident was independent with eating, hygiene, toileting, dressing and required supervision with showering and transferring. The MDS assessment indicated the resident was not up to date on the COVID-19 vaccination. B. Resident interviewResident #12 was interviewed on 1/28/26 at 9:15 a.m. Resident #12 said she would have taken the updated COVID-19 vaccine if it had been available when the flu vaccine was administered in the fall. Resident #12 said the facility offered and administered the COVID-19 vaccine to her on 1/27/26 (during the survey).C. Record reviewResident #12's name was highlighted on the 5/6/25 document provided by the IP as she wanted to receive the updated COVID-19 vaccination when it was available (see above).According to Resident #12's EMR, when the COVID-19 outbreak began at the facility on 1/13/26, the facility had not yet administered the updated COVID-19 vaccine (her previous COVID-19 vaccine was on 11/26/24). -Though Resident #12 said she received the vaccine on 1/27/26, the resident's EMR immunization record did not reflect the dose given on 1/27/26 (as of 1/29/26 at 7:50 p.m.)XVI. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on [DATE] . According to the January 2026 CPO, diagnoses included respiratory failure, paraplegia (loss of function in the lower half of the body) and septicemia (blood infection).The 1/14/26 MDS assessment identified Resident #1 was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment revealed the resident required set-up assistance for eating and was dependent upon staff for hygiene, toileting, showering, dressing and transferring. The MDS assessment indicated the resident was not up to date on the COVID-19 vaccination. B. Record reviewResident #1's EMR revealed his last COVID-19 vaccination occurred on 8/16/22. Resident #1's EMR did not reveal documentation of the facility providing education to Resident #1 about the updated COVID-19 vaccine in 2025.Resident #1's EMR revealed he tested positive for COVID-19 on 1/13/26. C. Staff interviewThe IP was interviewed on 1/27/26 at 9:01 a.m. The IP said Resident #1 was administered an antiviral medication (Paxlovid) after the onset of COVID-19. The IP said the nurse practitioner (NP) had evaluated residents to determine who was at higher risk for complications and recommended Resident #1 receive the antiviral medication.XVII. Resident #16A. Resident statusResident #16, age greater than 65, was admitted on [DATE]. According to the January 2026 CPO, diagnoses included heart disease, high blood pressure, cerebral palsy, depression and asthma.The 10/29/25 MDS assessment identified Resident #16 was cognitively intact with a BIMS score of 14 out of 15. The MDS assessment revealed the resident required supervision for eating and was dependent upon staff for hygiene, toileting, showering, dressing and transferring. The MDS assessment indicated the resident was not up to date on the COVID-19 vaccination. B. Record reviewResident #16's EMR revealed his last COVID-19 vaccination occurred on 6/14/22. Resident #16's EMR did not reveal documentation of the facility providing education to Resident #1 about the updated COVID-19 vaccine in 2025.Resident #16's EMR revealed she tested positive for COVID-19 on 1/14/26. C. Staff interviewThe IP was interviewed on 1/27/26 at 9:01 a.m. The IP said Resident #16 was administered an antiviral medication (Paxlovid) after the onset of COVID-19. The IP said the nurse practitioner (NP) had evaluated residents to determine who was at higher risk for complications and recommended Resident #16 receive the antiviral medication.XVIII. Resident #11A. Resident statusResident #11, age greater than 65, was admitted on [DATE]. According to the January 2026 CPO, diagnoses included heart failure, kidney disease, diabetes, anxiety and depression.The 12/31/25 MDS assessment identified Resident #11 was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment revealed the resident required set-up assistance for eating, supervision for hygiene, showering, dressing and transferring. The MDS assessment indicated the resident was not up to date on the COVID-19 vaccination. B. Record reviewResident #11's EMR revealed her last COVID-19 vaccination occurred on 10/20/22. Resident #11's EMR did not reveal documentation of the facility providing education to Resident #11 about the updated COVID-19 vaccine prior to the COVID-19 outbreak on 1/13/26 Resident #11's EMR revealed she tested positive for COVID-19 on 1/13/26.C. Staff interviewThe IP was interviewed on 1/27/26 at 9:01 a.m. The IP said Resident #11 was administered an antiviral medication (Paxlovid) after the onset of COVID-19. The IP said the NP had evaluated residents to determine who was at higher risk for complications and recommended Resident #11 receive the antiviral medication.XIX. Resident #4A. Resident statusResident #4, age greater than 65, was admitted on [DATE]. According to the January 2026 CPO, diagnoses included heart failure, high blood pressure, pneumonia and arthritis.The 11/26/25 MDS assessment identified Resident #4 had moderate cognitive impairment with a BIMS score of eight out of 15. The MDS assessment revealed the resident required set-up assistance for eating, and moderate assistance for hygiene, toileting, showering, dressing and transferring. The MDS assessment indicated the resident was not up to date on the COVID-19 vaccination. B. Record reviewResident #4's EMR revealed her last COVID-19 vaccination occurred on 12/16/21. Resident #4's EMR did not reveal documentation of the facility providing education to Resident #4 about the updated COVID-19 vaccine prior to the COVID-19 outbreak on 1/13/26.Resident #4's EMR revealed she tested positive for COVID-19 on 1/13/26.C. Staff interviewThe IP was interviewed on 1/27/26 at 9:01 a.m. The IP said Resident #4 was administered an antiviral medication (Paxlovid) after the onset of COVID-19. The IP said the NP had evaluated residents to determine who was at higher risk for complications and recommended Resident #4 receive the antiviral medication.XX. Resident #8A. Resident statusResident #8, age greater than 65, was admitted on [DATE]. According to the January 2026 CPO, diagnoses included pressure ulcer right buttocks, urinary retention, dysphagia (difficulty swallowing) and hypothyroidism.The 12/31/25 MDS assessment identified Resident #8 had moderate cognitive impairment with a BIMS score of nine out of 15. The MDS assessment revealed the resident required set-up assistance for eating and dressing, supervision for toileting, hygiene and transfers and moderate assistance for showering. The MDS assessment indicated the resident was not up to date on the COVID-19 vaccination. B. Record reviewResident #8's EMR did not reveal documentation of the facility providing education to Resident #8 about the updated COVID-19 vaccine prior to the COVID-19 outbreak on 1/13/26.Resident #8's hospital admission record was provided by the DON on 1/27/26 at 2:45 p.m. The hospital history of present illness, dated 1/13/26 at 10:36 a.m., revealed Resident #8 was transferred to the hospital due to altered mental status. The resident's temperature on admission to the hospital was 101.8 degrees Fahrenheit (F). The emergency department note plan revealed Resident #8's altered mental status was secondary to (a result of) acute pyelonephritis (upper urinary tract infection) and COVID-19 infection.C. Staff interviewThe DON was interviewed on 1/27/26 at 12:50 p.m. The DON said Resident #8 was diagnosed with COVID-19 at the hospital on 1/13/26. The DON said other residents tested positive for COVID-19 on the same date. The DON said Resident #8 had fallen, but did not initially want to go to the hospital. She said he later decided to go to the hospital and he was admitted to the hospital with a COVID-19 infection and UTI (urinary tract infection).XXI. Additional staff interviewsThe IP was interviewed on 1/27/26 at 9:00 a.m. The IP said updated COVID-19 vaccinations should have been addressed in October 2025. The IP said residents had not been educated about the COVID-19 vaccine since November 2024. The IP said she started a list of residents to see who might want the updated COVID-19 vaccine, and then she said she focused on providing the flu shot administrations. The IP said she spoke with the pharmacist who told her to let the pharmacist know when the IP had a resident list together for those residents who wanted updated COVID-19 vaccines. The IP said once the COVID-19 outbreak began on 1/13/26, she did not notify the medical director or the NP that no residents had received the updated vaccine.The IP said after the COVID-19 outbreak began, the NP evaluated residents' comorbidities and ordered antiviral medications for Resident #1 (who had a lot of symptoms of COVID-19), Resident #4, Resident #11 and Resident #16. The IP said she spoke with the NHA after the outbreak began about updated COVID-19 vaccines that were not offered and a performance improvement plan (PIP) was initiated around 1/20/26. The IP said there was no documentation that residents were educated and offered, or received the updated COVID-19 vaccine at any time in 2025.The NHA was interviewed on 1/27/26 at 9:45 a.m. The NHA said she was aware that some residents who wanted the updated COVID-19 vaccine had not received it, but was not made aware of the extent of residents who did not receive the vaccine. The NHA said she would expect the physician to be notified if there were residents who wanted the vaccine in the fall of 2025 and had not received them before the outbreak began on 1/13/26.The NP was interviewed on 1/27/26 at 10:05 a.m. The NP said when the facility notified her of the COVID-19 outbreak on 1/13/26, she was not informed that none of the residents had received updated COVID-19 vaccines. The NP said she was not certain if the updated vaccine was offered to residents. The NP said the facility had mentioned at a facility meeting that COVID-19 vaccines were going to be offered. The NP said typically COVID-19 vaccines were offered with the flu vaccine in the fall. The NP said it might have prevented worsening of symptoms if residents who wanted the updated COVID-19 vaccine had received them. The NP said residents who tested positive for COVID-19 and were immobile or at high risk for complications were treated with an antiviral medication.The medical director was interviewed on 1/27/26 at 12:10 p.m. The medical director said prior to the COVID-19 outbreak, he thought the facility had offered and was tracking vaccine administrations, including COVID-19 vaccinations. The medical director said the facility had contacted him when the outbreak began, however, the facility did not notify him th

Based on record review and interviews, the facility failed to ensure one (#3) of four residents reviewed for ancillary services out of 27 sample residents received 24-hour emergency dental care. Resident #3 was admitted on [DATE]. On 11/24/25 the resident lost a filling from her tooth. Resident #3 reported the issue to the nurse. The tooth became jagged from the missing filling. Resident #3 reported pain, difficulty eating and that a sore developed on her tongue. The facility failed to assist the resident with dental services for 34 days, resulting in the resident's continued pain. On 12/30/25, the resident saw the dentist and had immediate relief following the dentist smoothing the tooth. Specifically, the facility failed to ensure Resident #3 was provided timely dental services after reporting a missing filling. Findings include:I. Facility policy and procedureThe Dental Services policy, revised December 2016, was provided by the nursing home administrator (NHA) on 1/29/26 at 7:31 p.m. It read in pertinent part, Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Routine and 24-hour emergency dental services are provided to our residents through: referral to the resident's personal dentist; referral to community dentists or referral to other health care organizations that provide dental services. Social services representatives will assist residents with appointments, transportation arrangements and for reimbursement of dental services under the state plan, if eligible.II. Resident #3A. Resident statusResident #3, age [AGE], was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included urinary retention, recurrent urinary tract infection (UTI), and bilateral lower extremity edema (fluid buildup). The 1/10/26 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. She was independent with eating, required partial to moderate assistance with lower body dressing and supervision to touching assistance with upper body dressing. The MDS assessment indicated the resident had no dental issues. B. Resident interviewResident #3 was interviewed on 1/26/26 at 1:30 p.m. Resident #3 said she lost a tooth filling on Monday (11/24/25) and told the nurse the next day. She said the tooth had a jagged edge and started to cause pain on her tongue. Resident #3 said she had notified the nursing staff on several occasions and was told an appointment was going to be made by the social services director (SSD). She said she spoke to the SSD more than once to request a dental appointment. Resident #3 said after a month she was frustrated she had not been in to see the dentist and her tongue was hurting from the sore caused by the jagged edge of her tooth. Resident #3 said it was becoming more difficult to eat with the sore spot on her tongue. She said she filed a complaint hoping the complaint would be addressed. C. Record ReviewResident #3's progress notes revealed the following:A progress note, dated 11/26/25, documented the resident reported her missing filling to the medication nurse. Resident #3 complained it was rubbing on her tongue and making her tongue sore. The note documented the SSD would be updated. A social services progress note, dated 11/28/25, documented the SSD had left a message at a dentist's office for a missing filling and the tooth rubbing on her tongue bothering her.-However, there was no documentation in the resident's electronic medical record (EMR) addressing a follow-up call to the dentist. Resident #3 was admitted to the hospital on [DATE] and returned 12/15/25 for an unrelated medical issue. A progress note, dated 12/17/25, documented the SSD met with Resident #3 and a dentist appointment was requested related to the lost filling, 21 days after the resident first reported the missing filling to the nurse. A progress note, dated 12/25/25, documented Resident #3 had requested a dental appointment for the sore on her tongue to the nurse. The nurse documented a sore/lesion on the left lateral aspect of her tongue and documented Resident #3 said she reported the broken tooth over a month ago. The nurse left a note with the SSD and the director of nursing (DON). A progress note, dated 12/28/25, documented Resident #3 notified the nurse the tooth was cutting into her tongue and requested a dental appointment. The note documented a message was left for the SSD. A progress note, dated 12/29/25, documented the activity director (AD) made an appointment for Resident #3 at a local dentist due to the urgency of the missing filling and the sore on her tongue. -The appointment was scheduled for 12/30/25, 34 days after Resident #3 first reported the missing filling.A dental note, dated 12/30/25, documented Resident #3 was seen for a sore spot on her tongue due to a broken tooth. The tooth was smoothed and no longer sharp on her tongue. Resident #3 needed warm salt water rinses to help heal the sore spot on her tongue, which could take about two to three weeks.A progress note, dated 1/1/26, documented Resident #3 had immediate relief once the tooth's sharp edge was smoothed down. III. Staff interviewsThe AD was interviewed on 1/29/26 at 9:09 a.m. The AD said she assisted with transportation by getting the residents to their appointments and gathering the needed records for the appointment. She said she did not typically make the appointments as appointments went through the SSD's office. The AD said she made the dental appointment for Resident #3 because Resident #3 continued to complain about her sharp tooth and the sore on her tongue for over a month without any resolution. She said Resident #3 told the AD she had voiced this complaint to the nurses and to the SSD. The AD said she was able to get an emergency appointment the next day after calling. The SSD was interviewed on 1/29/26 at 10:00 a.m. The SSD said if residents needed medical appointments, the request was made through the SSD's office because she managed the transportation schedule. She said she received requests verbally or in writing from staff and/or the residents. The SSD said she made appointments based on the availability of the office and if the situation needed urgent attention. She said a missing filling and pain would be an urgent visit. The SSD said she was not aware Resident #3 was in pain from the missing filling until the end of December 2025 when the resident filed a complaint. -However, the 11/28/25 social services progress note, documented by the SSD, revealed the resident's tooth was rubbing on her tongue and bothering her (see record review above). The SSD said when she was notified of Resident #3's tooth needing a repair, she called and left a message with a dental office on 11/28/25 but did not follow up with a second call to schedule an appointment. The SSD said she called another dental office on 12/17/25, at the request of the resident, but the office was closed at the time of the call and she did not make a follow-up call to schedule the appointment. The SSD said there was no system in place to remind her of appointments but she should have followed up with the resident and made a dental appointment.-There was no progress note indicating the SSD made a call to a second dental office on 12/17/25 in Resident #3's EMR.

Based on record review and interviews, the facility failed to complete a performance review of every certified nurse aide (CNA) at least once every 12-months and provide regular in-service education based on the outcome of these reviews for five of five CNA.Specifically, the facility failed to complete annual performance reviews and provide regular in-service education which was based on the outcome of the reviews for CNA #1, CNA #3, CNA #4, CNA #5 and CNA #6. Findings include:I. Record reviewAnnual performance reviews were requested on 1/27/26 at 5:27 p.m. for CNA #1, CNA #3, CNA #4, CNA #5 and CNA #6.The facility was unable to provide annual performance evaluations for the five CNAs requested above (see interview below).The facility provided documentation on 1/28/26 at 2:43 p.m. that the CNAs above completed 12 hours annual in-service education. The facility did not base the education upon CNA annual evaluations as the annual evaluations had not been completed (see interviews below).II. Staff interviewsThe nursing home administrator (NHA) and the director of nursing (DON) were interviewed together on 1/28/26 at 10:54 a.m. The NHA said the facility had no records to provide for completion of CNA performance evaluations. The DON said a previous administrator instructed the DON to not complete annual CNA performance evaluations because the CNAs were not going to receive raises. The DON said annual CNA performance evaluations have not been done since she began working at the facility more than two years ago. The DON said CNA #1, CNA #3, CNA #4, CNA #5 and CNA #6 had worked at the facility for more than one year.The DON said annual performance evaluations should be completed for every CNA. The NHA said it was important to complete annual performance evaluations to understand the employees' competencies and provide appropriate training for deficits and to assist the employees with reaching performance goals.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for one of one unit. Specifically, the facility failed to:-Ensure correct transmission based precautions signage was posted on resident rooms;-Ensure staff wore appropriate personal protective equipment (PPE) while providing care to a resident requiring droplet precautions;-Follow infection control wound care guidelines for dressing changes;-Ensure housekeeping staff performed hand hygiene after glove removal and nursing staff used hand hygiene during medication administration; and,-Clean pulse oximetry equipment after contamination. Findings include:I. Facility policy and procedureThe Infection Control policy, revised October 2018, was provided by the nursing home administrator (NHA) on 1/29/26 at 12:12 p.m. It read in pertinent part, The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. The objectives of our infection control policies and procedures are to prevent, detect, investigate and control infections in the facility; maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors and the general public; establish guidelines for implementing isolation precautions, including standard and transmission based precautions; establish guidelines for the availability and accessibility of supplies and equipment necessary for standard and transmission based precautions; maintain records of incidents and corrective actions related to infections; and provide guidelines for safe cleaning and reprocessing of reusable resident care equipment.II. Failure to post correct transmission based precaution signageA. ObservationsOn 1/26/26 at 11:50 a.m. there was a contact isolation sign on the door of room [ROOM NUMBER].-The resident in room [ROOM NUMBER] required droplet precautions (see interview below).On 1/26/26 at 11:55 a.m. observed contact isolation sign on the door of room [ROOM NUMBER].-The resident in room [ROOM NUMBER] required enhanced barrier precautions (EBP) (see interview below)B. Staff interview and observationThe infection preventionist (IP) was interviewed on 1/26/26 at 4:30 p.m. The IP said the room [ROOM NUMBER] signage should be for droplet precautions. The IP said she would change the signage to the correct precautions.The IP said the room [ROOM NUMBER] signage should be for EBP. The IP said she would change the signage to the correct precautions.The IP interviewed again on 1/29/26 at 1:30 p.m. The IP said if the transmission based precautions signs were incorrect, staff might not wear the correct PPE and this could increase the risk of disease transmission.-At the time of interview, the facility had been in a COVID-19 outbreak since 1/13/26.III. Failed to ensure staff wore appropriate PPE while providing care to a resident in droplet precautionsA. Professional referenceAccording to the Centers for Disease Control (CDC), Coronavirus Disease Factsheet, Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or suspected COVID-19, (6/30/20), retrieved on 2/4/26 from https://www.cdc.gov/coronavirus/2019-ncov/downloads/A_FS_HCP_COVID19_PPE.pdf Identify and gather the proper PPE to don. Perform hand hygiene using hand sanitizer. Put on isolation gown. Tie all of the ties on the gown. Put on a NIOSH- approved N95 filtering facepiece respirator or higher (use a facemask if not available). If the respirator has a nosepiece, it should be fitted to the nose with both hands, not bent or tented. Do not pinch the nosepiece with one hand. Respirator/facemask should be extended under the chin. Both your mouth and nose should be protected. Put on face shield or goggles. Put on gloves. HCP (health care provider) may now enter patient room.B. Facility policy and procedureThe Personal Protective Equipment policy, revised October 2018, was provided by the NHA on 1/29/26 at 12:12 p.m. It read in pertinent part, Personal protective equipment provided to our personnel includes but is not necessarily limited to gowns/aprons/lab coats, gloves, masks and eye wear (goggles and/or face shields). Training on the proper donning, use and disposal of PPE is provided upon orientation and at regular intervals. Employees who fail to use PPE when indicated may be disciplined in accordance with personnel policies.C. ObservationsOn 1/26/26 at 12:33 p.m. an unidentified certified nurse aide (CNA) entered room [ROOM NUMBER]. The resident in room [ROOM NUMBER] required PPE for droplet precautions for COVID-19 (per IP interview above). The CNA entered the room wearing a gown, gloves and a surgical mask.-The CNA was not wearing an N-95 mask or a protective eye shield.On 1/26/26 at 12:36 p.m. an unidentified CNA entered room [ROOM NUMBER] wearing a gown, gloves and a surgical mask. -The CNA was not wearing an N-95 mask or a protective eye shield.D. Staff interviewThe IP was interviewed on 1/26/26 at 5:00 p.m. The IP said the facility had ample supply of N-95 masks and staff should be wearing these masks and face shields in the rooms of residents who required droplet precautions. The IP said when staff did not wear N-95 masks it could increase the risk of transmission of COVID-19.IV. Failed to follow wound care guidelines for dressing changesA. ObservationsOn 1/28/26 at 2:20 p.m. wound care was observed for Resident #4. Registered nurse (RN) #1 and the director of nursing (DON) entered Resident #4's room with wound care supplies for two dressing changes of wounds that were approximately two inches apart.-During the dressing change, RN #1 used the same gauze to pat dry both wounds.On 1/28/26 at 2:40 p.m. wound care was observed for Resident #23. When RN #1 prepared supplies for the dressing change. RN #1 used ungloved hands to pick up gauze and saturate the gauze with saline for the dressing change. -During the dressing change, RN #1 used the same gauze to clean the wound.B. Staff interview and observationThe DON was interviewed on 1/28/26 at 3:15 p.m. The DON said though Resident #4's wounds were in close proximity, the wounds should have been cleaned using a different gauze for each wound. The DON said RN #1 should have worn gloves when touching the gauze during preparation for Resident #23's dressing change.The IP was interviewed on 1/29/26 at 1:38 p.m. The IP said Resident #4's wounds should have been cleaned separately to ensure there would be no cross contamination of the wounds. The IP said RN #1 should have worn gloves to prepare the gauze for cleansing Resident #23's wound.V. Failed to ensure housekeeping and nursing staff used hand hygiene appropriatelyA. Observations and staff interviewsOn 1/28/26 at 9:49 a.m. housekeeper (HK) #1 was observed cleaning room [ROOM NUMBER]. HK #1 changed her gloves twice while cleaning the room and did not perform hand hygiene between glove changes.HK #1 was interviewed on 1/28/26 at 10:15 a.m. HK #1 said she forgot to use hand hygiene when changing her gloves.On 1/29/26 at 10:15 a.m. RN #1 was preparing an insulin medication at the medication cart for Resident #22. A transporter walked by the nurse with another resident who was in a wheelchair. The transporter handed RN #1 a packet of paperwork. RN #1 took the packet and set the papers aside. RN #1 then returned to preparing the insulin medication for administration.-RN #1 did not use hand hygiene between holding the paperwork and preparing the insulin medication.RN #1 was interviewed on 1/29/26 at 10:41 a.m. RN #1 said she should have used hand hygiene after touching the other resident's paperwork prior to her preparing Resident #23's insulin medication.B. Staff interviewsThe housekeeping supervisor was interviewed on 1/29/26 at 11:48 a.m. The housekeeping supervisor said HK #1 should have used hand hygiene between glove changes to prevent infection.The IP was interviewed on 1/29/26 at 1:38 p.m. The IP said she would have expected HK #1 to remove gloves and then use hand hygiene prior to replacing gloves. The IP said hand hygiene education is provided frequently to staff. The IP said RN #1 should have used hand hygiene after she touched the paperwork so as not to contaminate the medications she was preparing.VI. Failed to clean pulse oximetry equipmentA. ObservationOn 1/29/26 at 9:12 a.m. RN #1 was checking Resident #6's oxygen saturation level using the pulse oximetry equipment. RN #1 said she was having difficulty reading the level on the equipment. RN #1 removed the pulse oximeter probe from Resident #6's finger and placed it on RN #1's finger. RN #1 said it was working on her finger. RN #1 then removed the pulse oximeter probe from her finger and placed it back on Resident #6's finger.-RN #1 did not clean the pulse oximeter probe after it had been on her finger.B. Staff interviewRN #1 was interviewed on 1/29/26 at 10:40 a.m. RN #1 said she should have cleaned the pulse oximeter probe prior to replacing it on Resident #6's finger.The IP was interviewed on 1/29/26 at 1:38 p.m. The IP said the pulse oximetry probe should have been wiped with a disinfectant wipe after it had been on RN #1's finger to prevent infection.

Based on record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for two (#2 and #20) of five residents reviewed for unnecessary medications out of 27 sample residents. Specifically, the facility failed to:-Develop and implement a comprehensive care plan for Resident #2's pain medications and anxiety medications; and, -Develop and implement a comprehensive care plan for Resident #20's depression medications Resident #2 and Resident #20. Findings include:I. Facility policy and procedureThe Care Plan's Goal and Objectives policy, revised in April 2009, was provided by the social services director (SSD) on 1/29/26 at 6:30 p.m. It revealed in pertinent part, Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment. Goals and objectives are entered in the resident's care plan so that all disciplines have access to this information and can report whether the desired outcomes are being achieved. II. Resident #2A. Resident statusResident #2, age [AGE], was admitted on [DATE], According to the January 2026 computerized physician orders (CPO), diagnoses included depression, chronic pain syndrome, generalized anxiety disorder, type 2 diabetes mellitus, rheumatoid arthritis, history of long-term use of opiate analgesics, dementia and cellulitis (infection) of the right lower limb.The 12/23/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of 15. She was admitted to hospice in June 2025, required full assistance with bathing, dressing, personal hygiene, toilet use, and transfers using a Hoyer lift. B. Record review Review of the January 2026 CPO revealed the following physician's orders:Morphine sulfate 15 milligrams (mg). Give one tablet by mouth two times a day for pain, ordered on 8/20/25.Lorazepam .5 mg. Give one tablet by mouth three times a day related to anxiety, ordered on 12/10/25.Review of Resident #2's comprehensive care plan, revised on 11/14/25, did not reveal a care plan focus related to the resident's pain or anxiety. The care plan did not include side effects or behaviors to monitor related to the resident's anxiety. C. Staff interviewsRegistered nurse (RN) #1 was interviewed on 1/29/26 at 3:14 p.m. RN #1 said Resident #2's morphine was prescribed for pain and the lorazepam was for anxiety. RN #1 said medication side effects monitoring included respiratory rates and sedation levels. RN #1 said the care plans were updated by the infection preventionist (IP).The IP was interviewed on 1/29/26 at 6:41 p.m. She said she did not know Resident #2 did not have a care plan that addressed the resident's pain or anxiety. She said she would update the resident's comprehensive care plan. The IP said she was responsible for creating and updating care plans. The director of nursing (DON) was interviewed on 1/29/26 at 6:02 p.m. She said she did not know that Resident #2's comprehensive care plan did not address pain or anxiety. III. Resident #20A. Resident statusResident #20, age [AGE], was initially admitted on [DATE], and re-admitted on [DATE]. According to the January 2026 CPO, diagnoses included anxiety disorder, Parkinsonism, depression, systemic erythematosus lupus, low back pain, and sequelae of periprosthetic osteolysis of the internal prosthetic right knee joint. The 1/8/26 MDS assessment revealed the resident was cognitively intact, with a BIMS score of 14 out of 15. She required assistance with bathing, dressing, grooming, feeding and toileting.B. Record review Review of the January 2026 CPO revealed the following physician's order:Duloxetine 60 mg. Give one capsule daily for depression, ordered on 1/16/25.Review of the comprehensive care plan did not reveal a care plan focus related to the use of the duloxetine. C. Staff interviewsThe IP was interviewed on 1/29/26 at 6:42 p.m. She said she did not know why Resident #20's care plan did not address the use of duloxetine. The DON was interviewed on 1/29/26 at 6:03 p.m. She said she did not know there was not a care plan for Resident #20's duloxetine use.

Based on observations, record review and interviews, the facility failed to ensure one (#22) of one resident reviewed for insulin administration out of 27 sample residents was kept free from significant medication errors.Specifically the facility failed to ensure the insulin pen was primed prior to an insulin medication administration for Resident #22 Findings include:I. Professional referenceAccording to the manufacturer Sanofi-Aventis, Lantus Solostar (insulin glargine), May 2025, Instructions for Use, retrieved on 2/3/26 from https://products.sanofi.us/Lantus/Lantus.pdf. Always do a safety test before each injection to check your pen and the needle to make sure they are working properly and make sure that you get the correct Lantus dose. Select two units by turning the dose selector until the dose pointer is at the two mark. Press the injection button all the way in. When insulin comes out of the needle tip, your pen is working correctly.II. Facility policy and procedureThe Medication Errors policy (undated) was provided by the nursing home administrator (NHA) on 1/29/26 at 7:31 p.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 provider's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. A significant medication-related error is defined as: requiring medication discontinuation or dose modification, requiring hospitalization, or extending a hospitalization, resulting in disability, requiring treatment with a prescription medication, resulting in cognitive deterioration or impairment, life threatening and/or resulting in death. Medication errors are managed according to facility policy.III. Resident #22A. Resident statusResident #22, age [AGE], was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included respiratory failure, kidney disease, heart failure and diabetes.The 1/16/26 minimum data set (MDS) assessment identified Resident #22 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment revealed the resident required set-up assistance with eating, personal hygiene and toileting, moderate assistance for showering and supervision for transferring.B. Record reviewReview of Resident #22's January 2026 CPO revealed the following physician's order:Insulin Glargine subcutaneous solution 100 units per ml, inject 23 units subcutaneously two times per day, ordered 11/14/25.C. ObservationOn 1/29/26 at 10:10 a.m. registered nurse (RN) #1 was preparing an insulin medication for Resident #22, insulin glargine. RN #1 obtained the resident's insulin pen from the medication cart, cleaned the tip of the insulin glargine pen with an alcohol pad, applied a new needle and then dialed the insulin pen to 23 units. RN #1 entered Resident #22's room, advised the resident of the insulin medication, cleaned the resident's abdomen on the left side with an alcohol swab, removed the safety cap and administered the injected medication. -RN #1 failed to perform a safety test by priming the resident's insulin pen per manufacturer's directions (see professional reference above) prior to administering the medication.D. Staff interviewsRN #1 was interviewed on 1/29/26 at 10:40 a.m. RN #1 said she did not know that she should prime the insulin pen prior to administering the medication to the resident. RN #1 said she had worked at the facility for eight months, and had not learned that it was necessary to prime the insulin pen prior to dialing the dose to be administered. She said she did not know why priming the pen should be done.The director of nursing (DON) was interviewed on 1/29/26 at 10:49 a.m. The DON said it was important to prime the insulin pen prior to giving a dose of insulin to ensure the resident would receive the correct dose. The DON said if the pen was not primed prior to giving a dose of insulin, the dose could be incorrect, and it could affect the resident's blood sugar levels. The DON said she would review the education RN #1 had received for the process of administering insulin medications.

Based on observations, record review and interviews, the facility failed to ensure proper storage of medications for one of one medication storage room and one of one medication storage cart.Specifically, the facility failed to:-Date a resident's semaglutide pen with the date it was opened; -Discard medication that had expired; and,-Discard undated opened medication (tuberculin purified protein) from a medication refrigerator. Findings include:I. Professional referenceAccording to the manufacturer, Novo Nordisk, How to Store Your Ozempic pen, [DATE], retrieved on [DATE] from https://www/ozempic.com/how-to-take/ozempic-pen.html, After first use, store your pen in use for 56 days at room temperature between 59 degrees Fahrenheit (F) and 86 degrees F or in a refrigerator between 36 degrees F to 46 degrees F.According to the manufacturer, JHP Pharmaceuticals, Aplisol prescribing information, November, 2013, retrieved on [DATE] from https://www.fda.gov/files/vaccines%2C%20blood%20%26%20biologics/published/Package-Insert---Aplisol.pdf, Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency.II. Facility policy and procedureThe Storage of Medications policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 12:12 p.m. It read in pertinent part, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.III. Observations and interviewsOn [DATE] at 3:15 p.m. the medication cart was observed with licensed practical nurse (LPN) #1 and the director of nursing (DON). The following medications were found:-A used Ozempic (semaglutide) injectable pen for Resident #11, which was not labeled with the date it was opened. -An unopened Glutose 15 gel tube (a medication used to treat low blood sugar) with an expiration date of [DATE].LPN #1 said the Ozempic medication should be labeled with the date it was opened. LPN #1 said the Glutose gel should be discarded and she removed the medication from the medication cart.The DON said she checked with the pharmacist and the Ozempic pen had been delivered on [DATE]. The DON said the pharmacist advised the DON to label the pen as opened on [DATE] to ensure it would not be stored opened longer than 56 days.The DON said the Glutose 15 medication should have been discarded upon expiration and might not be as effective if used after the expiration date. On [DATE] at 3:35 p.m. the medication storage room was observed with the DON. The following medication was found:-A used vial of tuberculin purified protein derivative (Aplisol) 5 TU/.1 milliliters (ml). The vial was not labeled with the date it was opened.The DON said the medication should be labeled with the date it was opened and should be discarded 28 days after opening. The DON said the tuberculin purified protein might not be as effective if used after the recommended discard date.

Based on record review and staff interviews the facility failed to provide services for six (#2, #3, #6, #12, #15 and #17) out of nine sample residents according to professional standards of practice. Specifically, the facility failed to clarify physician's orders with dose information for the administration of topical skin medications for Residents #2, #3, #6, #12, #15 and #17. Findings include: I. Professional reference A. The Diclofenac gel drug information was accessed on 9/26/23 on the Physicians Drug Reference website at https://www.pdr.net/drug-summary/Voltaren-XR-diclofenac-sodium-2033. Diclofenac is a nonsteroidal anti-inflammatory (NSAID) medication that could be prescribed in intravenous, oral, topical, and ophthalmic formulations. The use of analgesic and antipyretic properties increases the risk of serious gastrio-intestinal events and may increase serious cardiovascular events; use the lowest dose of the shortest time. The topical dosage of diclofenac gel is prescribed as four grams (four and one half inches) topically four times a daily, with a maximum of 16 grams a day per lower extremity joint) and/or two grams (two and one fourth inches) topically four times daily per upper extremity joint. Do not exceed a total dose of 32 grams over all affected joints. B. The Icy Hot drug information was accessed on 9/26/23 on the Federal Drug Administration (FDA) website at https://fda.report/DailyMed/40c8c02f-fa5f-4e80-81a0-48271fa6f94b. Icy hot is used for temporary relief of aches and pain and is used only on the skin. Icy hot should be used as directed on the label or as prescribed by the physician. The active ingredient in icy hot is menthol and if over used, could lead to burning pain, swelling, and blistering of the skin where it was applied. The topical medication should not be applied more than four times daily. C.The Salonpas Lidocaine Plus cream drug information was accessed on 9/26/23 on the FDA website at https://fda.report/DailyMed/364924d3-fac3-4f4e-9b40-decd4ec48245. The cream contains lidocaine four percent and was used on the skin for temporary pain relief. Lidocaine cream should be used as directed on the label. If too much lidocaine was absorbed, symptoms of dizziness and agitation may occur and toxicity may lead to cardiovascular or respiratory failure. II. Facility policy The Medication Administration policy, dated April 2007, was received by the nursing home administrator on 9/27/23. The policy stated in pertinent part: Documentation must include, as a minimum: a. Name and strength of the drug; b. Dosage; c. Method of administration; d. Date and time of administration; e. Reason why medication was withheld or refused; f. Signature and title of the person administering the medication; g. Resident response to the medication. III. Record review Resident #15 had a physician order for muscle rub cream 10-15%. The order directed the medication to be applied every six hours and failed to include a dose. Resident #6 had a physician order for Voltaren gel one percent. The order directed the medication to be applied every six hours and failed to include a dose. Resident #3 had a physician order for muscle rub cream 10-15%. The order directed the medication to be applied every six hours and failed to include a dose. Resident #17 had a physician order for Icy Hot cream. The order directed the medication to be applied every six hours and failed to include a dose. Resident #12 had a physician order for muscle rub cream. The order directed the medication to be applied every six hours and failed to include a dose. Resident #2 had a physician order for Salonpas Lidocaine Plus cream four-10%. The order directed the medication to be applied every six hours and failed to include a dose. IV. Interviews Registered nurse (RN) #1 was interviewed on 9/27/23 at 3:49 p.m. She said that she was unaware diclofenac gel required a measured dose. She said she used a dime-sized amount of muscle rub and Lidocaine cream. She said if an order for medication was missing the dosage, the nurse should contact the physician for the correct dosage. The director of nursing (DON) was interviewed on 9/27/23 at 4:10 p.m. She said she was unaware the physician orders for Voltaren, Lidocaine and muscle rub did not include the dosage information. The DON said medication orders should contain dosage information and the nurse should contact the physician if the dosage information was not available.

Based on observations, record review and interviews, the facility failed to ensure comprehensive person-centered care plans were developed in accordance with professional standards of practice for three (#13, #15 and #19) of twelve reviewed out of 24 sample residents. Specifically, the facility failed to ensure a comprehensive care plan was initiated for: -Resident #15 for depression; -Resident #19 for urinary catheter care; and, -Resident #13 for hospice care and services. Findings include: I. Facility policy The Care Plan, Comprehensive Person-Centered policy, March 2022, was received from the nursing home administrator (NHA) on 3/ 27/23 at 4:59 p.m. The policy documented in pertinent part: A comprehensive, person-centered care plan that includes measurable objectives and timelines ato meet the resident's physical, psychological and functional needs is developed and implemented for each resident; The interdisciplinary team (IDT), in conjunction with the resident develops and implements a comprehensive, person-centered care plan for each resident; The comprehensive, person-centered care plan is developed within seven days; The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; The comprehensive care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychological well-being and reflects the standards of practice for problem areas and conditions. II. Resident #15 A.Resident status Resident #15, over the age of 65, was admitted on [DATE]. According to the September 2023 computerized physicians orders (CPO), diagnoses included major depressive disorder and a history of falling. The 7/14/23 minimum data set (MDS) assessment document the resident had no cognitive impairment as evidenced by a brief interview for mental status (BIMS) with a score of 15 out of 15. She required extensive, two-person assistance for bed mobility, transfers, toileting and locomotion on and off the unit. The resident was administered antidepressant medication when admitted to the facility. B. Record review The record review revealed the resident was prescribed and administered the antidepressant medication, fluoxetine, 20 milligrams (mg) one time a day on 4/21/23. The comprehensive care plan, initiated on 4/24/23 was reviewed and the care plan failed to identify individual needs that included a focus, goal and interventions for the care of the resident's depression. III. Resident #19 A. Resident status Resident #19, over the age of 65, was admitted on [DATE]. According to the September 2023 CPO, diagnoses included multiple sclerosis, diabetes, bone cancer, above the knee amputation, colostomy, urostomy (urinary catheter) and low back pain. The 6/16/23 minimum data set (MDS) assessment documented the resident had no cognitive impairment as evidenced by a brief interview for mental status (BIMS) with a score of 15 out of 15. She required supervision from staff for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toileting and personal hygiene. The resident had a urinary catheter at the time of her admission. B. Record review The comprehensive care plan, initiated on 3/26/23 was reviewed and the care plan failed to identify individual needs that included a focus, goal and interventions for the care of the Resident's urinary catheter including her supra pubic urinary catheter. IV Staff interviews Certified nurse aide (CNA) #1 was interviewed on 9/27/23 at 2:55 p.m She said she was aware Resident #19 had an urinary catheter.and the resident cared for her catheter. The CNA said she did not know about care she should provide such as monitoring for resident's urine amount or signs or symptoms of a urinary tract infection. She said she would notify the nurse if the resident had concerns about her urinary catheter. The CNA was interviewed regarding Resident #15. She said she was unaware the resident had depression and was unaware if the resident had individual needs regarding depression. The CNA said if she noticed changes in the resident's mood she would notify the nurse. Registered nurse (RN) #1 was interviewed on 3/27/23 at 3:49 p.m. She said and she said she was unaware of specific monitoring or care staff provided for Resident #19's urinary catheter. Resident #19 should be monitored for any signs or symptoms of infection, urinary tract infection, dehydration and whether the catheter was draining urine as expected. RN #1 was interviewed regarding Resident #15. She said she was aware the resident received antidepressant medication. The RN said she was unaware if the resident had specific needs for her depression and what triggered the depression for the resident. The director of nursing (DON) was interviewed on 9/27/23 at 4:10 p.m. She said resident care plans reflected individual care required by each resident. The DON said resident status was monitored by staff and care plans should be prepared and updated when required. The DON said the care plan was important because it was used by facility staff to ensure care was provided correctly to meet the needs of each resident. The DON said for a urinary catheter the staff should monitor skin integrity, hydration status, patency and positioning of the urinary catheter, catheter comfort and ability to provide self-care. The DON said when a resident has depression the care plan should include information specific to the resident that identified causes of depression, triggers to avoid or manage and mood management. 40960 V. Resident #13 A. Resident status Resident #13, age above 65, was admitted on [DATE]. According to the September 2023 computerized physician orders (CPO), the diagnoses included rhabdomyolysis (breakdown of muscle tissue), dementia, anxiety disorder, Parkinson's disease and essential tremors (shaking). The 6/28/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of four out of 15. He had disorganized thinking. He required extensive assistance with bed mobility, transfers, walking in room and corridor, locomotion on and off the unit, dressing, toilet use and personal hygiene. He required supervision with eating. He received a mechanically altered diet as well as a therapeutic diet. He had broken or loose fitting dentures. He had mouth or facial pain, discomfort or difficulty with chewing. B. Record review A physician's order dated 7/20/23 at 3:45 p.m., revealed the resident was admitted to hospice. The resident's plan of care was reviewed on 9/25/23 at 9:59 a.m. it did not reveal a care plan that addressed his hospice needs. C. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 9/27/23 at 3:13 p.m. She said the facility staff did all the activities of daily living (ADL) for the hospice resident. She said the hospice staff gave the shower and did pain management. She said there was not a care plan to follow. However, she communicated with the hospice staff verbally. She said hospice staff had a sign in sheet that they signed when visiting a resident. Registered nurse (RN) #1 was interviewed on 9/27/23 at 3:15 p.m. She said she communicated directly with the hospice staff during their visits. She said he did not have a hospice care plan in place. She said she was not sure if a care plan was required. The director of nursing (DON) was interviewed on 9/27/23 at 3:47 p.m. She said there was a hospice communication binder at the nurses station. She said the staff communicated with hospice in person and/or via the phone. She said all residents on hospice must have a care plan. She said it was important to have a hospice care plan in place to identify care needed, the residents goals and measure the outcome of the interventions. She said she would immediately audit residents on hospice services and assure they had a care plan in place.

Based on observations, record review and interviews, the facility failed to promote self-determination for five (#1, #2, #8, #11 and #13) of six residents reviewed for preferences and choices of 14 sample residents. Specifically, the facility failed to assess the resident daily preferences for care routine; identify interventions to meet the daily routine/care provision preferences of each resident; communicate the resident preference to staff through a plan of care as applicable (for example the baseline care plan, comprehensive care plan and/or the resident Kardex); and implement care based on resident self-determined preferences. Identified resident preferences included: -Being able to get up and go to bed when requested (Resident #1); -Being able to receive staff assistance in the resident's room without being having to get up and go to the dining room for a meal when requested (Resident #2); -Being in control of daily decisions and not feeling like staff were controlling their daily routine (Resident #8 and Resident #11); and, -Being asked about daily routine and being able to have a plan for staff to follow particularly for bathing needs (Resident #13). Findings include: I. Facility policy The Resident Rights policy, revised February 2021 was provided by the nursing home administrator (NHA) on 8/17/22 at 12:20 p.m. It read in pertinent part: Policy statement: 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: -A dignified existence; -Be treated with respect, kindness, and dignity; -Self-determination; -Be supported by the facility in exercising his or her rights; -Exercise his or her rights without interference, coercion, discrimination or reprisal from the facility; -Be informed about his or her rights and responsibilities; -Voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal; -Have the facility respond to his or her grievances. II. Resident #1 A. Resident status Resident #1, age 87, was admitted on [DATE]. According to the August 2022 computerized physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 5/28/22 minimum data set (MDS) assessment, the resident had intact cognition with a brief interview for mental status (BIMS) score of 15 out of 15; no mood or behavioral symptoms were documented. The resident needed extensive assistance mobility, transfers, toileting and limited and guided assistance with dressing, personal grooming and bed mobility; the resident did not walk. The assessment documented it was important to the resident to choose what clothes to wear, choose the type of bath received and choose a bedtime. B. Resident interview Resident #1 was interviewed on 8/16/22 at 5:02 p.m. Resident #1 said things were going better with most staff but some staff did not provide care the way she asked them. Resident #1 had talked with the social worker and NHA in the past when she had concerns but said some staff did not change. Resident #1 was not willing to name specific staff she had problems with but said she had a routine that she wanted all of the staff to follow. Resident #1 said she preferred to get up early to watch television most mornings and nap later in the day. Resident #1 was interviewed on 8/17/22 at 12:43 p.m. Resident #1 said there was one particular certified nurse aide (CNA) who when she was having a bad day that CNA did not always honor specific requests for the way the resident wanted care performed. Sometimes when the resident was not ready to receive care or get up out of bed, the CNA told her she had to get up and started providing care regardless of the resident's request. C. Record review The comprehensive care plan partially revised on 6/27/22, documented a care focus for resident activity and social preferences with interventions that included assess per protocol for participation and preferences and provide an ongoing activity program that meets needs and interests. The care plan also included a care focus that documented the resident had a potential for impaired sleeping patterns. Interventions included encouraging the residents to participate in activities of choice and encouraging the resident to stay up during the day to enable sleep at night. -The care plan did not document the resident preferences for getting up in the early hours of the morning to watch television and nap in the afternoon. III. Resident #2 A. Resident status Resident #2, age 65, was admitted on [DATE]. According to the August 2022 CPO diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 5/13/22 MDS assessment, the resident had intact cognitive ability with a BIMS score of 15 out of 15; no mood or behavioral symptoms were documented. The resident had functional limitations in range of motion on the right and left side in both the upper (shoulders, elbows, wrists, and hands) and lower (hips, knees, ankles, and feet) extremities. Was wheelchair dependent and unable to stand or walk. Additionally,the resident was totally dependent, where staff provided all the effort to complete activities of daily living (ADL) tasks. This included the resident needing assistance from two staff with mobility throughout the community, transfers, toileting, dressing, personal grooming, bed mobility and eating; the resident did not walk. Resident preferences were not reviewed during this MDS assessment. B. Resident interview Resident #2 was interviewed on 8/15/22 at 5:22 p.m. Resident #2 said a few staff were bossy and did not listen when he made a request to remain in bed for the dinner meal. Resident #2's preference was to have staff bring the meal and provide feeding assistance there instead of being made to get up and have to eat the dinner meal in the dining room. While most staff honored this request there were two staff who were bossy and did not listen to resident preferences. This did not make the resident happy with the way care was being provided. Resident #2 said those staff who did not listen always seemed in a hurry and did not take the time to listen. They just started to provide the care they wanted to provide. C. Record review The comprehensive care plan revised in part 6/28/22 documented a care focus for behavioral health needs. Interventions included Allow (resident name) to make decisions about treatment regime, to provide sense of control. IV. Resident #8 A. Resident status Resident #8, under the age of 65, was admitted on [DATE]. According to the August 2022 CPO diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 6/24/22 MDS assessment, the resident had severely impairment cognition with a BIMS score of seven out of 15 and unclear speech. However, the resident was usually able to express ideas with verbal and no verbal forms of communication when prompted and given time to communicate; and the resident was able to understand and comprehend verbal content. The resident was assessed to have mild depression with a score of six out 27 on the Patient Health Questionnaire (PHQ-9) for depression; and no behavioral symptoms were noted. The resident was wheelchair dependent and unable to stand and balance without assistance and not able to walk. The resident was totally dependent on staff with bed mobility and needed extensive assistance from two staff to transfer; move throughout the community; and complete other activities of daily living (ADL) tasks such as toileting, dressing, personal grooming, and eating. The resident said it was very important to do favorite activities. B. Resident interview Resident #8 was interviewed on 8/17/22 at 12:52 p.m. Resident #8 said some staff did not listen to what she wanted to do and instead told her what she was going to do. Resident #8 said she did not like it when staff told her what to do. Sometimes it made her feel angry. Resident #8 wanted to be her own boss and make decisions on when to get up and go to bed and what activities she would participate in. C. Record review The resident's comprehensive care plan revised 6/27/22 read in pertinent part: My name is (resident name) but I prefer to be called (name). I am (age) years old. I like to watch TV in the common areas and in my room. I also like to look out the window and watch the visitors and delivery people visit. I enjoy getting my nails, hair and make-up done. I also enjoy exercise, music and games as I choose. I enjoy sitting outside when the weather is nice with staff assistance. -Interventions included: Encourage the resident to attend activities of choice and honor resident's right to refuse. V. Resident #13 A. Resident status Resident #13, age 78, was admitted on [DATE]. According to the August 2022 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's MDS assessment was not completed due to the resident just having been admitted to the facility. The resident's medical record documented the resident was alert and oriented and able to make needs known. The resident's needed limited assistance with some parts of completing ADLs; however the resident had no limitations in range of motion. Once standing the resident was able to walk with a walker and self-toilet without staff assistance The initial nursing assessment dated [DATE] documented the resident said it was very important to choose what clothing to wear, what type of bathing she received and her bed time. B. Resident interview Resident #13 was interviewed on 8/17/22 at 7:50 a.m. Resident #13 said she had been in the facility for several days (four days) and no staff had discussed a daily routine or asked when she would like to get out of bed, attend meals or take a shower. Resident #13 said she would like to be able to take a shower soon, as she had not yet received one. Resident #13 said staff entered in the morning and told her when it was time to get up and when it was time to eat meals and at the end of the day a staff told her it was time to get ready for bed. Resident #13 thought that was the way things worked in the facility. C. Record review Resident #13 medical record was reviewed on 8/17/22; the care plan had not yet been updated with resident preferences for daily routine. The resident task kardex revealed the resident was scheduled to have a shower on Tuesdays and Satrudays. The resident admitted on a Saturday (8/13/22) and did not get the Saturday (8/13/22) or Tuesday (8/16/22) shower. VI. Resident #11 A. Resident status Resident #11, age 67, was admitted on [DATE]. According to the August 2022 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 6/29/22 MDS assessment, the resident had intact cognitive impairment with a BIMS score of 13 out of 15. No mood or behavioral symptoms were noted. The resident needed supervision oversight and or cuing assistance from staff to complete most activities of daily living; and limited assistance with dressing and grooming activities. The resident was able to transfer and walk without staff assistance and had no limitations in range of motion. The resident preferences for routine and activity were not reviewed during this assessment. B. Resident interview Resident #11 was interviewed on 8/17/22 at 12:48 p.m. Resident #11 was reluctant to speak about the way staff treated him, but said in general staff treated him well. Resident #11 said some staff were bossy. Resident #11 explained that some staff did not take the time to find out what he wanted and were in such a hurry that he had to take the assistance when staff were ready. Resident #11 said it bothered him when staff were in a rush and did not listen to what he wanted. C. Record review The resident's comprehensive care plan revised 6/27/22 read in pertinent part: My name is (resident name) . I enjoy . I like things done a certain way, and changes may bother me. Letting me know beforehand of any changes will definitely help my emotions about it. -Interventions included, in part: Explain the situation and options to the resident; do not approach the resident in an authoritative manner; and respect the resident's wishes. VII. Staff Interviews Registered nurse (RN) #1 was interviewed on 8/17/22 at 5:35 a.m. RN #1 said the nursing staff was expected to honor resident choices. If the resident wanted to get up early, lay down, or had any other request for care assistance, staff were expected to assist the resident with requests in daily care even if it were a deviation to the resident care plan routine for care. RN #1 said Resident #1 liked to get up at various times in the early hours in the morning to watch a favorite television show and lay down after the lunch meal. RN #1 said residents had the right to make changes in care routine and facility staff were expected to honor those requests. Certified nurse aide (CNA) #1 was interviewed on 8/17/22 at 5:42 a.m. CNA #1 said it was the expectation for staff to let the resident make decisions about daily routine like what time they wanted to get up, take a shower, eat meals as well as other decisions about what to wear and assist the resident with those choices. CNA #2 was interviewed on 8/17/22 at 6:29 a.m. CNA #2 said if a resident refused care she would talk to them about how the care would benefit them if the resident continued to refuse care assistance she would try to find out why and what they would like to do instead. Staff could ask the resident when they wanted care or reproach and offer care assistance at a later time. CNA #3 was interviewed on 8/17/22 at 8:15 a.m. CNA #3 said several staff approached residents by telling the residents it was time to get up, time to go to bed, time for dinner and did not allow the resident a determined time or care or honor the resident's right to refuse care assistance. Several residents have voiced complaints to CNA #3. CNA #3 said the residents did not want to get staff in trouble and if they refused care they would not get the care later because staff would be too busy or unwilling to return at a later time. CNA #3 said the residents did not seem to know their rights to ask for a different care routine. RN #2 was interviewed on 8/17/22 at 9:30 a.m. RN #2 was not aware of any resident complaints about staff providing them care when they did not want care and or complaints of residents not receiving services as requested. RN #2 said if a resident had a complaint they would be referred to the social services director (SSD). RN #2 was not aware of a formal grievance process but the facility had just placed a new complaint box in the dining room. RN #2 said if a resident voiced a complaint during the shift the nurse on duty should address the complaint to resolution with the resident. The concern and resolution should be documented in resident notes. The NHA was interviewed on 8/17/22 at 10:23 a.m. The NHA was aware that residents had concerns with the way CNAs were approaching care assistance. In order to address resident concerns the NHA said she made rounds with the nursing staff to observe approaches and provided coaching and education to the staff, as needed. Some staff were more direct in approach and would enter a resident room and say to a resident something to the effect, it's time for breakfast, let's get up rather than saying good morning they are cooking breakfast are you ready to get up? The NHA said the facility removed several nursing staff who did not have the residents best interests and felt the current nursing team consisted of caring and kind staff. After discussing the residents' concerns brought forward during the investigation (see above), the NHA said she would take this information to human resources to determine the best way to handle resident complaints about the way in which staff were not consistently honoring their daily preferences. The NHA planned to talk to residents about their rights for self-determination, during the next resident council meeting, and would address all resident concerns individually. CNA #4 was interviewed on 8/17/22 at 11:18 a.m. CNA #4 said there were a few CNAs who did not honor a resident's right to refuse care and residents were often told they had to get up in the morning whether they wanted to or not. Some of the residents did not realize they had the right to request other care arrangements. CNA #4 said several residents had requested certain CNAs not work with them but staffing was limited and they gave in to receive needed care. The residents did not want to get CNAs in trouble or fired. The social services director (SSD) was interviewed on 8/17/22 at 1:22 p.m. The SSD said residents had the right to determine daily preferences and change their minds about daily routine. The SSD was new to the position and was just getting to know all the residents. Moving forward the SSD planned to meet with residents and discuss preferences in daily routine and see if they had concerns with care.

Based on record review and interviews, the facility failed to ensure certified nurse aides (CNA) were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Specifically, the facility failed to ensure CNA staff had completed competencies prior to providing cares for four out of four CNAs reviewed for competencies. Findings include: I. Record review The nursing home administrator (NHA) provided requested employee records on 6/29/22 at 8:05 a.m. Review of the employee files revealed the four certified nurse aides (#1, #2, #3 and #4) did not have any competencies completed. CNA #1, #2, #3 and #4 were identified as working on the current schedule provided by the facility. II. Interview CNA #1 was interviewed on 6/28/22 at 9:26 a.m. She said she was not sure when she had her competencies reviewed. CNA #2 was interviewed on 6/28/22 at 9:28 a.m. She said she did not remember having her skills checked off by anyone recently. The NHA was interviewed on 6/29/22 at 11:40 a.m. She said she was not aware the CNA competencies had not been done. She said they were important to ensure the staff had the correct competencies to provide cares identified through resident assessments, and described in the plan of care.

Based on record review and interview, the facility failed to ensure a resident who displays or was diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being; most pertinent to one (#2) of two residents reviewed for dementia care out of 15 sample residents. Specifically the facility's failure to: -Provide Resident #2 with sufficient supervision/monitoring and interventions as care planned, to prevent the resident from getting into physical resident-to-resident altercations, where a non-aggressive dependent resident was hit in the head (Cross-reference F600 for abuse); and, -Identify and address Resident #2's escalating behavior following a blood glucose finger stick and insulin injection (Cross-reference F600); and, -Ensure staff had the knowledge of the resident's care plan to act effectively when responding to Resident #2's escalating behavioral expressions. Findings include: I. Facility policy and procedures The Dementia Clinical Protocol, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 11:30 a.m. The protocol read in part: The IDT (interdisciplinary team) will evaluate individuals with new or progressive cognitive impairment and help identify symptoms and findings that differentiate dementia from other causes. -Individuals with dementia can also have a personality disorder, mental illness, [CONDITION(S)], [CONDITION(S)], depression, adverse drug reactions (ADRs), or other conditions causing or contributing to impaired cognition and problematic behavior. -For the individual with confirmed dementia, the IDT will identify a resident-centered care plan to maximize remaining function and quality of life. -The physician will order appropriate interventions to address significant behavioral and psychiatric symptoms, based on pertinent clinical guidelines and consistent with regulatory requirements. -The IDT will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, and other relevant factors. The Behavioral Assessment, Intervention and Monitoring policy, revised [DATE], was provided by the NHA on [DATE] at 11:30 a.m. The policy read in pertinent part: The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. - The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. II. Resident #2 A. Resident status Resident #2, age 87, was admitted on [DATE]. According to the [DATE] computerized physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] minimum data set (MDS) assessment revealed the resident had severely impaired cognition and was unable to participate in the brief interview for mental status (BIMS) exam. Staff assessment of the resident's cognition revealed the resident had short and long-term memory deficits. The resident was unable to recall the current season, location of her room or the names and names and faces of staff. The resident presented with fluctuating signs of [CONDITION(S)]; disorganized thinking; altered levels of consciousness; hallucinations and delusions. The resident presented (almost daily) with physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing); and, verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others). The resident did not walk but used a manual wheelchair to get around the unit with limited assistance; and needed extensive assistance from staff to complete activities of daily living and rejected care assistance at times. According to the MDS assessment the resident was not on any antipsychotic medication at the time of the assessment despite the CPO documenting an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . B. Resident interview and observation Resident #2 was interviewed on [DATE] at 2:45 p.m. Resident #2 was not able to answer questions, but instead she scolded and said I don ' t care if you get yours done! and then she continued self-propelling herself down the hall At the time of the interview, Resident #2 was not supervised by staff and was wandering the hall in her manual wheelchair and holding onto her stuffed cat. Resident #2 seemed irritated by something but it was not apparent what was bothering her. At 3:03 p.m. Resident #2 was heard yelling at another resident in the hall. No staff were in the direct vanity of where Resident #2 was yelling at the other resident. After a few minutes, a certified nurse aide (CNA) responded to the common area and there was no physical exchange between the two residents. Resident #2 was not responsive to staff redirection and started yelling at the staff to leave her alone. Resident #2 was separated from the area and left to wander the hall. At 3:45 p.m. Resident #2 was observed heading to a back hallway were she was out of sight of staff a CNA followed and tried to get Resident #2 to go to the sunroom. The more staff tried to remove Resident #2 form the back hall the more Resident #2 yelled at the CNA to leave her alone. The CNA gave in and left the resident in the back hall. Resident #2 self-propelled out of the back hall after approximately five additional minutes (the back hall had a bathroom and a locked door to the basement). On [DATE] at 11:30 a.m., Resident #2 was observed in the dining room and a male CNA was assisting her to eat lunch. Resident #2 had a big smile and was talking and laughing with the male CNA. After lunch, at approximately 12:15 p.m. the male CNA assisted Resident with her toileting needs then brought her to the sunroom and told Resident #2 he had to leave but would be back later in the day. Soon after the male CNA left the facility, Resident #2 started to wander in the hall. From 2:16 p.m. to 3:00 p.m., Resident #2 was observed in the common area sunroom. Resident #2 became increasingly more agitated staff tried several diversionary tactics without success until a staff finally approached and took Resident #2 outside into the courtyard. -At 2:30 p.m., Resident #2 was in the common area sunroom clutching a baby doll and the cat. Yelling out daddy. -At 2:33 p.m., a CNA took Resident #2 for a stroll up and down the halls, Resident #2 continued to call out for daddy the whole time. -At 2:34 p.m., Resident #2 stopped the CNA and yelled out loudly I want my daddy! and No -At 2:36 p.m., the CNA was trying to talk to Resident #2 while touching the resident's doll and Resident #2 yelled out very loudly my baby! No and Go away. -Several staff rapidly attempted to interact with Resident #2 to address her needs but there is no consistent approach while responding to Resident #2. -At 2:37 p.m., Resident #2 was yelling out loudly Help! My baby Help! Staff were talking amongst themselves asking each other if Resident #2 was looking for something. Then Resident #2 yelled out leave her alone! -At 2:40 p.m., Resident #2 was yelling out Help and propelling herself out of the hallway towards the sunroom door, while still gripping the baby doll and cat looking out for daddy and trying to open the door. Staff reassured Resident #2 he would return (referring to the male CNA who was working with her earlier in the shift). The resident yelling out for daddy continued for several minutes. -At 2:50 p.m., another CNA approached and asked Resident #2 if she wanted to go outside. Resident #2 said yes, and the CNA took Resident #2 outside into the courtyard, where Resident #2 calmed down. C. Staff interviews CNA #5 was interviewed on [DATE] at 9:55 a.m. CNA #5 said Resident #2 had fluctuating moods and staff had to keep an eye on her for agitation and aggressive behaviors. When resident became agitated staff could sometime calm Resident #2 by spending time with her, offering her a snack or coloring with her. Sometimes just activating the cat so it would purr and meow would be calming. That worked yesterday. Sometimes nothing would calm Resident #2 and staff need to keep an eye on her from a distance. CNA #5 said when Resident #2 was upset she could become combative towards others and would also yell at others as she passed them in the hall or common areas. CNA #5 said the facility had provided recent staff training on dementia management, addressing resident behaviors and redirection/diversionary techniques in response to resident behaviors when providing care. CNA #5 felt confident with what she had learned during the training. CNA #3 was interviewed on [DATE] at 9:59 a.m. CNA #3 said Resident #2 had behavior almost daily and responded well to a few staff when she was upset. Resident #2 was frequently combative when upset and had to be monitored around other residents as a precaution, that was why the facility had placed Velcro stop signs on the outside of some residents doors so Resident #2 did not enter the room of another resident when unsupervised. CNA #2 said the Velcro stop signs were very effective to prevent Resident #2 for entering rooms of other residents. Activities/social services director (ASD) and activity assistant (AA) #1 were interviewed on [DATE] at 10:15 p.m. AA #1 said staff take turns spending time with Resident #2 especially when she was upset or wandering without purpose. Resident #2 preferred the company of one particular male CNA and thought he was her husband. She would get upset when his shift was over or he had to leave her to do something else. The ASD said Resident #2 enjoyed socializing with staff and would want staff individualized attention. Afternoons were difficult for the resident, but the resident could present with negative behaviors any time of day. The ASD and other staff would let Resident #2 spend time in their office when Resident #2 was having a particularly hard time calming down. The resident's family was also instrumental in helping the facility manage Resident #2's behaviors. Family would talk to the resident on the phone/facetime and stop in for visits. The resident's family provided two life like cats for the resident; Resident #2 had cats when she lived in her own home and found the company of cats calming. When diversionary activities and snacks did not work, giving the resident space and monitoring her from a far could be helpful in making sure she was not combative towards her peers. The ASD said during times when Resident #2 was calling out for mama and daddy, she was most difficult to calm. Taking the resident outside to look for neighborhood cats seemed to give her purpose and have a calming effect. There were a few neighborhood cats who would come up to Resident #2 looking for affection. C. Record review 1. Behavioral tracking Review of Resident #2 behavior tracking recorded by CNA staff revealed the resident displayed aggressive and other negative behaviors on almost a daily basis. Over the past 30 days from [DATE] to [DATE], Resident #2 was observed with the following behavioral symptoms: crying, yelling/screaming, kicking, pushing, grabbing, pinching/ scratching/ spitting, biting, wandering, using abusive language, threatening, and rejecting care. -However, the behavioral tracking documentation failed to provide data on the duration of Resident #2's behavioral symptoms or any interventions attempted to de-escalate Resident #2 symptoms to document if effective or not effective. Review of behavior tracking recorded by the nurses on the resident [DATE] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Behaviors: Delusions, biting, spitting, kicking, using profanities, yelling out, crying, looking for deceased family. Record number of episodes; side effects (injuries); and interventions (one on one, redirection, and distraction). -Documentation in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . -Progress notes revealed details of a few resident behaviors records (see above); however, the behavior tracking did not document the effectiveness of intervention used. [DATE] at 6:40 p.m., Behavior charting note read in part: Describe behavior mood: (Resident #2 was) yelling in the country kitchen, pushing chairs over, stating she wanted to be left alone, attempting to pull the cable box from the wall. What was the resident doing prior to or at the time of behavior/mood: Relaxing in a wheelchair in the hallway. Interventions attempted: Staff attempted to provide one on one, provided sandwich and drink, offered blanket, offered resident baby dolls and stuffed cat, offered periods of rest, music played, re-approached by different staff members. Offered to call her (family). Resident assisted back to her room where she allowed the nurse to assess blood glucose. Blood glucose was 182. Effectiveness of the interventions: Initially, residents agitated, continued with behaviors. Resident agreed to speak with (family), but there was no answer. Resident continued with agitation and yelling. Approximately 20 minutes after insulin administration, the resident was weepy, grabbing onto staff members hands, but was able to calm down and eat lunch, resting afterwards. -[DATE] at 7:25 p.m. Wellness note read in part: At approximately 4:40 p.m., this nurse saw Resident #2 wheeling herself past the medication cart and down the long hall. Resident was upset about her FSBG (finger stick for blood glucose assessment) that had just been checked. At 4:45 p.m., this nurse heard Resident #6 yelling out get her away from me she's hitting me nurse ran to resident and saw Resident #2 holding on to Resident #6s wheelchair . Resident #6 was sitting in the doorway of her room waiting for assistance from staff. No hitting seen by the nurse. CNA heading down the long hallway at the same time. Nurse and CNA were able to separate residents. This nurse in to talk to and assess Resident #6, resident states that another resident grabbed her wheelchair and ' wouldn't let go ' and then ' socked me in the back of the head. ' Resident denies any pain at this time but states that it did hurt when (Resident #2) hit her. No redness, swelling or bruising noted, ROM (range of motion) in neck and arms intact. Nurse then to Resident #2 to assess resident, remains combative with nurse attempting to spit and strike staff. No redness or swelling noted to hands or arms. -[DATE] at 11:11 a.m., Social services note read in part: Resident has been having outbursts about her mamma and daddy this morning. She has been screaming throughout the facility. SSD (social services director) invited resident into her office to give her some time away from the other staff and residents. Resident #2 shared her stories and concerns with her family. Resident continues to cry and scream out. SSD asked the resident if she was hungry and she said yes. SSD asked the kitchen to bring her a snack and drink. The most recent progress note on [DATE] at 3:25 p.m. revealed that Resident #2's peers continued to be at risk of being a victim of resident-to-resident altercations from a physical confrontation initiated by Resident #2, which documented Resident #2 became agitated during dining services, and started swinging around a cloth-clothing protector and hit another resident with the cloth. Staff separated the two residents and placed Resident #2 on one to one supervision during the shift. Neither resident was injured in the incident. 2. Care plan Resident #2's comprehensive care plan, revealed the following needs: Care focus for impaired activity participation, revised [DATE]: I enjoy playing Bingo, spelling, folding towels, playing with the baby doll, listening to country music, having my nails done, crafts, watching animal videos on a tablet and socializing with people. I like to facetime my (family) on the ipad. I like to watch shows on occasion on the television. My favorite snacks are goldfish crackers and PBJ (peanut butter and jelly) sandwiches. I raised farm animals such as sheep, goats and chickens. I love cats and get excited when I see one. I love to play dominoes and go outside when the weather is good. Since I am in a wheelchair, staff will assist me to activities outside of my room. When I am having some behavior issues, taking me outside sometimes helps with my mood. I am at risk for unsafe wandering and at risk of falling. -Interventions included: Go outside when weather permits if resident is having behaviors. -Staff will encourage resident to listen to music. -Staff will offer an ipad tablet to watch funny animal videos for her enjoyment. Care focus for wandering/elopement, revised [DATE]. At risk for elopement due to dementia with behavioral issues. Interventions included: -Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. -Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. -Complete 15 minute checks for active Wandering/Elopement -Give clear explanation of all care activities prior to and as they occur during each contact. -Interventions when noticing resident eloping or showing signs and symptoms include: redirecting by calling family, provide with reading materials, one on one visits, reminiscing about family, watching television, listening to calming music in a low-stimulus environment, and holding a baby doll. -Monitor and analyze key times, places, circumstances, triggers, and what deescalates behavior and document. -Provide structured activities such as word search puzzles, jigsaw puzzles, reading material, video calls with family, one on one visits, holding a doll, and reminiscing. Care focus for dementia management revised [DATE]. (Resident name) has moderately impaired decision making ability with short and long term memory recall. Resident requires cues and supervision. At risk for behavioral behaviors such as agitation, anxiety as evidenced by biting; yelling; using profanity; spitting and kicking; trying to get out of wheelchair; not wanting to be alone; tearful; hallucinations and delusions (looking for family and seeing things that are not present during daily routine.) Goal: Resident will function at the highest practical level without any preventable decline in orientation, memory, and judgment. Interventions: -Do not rush resident or show impatience while performing care. -Explain the purpose of the visit throughout the visit. -Gently reorient resident as needed. -Introduce yourself to resident and call the resident by name each time addressed. -Keep resident informed of activities taking place. -Monitor Behaviors of Agitation and anxiety: Biting; yelling; using profanities; spitting; kicking; not wanting to be alone; tearful; delusions. -Offer resident her baby doll as it aids in calming her down. -Praise resident when decisions are made. -Provide reassurance to assure resident feels safe and secure. -Show resident items of familiarity and pictures of family to help resident stay oriented. Care focus for depression, revised [DATE]: (Resident name) had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions: Encourage (resident name) to express feelings of anger, frustration, sadness, etc. Provide support and reassurance. -Monitor for signs and symptoms of depression, i.e. crying, tearfulness, searching for family, yelling out, changes in sleep pattern or appetite & negative statements. -Offer outside time, Calming music in a low-stimulus environment, family zoom calls, snacks and activities to redirect resident during behaviors. -Offer resident her baby doll as it aids in calming her down. Care focus for behavioral issues, revised [DATE]: Goal: Will have no verbal or physical outburst towards others. Interventions: -One to one (1:1) therapeutic conversation. -Distraction or redirect resident by talking about family, holding baby a doll, or offering activities of choice such as coloring. -Encourage family visits. -Encourage socialization with residents of similar interests following social distancing guidelines. -Invite/encourage to attend activities of choice. -Monitor every shift for episodes describing behavior and record on medicalization administration record (MAR). -Notify social services, nurse manager and NHA of all behaviors. -Offer emotional support -Staff will encourage regular family visits. Assist with calls, video calls and window visits. -Staff will encourage resident to express feelings. VI. Administrative interview The NHA was interviewed on [DATE] at 1:45 p.m. The NHA said the interdisciplinary team (IDT) had several discussions about Resident #2 behaviors and the IDT determined Resident #2 would be better served in a dedicated memory care unit that specializes in dementia managed care but the referral fell through when the facility decline to accept Resident #2 due to behavioral history. The IDT reassessed Resident #2 needs and provided an all staff dementia management training with specific referenced to how to monitor and provide redirection care and support to Resident #2. Although Resident #2 responded best to three or four particular staff, each staff had to have the knowledge and skills to prove care plan intervention to Resident #2 for the most effective behavioral management. In addition to staff training, the IDT recognized the resident's family was instrumental in assisting with behavioral redirection. Family visits and support plays a key role in offering the resident calming and security. Resident #2's family brought in the life like cats that meow and purr and engage in video calls when they cannot be present. Staff have been directed to provide Resident #2 with one-to-one supervision and support when she was wandering and upset at the same time. It is important to meet Resident #2 in her world, and acknowledge her present state of mind, without trying to orient her to reality. Staff should encouraging Resident #2 to vent her feelings and offer simple choices with daily activities.

Based on observations, record review and interviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for one (#7) of three residents reviewed for oxygen therapy out of 15 sample residents. Specifically, the facility failed to ensure oxygen was administered according to physician orders for Residents #7. Findings include: I. Professional reference According to Potter/Perry, Fundamentals of Nursing, ninth edition, Elsevier, Canada, 2017, p 900, Oxygen is a therapeutic gas and must be prescribed and adjusted only with a health care provider's order. II. Facility policy The Oxygen Administration policy, revised in October 2012, was provided by the nursing home administrator (NHA) on 6/29/22 at 12:49 p.m. via email. The policy included: Preparation: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. General guidelines: The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band placed around the resident's head. Documentation: After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed. 2. The name and title of the individual who performed the procedure. 3. The rate of oxygen flow, route, and rationale. 4. The frequency and duration of the treatment. 5. The reason for p.r.n. administration. 6. All assessment data obtained before, during, and after the procedure. 7. How the resident tolerated the procedure. 8. If the resident refused the procedure, the reason(s) why and the intervention taken. 9. The signature and title of the person recording the data. Reporting: 1. Notify the supervisor if the resident refuses the procedure. 2. Report other information in accordance with facility policy and professional standards of practice. III. Resident #7 A. Resident status Resident #7, age 72, was admitted on [DATE]. According to the June 2022 computerized physicians orders (CPO), diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/8/22 minimum data set (MDS) assessment revealed the resident's cognitive status was moderately impaired with a brief interview for mental status (BIMS) score of 11 out of 15. He had no identified behaviors or rejections of care during the assessment period. He was identified using oxygen. B. Record review The care plan, initiated 2/25/22, identified the use of oxygen therapy related to aspiration pneumonia. Interventions included: -Give medications as ordered by physician. -Oxygen settings: Resident #7 has oxygen (O2) via nasal cannula at three liters a minute (3L/min). The June 2022 CPO included: -Supplemental oxygen continuous 3L/min via nasal cannula. Ordered on 2/23/22. The June 2022 electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Observations and interview Resident #7 was in his room on 6/26/22 at 2:35 p.m. with his nasal cannula hanging off the bedside table. Resident #7 said he did not have to wear oxygen all the time. At 4:09 p.m. he said the oxygen was on for when he needed it, and would use it when he felt out of breath. Resident #7 was in his room on 6/27/22 at 8:57 a.m. He was not wearing his oxygen. He said he did not need it. Registered nurse (RN) #1 was interviewed on 6/28/22 at 9:47 a.m. She said Resident #7 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She went to his room and found him not wearing his oxygen. She said he did have a history of taking off his oxygen. She said oxygen was considered a medication and it should have been worn continuously as ordered by the physician. -However, the resident having a history of taking off his oxygen was not identified on his care plan (see above). D, Interviews Certified nurse aide (CNA) #1 was interviewed on 6/28/22 at 9:26 a.m. She said Resident #7 wore oxygen via nasal cannula at 2L/min. She said he never wore it and had it on in case he did. CNA #2 was interviewed on 6/28/22 at 9:28 a.m. She said his oxygen was at 3L/min, and he wore it only when he wanted to. The director of nursing (DON) was interviewed on 6/28/22 at 11:40 a.m. She said she considered oxygen to be a medication due to needing an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she would talk to the resident and the providers about Resident #7 refusing to wear the oxygen continuously.

Based on observations, record review and interviews, the facility failed to ensure that a resident who displays or was diagnosed with mental disorder receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for one (#7) of 15 sample residents. Specifically, the facility failed to identify behaviors and develop a person-centered individualized care plan to include interventions to address identified inappropriate and/or disruptive behaviors for Resident #7. I. Facility policy The Behavioral Assessment, Intervention, and Monitoring policy, revised in March 2019, was provided by the nursing home administrator (NHA) on 6/29/22 at 12:17 p.m. via email. The policy stated: Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment. Cause Identification: The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident ' s change in condition, including: -Physical or medical changes (for example): infection, dehydration, pain or discomfort, constipation, change related to medications, and/or worsening of or complications related to other conditions. -Emotional, psychiatric and/or psychological stressors (for example): depression, boredom, loneliness, anxiety, and/or fear. -Functional, social or environmental factors (for example): alteration in routine, change in caregivers, sleep disturbances, decline in ability to perform self-care or tasks that he or she could previously complete without help, poor or excessive lighting, noise, and/or uncomfortable temperatures. Management 1. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. a. Atypical behavior will be differentiated from behavior that is dangerous or problematic for the resident(s) or staff, or behavior that signals underlying distress. Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident ' s distress or loss of abilities. Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. The care plan will include, as a minimum: A description of the behavioral symptoms, including: frequency, intensity, duration, outcomes, location, environment; and precipitating factors or situations. -Targeted and individualized interventions for the behavioral and/or psychosocial symptoms; -The rationale for the interventions and approaches; -Specific and measurable goals for targeted behaviors; and -How the staff will monitor for effectiveness of the interventions. II. Resident #7 A. Resident status Resident #7, age 72, was admitted on [DATE]. According to the June 2022 computerized physicians orders (CPO), diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/8/22 minimum data set (MDS) assessment revealed the resident's cognitive status was moderately impaired with a brief interview for mental status (BIMS) score of 11 out of 15. He had no identified behaviors or rejections of care during the assessment period. B. Record review The care plan, initiated 3/25/22, identified the use of [MEDICATION(S)] (antidepressant medication) for the behaviors of self isolation, refusing care, refusing therapies, and statements of feeling depressed. Interventions included: -Document and report increased or worsening behaviors to SSD (social services director) and to PCP (primary care provider). -Monitor targeted behaviors of self isolation; refusing care; refusing therapies; statement of feeling depressed. -The care plan did not have person-centered individualized interventions for inappropriate and/or disruptive behaviors. The June 2022 behavior monitoring tracking in the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] During the 6:00 a.m. to 2:00 p.m. shift, Resident #7 displayed behaviors on three occasions, During the 2:00 p.m. to 10:00 p.m. shift, Resident #7 displayed behaviors on two occasions. During the 10:00 p.m. to 6:00 a.m. shift, Resident #7 displayed behaviors once. The progress notes for the month of June 2022 (between 6/1/22 to 6/26/22) documented 14 inappropriate and/or disruptive behaviors. -Review of the resident's record did not reveal the resident was working with a mental health provider and was not initiated until identified during the survey (see NHA interview below). C. Interviews Certified nursing aide (CNA) #1 was interviewed on 6/28/22 at 9:26 a.m. She said Resident #7 did have behaviors. She said he had recently kicked a staff member during cares. She said he would make inappropriate comments to her that included I love you and sexual comments. She said when he was inappropriate, she would tell him to stop talking like that to her and she would report the behavior to the nurse. She said she had not had any training specifically for the identified behaviors. CNA #2 was interviewed on 6/28/22 at 9:28 a.m. She said Resident #7 had several behaviors that included yelling out, cussing out, and saying inappropriate sexual comments to include I love you to staff. She said when he displayed the behavior, she would remind him the behavior was inappropriate. If he continued the behaviors, she would complete the identified needs and leave without saying anything to him. She said she would notify the nurse who would make a note. She said Resident #7 had behaviors all the time. Registered nurse (RN) #1 was interviewed on 6/28/22 at 9:47 a.m. She said she did not know exactly what behaviors Resident #7 displayed. She said she had heard from the aides that he had made inappropriate sexual comments. She said when he made sexual remarks she would talk to him, remind him saying those things was inappropriate. She said she would report the comments to the social services director (SSD), the NHA, the director of nursing (DON), the family, and the provider. She said when staff report the behavior she would write a progress note. She said she was not familiar with the frequency of the behaviors. The SSD was interviewed on 6/28/22 at 11:15 a.m. She said recently there was an incident when he kicked a member and it caused him to have a significant change in behavior. She said after the incident, he started commenting on being in love with staff members, expressing a need to be loved, and inappropriate comments to staff of a sexual nature. She said she had provided training to staff to provide the cares he needed, but not to respond to the behavior, to ignore the comments and to leave and report to the nurse on duty what was said. She said the expectation was for the nurse who the behavior was reported to to write a progress note. She said she was to read all the notes, but had not yet summarized the information. She said she had not had a chance to update the care plan to include person-centered individualized interventions to address the new behaviors. She said she had talked several times to the resident but had not had the time to write a note after each visit. She said she would update the care plan to ensure all staff utilized consistent interventions for the identified behaviors. The DON and NHA were interviewed on 6/28/22 T 11:40 a.m. The DON said Resident #7 had made inappropriate sexual comments on several occasions. The DON said staff had been educated to redirect the behavior and let the nurse know. The DON said she wanted the nurse to make a progress note. The NHA said staff had been provided one-on-one education to redirect Resident #7, provide care, be kind, and report any behaviors to the nurse. They said they want all staff to utilize the interventions, and that the care plan should have been updated with person-centered individualized interventions. The NHA said he would be receiving mental health services going forward.

Based on observation, record review and interviews, the facility failed to ensure that all residents were free from abuse, neglect, and exploitation, for two (#6 and #2) of two residents reviewed out of 15 sample residents. Specifically, the facility failed to provide adequate supervision and effective interventions to prevent a resident-to-resident physical altercation between Resident #2 and #6. Cross-reference F744 for failure to provide adequate dementia management care. Findings include: I. Facility policy The Abuse Prevention policy, dated December 2016, was provided by the nursing home administrator (NHA) on 6/29/22 at 11:09 a.m. It read in pertinent part: Policy statement: Our 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. Policy Interpretation and Implementation As part of the resident abuse prevention, the administration will: -Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individuals. -Identify and assess all possible incidents of abuse. II. Residents involved with the altercation A. Resident #2 1. Resident status Resident #2, age 87, was admitted on [DATE]. According to the June 2022 computerized physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/28/22 minimum data set (MDS) assessment revealed the resident had severely impaired cognition and was unable to participate in the brief interview for the mental status (BIMS) exam. Staff assessment of the resident's cognition revealed the resident had short and long-term memory deficits. The resident was unable to recall the current season, location of her room or the names and names and faces of staff. The resident presented with fluctuating signs of delirium; disorganized thinking; altered levels of consciousness; hallucinations and delusions. The resident presented (almost daily) with physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing); and, verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others). The resident did not walk but used a manual wheelchair to get around the unit with limited assistance; and needed extensive assistance from staff to complete activities of daily living and rejected care assistance at times. According to the MDS assessment the resident was not on any antipsychotic medication at the time of the assessment despite the CPO documenting an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Record review Review of progress note revealed the resident had additional altercations with other residents in the facility on 6/18/22 at 3:25 p.m., Resident #2 became agitated during dining services, and started swinging around a cloth-clothing protector and hit another resident with the cloth. Staff separated the two residents and placed Resident #2 on one-to-one supervision during the shift. Neither resident was injured in the incident. Review of Resident #2 behavior tracking recorded by CNA staff revealed the resident displayed aggressive and other negative behaviors on almost a daily basis. Over the past 30 days from 5/29/22 to 6/28/22, Resident #2 was observed with the following behavioral symptoms: crying, yelling/screaming, kicking, pushing, grabbing, pinching/ scratching/ spitting, biting, wandering, using abusive language, threatening, and rejecting care. Resident #2's comprehensive care plan was very detailed with care focus and interventions for resident behaviors, medical needs and social preferences. The care plan documented a care focus to address a resident-to-resident physical altercation. The care focus was initiated 3/17/22. The care focus revealed the resident physically assaulted another female resident by slapping the other resident in the face after a negative verbal exchange. The care focus was not updated or revised with a repeat physical resident-to-resident altercation that occurred most recently with a different female peer within the facility on 5/22/22. The care focus read in pertinent part: Resident #2 will not have another altercation. Interventions: Redirect residents as needed when showing signs of behaviors including - agitation. Resident on 15 minute checks. 3. Resident interview and observation Resident #2 was interviewed on 6/26/22 at 2:45 p.m. Resident #2 was not able to answer questions, but instead she scolded and said I don't care if you get yours done! At the time of the interview Resident #2 was not supervised by staff and was wandering the hall in her manual wheelchair and holding onto her stuffed cat. Resident #2 seemed irritated by something but it was not aparant what was bothering her. On 6/26/22 at 3:03 p.m. while interviewing another resident near the common area entrance of the facility Resident #2 could be heard yelling at another resident in the hall. Activities staff responded to the common area and there was no physical exchange between the two residents (cross-reference to F744). -Cloth Velcro stop signs were placed on the doors of other residents in the facility to prevent Residents who wandered from entering the rooms of others. This would discourage Resident #2 from entering another resident room when wandering and upset or agitated and prevent any potential resident-to-resident altercations. B. Resident #6 1. Resident status Resident #6, age [AGE] years old, was admitted on [DATE] and readmitted [DATE]. According to the June 2022 computerized physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/28/22 minimum data set (MDS) assessment revealed the resident had intact cognition as evidenced by a score of 15 out of 15 on the brief interview for mental status (BIMS). The resident was usually understood but had difficulty communicating some words or furnishing thoughts and was able, if prompted or given time and usually understood conversation but missed some part of the intended message. Resident #6 needed limited to extensive assistance to complete activities of daily living including with mobility throughout the facility. The resident did not walk and used a manual wheelchair to get around. The resident did not present with negative behavioral expressions. 2. Record review Resident #6's comprehensive care plan revised 6/27/22, did not have a care focus for protecting her against resident-to-resident abuse. There were no interventions for protecting the resident from being a repeat victim of resident to resident abuse by Resident #2; despite Resident #6 having a Velcro stop sign attached to the outside of her door to prevent resident #2 from entering her room. 3. Resident interview Resident #6 declined an interview. III. Facility reported incident (FRI) Description of the incident-allegation of physical abuse between Resident #2 and Resident #6 The investigation report dated 5/22/22, documented that Resident #2 had just received a finger stick to test blood glucose (BG) level and then received an insulin injection. Resident #2 was agitated after this and self-propped herself down the hall away from the nurse. Resident stopped outside of Resident #6's room, where Resident #6 was sitting in the doorway in a manual wheelchair. Registered nurse (RN) #2 documented observing Resident #2 at approximately 4:40 p.m., just after assessing the resident's BG levels and giving the prescribed insulin injection. Resident #2 was upset about getting her finger poked for a fasting blood glucose exam, and began wheeling down the long hall, past the medication cart, in a manual wheelchair. At approximately 4:45 p.m., RN #2 heard Resident #6 yelling get her away from me, she's hitting me. RN #2 responded to the location of Resident #6 (just outside of Resident #6's room) and observed Resident #2 holding onto Resident #6's wheelchair. RN #2 and a certified nurse aide (CNA) separated the two residents. Each resident was assessed for physical injury and there were no visual signs or symptoms of physical injury to either resident. RN #2 interviewed each resident immediately following the incident. Resident #6 told staff she was waiting outside of her room for staff to return when Resident #2 approached, grabbed her (Resident #6's) wheelchair refusing to let go. Then Resident #2 started yelling at her and socked (hit) her (Resident #6) in the back of the head. Resident #6 said the impact of the hit on the head hurt at the time of the hit but did not hurt when assessed by the nurse. Resident #6 did not have any redness or bruising to the back of her head where she indicated that Resident #2 hit her. Resident #2 was unable to explain her actions and remained combative towards staff (attempting to hit and spit at staff). Staff interviews revealed none of the staff on duty had direct line of sign of Resident #2 as she wandered down the hall in an angry state. Staff failed to follow the care plan (see Resident #2's record review above) to redirect Resident #2 when she was showing signs of behavior. Following the incident Resident #2 was placed on 15-minute checks for 72 hours and the interdisciplinary team decided it would be appropriate to seek a secured placement for Resident #2. No other changes were made to Resident #2's treatment or care plan. IV. Staff interview The NHA was interviewed on 6/29/22 at 1:45 p.m. The NHA said Resident #2 had displayed disruptive behaviors in the past and after this last incident on 5/22/22. The facility was trying to find a more appropriate placement for the resident but had not had much luck with securing a memory care placement for the resident due to her aggressive behavior towards others. The IDT discussed Resident #2 behavior and reviewed interventions. The NHA said that Resident #2 responded well to three facility staff but they were not always available when Resident #2 needed extra attention, so the IDT developed training for staff on how to respond to the resident when she was agitated and otherwise acting out with aggressive behaviors. The NHA said staff were instructed to provide one-to-one supervision of Resident #2 when she was presenting with agitation and aggressive combative behaviors directed towards others. Staff were educated on how to use various tools and techniques to use with Resident #2, several had been successful in aiding Resident #2 to calm in the past. With the help of Resident #2's family, the facility had obtained several items to help calm Resident #2. The resident had a life like cat that purred and responded to the resident, life like dolls and a couple of other stuffed animals. The resident responded well to these items; holding the items usually had a calming effect on her. In addition, staff could offer music listening, coloring with staff and going outside to look for live cats who frequented the neighborhood as diversionary activities to calm Resident #2 when she was upset.

Based on record review and staff interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for two (#6 and #12) of five residents reviewed for immunizations out of 15 sample residents. Specifically, the facility failed to offer and provide the pneumococcal conjugate vaccine (PCV13) and or pneumococcal polysaccharide vaccine (PPSV23) to Resident #6 and #12. Findings include: I. Professional standard According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged [AGE] years or Older, United States, 2022, retrieved on 7/5/22, from: https://www. cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, The document read in pertinent part: Routine vaccination - pneumococcal -For those ages 19 to 64 with an additional risk factor or another indication was: One (1) dose PCV15 (pneumococcal 15-valent conjugate vaccine PCV15 [MEDICATION(S)]) followed by PPSV23 (pneumococcal 23-valent polysaccharide vaccine PPSV23 [MEDICATION(S)] 23)or one (1) dose PCV20 (pneumococcal 20-valent conjugate vaccine PCV20 Prevnar 20). (see notes) -For those over the age of 65 who meet age requirement and lack documentation of vaccination, or lack evidence of past infection was: One (1) dose PCV15 followed by PPSV23 or one (1) dose PCV20. Special situations: Age 19-[AGE] years with certain underlying medical conditions or other risk factors who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown: One (1) dose PCV15 or one (1) dose PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose. A minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition, cochlear implant, or [CONDITION(S)] to minimize the risk of invasive pneumococcal disease caused by serotypes unique to PPSV23 in these vulnerable groups. -Note: Immunocompromising conditions include [CONDITION(S)], [CONDITION(S)], immunodeficiency, iatrogenic immunosuppression, generalized malignancy, human immunodeficiency virus ([CONDITION(S)]), Hodgkin disease, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], solid organ transplants, congenital or acquired asplenia, [CONDITION(S)] disease, or other hemoglobinopathies. -Note: Underlying medical conditions or other risk factors include alcoholism, chronic heart/liver/lung disease, [CONDITION(S)], cigarette smoking, cochlear implant, congenital or acquired asplenia, CSF (cerebral spinal fluid) leak, diabetes mellitus, generalized malignancy, [CONDITION(S)], Hodgkin disease, immunodeficiency, iatrogenic immunosuppression, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], solid organ transplants, or [CONDITION(S)] disease or other hemoglobinopathies. For guidance for patients who have already received a previous dose of PCV13 and/or PPSV23, see www.cdc.gov/mmwr/volumes/71/wr/mm7104a1.htm. II. Facility policy The Pneumococcal Vaccine policy, revised August 2016, was provided by the nursing home administrator (NHA) on 6/29/22 at 9:44 a.m. The policy read in pertinent part: All residents will be offered the [MEDICATION(S)] (pneumococcal vaccine) to aid in preventing pneumococcal infections (e.g., pneumonia). For residents who receive the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record. Administration of the pneumococcal vaccination or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. -The facility policy was not up to date with the 2022 changes in pneumococcal vaccines (see professional reference listed above). III. Resident #6 A. Resident status Resident #6, age [AGE] years old, was admitted on [DATE] and readmitted [DATE]. According to the June 2022 computerized physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/28/22 minimum data set (MDS) assessment revealed the resident had intact cognition as evidenced by a score of 15 out of 15 on the brief interview for mental status (BIMS). The resident was usually understood but had difficulty communicating some words or furnishing thoughts and was able if prompted or given time and usually understood conversation but missed some part of the intended message. The resident was receiving oxygen therapy. According to the MDS assessment, the resident's pneumonia vaccine was up to date. -However, the resident's electronic medical record (EMR) documented the resident was not offered, did not refuse and did not receive the PPSV23 vaccine. B. Resident interview Resident #6 declined an interview. C. Record review The resident electronic medical record (EMR) contained one signed informed consent form, for the PCV13 signed by the resident on 3/14/19. There was no informed consent form to either accept or refuse the PPSV23. The informed consent for the PCV13 vaccine indicated the resident refused the vaccine documenting already received the vaccine on 11/1/2018. -The resident's EMR failed to document a conversation with the resident or physician with regard to the status and recommendation for the resident to receive the PPSV23 vaccine. IV. Resident #12 A. Resident status Resident #12, age [AGE] years old, was admitted on [DATE]. According to the June 2022 CPO diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/13/22 MDS assessment revealed the resident had severely impaired cognition as evidenced by a score of seven out of 15 on the BIMS. The resident usually understood conversations but had difficulty communicating some words or furnishing thoughts and was able if prompted or given time and usually understood conversation but missed some part of the intended message. According to the MDS assessment, the resident's pneumonia vaccine was up to date. -However, the resident's EMR documented the resident was not offered, did not refuse and did not receive the second pneumococcal vaccine (see record review below). B. Resident interview Resident #12 was interviewed on 6/28/22 at 3:22 p.m. Resident #12 was unable to comment on her vaccination status. C. Record review The resident's EMR failed to document any signed informed consent or discussion with the resident's legal representative and/or physician with regard to the status and recommendation for the resident to receive either the PCV13 or the PPSV23 vaccines. The resident's EMR vaccination record revealed the resident received the [MEDICATION(S)] Dose 1 on 10/24/06 but there was no documentation of receipt or the second recommended pneumococcal vaccination. V. Staff interview The NHA was interviewed on 6/29/22 at 1:28 p.m. The NHA said the facility provided vaccines based on guidance from the pharmacy. Nursing staff reviewed the resident record for vaccination status upon admission, educated the resident about the benefits of vaccines and obtained informed consent prior to giving a vaccine. The facility had a form the resident or resident's legal representative signed for consent or refusal for any vaccine offered by the facility. If the resident consented to receive the first dose of one of the pneumococcal series vaccines the second dose would be entered into the resident's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . The NHA said she would review Resident #6 and #12 medical records for additional consent forms and to see why there was no commendation for each resident second dose of pneumococcal vaccine being administered, scheduled or refused. VI. Follow up No additional documentation was provided at the conclusion of the survey on 6/29/22 based on the NHA interview (see above).

Based on observations, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, in one of one medication storage rooms. Specifically, the facility failed to ensure the medication storage room was secure with wandering residents nearby. I. Facility policy The Storage of Medication policy, revised in November 2020, was provided by the nursing home administrator (NHA) on 6/29/22 at 12:49 p.m. via email. The policy included: Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. II. Observation and interview The medication storage room was propped open on 6/26/22 at 2:15 p.m. There were two residents wandering in the hallway at the same time. Registered nurse (RN) #1 said she did not realize the medication room had been propped open. She said her and the director of nursing (DON) had been in and out of the medication storage room all day. III. Interview The DON was interviewed on 6/29/22 at 1:04 p.m. She said the medication storage room should not have been propped open. She said when it was brought to her attention education was provided on the importance of keeping the medication storage room secure at all times especially when there are wandering residents for their safety also.

Based on record review and interviews, the facility failed to designate a registered nurse (RN) to serve as the director of nursing (DON) on a full time basis. Specifically, the facility utilized the nurse home administrator (NHA) to also serve as the DON and she was unable to work full time hours as the DON. Findings include: I. Administration job descriptions A. DON job description The Director of Nursing Services job description was provided by NHA #3 on 4/20/21 at 11:29 a.m. The job summary read, The Director of Nursing Services coordinates all of the nursing care and provides on-going education and training to the employees under this directorship. The description included the position reported to the administrator. B. NHA job description The NHA job description was provided by NHA #3 on 4/20/21 at 11:29 a.m The job summary read, The Nursing Home Administrator oversees all operations and ensures compliance and financial responsibility. The description included that the position reported to the owner of the facility. II. Staff interviews The social services director (SSD) was interviewed on 4/14/21 at 8:14 a.m. She said the NHA was not currently at the facility. When asked if the DON was at the facility; she said the facility did not currently have a DON. She said the current NHA had formerly worked as the DON, however, a new DON had not been hired. She said that the administrative staff typically would arrive to work around 9:00 a.m. She could not identify who the manager on duty was. NHA #3 was interviewed on 4/14/21 at 8:40 a.m. She said that she had received her temporary administrator licence in February 2021 and transitioned to serving as the facility NHA from her former position as the DON. She said the facility did not currently have someone to act full time as the DON. She said the facility's corporate management team would regularly send consultants that would help support her in her new position serving as the NHA. She said the consultants were not acting as the NHA or DON when they were in the facility. She said she was still providing nursing oversight while acting as the NHA. She said that the facility's corporate management was utilizing a recruiter to try to fill the DON vacancy. She said she had tried promoting the RNs currently working at the facility and local recruitment, however, had not yet been able to fill the position. NHA #3 was reinterviewed on 4/20/21 at 8:23 a.m. She said that she worked about half of her time at the facility as the NHA and the other half of her time continuing to assist with nursing oversight. She said that she did not work the floor, however, assisted with wound care and served as the facility's infection preventionist. She said that other staff assisted her with some of her responsibilities but specific tasks from the DON position had not been officially assigned to facility RNs to share the position. She said she worked hard to try to maintain quality assurance in the facility while trying to cover the responsibilities of two administrative positions. She said the facility did not have a waiver in place. III.Record review Review of the administrative staff schedule for the week of 4/11/21 to 4/17/21 revealed that the NHA was scheduled as the Admin/DON. She was scheduled to work the following hours: -On 4/12/21 she was scheduled from 8:00 a.m. to 5:00 p.m. -On 4/13/21 she was scheduled from 8:00 a.m. to 4:00 p.m. -On 4/14/21 she was scheduled from 8:00 a.m. to 6:00 p.m. The NHA was not at the facility at 8:00 a.m. as indicated on the schedule, see SSD interview (see above). -On 4/15/21 she was scheduled from 8:00 a.m. to 6:00 p.m. -On 4/16/21 she was scheduled from 8:00 a.m. to 5:00 p.m.

Based on observations, record review and interviews, out of a total of 20 sampled residents, the facility failed to ensure the environment for four (#1, #6, #5 and #7) out of five residents reviewed remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents. The facility failed to provide Residents #1, #6, and #5 the supervision necessary to prevent elopements, and Resident #7 the supervision and interventions necessary to prevent unsafe wandering, elopement, and resident to resident altercations. These facility failures created a situation with serious harm (Resident #1) and the likelihood of serious harm if not immediately corrected for Residents Resident #5, #6, and #7. Resident #1, diagnosed with [REDACTED]. On 9/3/2020, the resident was found outside again, in the middle of the night, lying on the ground with multiple fractures after exiting the north side of the facility and falling down a concrete set of stairs. The facility failed to ensure the wander guard alarm was in place and functioning appropriately and failed to ensure staff turned door alarms back on after passing through. The facility failed to properly investigate either incident as an elopement attempt and initiate interventions to prevent a recurrence and to ensure the resident's safety. Resident #6 diagnosed with [REDACTED]. A physician-ordered wander guard with daily 24 hour monitoring was in place as of 2/7/2020. Per progress notes, the resident expressed a desire to leave the facility on several occasions. The facility was also aware the resident had a history of [REDACTED]. The electronic medical record documented the resident had at least 17 successful elopements with and without staff's knowledge. Notes also documents at least three successful elopements without supervision on 7/19/2020, 8/20/2020 and 9/3/2020. On the evening of 7/19/2020, the resident successfully eloped without the staff's knowledge, after cutting off her wander guard. She was missing for an undetermined amount of time before a neighbor notified the facility the resident was outside. The facility failed to provide adequate supervision and interventions to prevent the resident's elopement. Resident #5 was determined to be a high risk for elopement and a wander guard was placed on 4/14/2020. Record review revealed the resident exhibited increased anxiety with exit seeking behaviors and the resident successfully exited the facility on four different occasions, one time sustaining a [MEDICAL CONDITION] and prompting transport to the emergency room . The facility failed to investigate these incidents as elopement attempts, failed to initiate interventions to prevent wandering and elopement attempts and failed to provide adequate supervision. Resident #7 was diagnosed with [REDACTED]. She had a history of [REDACTED]. A physician-ordered wander guard was applied on 1/29/2019. The facility was aware of Resident #7's successful elopements with the wander guard in place. Resident #7's record review revealed she engaged in exit seeking, some days constantly, as well as engaging in other unsafe behaviors, such as hollering out, agitation, and refusing care, and wandering into other residents' bedrooms. The facility failed to adequately provide Resident #7 with the level of supervision and interventions her condition and behaviors required. In addition, Resident #5 had eight falls in three months. The facility failed to investigate the root cause of the residents' falls and initiate effective interventions after each fall to prevent the potential for recurrence and resident injury. Cross-reference F609 (incident reporting), F610 (incident investigations), F656 (person-centered care planning), F641(resident assessment) and F744 (dementia care) Findings include: I. Immediate jeopardy A. Situation of immediate jeopardy The facility was aware of several residents leaving the facility and going into unsafe areas around the facility and into the road. Resident #1, with dementia, was found outside on 9/4/2020 at 11:30 p.m. on the ground. She fractured her nose, bilateral orbits and C-4. She was found by maintenance staff. The resident wore a wander guard at the time of this incident but the staff failed to ensure the alarms were engaged. Resident #6, with dementia, successfully left the building on 17 different occasions and was found walking in the street on three occasions. On the evening of 7/19/2020, she cut off her wanderguard alarm, eloping without notice and the facility was notified by a neighbor that the resident was out of the facility (it was unknown how long she had been missing from the facility). Resident #5, with dementia, exit seeks frequently and successfully left the building four times in a two month period. Resident #7, with [MEDICAL CONDITION], successfully left the building four times in a two month period. The facility failed to provide supervision to known exit seeking residents with poor safety awareness and failed to identify the reason for residents to seek elopement. The facility's failure to implement appropriate interventions to keep residents safe created the likelihood of serious harm if the facility's response was not immediately corrected. B. Imposition of immediate jeopardy On 9/30/2020 at 6:42 p.m., the director of nursing (DON) and the minimum data set (MDS) coordinator were notified of the immediate jeopardy situation created by the facility's failure to provide supervision to known eloping residents with poor safety awareness, creating the potential for serious harm to Residents #1, #6, #5 and #7. C. Facility response to immediate jeopardy On 10/2/2020 at 2:36 p.m., the facility submitted a plan to abate the immediate jeopardy. The abatement plan read: 1. Corrective action Rounds, around the facility to each exit door, were done with the maintenance director (MD) and MDS coordinator on 10/2/2020 at 7:35 p.m. to ensure all door alarms and wander guard alarms were functioning properly. Staff was educated on the plan for the wander guard alarm checks and responding to the sound of the alarms. The nurses were to be educated on each location of all doors and the form to be used during rounds to document all alarms are working properly. All nurses were educated on the proper easy (way) to check the functioning of the wander guard bracelets. Since all doors alarm when opened, all staff and outside vendors will be educated on ensuring every door alarm is turned back on after passing through the door. Education will be completed with each staff member prior to working their next scheduled shift. Education for all staff will be completed by the DON or designee by 10/6/2020. 2. Identification of others The facility will assess all residents and identify those presenting with elopement behaviors and those residents with a wander guard system in place to ensure proper monitoring and safety checks. This was completed 10/2/2020. 3. Systemic changes When the wander guard alarm sounds during the day and evening shifts (6:00 a.m. to 10:00 p.m.), all available staff will check the outside perimeter of the facility immediately. Team 1 nurse and Team 2 nurse will check for their residents and do a head count using a nurses ' report sheet. The night shift nurse (10:00 p.m. to 6:00 a.m. ) will count all residents and all available certified nurse aides (CNAs) will check the inside and outside perimeter of the facility. The night shift nurse will use the nurses report sheet for headcount. If a resident is not accounted for during the initial search, the search will be expanded beyond the perimeter. If the resident is not located within 10 minutes, the Police department and the nursing home administrator (NHA) will be contacted. The facility is working with a safety equipment company to have a new door alarm system installed with keypad entry/exit for all doors. 4. Monitoring Hourly rounds to check all doors will be done by team 1 nurse. Both the door alarm and the wander guard alarm will be tested on each exit door of the facility. Hourly rounds will continue until the new door alarm system is in place. Team 1 nurse to notify team 2 nurse by walkie talkie if unable to do the rounds so that the rounds may be done by Team 2 nurse. Fifteen minute checks will be done on residents that are at high risk for removing the wander guard alarms. Fifteen minute checks will continue until the new door system is in place. Fifteen minute checks are documented in Point Click Care on the Point of Care side. The charge nurse will track documentation at the end of each shift by running an audit report of their current shift. The facility will create an Elopement Binder, to contain a recent photo, current face sheet and other patient health information for each resident that is at risk of elopement/wandering, to be available to emergency personnel. Elopement binder was completed 10/2/2020. D. Removal of the immediate jeopardy The above plan was accepted on 10/2/2020 at 2:36 p.m.; however, observations, record review and interviews revealed deficient practice remained at G level, actual harm that is isolated. II. Facility policy and procedure The Wandering and Elopement policy and procedure, revised March 2019, was provided by the business office manager (BOM) on 10/2/2020 at 10:33 a.m. The policy read in pertinent part: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. -If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. -If an employee observes a resident leaving the premises, he/she should: Attempt to prevent the resident from leaving in a courteous manner; -If a resident is missing, initiate the elopement/missing resident emergency procedure; -When the resident returns to the facility, the director of nursing or charge nurse shall: Examine the resident for injuries; contact the attending physician and report findings and conditions of the resident; notify the resident's legal representative (sponsor); complete and file an incident report; and document relevant information in the resident's medical record. III. Residents Known to Elope and/or to Exhibit Unsafe Behaviors A. Resident #1 1.Resident status Resident #1, age 89, was admitted [DATE] and readmitted [DATE]. According to the October 2020 computerized physician orders [REDACTED]. The 9/2/2020 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The resident required limited assistance of one person for her activities of daily living (ADLs), including bed mobility, transfers, walking in room and corridor, locomotion on and off the unit, dressing, toilet use and personal hygiene and bathing. She required set up assistance only for eating. The resident had two or more falls with no injuries. Wandering was not exhibited. (Cross-reference F637 - failure to complete a significant change assessment) 2. Observations On 9/29/2020 at 5:23 p.m., Resident #1 was wandering in and out of resident rooms, going through other residents' drawers and attempting to eat other residents ' food. The staff would redirect the resident out of other residents ' rooms when they walked by and saw her, but they did not attempt to find out what the resident was looking for. The resident had a wander guard bracelet visible on her left ankle. 3. Record review and interview Record review revealed two elopements, the second with significant injury. The facility failed to investigate the incidents as elopements and take steps to prevent a reoccurrence. a. An 8/20/2020 progress note revealed the resident was found outside the back door at 6:30 a.m. after the door alarm was set off, standing on the second step of the stairs. The resident was not able to figure out how to go up or down the stairs. The note read the physician was notified and an order for [REDACTED]. A telephone order was received on 8/20/2020 for a wander guard two times a day. The order did not include a reason or [DIAGNOSES REDACTED]. No consent for the wander guard was found in the resident's record, and there was no documentation indicating the wander guard bracelet was placed on the resident. The resident's care plan was not updated with information on the incident, on the resident's wandering behavior or on the order for and placement of the wander guard bracelet. No interventions were put in place to assist the resident with her wandering behavior. The 8/31/2020 wandering risk assessment revealed a score of nine, putting the resident at risk for wandering; however, the assessment was inaccurate. It indicated the resident had no history of escape or elopement and had no reported episodes of wandering in the past six months. The assessment did not include the episode on 8/20/2020, when the resident was found outside of the facility unsupervised and the order for a wander guard was received. There was no evidence the 8/20/2020 incident was investigated to determine why and how the resident left the building. b. A 9/4/2020 progress note revealed the resident was not able to be located in her room on 9/3/2020 at 11:15 p.m. and a search of the facility began. Maintenance staff observed the resident on the ground outside the north door. The note read the resident had a skin tear to her right knee, left shin, and a hematoma over her left and right eyes with a laceration over the right eye. The resident was sent to the emergency room via ambulance on 9/3/2020 at 11:45 p.m. and was admitted with fractures to her bilateral superior orbits (bones around the eye) and a cervical fracture. There was no mention in the note of door alarms or wander guard alarms being set off or sounding. However, a 9/30/2020 at 11:30 a.m. interview with the maintenance director (MD) who discovered Resident #1 lying on the ground in front of the stairs on the north side of the building revealed neither the door alarm nor the wander guard alarm were sounding at that time. According to the 9/4/2020 emergency room progress note, the emergency medical technicians (EMTs) reported the resident had been missing from her room at the facility for about an hour until a maintenance staff member found her at the foot of three or four concrete steps where she had fallen and hit her head and face. The note read she had a laceration on the right side of her head with injury to the periorbital region and had bruising and severe swelling of the eyelids. The 9/4/2020 computerized tomography (CT) scan report showed non-displaced fractures bilaterally of maxillary sinus walls (nose), superior bilateral orbits (eyes) and the left [MEDICATION NAME] process C4 (cervical spine) with significant periorbital soft tissue swelling. A 9/4/2020 progress note revealed the resident had returned to the facility at 3:30 p.m. It indicated she had bruising to both of her eyes and a laceration with sutures to the right eye, skin tears to right and left shins with dressings intact. The 9/4/2020 readmission wandering risk assessment revealed a score of 12, indicating a high risk to wander. The assessment was inaccurate in marking the resident had no reported episodes of wandering in the past three months. There was no mention of the wander guard being in place. The facility investigated the incident on 9/3/2020 as a fall, but not as an attempted elopement. No interventions were put into place to prevent the incident from reoccurring. A 9/19/2020 progress note revealed the resident had been trying to ambulate in the hall and tried to get out the door once. It indicated she was redirected. There was no mention of the wander guard being in place. A consent for a wander guard form indicated a verbal consent was obtained on 9/29/2020, but it did not indicate who had given consent. B. Resident #5 1.Resident status Resident #5, age 83, was admitted [DATE] and readmitted [DATE]. According to the October 2020 CPO, [DIAGNOSES REDACTED]. The 9/15/2020 MDS assessment revealed the resident had no cognitive impairment with a BIMS score of 13 out of 15. The resident's wandering occurred one to three days during the assessment period. She required extensive assistance of one staff member for her ADLs, including bed mobility, transfers, walking in the room or corridor, locomotion on and off the unit, dressing, toileting, personal hygiene and bathing. She had two or more falls with no injury and two or more falls with injury since the last assessment on 6/15/2020. 2. Elopements a. Record review According to the CPOs, an order for [REDACTED]. Review of the record on 9/30/2020 revealed the resident did not have a consent for placement of the wander guard bracelet. The care plan, last revised 9/9/2020, revealed the resident was at risk for elopement related to a [DIAGNOSES REDACTED]. Interventions included: -Identify patterns of wandering such as it is purposeful, aimless, or escapist. Is the resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate, initiated 6/15/2020; -If the resident attempts to ambulate in and out of residents' rooms. Redirect ambulation to hallway to promote safely, initiated 6/15/2020; -Obtain consent for wander guard, initiated 6/15/2020; -Utilize wander guard device, initiated 6/15/2020; -Check wander guard per shift by charge nurse, initiated 9/14/2020; and -Provide structured activities such as toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes, last revised 9/14/2020. A 6/15/2020 quarterly wandering risk assessment revealed a score of nine, indicating the resident was at risk for wandering. A 6/29/2020 progress note revealed the resident was found at 6:30 a.m. on the ground outside the back door at the bottom of the steps on top of her walker after the door alarm sounded. It indicated the resident had a laceration to the left side of her head, a laceration to one of her fingers, a bruise to her left elbow and forearm. The note indicated the resident was sent to the emergency room for further evaluation. The facility investigated the incident on 6/29/2020 as a fall but not as an attempted elopement. No interventions were put into place to prevent the incident from reoccurring. A 7/11/2020 progress note revealed the resident was anxious and attempting to leave the building through all the exits, reaching up, attempting to shut off the alarms on the doors. It indicated the facility staff gave the resident several games to play and called the resident's friend to visit with the resident through the window. The PCP (primary care physician) was called and an order for [REDACTED]. A 7/17/2020 progress note revealed the resident had been up walking the halls with her walker since before midnight, repeatedly trying to go out each exit door, determined to go to school. It indicated the resident was very anxious and agitated and was difficult to redirect, seeing horses and family members that were not there. The note read the resident was given [MEDICATION NAME]. A 7/26/2020 progress note revealed the resident had increased anxiety, pacing around room, breathing hard and trying to leave the building. It indicated the PCP was notified and an order for [REDACTED]. Another 7/26/2020 progress note, written two hours and 14 minutes later, revealed the resident had been agitated, pacing and trying to get out of the facility. It indicated [MEDICATION NAME] was given and effective, the resident was asleep in bed. A 7/27/2020 progress note revealed the resident had been agitated, pacing, trying to get out of the facility, and was refusing care from the staff. It indicated [MEDICATION NAME] was given and effective, the resident was asleep in bed. An 8/8/2020 progress note revealed a housekeeper had seen the resident outside and asked the nurse if the resident was supposed to be outside. The note read the resident was out by the mailbox checking the mail and was immediately brought back into the facility. This was a late entry note created on 8/12/2020. There was no mention of the door alarms or the wander guard alarm going off when the resident exited the building. The facility did not investigate the incident any further. An 8/9/2020 progress note revealed the resident was observed by the dietary staff walking in the alleyway. It read the nursing staff was notified and the resident was easily redirected back into the facility. This was a late entry created on 8/12/2020. There was no mention of the door alarms or the wander guard alarm going off when the resident exited the building. The facility did not investigate the incident any further. An 8/10/2020 progress note revealed the resident was acting anxious, wandering around, and trying to leave the facility, saying she needed to go to the hospital. It indicated the PCP was notified and reordered the resident's [MEDICATION NAME] which was given for signs of anxiety. An 8/16/2020 progress note revealed the resident was very anxious, breathing fast, having a hard time following directions and was trying to get outside so she could go to the hospital. An 8/20/2020 progress note revealed the resident attempted to go out the facility doors three times, stating she was going home. It indicated the wander guard did alarm and the resident was able to be redirected, although resistive. An 8/29/2020 progress note revealed the resident was up during the night, pacing, hyperventilating and trying to leave the facility. It indicated the resident was given [MEDICATION NAME], had no further complaints or concerns and went to bed. A 9/12/2020 progress note revealed the resident was very agitated, hyperventilating and tried leaving the facility several times. It indicated the resident was given [MEDICATION NAME] and eventually settled down on her bed and went to sleep. A 9/14/2020 MDS assessment note revealed the resident had a wander guard related to cognitive deficits and known wandering about the facility. It indicated the resident would often try to go outside by herself due to enjoying the warm weather. A 9/14/2020 quarterly wandering risk assessment revealed a score of 12, indicating the resident was a high risk to wander. It indicated the resident often wandered about the facility and often attempted to go outside but never left the community (but see incidents 8/8 and 8/9/2020 above). A 9/25/2020 progress note revealed the resident was very anxious, hyperventilating, and adamant about going home and left the facility twice during the evening shift but was easily redirected back inside. It indicated the resident was given [MEDICATION NAME] and a snack and went to bed. Although she left the facility twice, there was no mention of the door alarms or the wander guard alarm going off when the resident exited the building. The facility did not investigate the incident any further. A 9/29/2020 progress note revealed the resident was very uneasy most of the day and seemed confused, pacing the halls. It indicated the resident was redirected and distracted several times. b. Facility follow-up during survey and after notified of the immediate jeopardy (9/30/2020). On 10/1/2020 the wander guard order was changed to read, wander guard - check for placement every hour. The order did not give a reason or [DIAGNOSES REDACTED]. On 10/1/2020 a verbal consent was obtained from the power of attorney (POA) for the use of the wander guard. On 10/2/2020 the care plan was updated to include the following: The resident scored 18 on the wandering risk assessment which is high risk for wandering. Requires wander guard for safety. Interventions added include: -Apply wander guard to her person; -Check placement of the wander guard every 15 minutes when checking the resident's location; -Do hourly rounds to check the functioning of the wander guard on all doors and document the check; -Educate all staff to respond to any alarm; -Inform the PCP and POA for the need for the safety device; -Notify the police of missing resident within 10 minutes of their absence; -Notify PCP and POA of any attempts or actual elopements and document the information as soon as possible; -Utilize the elopement risk binder in the medication room to keep self-informed of those who are at risk of elopement/wandering; and -When an at risk adult goes out the door without supervision, complete an incident report as this is a reportable occurrence. 3. Falls a. Facility policy and procedures The Managing Falls and Fall Risk policy and procedure, last revised March 2018, provided by the MDS coordinator on 10/1/2020 at 2:18 p.m., revealed in pertinent part, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. The Clinical Protocol for Falls policy and procedure, last revised March 2018, provided by the MDS coordinator on 10/1/2020 at 2:18 p.m. revealed in pertinent part, For an individual who has fallen, the staff will begin to try to identify possible causes within 24 hours of the fall. Based on the assessment, the staff will identify pertinent interventions to try to prevent subsequent falls. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, until falling reduces, or stops or until a reason is identified for its continuation. b. Resident #5 status See above; Resident #5, [AGE] years old, wandered and required extensive assistance with ADLs, including bed mobility, transfers, walking in the room or corridor, locomotion on and off the unit. Progress notes revealed she could become anxious, agitated, and pace around her room. The 6/15/2020 quarterly fall risk observation/assessment revealed a score of 18, indicating the resident was a high fall risk. The care plan, initiated 3/11/2020, revealed the resident was at risk for falls. Interventions included: -Physical therapy (PT) evaluation and treatment as ordered or as needed; and -Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Educate the resident/family/caregivers/IDT as to causes. c. Falls 6/29/2020 fall: A 6/29/2020 progress note revealed the resident was found at 6:30 a.m. on the ground outside the back door at the bottom of the steps on top of her walker after the door alarm sounded. It indicated the resident had a laceration to the left side of her head, a laceration to one of her fingers, a bruise to her left elbow and forearm. The note indicated the resident was sent to the emergency room for further evaluation. The 6/29/2020 emergency physician progress notes [REDACTED]. It indicated the [MEDICAL CONDITION] was closed with Derma bond (medical glue) and steri-strips were applied. A 6/29/2020 facility progress note revealed the resident had returned to the facility and orders were obtained for a fall mat and bed alarm. It indicated the laceration to the left eye was unable to be measured due to the steri-strips but the bruise to the area measured 7.5 centimeters (cm) by 3.5 cm. It indicated the resident had a bruise to the left elbow measuring 12 cm by 7.5 cm, a bruise to the left wrist 4 cm by 3.5 cm and a bruise to the left inner wrist 2.5 cm by 1.5 cm. The care plan was updated on 7/1/2020 to include the following: Pressure alarm while in bed and fall mat in place for safety related to recent falls and a history of falling. Interventions included: -Assess skin integrity weekly; -Consult the nursing staff to determine the resident's cognitive and physical status/limitations; -Document ineffectiveness and further interventions being put in place; -Document resident refusing to use pressure alarm and reasoning. Update POA and PCP on refusals; -Educate the POA, resident and all staff of the alarm to ensure placement; -Ensure proper implementation of alarm by staff; -Evaluate if the resident can remove or turn off alarm by herself; -Place pressure alarm under resident while in bed. Ensure it is placed correctly under the resident; -Ensure fall mat is in place at appropriate times; -Ensure resident safety; and -Review medical record and change in mental status in relation to recent falls. Document on falls per facility protocol. 7/13/2020 fall: A 7/13/2020 progress note revealed the resident was found at 2:10 p.m. sitting on the floor with her legs out in front of her and her hands holding her back up. It indicated an assessment was completed and neurological checks were started. The PCP was notified and an order was received for consultations with PT and occupational therapy (OT). Review of the record revealed PT services started 7/17/2020 and ended 8/29/2020 and OT services started 7/22/2020 and ended 8/16/2020. 7/26/2020 fall: The 7/26/2020 progress note revealed the resident was observed sitting on the floor of her room beside the bed and the resident stated she slid off the bed. The note read the bed alarm plug in was moved to a different location to prevent the resident from turning the device off. The 7/27/2020 post incident/accident investigation revealed interventions put into place after the fall were a referral to PT, the placement of the alarm was adjusted and the resident was educated on transfer protocol. The 7/31/2020 PT progress note revealed the resident was moved to a new room given her declining cognitive status; however, her new room was much more cramped and required more practice and tact to negotiate obstacles and reduce her fall risk. The resident's care plan was not updated to reflect her move or her declining cognitive status, both(TRUNCATED)

Based on observations, record review and interviews, out of 20 sampled residents, the facility failed to ensure three (#8, #5, and #3) of seven residents reviewed received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being. Resident #8, who was severely cognitively impaired, was assessed to require supervision and encouragement with eating and failed to receive adequate and timely interventions to promote his nutritional status (weight maintenance and/or weight gain). The resident experienced a steady decline in weight over an eight month period since initially admitted in February 2020. The medical record revealed severe weight loss since readmission in March 2020 of 15.2 pounds (lbs)/11.59% in three months and 30.2 lbs/20.66% in six months. The facility failed to ensure a registered dietician (RD) assessed the resident in a timely manner. Resident #3, who was severely cognitively impaired, had poor nutritional intake. She was assessed to require supervision (oversight, cuing and encouragement) while she ate. The resident experienced a steady decline in weight over a 10 month period from October 2019. The medical record revealed a progression of severe weight loss, between February 2020 and August 2020, of 9.41% in one month, 14.92% in three months and 20.48% in six months. The facility failed to implement nutritional resident-centered interventions and ensure a RD assessed the resident in a timely manner. Resident #5 had a severe weight loss since April 2020 with a 16.24% weight loss in six months, 7.0% weight loss in three months, 4.69% weight loss in one month. The facility failed to ensure a RD assessed the resident at admission or when weight loss was identified. Once weight loss was identified and interventions were initiated, the facility failed to offer the care planned interventions routinely and failed to document accurate meal intakes. The resident had a significant decline in functional status. The facility's failure to timely and adequately address Residents #8, #5, and #3's severe weight loss contributed to the likelihood of serious harm if not immediately corrected. Cross-reference F557 (timely assistance with meals), F637 (reassessment with significant change), F656 (person-centered care planning), and F806 (resident preferences). Findings include: I. IMMEDIATE JEOPARDY A. Situation of immediate jeopardy Resident #8 experienced a severe weight loss of 11.5% in three months and 20.66% in six months. The resident did not receive timely interventions to address the weight loss. The resident did not consistently receive the interventions which were part of his plan of care. The RD did not assess the resident timely. Resident #3 experienced a severe weight loss of 9.41% in one month, 14.92% in three months and 20.48% in six months. The facility failed to implement nutrition, resident-centered interventions timely. The RD did not assess the resident timely. Resident #5 had a gradual (severe) weight loss since April 2020 with a 16.24% weight loss in 6 months, 7.0% weight loss in 3 months, 4.69% in one month and the resident experienced a major change in functional status. The facility failed to offer care planned interventions routinely and failed to document accurate meal intakes. The facility failed to ensure a registered dietitian assessed the resident timely. B. Imposition of immediate jeopardy On 10/1/2020 at 6:50 p.m., the nursing home administrator (NHA), director of nursing (DON) and minimum data set coordinator (MDSC) were notified of the immediate jeopardy situation created by the facility's failure to prevent severe weight loss for Resident #8, #3 and #5. C. Facility plan to remove immediate jeopardy On 10/2/2020 at 5:48 p.m., the facility submitted a plan to abate the immediate jeopardy. The abatement plan read: 1. Corrective action The MDS coordinator (MDSC) will pass the evening shift snacks on 10/1/2020. Nursing staff will assist residents that require assistance with eating. Each certified nurse aide (CNA), on a routine basis, will give the snack to the resident on their assignment sheet. Nursing staff will have access to a fully stocked snack cart for night shift to give as needed (PRN) snacks. 2. Identification of others A weight report will be run and reviewed by the dietary manager (DM) and DON for the last six months. Any residents with weight loss identified will be communicated with the registered dietitian (RD). Interventions will be put into place immediately and if current interventions are ineffective, new interventions will be initiated. The primary care provider (PCP) and power of attorney (POA) will be informed of weight loss and interventions. The RD will review the report and assess identified residents on 10/2/2020 and implement necessary interventions to prevent ongoing weight loss. The RD will obtain a weight report from Point Click Care. 3. Systemic changes When a resident eats less than 25% of their meal, the resident will be offered an alternative option by dietary staff and document on the sheet what was offered and if the resident accepted or refused. Staff will be educated on documenting the accuracy of percentile of food consumed in accordance with what was served to the resident compared to the posted menu option and should include carbohydrate and protein. Dietary staff will notify the nurse if a resident refuses a meal. The nurse will do an intervention and document the outcome, i.e, the nurse will provide supplement, ask for preferences and offer an alternate meal. RD visits will be increased to bi-monthly the first and third week of the month beginning in October 2020. The facility will have a greater variety of nutritional supplements, so a greater variety of interventions are available if someone (is) not eating/drinking. These will include Nepro, Ensure, [MEDICATION NAME] and Boost Breeze. The nurses will be educated to offer supplements to residents who refuse their meal/alternate meal and will encourage intake and cue at each administration. This will be documented in the PRN supplement order for each resident to be put in 10/2/2020. The nurse (is) to document percent consumed. The nurses will be educated by 10/6/2020 by the DON. 4. Monitoring The facility will conduct a weekly nutrition at risk (NAR) meeting with the DON (or designee), the DM (dietary manager), and the RD (registered dietitian) to review each resident identified to be at risk for weight loss including residents identified eating less than 25 % of their meal for three or more days. The DM and DON will review meal intake five days a week. Any resident with decreased intake of 25% or less for three or more days will be referred to their PCP (primary care provider). D. Removal of the immediate jeopardy The above plan was accepted on 10/2/2020 at 5:48 p.m., and the immediate jeopardy removed. However, observations, record review and interviews revealed deficient practice remained at a G level, actual harm that is isolated II. FACILITY POLICY AND PROCEDURES The Nutritional Assessment policy, revised October 2017, was provided by the business office manager (BOM) on 10/1/2020 at 3:53 p.m. It read, in pertinent part, As part of the comprehensive assessment, the nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. The dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition. As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. The multidisciplinary team shall identify, upon the resident's admission and upon his or her change of condition, situations that place the resident at increased risk for impaired nutrition: -Cognitive or functional decline - includes anything that impairs the resident's ability to eat the meals that are provided (decreased mental alertness); -Increased need for calories and/or protein - onset or exacerbation of diseases or conditions that result in a hypermetabolic state and an increased demand for calories and protein ([MEDICAL CONDITION]). Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident's for nutritional complications. 2. The Weight Assessment and Intervention policy, revised on September 2008, was provided by the business office manager (BOM) on 10/1/2020 at a.m. at 3:55 p.m. The policy read in pertinent part: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Weight Assessment: -The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. -Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Verbal notification must be confirmed in writing. -The Dietitian will respond within 24 hours of receipt of written notification. -The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. -The threshold for significant unplanned and undesired weight loss will be based on the following criteria: One month- 5% weight loss is significant; greater than 5% is severe. Three months- 7.5% weight loss is significant; greater than 7.5% is severe. Six months - 10% weight loss is significant; greater than I0% is severe. III. RESIDENTS WITH SEVERE WEIGHT LOSS A. Resident #8 1. Resident status Resident #8, age 85, was admitted on [DATE] and readmitted on [DATE]. According to the September 2020 computerized physician orders [REDACTED]. According to the 8/26/2020 minimum data set (MDS) assessment, the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of 15. He required extensive one-person assistance with bed mobility, transfers, dressing, toileting, and personal hygiene, and supervision set-up for ambulation on the unit and for eating. The swallowing/nutritional status MDS, dated [DATE], documented the resident had a weight loss of 10% or more in the last six months and was not on a prescribed weight loss program. The most current dietary profile, dated 8/26/2020, documented the resident required set-up assistance for meals and partial assistance for eating. A provider progress note dated 9/9/2020 revealed the resident's weight was not stable. 2. Observations On 9/29/2020 at 5:01 p.m., the resident's room tray was delivered. The resident was served potato soup, grilled cheese, beets, and dessert. The resident only ate a few bites of his grilled cheese sandwich. The dietary staff picked up the resident's dinner tray at 5:37 p.m. and discarded it in the trash, documenting the resident ate 26-50%. On 10/1/2020 at 4:56 p.m., the resident was served a chicken patty and mashed potatoes covered in gravy, spinach and pudding in his room. The resident only ate a few bites of his food. None of the nursing staff entered the resident's room to assist him or offer an alternative meal. The dietary staff picked up the resident's dinner tray at 5:58 p.m. and discarded it in the trash, documenting the resident ate 0-25%. Dietary staff, too, did not offer him an alternative. 3. Record review revealed severe weight loss since the resident's readmission 3/20/2020. While the 8/26/ swallowing/nutritional status MDS (see above) documented the resident had experienced a 10 % weight loss or more in the last six months, Resident #8 experienced a severe weight loss of (15.2 lbs/11.59%) in three months and (30.2 lbs/20.66%) in six months. Specifically, he weighed: 3/31/2020: 146.2 lbs 6/30/2020: 131.2 lbs 8/31/2020: 119 lbs 9/29/2020: 116 lbs 3. Facility response to Resident #8's weight loss Care plan: The resident's care plan 3/20/2020 (last revised on 8/26/2020) revealed the resident was on a regular diet with regular textures and thin liquids. The resident had a nutritional problem or potential nutritional problem related to a history of failure to thrive. Interventions included: -Assist with menu choices and make substitutions as needed, initiated 3/24/2020; -Continue to notify the PCP and POA of weight status, initiated 4/27/2020; -Encourage all meals and snacks, initiated 4/27/2020; -Monitor/document/report to physician as needed (PRN) for signs and symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth. Several attempts at swallowing. Refusing to eat. Appears concerned during meals, initiated 3/20/2020; -Offer house supplement at 1000 (10:00 a.m.) and 1900 (7:00 p.m.). Nurse to administer and document percent consumed, initiated 5/27/2020 and revised revised 8/24/2020; -RD to evaluate and make diet change recommendations PRN, initiated 3/20/2020; and -Record percent of all meal intake, initiated 3/24/2020. Nutrition, weight and nursing progress notes: -A nutrition progress note by the RD following the resident's original admission was not found upon review of the resident's record. -A nutrition progress note by the RD following the resident's readmission 3/20/2020 was not found upon review of the resident's record. -The first nutrition progress note by the RD was dated 5/21/2020. It revealed the resident's current body weight (CBW) was 139.6 lbs with a BMI of 26.4, suggesting the resident was slightly overweight. The RD documented the resident was seen for weight risk and quarterly nutritional assessment. The resident's weight was down 3 lbs (2.1%) for one month and 18 lbs (11.5%) over the past three months since admission. The resident was on [MEDICATION NAME] 40 milligrams (mg) for [MEDICAL CONDITION] and was expected to have some weight fluctuation related to fluid loss. Estimated nutritional needs were calculated using the resident's ideal body weight (IBW) of 123 lbs. The resident had inadequate meal intake due to dementia as evidenced by significant weight loss over three months since admission. This was the first nutrition progress note documented by the RD since the resident readmitted to the facility. -A nutrition progress note 5/27/2020 revealed the resident's BMI was 28.9 and his appetite was good. The RD would continue to monitor the resident. -A nutrition progress note dated 6/24/2020 revealed the resident's current weight was 132.8 lbs, suggesting the resident was overweight. The RD documented the resident was reviewed for significant weight loss, as the resident had a 10% weight loss over the past three months. The etiology (cause) for weight loss was unknown, but thought to be related to sporadic meal intakes. The resident's meal intake was generally between 25% and 75%. The RD did not make changes to the nutritional plan of care as the resident's weight appeared to be stabilizing. -A nutrition progress note dated 7/30/2020 revealed the resident's current weight was 130.2 lbs with a BMI of 24.6. The resident had a weight loss of 9.6 lbs (6.8%) in less than a month. The RD documented the resident was eating 50% of most meals, drank the nutritional supplement and overall met his nutritional needs. The nutritional supplement could be increased to 8 ounces (oz) if the resident continued to lose weight. RD will continue to monitor as needed (prn). -A nutrition progress note dated 8/26/2020 revealed the resident's current weight was 118 lbs with body mass index (BMI) of 22.3. The resident had a weight loss of 12.2 lbs (9.4%) in one month. The residents meal intake was less than 50%. The RD documented increasing the supplement to 8 oz twice a day if his meal intake remained poor. -A weight progress note dated 9/16/2020 revealed the resident's current weight was 114.4 lbs, a decrease of 4 lbs. In the last seven days, the resident refused three meals and ate 0% to 25% of six meals. The resident received a nutritional supplement twice a day. The RD was asked to evaluate the resident for weight loss. -A nursing progress note, dated 10/1/2020 revealed the resident took a few bits of breakfast and lunch. He was asked if he would like something else to eat and he replied he just was not hungry. CPOs: -The resident had orders to receive 4 oz of nutritional supplement once a day, start date 6/24/2020 -The resident had orders to receive 4 oz of nutritional supplement twice a day, start date 8/17/2020. -The resident had orders to receive 4 oz of nutritional supplement once a day at 10:00 a.m. and 7:00 p.m., start date 8/24/2020 -The resident had orders to receive 8 oz of nutritional supplement twice a day, start date 10/6/2020. 4. Failures in facility response to Resident #8's severe weight loss. a. See nutrition and weight progress notes above; the RD did not assess the resident's nutritional status in a timely manner. Record review revealed the resident was not seen by nutrition services until 5/21/2020, two months after his readmission 3/20/2020 and three months after his original admission. At the time of the May assessment, the resident had lost 6.6 lbs/4.51%. b. See nutritional progress notes 7/30/2020 and 8/26/2020 and CPOs above; The resident did not receive timely interventions to address the weight loss. Although the RD wrote in the 7/30/2020 note that the resident's nutritional supplement could be increased from 4 oz to 8 oz, the resident's supplement was not increased until 8/17/2020. This was 18 days the 7/30/2020 note, documenting the resident had lost 3.6 lbs/2.7%. Further, although the RD note on 8/26/2020 documented a supplement increase of 8 oz from once to twice a day, the resident's supplement was not increased twice a day until 10/6/2020 (during survey), 41 days later. c. See weight progress note 9/16/2020 above; the RD was asked to evaluate the resident for weight loss (resident's weight 114.4 lbs, down 4 lbs), meal refusals, and poor intake (0- 25% for six meals. However, there was no evidence of follow up from the RD that s/he had completed an assessment. d. See observations on 9/29/2020 and 10/1/2020, nutrition notes and a 10/1/2020 nursing note above; the resident did not consistently receive the interventions which were part of his plan of care. Observations revealed the resident was not assisted or encouraged during the two meals observed. And, although the resident was asked if he would like something else to eat on 10/1/2020, there was no documentation the resident received assistance and encouragement during the meal. Observations further revealed on 9/29/2020, dietary staff incorrectly calculated the resident's meal intake, calculating bites as intake of 26-50%. Nutrition notes further revealed that, contrary to the care plan, the RD did not evaluate and make diet change recommendations timely. As noted above, the RD did not assess Resident #8 until 5/21/2020. B. Resident #5 Resident #5, age 83, was admitted [DATE] and readmitted [DATE]. According to the October 2020 CPO, [DIAGNOSES REDACTED]. The 9/15/2020 MDS assessment revealed the resident had no cognitive impairment with a BIMS score of 13 out of 15. This assessment revealed a significant decline in status in relation to the previous assessment on 6/15/2020. The resident had a 17 pound weight loss and was not on a prescribed weight loss regimen. The resident required more assistance with her activities of daily living (ADLs) including bed mobility, transfers, walking in the room and corridor, locomotion on and off the unit, and toileting. The resident was now frequently incontinent bowel and bladder. The resident was now wandering, was restless and agitated and had two or more falls with no injury and two or more falls with minor injury. (Cross-reference F637 for failure to do a significant change assessment) The resident's care plan, initiated 3/10/2020, revealed the resident was on a regular diet with regular textures and thin liquids. Interventions included: -Assist with menu choices and make substitutions as needed, initiated 3/10/2020; -Monitor/document/report to the physician as needed any signs and symptoms of dysphagia (difficulty swallowing), initiated 3/10/2020; 1. Resident nutritional/weight status April 2020 through July 2020 According to the weight summary record, the resident's weight upon admission on 3/10/2020 was 152 pounds. Her ideal body weight (IBW) range was 158 - 191 pounds. By 4/2/2020, the resident's weight was 155.2 pounds; however, by 5/1/2020, the resident's weight was down to 149.6 pounds. On 6/2/2020, the resident's weight was 147 pounds. A dining services progress note on 6/17/2020 revealed the resident's appetite was fair and her body mass index (BMI) was 22.3 (a normal BMI is 18.5-24.9). According to the weight summary record, on 7/1/2020, the resident's weight was down to 139.8 pounds. This was a 9.92 % weight loss in three months. A week later on 7/8/2020, the resident's weight was 133.8 pounds, a six pound weight loss. A 7/30/2020 dining services progress note by the RD revealed the resident's BMI was 20.6 (a 1.7 drop in 6 weeks) and current weight was 135.2 pounds with her weight trending down with an 11 pound (11 percent) weight loss in one month. 2. Facility response and failures in response to Resident #5's severe weight loss April 2020 through July 2020 a. Facility response Progress notes: A 7/8/2020 weight progress note revealed the resident was reviewed by the dietary manager (DM) and the director of nursing (DON) in the weekly weight meeting. However, the resident's weight of 139.8 pounds from 7/1/2020 was used instead of the weight of 133.8 pounds obtained on 7/8/2020. The note indicated the resident's appetite was fair and she was to receive the house supplement three times a day related to a nutritional deficiency and weekly weights were to be monitored. A 7/22/2020 weight change progress note revealed the provider was to review the resident's weights and medications. It indicated the resident's cognitive decline contributed to her weight loss. The 7/30/2020 dining services progress note by the RD (see above) indicated Resident #5's weight (135.2) was stable since starting nutritional supplements and the plan was to continue the supplements three times a day and the RD would follow as needed. Orders: The July 2020 physician orders [REDACTED].>-A house supplement three times a day. Record percent of amount consumed, ordered 7/8/2020; -Offer half a peanut butter and jelly sandwich after meals, ordered 7/22/2020. Care plan: The resident's care plan (see above) was updated to include the following interventions: -Encourage all meals and snacks, initiated 7/24/2020; -Report continued loss to the physician, initiated 7/24/2020; -Offer house supplement three times a day as ordered, initiated 7/24/2020 b. Failure in facility response - untimely RD assessment The 7/30/2020 dining services progress note by the RD (see above) was the first documented assessment by the RD since the resident's admission in March 2020. There was no indication in the resident's record that the RD was involved prior to 7/30/2020, as the resident's weight declined. 3. Resident nutritional/weight status August 2020 to October 2020 a. August 2020 - continued weight loss, facility response and failures in facility response Review of the weight summary report revealed the resident's weight was only obtained twice in August 2020 on 8/1 and 8/12/2020. However, weights were documented in the follow progress notes: -An 8/13/2020 weight progress note revealed the resident was reviewed in the weekly weight meeting with the DM and DON. It indicated the resident's current weight was 130.4, a decrease of 2.4 pounds since 8/1/2020. The plan was to continue to monitor weekly weights. -An 8/20/2020 weight progress note read the resident's current weight was 132.8 pounds, an increase of 2.4 pounds. It revealed the resident would continue with supplements three times a day and the resident's weight would be monitored monthly. -An 8/26/2020 weight progress note by the RD revealed the resident was being seen for a weight loss of 16.6 pounds in less than three months (11.3% indicating severe weight loss). It revealed supplements were recently started and would continue three times a day with the current diet. This was the first comprehensive assessment documented by the RD that included the resident's estimated nutritional needs of calories, protein and fluid. The resident's care plan was revised 8/26/2020 to include that the nurse was to administer supplement at 10:00 a.m., 2:00 p.m., and 7:00 p.m. and document the percent amount consumed. b. September 2020 to October 2020 - continued weight loss, facility response and failures in facility response Review of the weight summary report for September 2020 revealed the following weights: -9/1 -136.4 pounds; -9/7 - 133.8 pounds; -9/15 - 129.8 pounds; and -9/22 - 130 pounds. Review of the weight summary report for October 2020 revealed the resident's weight on 10/2/2020 was 127.6 pounds, a 2.4 pound weight loss in a week. Facility response: -A 9/11/2020 weight progress note revealed the resident's current weight was 133.8 pounds. It indicated the resident had a six pound weight gain in one month. It did not, however, indicate the resident was again losing weight (see weight summary report above). The note revealed the primary care physician (PCP) requested clarification by the resident's power of attorney (POA) if they wished to pursue artificial nutrition by tube according to the resident's MOST (advance directive) form. -Another 9/11/2020 weight progress note revealed the POA did not want artificial nutrition by tube at that time and the pharmacist was asked to review the resident's medications due to weight loss. -A 9/14/2020 MDS assessment note revealed the resident had a 14.2 pound weight loss from 6/2-8/1/2020 and her food intake was probably inadequate at that time according to the percentages the resident was consuming. -A 9/16/2020 weight progress note revealed the resident's current weight was 129.8 pounds, a decrease of four pounds. It indicated the resident had a fair appetite; however, the resident had nine meals in the last seven days that she consumed 0-25 %. It indicated the resident had an order for [REDACTED]. -A 9/16/2020 dining services progress note revealed the resident's appetite was fair and her BMI was 19.7 (down 0.9 in 7 weeks). It indicated the resident was offered a house supplement three times a day, peanut butter and jelly sandwich with the bedtime snacks (ordered to be given after meals), a soda at the 2:00 p.m. snacks and ice cream at lunch and supper. -A 9/18/2020 weight progress note by the RD revealed the resident's weight was trending down. It indicated the resident was receiving a house supplement three times a day, half of a peanut butter and jelly sandwich after meals, and ice cream twice a day. It revealed the resident was drinking the house supplements and the plan was to wait to see the effectiveness of the ice cream. -A 9/24/2020 weight progress note revealed the resident's current weight was 130 pounds. It indicated the resident was getting the house supplement three times a day, ice cream at lunch and supper, peanut butter and jelly sandwiches for the night snack, a soda and meat sandwich at the afternoon snack, and a high calorie cookie at the morning snack. It indicated assessments had been completed by the pharmacist and the RD and given to the PCP for review with no response at that time. The plan was to continue to monitor weekly weights. The resident's care plan was revised 9/28/2020 to read, Will offer ice cream at lunch and supper, a hi-calorie cookie with the 9:00 a.m. snacks, a meat sandwich, chips and soda with the 2:00 p.m. snacks and a peanut butter and jelly sandwiches with the night time snacks, revised 9/28/2020. According to a 9/29/2020 nurse practitioner (NP) progress note, the resident had been having weight loss probably due to isolation, inability to go out weekly due to COVID-19, the death of her daughter and progressive dementia. It indicated she was eating 0-25% of breakfast most of the time so they added ice cream at noon and supper and sandwiches between meals (but see observations above). The note indicated her weight was 130 pounds and had stabilized. Review of all the PCP progress notes since the resident's admission in March 2020 revealed the 9/29/2020 NP note was the first mention of the resident's weight loss since her admission in March, 2020. Failures in facility response: Observations revealed care planned interventions (see care plan above) were not consistently implemented; specifically, the resident was not encouraged to eat, she was not offered ice cream as planned, and in addition, the resident's meal intake was not being accurately recorded. -On 9/29/2020 at 12:07 p.m., the resident was ambulating down the hallway. Her lunch tray was in her room on the over-the-bed table and had not been touched. The resident was served roast beef, mashed potatoes, corn and peaches. Ice cream was not on the resident's tray. The dietary staff picked up the resident's lunch tray at 12:14 p.m. and discarded it in the trash. Staff documented the resident had refused the meal. -On 9/29/2020 at 4:46 p.m., the resident was served potato soup, grilled cheese, beats and a glass of juice. Again, there was no ice cream on the resident's tray. At 5:28 p.m. the resident was leaning over the armrest of her recliner. She had eaten only the soup and did not drink the juice. The dietary staff picked up the resident's supper tray at 5:36 p.m. and discarded it in the trash. Staff did not offer the resident an alternative or ice cream afterwards. Staff documented the resident ate 0-25% of the meal. -On 9/30/2020 at 11:53 a.m., the resident was lying in her bed. Her lunch tray was on the bed-side-table and had not been opened, her coffee was still covered with plastic wrap. The resident had been served a chicken patty with gravy, green beans and cake. No ice cream was on her tray. At 11:58 a.m., the nurse walked into the resident's room, woke her up and assisted her to sit up on the side of the bed; the nurse then left the room. At 12:03 p.m., the resident was lying down on the bed again and had not touched her food. At 12:22 p.m. the dietary staff picked up the resident's lunch tray and discarded it in the trash. She had not consumed either food or fluids and she was not offered an alternative or ice cream afterw(TRUNCATED)

Based on observations, record review and resident and staff interviews, it was determined that the facility failed to provide care and services to attain or maintain the highest practicable physical well-being for one (#4) of 11 sample residents. Specifically, the facility failed to: -Ensure physician ordered pain medications were provided timely, -Notify the Primary Care Physician (PCP) when the resident experienced severe pain, -Ensure the ordered [MEDICATION NAME] was available for administration for resident #4, a hospice resident with a [DIAGNOSES REDACTED]. -Appropriately assess, monitor, address, manage and document resident #4's pain, and -Timely initiate all physician orders [REDACTED]. Although the resident had multiple physician ordered medications, the facility failed to administer increased doses and combinations of those medications as ordered for pain relief. Specifically, the facility failed to medicate the resident with other ordered medications when one of the pain medications was ineffective for pain relief. The resident voiced that his pain remained at 9/10 from 8:45 a.m. through 4:45 p.m., even after small doses of [MEDICATION NAME] were administered starting at 1:58 p.m., when the dose of [MEDICATION NAME] was first available and administered (on 12/12/11). review of the resident's medical record revealed [REDACTED]. At the time the resident voiced that his pain level was at 9/10, same as it was at 8:30 a.m., that day. These failures contributed to the resident experiencing uncontrolled pain which he, consistently (for three days), described as 9/10 on a scale of 1-10, with 10 being the highest level of pain, and that the assessing nurse described as a "pain crisis." Findings include: I. Expectations for Pain Management A. Professional Reference: 1. "Clearly, for many years clinicians have been placed in a challenging situation . . . they had no standards for assessment and treatment (of pain). . . . Critical to correcting this is establishing a standard for assessing the existence and intensity . . . if caregivers do not agree on a standard for assessing pain intensity, each is likely to assess pain differently . . . the care of a single patient can vary from one caregiver to another, very likely resulting in unrelieved pain. . . . Many studies have shown that either lack of pain assessment or the existence of differences between the clinicians' pain ratings and those of patients is a major cause of inadequate pain management. Source: McCaffery, Margo and Pasero, Chris, "Pain: Clinical Manual," 2nd edition, Mosby, St. Louis, 1999, pp. 5 and 36.) 2. McCaffery M, Pasero C: Pain: Clinical Manual, Copyright 1999, Mosby, Inc. Standards for Pain, Assessment, Treatment, and Documentation, P. 732, in pertinent part, read: -Patients will be promised attentive [MEDICATION NAME] care by being informed verbally and in writing at the time of their initial interview that effective pain relief is an important part of their treatment, that their report of unrelieved pain is essential, and that staff will respond quickly to their reports. -Patients will be taught to use a pain rating scale. When patients are taught to use the pain rating scale, they will be asked to set a comfort (pain relief) goal. Patients will be told that pain rated above the goal . . . will trigger an [MEDICATION NAME] dose increase, additional [MEDICATION NAME], other pain relief intervention. -Pain ratings that are persistently above the comfort goal will trigger interdisciplinary review of the pain management plan and a modification in treatment. B. Facility Pain Management Policy: The facility's pain management policy was requested from the Director of Nursing (DON) on 12/12/11. The policy read in pertinent part: "PAIN MANAGEMENT . . . Purpose . . . To ensure comfort for Residents and manage pain . . . Identify by: Observations . . . or interviewing resident . . . Reviewing residents' records-e.g. . . . residents receiving palliative care . . . Procedure: All residents will be assessed . . . or reassessed for pain . . . using the pain evaluation tool . . . when there is a change in the resident's health status that affects their pain . . . The residents . . . pain will be monitored . . . as needed (PRN) for any changes in their pain status. The assessment will be documented . . . The resident's pain will be measured by using the Wong Baker or Numeric FLACC Scale every shift by the licensed nurse. The licensed nurse will provide and document effectiveness of pharmacological and non-pharmacological interventions on the residents MAR (medication administration record) and clinical record. . . . An individualized care plan will be determined and initiated along with treatment options . . . The effectiveness of the interventions will be evaluated. Consideration will be given to alternative interventions as appropriate." The policy further indicated that the licensed nurse would evaluate the pain, communicate with the physician (MD) as needed, and monitor the effectiveness of interventions, and document pain interventions and their effectiveness." Resident #4, [AGE] years old, admitted to facility on 10/11/11. His primary admission [DIAGNOSES REDACTED]. The resident was admitted for palliative care. On 10/20/11, physician's notes indicated that the resident was admitted to hospice care secondary to a small bowel obstruction for which the resident and family had refused surgery. 1. Resident Status The resident's Minimum Data Set (MDS), dated [DATE], was reviewed and revealed the following: -The resident scored 15 on his brief interview for mental status (BIMS), indication of no cognitive deficits. The resident had no short-term or long-term memory impairments. The resident understood others and was usually understood by others as he had unclear speech. The resident had no behavioral symptoms. -The resident was totally dependent on one to two staff for all activities of daily living (ADL's). The resident had limitations with range of motion (ROM) in all four extremities. The resident used a wheelchair (WC) for mobility. -The resident had an indwelling Foley catheter in place and [MEDICAL CONDITION] in place. -The MDS indicated no scheduled pain medication regiment. The MDS indicated that the resident rarely had pain. The resident rated the intensity of his pain as moderate. The MDS indicated that the resident received Hospice care. 2. Pain Management Care Plans a. Facility Care Plan The resident's facility care plan was reviewed and no specific pain management care plan was revealed. However, the resident's care plan, dated 10/20/11, indicated that the resident/family expressed wishes for no aggressive medical treatment with goals of being kept comfortable, due to bowel obstruction. The care plan read in pertinent parts: "Hospice Care." The goal for the care plan read in pertinent parts: "Resident's wishes will be respected as evidenced by verbal/nonverbal indications of comfort x 90 days. Approaches to the care plan read in pertinent parts: Administer medications as ordered . . . Encourage resident to express feelings . . . Follow orders and guidelines for comfort care as outlined by physician orders [REDACTED]. . . All orders per Hospice . . . See Hospice care Plan in chart." Review of the resident's chart revealed no hospice care plan. On 12/13/11 at 4:30 p.m., the DON was asked to provide the resident's hospice care plan; none was provided prior to exit or faxed after exit. Pain Medications Review of computerized physician orders [REDACTED]. 1. "[MEDICATION NAME] 20/mg/ml sol (solution) 0.5-1 ml (=5-20 mg) under tongue every hour as needed for pain." That order was initiated on 10/19/11. 2. Tylenol 325 mg tab (tablet) . . . 2 tablets . . . p.o. (orally) every 6 hours as needed for fever." That order was initiated on 6/25/09. 3. [MEDICATION NAME] ([MEDICATION NAME]) 50 mg tab p.o. every 6 hours as needed for pain. One tab orally three times a daily as scheduled, for a [DIAGNOSES REDACTED]." [MEDICATION NAME] was initiated on 10/18/11. "Pain Assessment q (every) shift, record results (1/10 scale)." A pain management flow sheet was included in the resident's MARs. The flow sheet read in pertinent parts: "For each medication enter medication name/date, dose/time pain rating score (from scale below), related behavior and vital signs." The scales as indicated in the facility pain management policy read as follows: "0 (zero) no pain . . . 2 Mild Pain Annoying . . . 4 Nagging Pain, Uncomfortable, Troublesome . . . 6 Miserable Distressing . . . 8 Intense, Dreadful, Horrible . . . Unable to do most activities because of pain ...10 Worst Pain Possible, Unbearable . . . unable to do any activities." Although the resident was assessed with [REDACTED]. Review of the 12/11 MARs and nurses' notes for pain medication administration revealed: Review of the resident's pain assessment indicated no pain (0) (or fever) documented on all shifts on 12/7/11 and 12/9/11. Yet the resident was medicated with Tylenol on those dates. In addition, there were no documented times or reasons for the administration of Tylenol on those dates, as indicated by the facility policy. Furthermore, there was no documentation that indicated that the results of the interventions were assessed, also indicated by the facility policy. Review of the resident's pain assessment indicated no pain (0) on all shifts on 12/10/11, yet the resident was medicated with Tylenol on 12/10/11 at 6:30 p.m., for the complaint (C/O) of a headache. Again, on that date, the resident's level of pain was not assessed. There was no documentation that indicated the results of the interventions were assessed, as indicated by the facility policy. The 12/11 MAR revealed that, on 12/11/11 at 7:30 p.m., the resident was medicated with [MEDICATION NAME] for a C/O right (R) elbow pain. Again, the pain assessment on all shifts was erroneously documented that the resident had no pain that day. There was no indication or documentation of the resident's elbow pain intensity or if [MEDICATION NAME] relieved that pain on 12/11/11, as indicated by the facility policy. The 12/11 MARs revealed that, on 12/12/11 at 8:30 a.m., the resident was medicated with [MEDICATION NAME] for a C/O left arm pain. Review of pain assessment for the day shift read in pertinent parts: "+". There was no indication that the intensity of the pain was assessed at that time. There was no indication or documentation if [MEDICATION NAME], which was administered at 8:30 a.m., relieved the resident's pain or if a nurse had re-assessed the resident's pain after 8:30 a.m. By 1:40 p.m., the resident rated his pain level as 9/10 and had only been medicated with [MEDICATION NAME] at 8:30 a.m. The resident was still in pain at 10:00 a.m. (see nurses' notes below). No further medications were given and no physician notification was initiated for further instructions, as indicated. A review of nurses' notes, on 12/12/11 at 1:35 p.m., revealed no evidence of nurses' notes, dated 12/12/11, in regards to the resident's change of condition (increased pain or follow up). The last documented nurses' notes were dated 12/11/11 at 10:55 p.m., and read in pertinent parts, "24 . . . (hour) chart review complete." Observations: On 12/12/11 at 1:40 p.m., resident #4 was observed while sitting up in W/C. The Hospice Registered Nurse (HRN) was assessing the resident's pain at the time. In the presence of the HRN and the surveyor, the resident, who used a board for communication, indicated that his pain to his right arm was at 9/10 at a scale of (10/10). Through the communication board and HRN interpretation, the resident stated that the pain had been ongoing for three days. The resident stated that his right arm was hurting since Friday (12/9/11). The HRN stated that the facility RN had called the Hospice nurse that morning, at about 9:00 a.m., and indicated that the resident's [MEDICATION NAME] was not relieving the resident's pain. The HRN stated, "The pain medications are not helping. I just brought in some [MEDICATION NAME]." Although the resident's computerized physician orders [REDACTED]. The resident was administered [MEDICATION NAME] at 8:30 a.m., without relief by 10:00 a.m., and no other medications, specifically [MEDICATION NAME], was available for administration, even though it had been ordered by the resident's physician on 10/19/11. Despite the Hospice nurse being notified that [MEDICATION NAME] was unavailable, the resident's physician was not notified that [MEDICATION NAME] was unavailable and/or for further instructions when the resident experienced increased pain (which was a change for the resident) or unrelieved pain. The HRN further stated that RN #1 (the resident's primary RN) had called the HRN that morning at about 9:00 a.m., and requested some [MEDICATION NAME] for resident. The HRN stated, "[MEDICATION NAME] was not helping much . . . I could not get in to see the patient (resident) right away, I was seeing other patients (outside of the facility as clarified by the HRN in that interview) and I am waiting for the pharmacy to fill the [MEDICATION NAME] . . . I was able to get in a little while ago, at about 1:30 p.m." During that conversation, the resident stated, "It has been hurting since Friday (12/9/11)." The resident stated that there had been no change in his pain level since the morning on that date. The resident stated to the HRN and surveyor that his pain level remained at a 9/10 since that morning until now (1:40 p.m.). At 1:58 p.m., RN #2 (who was covering for RN #1, the resident's primary nurse) was notified of the resident's complaint of pain. RN #2, without assessing the resident's pain level, administered [MEDICATION NAME] to the resident. As RN #2 administered the medication, the HRN stated to the resident, "You are getting [MEDICATION NAME]. Let's see how that works." On 12/12/11 at 2:00 p.m., RN #2 was asked about the resident's pain level. In the interview RN #2 stated, "When I gave the [MEDICATION NAME], I did not assess his pain level . . . Normally I assess pain level before administration of pain medication," as indicated by the facility policy. On 12/12/11 at 2:51 p.m., RN #1 was interviewed about the resident's pain through the course of the day. RN #1 confirmed that she was resident #4's primary nurse. RN #1 stated, "I was told by a CNA that the resident was having left arm pain this morning. . . . I went to the dining table where he was sitting (at 8:30 a.m.) . . . I went and talked to him and he was having pain . . . I did not rate the pain level at that time . . . I gave him [MEDICATION NAME] . . . At about 9:00 a.m., the Hospice Certified Nurse Aide (HCNA) reported to RN #1, that the resident's pain was a 9/10, that was after I administered [MEDICATION NAME]. . . . I did not go to assess the resident myself . . . I went with the CNA's word . . . I then called Hospice for [MEDICATION NAME] . . . I did not look at the resident at that time (9:00 a.m.) . . . There was no [MEDICATION NAME] to give (as ordered by the physician)." On 12/12/11 at 2:23 p.m., RN #1 was observed as she assessed the resident's left arm. The resident communicated by pointing and using the communication board that it was not the left arm that hurt, instead, it was the right arm. RN #1 stated to the surveyor for clarification, "He says that it is the right arm that hurts. I did not assess the right arm this morning, instead, I looked at the left arm. . . . I think I recorded the pain in the MARs from this morning." After reviewing the resident's MARs with RN #1, she stated, "There is no recording on where the resident's pain was located this morning but I recorded on the MARs that I gave [MEDICATION NAME] at 8:30 a.m. . . . Instead of the right arm, I looked at the left arm. . . . I have not documented the resident's change in pain elsewhere. . . . At 9:00 a.m., after the HCNA assessed the resident, . . . I called the Hospice RN. . . . There was nothing else for me to give the resident . . . I did not re-assess the resident's pain level after I gave the [MEDICATION NAME] this morning . . . Normally I assess pain but today I forgot." There were late nursing note entries, dated 12/12/11, (timed 9:00 a.m., 10:00 a.m. and 2:45 p.m.). Those late entries in the nurse's notes, dated 12/12/11 at 9:00 a.m., read in pertinent parts, "At 8:20 (a.m.) CNAs informed me (RN #1) . . . resident) was having left arm pain . . . assessed for pain (although interview with RN #1 revealed no pain level rating) . . . stated that he was having pain . . . Full assessment not done . . . gave [MEDICATION NAME] ([MEDICATION NAME]) at 8:30 (a.m.) . . . 10:00 (a.m.) Hospice aide (HCNA) reported . . . (resident) stated pain is 9/10." Again, there was indication that RN #1 assessed the resident's pain level at this time as indicated, instead she called the Hospice nurse and reported what the HCNA had voiced (pain of 9/10). Nurses' notes further read in pertinent parts, "I called the Hospice nurse . . . reported . . . pain . . . that the [MEDICATION NAME] was unsuccessful in . . . (reducing) . . . (resident's) pain . . . Hospice nurse stated she would get . . . [MEDICATION NAME] from pharmacy and bring to facility . . . While I (RN #1) was gone to lunch the covering nurse (RN #2) reports she gave [MEDICATION NAME] 0.5 ml . . . to . . .(resident) for pain. To my (RN #1's) knowledge, hospice RN was assessing . . . (between 1:30 to 1:58 p.m.) pain." After the surveyor brought it to the facility's attention, RN #1's notes read in pertinent parts, "1445 (2:45 p.m.) I assessed . . . (resident's) pain is 9/10 in right arm. I palpated . . . (R) arm, did not feel any deformities . . . no [MEDICAL CONDITION], and denies any injuries and trauma. Administered [MEDICATION NAME] 0.5 ml . . . 1600 (4:00 p.m.). I passed by . . . (resident's) room several times. I observed him watching TV, no moaning or grimacing noted . . . At 1645 (4:45 p.m.) I re-assessed . . . (resident's) pain was 8/10, Tylenol 650 mg given." Although the resident was ordered multiple pain medications, review of the resident's MARs revealed that all the medications that the resident could have were not administered in all the possible doses and combinations. The resident continued to experience unrelieved pain levels between 8:30 a.m. and 4:45 p.m. on 12/12/11. Minimal medications and doses were administered during that time, and the resident's pain level remained at 9/10 during that time period on 12/12/11. The 12/11 MAR indicated, through documentation, that pain medications were administered on 12/12/11 between 8:30 a.m. and 4:45 p.m., however, without pain relief for the resident. These included: -At 1:30 p.m., (although observations indicated administration of [MEDICATION NAME] at 1:58 p.m.) [MEDICATION NAME] 0.25 ml for pain of 9/10. -At 2:55 p.m., [MEDICATION NAME] 0.5 ml for pain of 9/10. -Although the resident could have 1.0 ml of [MEDICATION NAME] every hour, no further [MEDICATION NAME] was documented as administered between 8:30 a.m. through 4:45 p.m. the resident's pain level remained at 9/10. -[MEDICATION NAME] was administered at 8:30 a.m., without pain relief (HCNA reported pain level of 9/10 to the RN at 8:45 a.m. or 9:00 a.m.). No further doses were administered that day, although the resident could have [MEDICATION NAME] 50 mg every 6 hours as need. -Tylenol, although ordered every six hours as needed for fever, was administered to the resident when he complained of pain. On 12/12/11 the resident was administered Tylenol for right arm pain of 9/10 at 4:05 p.m. The resident could have a maximum of 4 GM of Tylenol every 24 hours. On 12/13/11 at 1:30 p.m., the Director of Nursing was interviewed about pain management for the resident. In this interview, the DON stated, "RN #1 gave [MEDICATION NAME] at 8:30 a.m. At 9:00 a.m., when the resident continued to complain of pain, she should have offered Tylenol and she did not offer . . . [MEDICATION NAME] was not here (available) . . . If we have orders for [MEDICATION NAME] (resident had physician orders [REDACTED]. . . I was not aware that we did not have [MEDICATION NAME] available for the resident (as ordered by the physician) . . . When the resident was admitted to Hospice, his physician ordered [MEDICATION NAME] . . . Hospice should have brought the medication in for the resident, when it was ordered . . . They did not have to wait till he experienced pain." The DON further stated, "Our process is if we have orders for [MEDICATION NAME], we get the medications in (available for resident administration) . . . [MEDICATION NAME] was not delivered (for the resident) timely for the resident when ordered. Hospice is supposed to deliver it when it's ordered . . . I spoke to the Hospice Nurse Supervisor today and she agreed that [MEDICATION NAME] should have been provided for the resident when it was originally ordered." The DON further stated that when the resident experienced no pain relief from [MEDICATION NAME] which was administered at 8:30 a.m., RN #1 should have re-assessed the resident's pain level. The DON stated that RN #1 should have tried to administer other ordered pain medications as ordered by the physician. The DON stated, "There is no reason as to why the resident did not get all three ordered medications in combination with each other by 4:00 p.m. yesterday . . . There is no reason as to why RN #1 did not call the physician on 12/12/11, for further instructions when there was no [MEDICATION NAME] (available) between 8:30 a.m. and 1:58 p.m." The DON stated that the facility had an emergency kit which contained other medications for pain management and the physician could have ordered other pain management medications for the resident who experienced unrelieved pain which he rated at 9/10 from 8:30 a.m. through 2:45 p.m. on 12/12/11. In that interview the DON acknowledged that the pain assessment was not timely and all possible pain medications combinations were not given as indicated on 12/12/11. The DON stated that nursing staff would be inserviced. The facility failed to timely assess and manage the resident's pain on 12/12/11.

Based on observations, staff interviews and record review, the facility failed to provide adequate care and services for pressure ulcer prevention and management for one (#5) of 11 sample residents. Specifically, the facility failed to ensure that resident #5 received necessary treatment and services to prevent pressure ulcers, to promote healing when ulcers developed and to prevent new ulcers from developing. Resident #5 entered the facility with pressure ulcers and developed other pressure ulcers after admission. The findings include: A. Professional Reference The National Pressure Ulcer Advisory Panel's (NPUAP) February 2007 guidelines, found at the website: http//www. npuap.org. provided the following definitions: "Pressure Ulcer Definition: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction . . . Pressure Ulcer Stages -Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence . . . -Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister . . . -Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. -Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. -Unstagable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed." B. Resident Failures 1. Resident #5 The resident's medical record was reviewed on 12/12/11 through 12/15/11. Record review revealed resident #5, an [AGE] year-old male, was originally admitted to the facility on [DATE] and discharged to an assisted living facility after that stay. The resident was readmitted to the facility, on 11/21/11, for physical and occupational therapy (PT/OT), after a hospital stay from 10/2/11 through 11/21/11. The resident had [DIAGNOSES REDACTED]. The resident had an open wound to left hip and thigh on admission. The admission minimum data set (MDS) assessment, dated 12/3/11, revealed: -He understood others and others understood the resident. On the Brief Interview for Mental Status (BIMS), the resident scored 12 and was independent with daily decision-making skills. The resident had no behavioral symptoms. -He required extensive assistance of two persons for bed mobility, transfer, toileting and bathing. The resident was non-ambulatory. The resident required limited one-person assistance for locomotion, and personal hygiene. -He used a wheelchair; was continent of bowel, was without urinary output and received [MEDICAL TREATMENT] three times a week. -He was coded at risk for pressure sores and was coded without pressure ulcers. a. Risk for Pressure Sores Braden Risk Assessment Scales On 11/21/11, 11/28/11 and 12/5/11, the skin breakdown assessment tool assessed resident #5's scores of 19, 17 and 18 respectively, indications of mild pressure sore risk (specifically scores below 12 on the Braden's scale were indications of high pressure sore risk). Care Plans (1) Identification of risk factors for skin breakdown Resident #5's plan of care, dated 11/22/11, read in pertinent part, "Resident admitted with soaked area in (L) left hip, etiology unknown 1.5 cm x .5." The goals read in pertinent parts, "Area to show no signs of infection and be healed within 30 days." The approaches included treatment (Tx) as ordered, weekly skin assessments, repositioning (one/two) staff assist with activities of daily living (ADLs) four times a shift and encouragement of proper nutrition. The care plan further indicated a scab to the resident's right (R) shin which measured 1.5 cm x 1 cm on admission. The goal indicated healing within 60 days. Approaches to that care plan included monitoring and measuring weekly and treatments as ordered. The skin breakdown care plan was updated on 12/2/11 and indicated that the resident was at risk for pressure sores due to decreased mobility, debilitation of conditions and fragile skin. The goal indicated no altercation in skin integrity or pressure ulcers over the next 90 days. -The approaches included, "pressure relieving mattress & cushion in W/C (wheelchair) . . . Enc (encourage) & assist (with) position changes at least 4 x a shift . . . Skin assessment weekly & PRN (as needed) . . . Keep PCP (primary care physicians) and responsible party informed of status . . . Treatment as ordered." Physician Telephone Orders (PTO) and Medication Administration Records (MARs)/treatment record administration (TARs), dated 11/23/11, indicated in pertinent parts, "Wound care to (L) Hip. Clean with NS (normal saline), apply . . . cover . . . Assess for infection until healed. Q (every) 3 days . . . Wound care (R)shin. Clean with NS pat dry apply . . . cover with mepore (a type of medicated bandage or wound dressing) until healed q 3 days." Further PTO orders dated 12/8/11 read in pertinent parts, "Clarification of orders: Warm moist pack qid (four times a day) for 10 minutes to (R) shin." Further PTO orders dated 12/10/11 read in pertinent parts, "Referral for . . . PT obtains deep wound Culture & Wound care/Debridement to Right lower wound." Per DON's clarification (12/13/11), this referred to the right shin wound). Chart Review: Nursing Admission Notes, dated 11/21/11 at 6:30 p.m., read in pertinent parts, "Arrived at this facility, family with staff . . . Some [MEDICAL CONDITION] noted left LE (lower extremity) . . . Bruising noted left upper arm, right upper arm. Old scabs noted left knee. Wound on right abdomen, left hip . . . & more noted above right eye. Also wound present to right shin area . . . skin turgor fair some tenting . . . with some bruising already noted . . . Some bloody bandage noted on right nose . . . stated he does use Ocean Saline spray for that." Review of the resident's initial skin assessment, dated 11/21/11, revealed no skin breakdown to his right calf. Review on nurse's notes, [MEDICAL TREATMENT] communication notes, and the resident's medical record revealed no indication that the resident was identified with or received treatment for [REDACTED]. In summary, the resident's computerized physician orders [REDACTED]., and weekly skin assessments revealed no right calf pressure sore in 11/11 or 12/11, prior to 12/13/11, when the surveyor notified the DON during wound care observations. -Weekly Wound skin healing record (WWHR), dated 12/22/11, identified a (R) shin scab which the resident had on admission-The scab measured 1.5 x 1 (cm) with no exudates. The assessment also indicated that the resident was admitted with a stage I scabbed over wound to her (L) hip which measured 1.5 x 0.5 (cm). Those wound's progress and treatments were respectively assessed weekly on 11/29/11, 12/6/11 and 12/13/11. Wound Care Observations: On 12/13/11 between 2:15 p.m. and 2:45 p.m., the DON, who was also the facility's wound nurse, and Unit Registered Nurse (RN) were observed during wound care observation. The DON stated that the resident was admitted with a wound (specifically a scab) on his shin and a stage II wound on his hip (which was basically resolved). 1. Right Leg Shin: The open area to the right shin measured 2.8 x 5.4 cm. The wound had yellow slough with black eschar. The surrounding tissue was purple to red, tout and shiny, that surrounding area measured 15 cm x 11 cm. During those observations, the DON stated that she was not sure if the surrounding area was worse or better as it was not measured or documented prior to surveyor's request. The DON stated the wound had remained the same, and the resident had orders (written on 12/10/11), for follow up at the wound clinic. 2. Right Calf: During those observations (12/13/11 at 2:15 to 2:45 p.m.), the DON was observed as she removed a dressing from the resident's calf. The surveyor looked at the calf and observed a blacked area which was brought to the attention of the DON and the unit RN. At that time, they both stated that they were unaware of that blackened area to the resident's right calf. The RN stated, "This is the first I have seen this one (wound on right calf)." The DON stated, "I am the wound care nurse, I measure wounds weekly . . . I did not know he had a wound on the back of his right leg . . . I only know of his wound to his shin . . . that wound to the back of right leg is not documented . . . There is no wound care orders to for the right calf . . . it is not done . . . there are no orders on the TARs (11/11 or 12/11 TARs)." The DON asked the resident if he was aware of the wound on his calf and the resident stated that he was unaware of that wound. The DON stated that the resident had an order (dated 12/10/11 per record review and DON's clarification), for wound care clinic evaluation for his right shin wound. After the surveyor brought it to the facility's attention, the right calf wound was assessed, the physician was notified and initial treatment orders were obtained. The pressure wound to the right calf measured 2.4 cm x 2.4 cm and was covered with black eschar. To the right of that blackened right calf wound, another stage II wound, which was undocumented, was observed. The stage II on the right calf measured 1.4 x 2.0 cm. To the left of the right calf eschar covered wound, another undocumented open stage II wound was discovered during wound observations, and it measured 0.7 cm x 0.5 cm. The DON confirmed that all three wounds, which were undocumented, were new pressure sores. The DON stated that the resident was observed daily as staff provided cares for the resident and she was surprised that those wounds were first brought to the facility's attention by the surveyor. The DON obtained physician orders [REDACTED]. On 12/14/11 at 9:30 a.m., the DON stated that she conducted an investigation. The DON stated that her investigation revealed that the facility's night nurse first saw the resident's right calf wound on 12/7/11 (six days before observed by the surveyor) on the night shift. The DON stated that the night nurse failed to document or notify the physician of that wound on that date or any other date, until the surveyor brought it to the facility's attention. The DON stated that without documenting the wound or notifying the MD, the night nurse initiated a dressing to the right calf wound which he/she believed was a blister on 12/7/11. In that same interview, the DON stated that her investigation revealed that one of Certified Nurse Aides (CNAs) first saw the right calf wound in mid-November (11/11) and had informed a nurse. The DON further stated that the resident received [MEDICAL TREATMENT] three times a week and [MEDICAL TREATMENT] nurses were also unaware of the resident's right calf wound. On 12/12/11, the surveyor obtained and reviewed the resident's original weekly skin assessment and treatment sheets (12/11), indicated the resident's weekly skin assessments were scheduled on 12/6/11 and 12/13/11. A form without a title read in pertinent parts, "Oral Mucus . . . Skin Turgor . . . [MEDICAL CONDITION] . . . Break in Skin . . . Redness . . . Pressure Sore . . . Stage/Location . . . Nurse Initial," with corresponding dates of 12/6/11 and 12/13/11, was attached to the weekly skin assessment orders. Despite this resident being documented with multiple skin breakdowns on admission, this untitled form revealed no documentation (left blank) of the resident's skin condition. Observation of the wound on 12/13/11 revealed that the right calf wound had worsened from a blister to an unstagable pressure sore, covered with black eschar and measured 2.4 cm x 2.4 cm. Yet on 12/14/11, the DON provided a revised weekly assessment form which indicated that the untitled form, with the same dates as copied by the surveyor on 12/12/11, and was originally left blank when copied on 12/12/11, had been revised and completed. On 12/14/11 at 9:40 a.m., the DON who was also the wound care nurse, stated, "The nurse should have called the physician (MD) on 12/7/11 to get treatment orders. . . . The nurse should have assessed and documented the wound on the weekly pressure ulcer record for follow up." The DON further clarified, "Yesterday was the first time I saw it (right calf pressure sores) when the surveyor pointed out. . . . We are in the fourth week (resident was admitted four weeks ago) and we are not aware of a pressure sore that the resident might have come in with (admitted with). . . By the time we assessed (12/13/11) the wound was no longer a blister, it was unstagable with eschar and two other stage II's were discovered too." The DON acknowledged that weekly skin assessments were not consistently done, as scheduled. The DON stated that she would follow up by educating staff. Failures: -The facility failed to consistently provide weekly skin assessment as scheduled. -The resident, who was at risk for pressure sores, developed undocumented pressure sores to his right calf. There was no documented evidence that the physician had been notified of the pressure ulcers and/or any treatment was ordered until identified by the surveyor. -The facility failed to timely document and initiate treatment to the resident's right calf pressure sores; those pressure sores worsened. Action Taken During Survey: The resident's right calf area was assessed with [REDACTED].