Every finding on record at Larchwood Health and Rehab LLC

Based on record review and interviews, the facility failed to prevent a significant medication error for one (#1) of three residents out of seven sample residents.Resident #1 was admitted to the facility on [DATE] with a history of cerebral infarctions due to an embolism (stroke) and a prosthetic mechanical heart valve.On 7/8/26 the facility entered the following physician's orders from Resident #1's admission orders:Coumadin (a blood thinning medication) 3 milligram (mg) tablets, give 9 mg every day for five days. Recheck the international normalized ratio (INR - a test to measure if the blood thinner is within the therapeutic level to prevent blood clotting) on day five and obtain new physician's orders for Coumadin, scheduled to start on 7/9/26 and end on 7/13/26. A transcription error occurred when the physician's order for the Coumadin and the lab draw were not entered separately, and the Coumadin order was entered with a stop date (of 7/13/26). The physician's order on Resident #1's July 2026 medication administration record (MAR) was documented as completed, but there was no documentation to indicate that Resident #1's INR results were obtained, the physician was notified, and a new physician's order was entered. As a result, Resident #1's Coumadin was automatically discontinued after the fifth dose of the medication on 7/13/26.A separate physician's order was entered to recheck Resident #1's INR, communicate the results to Resident #1's primary care physician and obtain new Coumadin orders one time only, scheduled for 7/15/26. However, an error occurred and the order was marked as completed, but no new physician's orders were obtained.Resident #1 did not receive any Coumadin from 7/14/26 through 7/20/26. During a dialysis appointment, the dialysis clinic completed an INR check and found Resident #1's INR to be critically low. Resident #1 was hospitalized from [DATE] through 8/2/26 to treat his critically low INR.Specifically, the facility failed to administer Resident #1's Coumadin for seven days, resulting in Resident #1 requiring hospitalization for a critically low INR.Findings include:Record review and interviews confirmed the facility corrected the deficient practice related to Resident #1's significant medication error prior to the onsite investigation on 8/19/26 to 8/24/26, which resulted in the deficiency being cited as past non-compliance with a correction date of 7/21/26.I. Situation of serious [NAME] 7/8/26 at approximately 6:00 p.m. licensed practical nurse (LPN) #3 entered the following physician's admission orders for Resident #1:Coumadin 3 mg tablets, give 9 mg by mouth every day for five days. Recheck the INR on day five and obtain new physician's orders for Coumadin, scheduled to start on 7/9/26 and end on 7/13/26. A transcription error occurred when LPN #3 entered the Coumadin medication order and the lab order in the same physician's order entry instead of separately. The Coumadin order was additionally entered with a stop date (of 7/13/26). When Resident #1's Coumadin order automatically discontinued after the fifth dose on 7/13/26, the physician's order was documented as completed on the July 2026 MAR, but record review revealed no documented INR results on 7/14/26, no documentation to indicate the physician was notified of the results and no new physician's order for Coumadin. A separate physician's order was entered to recheck the resident's INR, communicate the results to Resident #1's primary care physician and obtain new Coumadin orders one time only, scheduled for 7/15/26. -However, staff documented the physician's order was completed, but staff did not obtain new physician's orders for Resident #1's Coumadin. The errors with order transcription and documentation resulted in Resident #1 not receiving his Coumadin medication from 7/14/26 through 7/20/26.During Resident #1's scheduled dialysis appointment on 7/20/26, at approximately 11:30 a.m., the dialysis nurse obtained a blood sample to check Resident #1's INR. Resident #1's INR was identified to be critically below the therapeutic level during the dialysis appointment. Resident #1 was admitted to the local area hospital for a critically abnormal INR on 7/20/26. The facility's failures in documenting, transcribing, and following Resident #1's Coumadin order and failures in communication with the dialysis center likely resulted in Resident #1's hospitalization.II. Facility plan of correctionThe corrective action plan the facility implemented in response to Resident #1's significant medication error was provided by the regional nurse consultant on 8/20/26 at 3:09 p.m.The plan read:On 7/21/26 the facility identified that a resident (Resident #1) receiving warfarin (Coumadin) for anticoagulation therapy had not received the medication as ordered and that an ordered INR result had not been received or acted upon. Resident #1's Coumadin order carried a scheduled stop date of 7/14/26, which caused the order to be automatically removed from the medication administration record; as a result, Resident #1 received no doses of warfarin from 7/14/26 through 7/20/26. The facility identified that this constituted noncompliance with regulations and initiated an internal critical incident response plan. The facility completed an audit of all residents receiving anticoagulant therapy, and found no other residents who had completely missed doses of anticoagulant medications, and no other residents in the facility required INR monitoring. The facility determined the root cause for the incident with Resident #1's Coumadin error was a breakdown in the process for managing a Coumadin order. Resident #1's Coumadin order was entered with a stop date that relied on receiving lab values collected by the dialysis center. The dialysis communication form, dated 7/10/26, revealed the dialysis center completed an INR draw, but did not provide the results on the dialysis communication form. Investigation into the root cause additionally revealed no documentation of follow-up communication attempts from the facility or the dialysis center. Additionally, the facility had no defined mechanism to track outstanding INR results ordered from an outside provider (dialysis center) or to follow-up when a result was not received within the expected timeframe, which prevented the physician from being notified and from issuing a new Coumadin order for Resident #1. These transcription and communication errors resulted in the automatic discontinuation of Resident #1's Coumadin order from the resident's MAR without a system prompt for nursing staff or the prescriber to review the anticoagulant therapy plan. On 7/21/26 the facility provided education on new expectations and procedures forobtaining INRs via the in-house INR machine on the date a resident's INR was due. Staff were educated on the proper use of the in-house INR machine, with competency verified; and on the use of the INR progress note template for transcribing, communicating, and following up on INR results. The facility additionally provided education on processes and expectations to follow-up with outside providers when a lab result was not received within the expected timeframe. The facility continued to complete audits on residents receiving anticoagulant medications. The facility implemented a plan to audit all physician's orders for 12 weeks whenever the next resident requiring INR monitoring was admitted to the facility.III. Professional referenceAccording to the 2020 American College of Cardiology/American Heart Association Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines, by [NAME], [NAME] M., retrieved on 8/26/26 from https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000923, For current-generation mechanical valve prostheses in the aortic position, an INR of 2.5 (range, 2.0 - 3.0) provides a reasonable balance between the risks of thromboembolism (a blood clot) and bleeding.IV. Facility policy and procedureThe High Risk Medications - Anticoagulants policy, revised 7/21/26, was provided by the regional nurse consultant on 8/20/26 at 3:09 p.m. It revealed in pertinent part, Anticoagulants shall be prescribed by a physician or other authorized practitioner with clear indications for use. Examples include prevention and treatment of deep vein thrombosis,pulmonary embolism, atrial fibrillation with embolization, stroke or management of myocardial infarction. Target symptoms (lab values) and goals for use (prevention or treatment) of anticoagulants shall be documented in the resident's medical record. Duration of use shall be appropriate to the resident's condition and indication for use. Routine labs, including baseline and subsequent labs, shall be ordered for each resident requiring anticoagulant medication. Results shall be communicated to the physician in a timely manner. General guidelines include: -Lab results within normal limits and within the target range for the individual resident shall becommunicated via normal/routine procedure;-Lab results that are outside the normal limits or target range for the individual resident, but not critical values, shall be communicated to the physician within 24 hours; and,-Lab results that are considered critical values per facility lab specificity shall be communicated to the physician immediately upon receipt of the critical lab value, but no greater than two hours.V. Resident #1A. Resident statusResident #1, age [AGE], was admitted on [DATE] and discharged to the hospital on 7/20/26. According to the July 2026 computerized physician orders (CPO), diagnoses included hypertension, cerebral infarction due to embolism (stroke), prosthetic heart valve, diabetes, diabetic neuropathy (nerve pain), end stage renal disease and dependence on renal dialysis.The 7/15/26 minimum data set (MDS) assessment revealed Resident #1 was cognitively intact with a brief interview for mental status (BIMS) score of 15 of 15.The MDS assessment indicated the resident received dialysis and anticoagulant medication. B. Record reviewResident #1's anticoagulant care plan, revised 7/10/26, documented Resident #1 was at risk for Coumadin related complications. Interventions included administering medications as ordered, daily skin inspections, monitoring and reporting for symptoms of adverse reactions to anticoagulant therapy (blood tinged urine, black tarry stools, dark or bright red blood in stools,sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy,bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status and significant or sudden changes in vital signs), and avoiding foods, such as leafy greens due to high vitamin K content.Review of Resident #1's July 2026 CPO revealed the following physician's orders:Coumadin 3 mg tablets, give 9 mg by mouth every day for five days. Re-check the INR on day five, then obtain new physician's orders for Coumadin; start 7/8/26 and end 7/13/26.Recheck Resident #1's INR, communicate the results to Resident #1's primary care physician and obtain new Coumadin orders one time only, scheduled for 7/15/26.Review of Resident #1's July 2026 MAR revealed nursing staff documented Resident #1's Coumadin administration was completed each day from 7/8/26 to 7/13/26.-However, record review revealed no documentation to indicate staff completed an INR check, contacted the physician, or obtained new Coumadin orders after the resident received his fifth dose of Coumadin on 7/13/26, resulting in the physician's order being discontinued after the resident received his fifth dose of Coumadin on 7/13/26. Review of Resident #1's July 2026 treatment administration record (TAR) revealed the task to check Resident #1's INR on 7/15/26, report the result to the physician and obtain new physician's orders for Coumadin was documented as completed. -However, record review revealed no documentation to indicate staff completed an INR check and contacted the physician with the resident's INR results on 7/15/26.-Additionally, review of Resident #1's July 2026 CPO revealed no further physician's orders for a Coumadin dose after 7/13/26.-Review of Resident #'1 electronic medical record (EMR) revealed there were no dialysis communication forms for Resident #1's dialysis appointments on 7/15/26 and 7/17/26. Cross-reference F698 for failure to provide dialysis services consistent with professional standards of care.The dialysis clinic notes, dated 7/15/26 and 7/17/26, and received by the facility on 7/20/26 (seven days after the resident's last dose of Coumadin was administered on 7/13/26), revealed the following:The 7/15/26 dialysis clinic note documented Resident #1's INR during dialysis was 2.7 and within the therapeutic range for Resident #1.The 7/17/26 dialysis clinic lab results documented Resident #1's INR result was 1.58 and below the therapeutic range on 7/17/26. The progress note, dated 7/20/26 at 6:06 p.m. documented the facility received a call from the local area hospital. The progress note documented Resident #1 was admitted to the hospital and required a heparin drip for a critically low INR. The hospital progress note, dated 7/20/26 at 12:18 a.m., documented Resident #1 presented to the emergency room on 7/20/26 with a below therapeutic INR, despite attempts to take Coumadin until the medication was held by the facility for unclear reasons. The progress note documented the dialysis center reported an INR reading of 1.2 for the resident during dialysis. The progress note documented upon arrival to the emergency room, Resident #1 had stable vital signs and an INR reading of 1.32 (on 7/20/26 at 8:02 p.m.) The progress note documented the goal range for Resident #1's INR readings was between 2.0 and 3.0. The progress note documented Resident #1's below therapeutic INR, in combination with his high risk conditions of a mechanical heart valve and previous strokes presented a potential threat to the life or bodily function of Resident #1. The progress note documented Resident #1 required a heparin drip ( an infusion of blood thinning medication) and admission to the hospital. The hospital Discharge summary, dated [DATE] at 3:04 p.m. revealed that during the resident's hospital stay, Resident #1's INR was first stabilized with intravenous heparin before transitioning back to oral Coumadin. The discharge summary documented Resident #1 was transferred to the hospital's acute rehabilitation unit on 8/2/26 to complete additional physical therapy and occupational therapy prior to returning home.VI. Dialysis nurse interviewThe dialysis clinic nurse was interviewed on 8/19/26 at 4:41 p.m. The dialysis nurse said he saw Resident #1 for dialysis three times a week. The dialysis nurse said he was aware of the dialysis communication form used by the facility, but he said he did not always receive one during Resident #1's appointments. The dialysis nurse said Resident #1 had a physician's order to have his INR drawn during his dialysis appointments. He said he would collect Resident #1's blood, attach a written copy of the physician's order and send the vial of blood to the lab in the hospital. The dialysis nurse said the hospital staff in the lab would have been the staff member to alert the facility with a critical lab value for the resident. The dialysis nurse said Resident #1 went to the hospital on 7/20/26 due to a critically low INR obtained at dialysis. He said the resident transferred to the acute rehab unit in the hospital on 8/2/26 and was discharged home on 8/11/26. VII. Staff interviewsLPN #1 was interviewed on 8/19/26 at 12:10 p.m LPN #1 said she was Resident #1's nurse on 7/20/26. She said she remembered the dialysis center called to report Resident #1's INR was critically low and he was sent to the emergency room. LPN #1 said she looked at the resident's July 2026 MAR and immediately noticed Resident #1 had not received Coumadin for six to seven days. LPN #1 said she notified the director of nursing (DON) of the resident's missed doses of Coumadin and the reported critical INR results. LPN #1 said the nurse who entered the admission physician's orders made a transcription error when entering Resident #1's Coumadin order. LPN #1 said normally, the Coumadin medication order was scheduled indefinitely and separately from the treatment orders to check the INR and contact the physician. LPN #1 said the way the admitting nurse entered the physician's order for Coumadin for Resident #1 caused confusion and Resident #1's Coumadin dropped off of the MAR, resulting in the missed doses of the medication for the resident. LPN #1 said once the facility investigated the cause of the medication error, the DON, assistant director of nursing (ADON) #1 and ADON #3 began education to the nursing staff the following day. LPN #1 said the education included hands-on instructions with the facility's INR machine and step-by-step instructions to contact the provider and enter a new Coumadin order when needed. LPN #1 said the facility additionally provided education on how to complete a new documentation form in the residents' EMR to show each step of the Coumadin/INR process was completed in a timely manner.The nursing home administrator (NHA), the DON, and the regional nurse consultant were interviewed together on 8/20/26 at 9:37 a.m. The DON said he started the investigation on 7/20/26 after the facility was notified by the dialysis clinic of Resident #1's critically low INR result. The DON said the investigation identified problems with communication between the facility and the dialysis center, as well as problems with the way Resident #1's Coumadin order was entered. The regional nurse consultant said it was not normal to include INR testing instructions with the Coumadin order, but because the physician's order for Resident #1 included instructions to obtain a new physician's order for Coumadin after five days, the medication order was entered incorrectly with an end date. The regional nurse consultant said following the incident, all Coumadin orders were to be entered without a stop date and the physician's order to check the residents' INRs and contact the physician was to be entered separately. The DON said prior to the incident with Resident #1's Coumadin on 7/20/26, the floor nurses were obtaining the resident's INR results from the dialysis center after each visit, but they were missing communication forms between the dialysis center and the facility. The DON said the dialysis center nurse would complete the resident's INR blood draw and send it to the lab, then typically write the results on the dialysis communication form or call the floor nurse directly. The regional nurse consultant and the DON said they could not find Resident #1's dialysis communication forms for 7/15/26 or 7/17/26. The DON said he thought he remembered the floor nurse on 7/15/26 sending a fax with Resident #1's INR results to the physician, but there was no documentation in Resident #1's records to show the facility was notified of the INR results or contacted the physician on 7/15/26. The DON said a floor nurse should document any time they attempted to contact a physician or did not receive expected lab results. The DON said staff should document follow up attempts with outside providers, such as the dialysis clinic. The regional nurse consultant said there was no documentation to show the facility was notified by the dialysis center of Resident #1's INR results on 7/17/26 in order for the facility to have responded to the resident's below therapeutic level, but not critical lab value on that date. The DON said after the incident with Resident #1 on 7/20/26, all residents' INR results were to be obtained in-house by the floor nurses. The DON said any staff member who did not attend the scheduled education regarding the Coumadin/INR process changes on 7/21/26 received education of the change in the process over the phone and were told they needed to complete a check off on the INR machine during their next shift.The NHA said not all nurses were able to attend the in-person education regarding the change in protocol and use of the INR machine because some staff did not work full time and had not been back to work since the facility made the changes. The NHA, the DON and the regional nurse consultant were interviewed together a second time on 8/20/26 at 2:06 p.m. The regional nurse consultant said the facility had implemented additional safety measures and monitoring going forward to prevent reoccurrence of the missed Coumadin administration. The regional nurse consultant said one of the facility's ADONs was assigned to review all residents' post-dialysis communication to ensure proper monitoring and communication between the facility and the dialysis center. The regional nurse consultant said the facility had no residents that had been admitted to the facility with Coumadin orders since Resident #1. The regional nurse consultant said the DON completed audits of all residents on anticoagulants and when the next resident with a Coumadin or INR order entered the facility, the regional nurse consultant planned for the DON to audit all of the resident's Coumadin and INR physician's orders for the following 12 weeks to ensure accurate and timely orders. LPN #2 was interviewed on 8/24/26 at 5:50 p.m. LPN #2 said she received education about the change in the facility's Coumadin management process during an in-service education on 7/21/26. LPN #2 said she received hands-on training for how to use the in-house INR machine and completed a return demonstration. LPN #2 said the facility showed her how to complete the new Coumadin documentation form. The pharmacist was interviewed on 8/24/26 at 9:46 a.m. The pharmacist said INR monitoring was typically not reviewed by the pharmacist, since it was typically ordered as a treatment and the pharmacist only looked at medication orders. The pharmacist said Coumadin should not be stopped abruptly because that could cause someone to have a blood clot. The pharmacist said if a facility missed completing a timely INR for a resident, she would prefer the facility continued to give the Coumadin while contacting the ordering physician for a STAT (immediate) INR. -An attempt was made to contact the facility's medical director during the survey, however no return call was received prior to the survey exit on 8/24/26.

Based on record review and interviews, the facility failed to implement and maintain adequate documentation of communication for dialysis services for one (#1) of two residents out of seven sample residents. Specifically, the facility failed to:-Ensure physician's orders for dialysis were obtained for Resident #1;-Ensure consistent communication between the facility and the dialysis center related to Resident #1's lab results collected by the dialysis center; and,-Ensure Resident #1's dialysis communication forms were completed thoroughly and consistently and maintained for each dialysis appointment.Findings include:I. Facility policy and procedureThe Hemodialysis policy, revised 5/5/26, was provided by the regional nurse consultant on 8/20/26 at 3:09 p.m. It revealed in pertinent part, The facility will ensure that the physician's orders for dialysis include: the type of access for dialysis (graft, arteriovenous shunt, external dialysis catheter) and location; the dialysis schedule; the nephrologist name and phone number; the dialysis facility name and phone number; transportation arrangements to and from the dialysis facility; any medication administration or withholding of specific medications prior to dialysis treatments; any fluid restriction if ordered by the physician. The facility will coordinate and collaborate with the dialysis facility to assure that: the resident's needs related to dialysis treatments are met; the provision of the dialysis treatments and care of the resident meets current standards of practice for the safe administration of the dialysis treatments; documentation requirements are met to assure that treatments are provided as ordered by the nephrologist, attending practitioner and dialysis team; and there is ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing home and dialysis staff. The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to: timely medication administration (initiated, held or discontinued) by the nursing home and/or dialysis facility; physician/treatment orders, laboratory values, and vital signs; advance Directives and code status; specific directives about treatment choices; and any changes or need for further discussion with the resident/representative, and practitioners; nutritional/fluid management including documentation of weights, resident compliance with food/fluid restrictions or the provision of meals before, during and/or after dialysis and monitoring intake and output measurements as ordered; dialysis treatment provided and resident's response, including declines in functional status, falls, and the identification of symptoms that may interfere with treatments; dialysis adverse reactions/complications and/or recommendations for follow up observations and monitoring, and/or concerns related to the vascular access site; changes and/or declines in condition unrelated to dialysis; the occurrence or risk of falls and any concerns related to transportation to and from the dialysis facility.II. Resident #1A. Resident statusResident #1, age [AGE], was admitted on [DATE] and discharged to the hospital on 7/20/26. According to the July 2026 computerized physician orders (CPO), diagnoses included hypertension, cerebral infarction due to embolism (stroke), prosthetic heart valve, diabetes, diabetic neuropathy (nerve pain), end stage renal disease and dependence on renal dialysis.The 7/15/26 minimum data set (MDS) assessment revealed Resident #1 was cognitively intact with a brief interview for mental status (BIMS) score of 15 of 15. The MDS assessment indicated the resident received dialysis.B. Record reviewReview of Resident #1's July 2026 CPO revealed there were no physician's orders for dialysis.Resident #1's care plan, revised 7/10/26, documented Resident #1 required hemodialysis every Monday, Wednesday and Friday. Interventions included ensuring staff did not draw blood or take Resident #1's blood pressure in the arm containing the graft used for dialysis; monitoring and reporting any signs of infection to the access site; assessing, monitoring and reporting any changes to the dialysis access site each shift; monitoring and reporting signs and symptoms of bleeding or septic shock; and symptom management for side effects of dialysis including cramping, fatigue, headaches, itching, anemia and bone demineralization.Review of Resident #1's dialysis communication forms revealed the following:The dialysis communication form, dated 7/10/26, revealed missing post-dialysis assessment documentation, including vital signs and assessment of the resident's dialysis access site. The dialysis communication form documented Resident #1 had an international normalized ratio (INR - a test to measure if the blood thinner is within the therapeutic level to prevent blood clotting) drawn during the dialysis appointment. The dialysis communication form documented the INR results were not ready at the end of the resident's appointment and the dialysis nurse would send them to the facility once available.-However, review of Resident #1's electronic medical record (EMR) revealed no documentation of follow-up communication from the facility or the dialysis center regarding the resident's 7/10/26 INR lab results obtained at the dialysis center.The dialysis communication form, dated 7/13/26, revealed missing post-dialysis documentation, including vital signs and assessment of the resident's dialysis access site.-Review of Resident #1's EMR revealed there were no dialysis communication forms for the resident's dialysis appointments on 7/15/26 and 7/17/26. Cross-reference F760 for failure to prevent significant medication errors.III. Dialysis nurse interviewThe dialysis clinic nurse was interviewed on 8/19/26 at 4:41 p.m. The dialysis nurse said he saw Resident #1 for dialysis three times a week.The dialysis nurse said he was aware of the dialysis communication form used by the facility, but he said he did not always receive one during Resident #1's appointments. The dialysis nurse said Resident #1 had a physician's order to have his INR drawn during his dialysis appointments. He said he would collect Resident #1's blood, attach a written copy of the physician's order and send the vial of blood to the lab in the hospital. The dialysis nurse said anyone receiving dialysis needed assessments during and after dialysis treatments to ensure they did not experience complications or uncomfortable side effects from dialysis.IV. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 8/24/26 at 9:38 a.m. LPN #2 said when a resident was sent to the dialysis center, the nurse needed to complete a dialysis communication form and send the form with the resident. LPN #2 said the dialysis communication form included a box for the resident's vital signs, assessments and communications to the dialysis center that were completed before the appointment. LPN #2 said the dialysis center filled out the middle section of the dialysis communication form, which included any medications given or lab results. LPN #2 said when the resident returned to the facility, the nurse responsible for the resident's care needed to complete the last section of the dialysis communication form to assess the resident's vital signs and the resident's dialysis access site for any changes after dialysis. LPN #2 said the post-dialysis assessment was to make sure the resident was safe and comfortable after treatment. LPN #2 said sometimes the dialysis communication form did not make it back to the facility with the resident. She said when the dialysis communication form was lost for whatever reason, she would complete a progress note to indicate that the resident's post-dialysis assessment was completed. The nursing home administrator (NHA), the director of nursing (DON), and the regional nurse consultant were interviewed together on 8/20/26 at 9:37 a.m. The DON said when the facility was investigating the concern regarding Resident #1's Coumadin orders , they found they never received Resident #1's INR lab values from the dialysis clinic after the resident's dialysis appointment on 7/10/26. The DON said the investigation revealed the paper dialysis communication form was not reliable enough to be the only documentation that tracked the coordination of care between the facility and the dialysis center.Cross-reference F760 for failure to prevent significant medication errors. The DON said he was not sure why Resident #1's dialysis communication forms from 7/10/26 and 7/13/26 were incomplete and he was not sure why the dialysis communication forms from 7/15/26 and 7/17/26 were missing. The DON said he would need to talk to the floor nurses who took care of Resident #1 to find out why the documentation was missing or incomplete. The DON said it was possible the nurses never received the resident's dialysis communication forms back from the dialysis center on 7/15/26 and 7/17/26. He said if that was the case, he would expect his floor nurse to enter a progress note that the assessment was completed. The DON said he would also expect the floor nurse to enter a progress note any time they called a physician or outside providers, such as the dialysis center. The DON said the night nurses double checked all paper documentation to ensure it was complete, so he was surprised the night shift staff did not alert him about the missing dialysis communication documentation for Resident #1. The DON said going forward, he planned for the assistant director of nursing (ADON) to review all dialysis communication forms for their current residents on dialysis to ensure timely and accurate documentation. The DON said the floor staff needed to complete assessments on residents after dialysis because dialysis could cause uncomfortable side effects and staff needed to make sure there were no signs of infection around the residents' dialysis access sites.

Based on observations, record review and interviews, the facility failed to ensure food was stored, prepared, distributed and served under sanitary conditions in the main kitchen.Specifically, the facility failed to ensure staff followed appropriate hand hygiene practices during the meal service.Findings include:I. Professional referenceAccording to the Colorado Retail Food Regulations (3/16/24), chapter 2-301.12, retrieved on 5/29/26, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; using tobacco products, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands. (2-301.14)II. Facility policy and procedureThe Handwashing/ Hand Hygiene policy, revised November 202s, was provided by the director of nursing (DON) on 5/26/26 at 11:13 a.m. The policy read in pertinent part, Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. All employees who handle, prepare or serve food are trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. Employees must wash their hands during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks Hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens.III. Observations 1. Kitchen meal serviceDuring a continuous observation of the lunch meal service in the kitchen on 4:05 p.m. beginning at 4:05 p.m. and ending at 5:38 p.m., the following was observed:At 4:38 p.m. cook #1 began plating residents' meals. At 5:11 p.m. cook #1 left the steam table. She pulled soup from a box with her gloved hands, touching the bottom shelf and the outside of the box. She returned to the steam table and continued to plate food.At 5:22 p.m. the dietary manager (DM) placed her left gloved hand to touch her shirt collar and wipe her cheek. The DM removed her gloves and pulled out a pan of mancotti from the oven with pot holders. She did not perform hand hygiene after removing her gloves. At 5:25 p.m. cook #1 pushed the trash down in the bin with her gloved hands, she removed the gloves and donned new gloves without performing hand hygiene. At 5:26 p.m. with the same gloved hands, cook #1 used the thermometer to take the temperature of the pan of manicotti. 2. Room tray deliveryDuring a continuous observation of the lunch meal service in the a resident hall on 5/18/26 beginning 12:50 p.m. and ending at 1:30 p.m., the following was observed:At 1:05 p.m. certified nurse aide (CNA) #5 picked up a cart delivered to the first room tray room. She did not use hand hygiene before collecting the tray. CNA #5 proceeded to help set up the resident's meal for her. CNA #5 exited the resident's room and filled another resident's water cup without performing hand hygiene. CNA #5 collected another resident tray out of the food cart without performing hand hygiene. She exited the room and performed hand hygiene. At 1:20 p.m. CNA #5 pulled out another room tray without hand hygiene, shut the cart door with her foot and served the meal to a resident. She exited the room, picked up an item off the floor, knelt down with her hands on the floor near the cart. She stood up, pulled another tray out of the room cart without performing hand hygiene.At 1:25 p.m. CNA #5 delivered the tray to a resident's room. She exited the room without hand hygiene, picked up another tray and entered another resident's room without hand hygiene. At 1:30 p.m. CNA #5 performed hand hygiene and delivered the last room tray. V. Staff interviewsThe DM was interviewed on 5/21/26 at 3:21 p.m. The DM said hand hygiene should be completed thoroughly for 30 seconds, conducted after every task change and before putting new gloves on. The DM said she saw cook #1 not perform hand hygiene in between glove changes. Room tray observations were shared with the DM. She said staff should perform hand hygiene in between passing trays in resident rooms. She said she had not conducted recent staff training with staff on hand hygiene during meal service and delivery.

Based on observations, record review and interviews the facility failed to ensure the resident environment remained as free of accident hazards as possible for two (#60 and #84) out of six residents reviewed out of 41 sample residents and eight of 12 resident rooms reviewed. Specifically the facility failed to:-Implement a fall risk care plan for Resident #60;-Ensure thorough root cause analysis were completed for Resident #84 after multiple falls; -Ensure Resident #84's fall interventions were consistently in place and documented on his care plan; and, -Ensure tap water in the facility was kept within a safe temperature range.Findings include: I. Fall failures A. Facility policy and procedure The Falls-Clinical Protocol policy, revised March 2018, was provided by the director of nursing (DON) on 5/21/26 at 11:53 a.m. It documented in pertinent part, The staff and the physician Will identify pertinent interventions to try to prevent subsequent Falls to address the risk of clinically significant consequences of falling. If underlying issues cannot be readily identified a corrected staff will try various relevant interventions, based on assessment of nature or category falling, until falling reduces or stops or until a reason is identified for its continuation. The staff with the physician's guidance will follow up on a fall with associate injury until the resident is stable and delayed complications such as a late fracture or hematoma have been ruled out or resolved. The staff and the physician will monitor and document the individual's response to the interventions intended to reduce falls or consequences of falling . If interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with the position whether these measures are still needed, for example if the problem required the intervention has been resolved by addressing the underlying cause. If the individual continues to fall, the staff and physician will reevaluate the situation and reconsider possible reasons for the residents falling and also reconsider the current interventions. B. Resident #60 1. Resident status Resident #60, age [AGE], was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO) diagnoses included asthma, heart failure and cerebrovascular accident (CVA) stroke. The 3/17/26 minimum data set (MDS) assessment revealed Resident #60 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. He required minimal assistance with activities of daily living (ADL). 2. Record review The ADL care plan, dated 4/5/26, documented the resident had a decrease in independence with physical mobility related to CVA. Pertinent interventions included giving the resident reminders to use a walker and monitor for any signs or symptoms of immobility. -Review of Resident #60's comprehensive care plan failed to reveal a fall care plan that included person centered fall interventions. The nurse note, dated 5/10/26, documented Resident #60 told a staff member that he went to the bathroom and on his way back to bed he got dizzy and fell hitting the right side of his head on the bedside table. The resident sustained an abrasion and a raised purple bruise. The skin check note, dated 5/11/26, documented the resident had an abrasion noted to the right side of resident's head with a long purple raised bruise. The fall risk evaluation note, dated 5/11/26, documented no falls in the past three months. He had a fall risk score of 5, which showed low to moderate risk. -However, the evaluation failed to include that Resident #60 sustained a fall on 5/10/26. 2. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 5/20/26 at 2:02 p.m. She said when a resident had a fall, an assessment was completed by the registered nurse (RN), vital signs were taken and treatment was provided as needed. She said the resident was interviewed to find out what happened if the fall was unwitnessed and staff members. The director of nursing (DON) was interviewed on 5/20/26 at 4:20 p.m. She said Resident #60 had a fall on 4/5/26. She said the interdisciplinary team (IDT) met weekly to discuss falls to determine new interventions. She said the resident had a sign in his room that read Remember to use your walker. She said there was no other interventions added except to keep a close eye on the resident which was told verbally to the staff. C. Resident #84 1. Resident status Resident #84, age greater than 65, was admitted on [DATE] . According to the May 2026 CPO, diagnoses included end stage renal disease with dependence on renal dialysis, age-related osteoporosis without current pathological fracture, unspecified dementia, mild without behavioral disturbance, psychotic disturbances or mood disturbances, and repeated fall The 4/21/26 MDS assessment revealed Resident #84 had severe cognitive impairment with a BIMS score of four out of 15. He did not have wandering behaviors or rejection of care. He used a wheelchair for mobility. He was dependent on staff for lower body dressing and toileting hygiene. He required moderate assistance for getting on and off the toilet, chair to bed transferring and sit to stand. The MDS assessment documented Resident #84 was frequently incontinent of bowel and bladder and was not on a toileting program. 2. Observations On 5/19/26 at 4:24 p.m. Resident #84 was in the hallway in his wheelchair without his lap buddy on his chair. At 4:29 p.m. Resident #84 was assisted to the dining room table. At 4:37 p.m. Resident #84 self propelled himself out of the dining room and down the hall towards his room. Certified nurse aide (CNA) #3 walked passed Resident #84 in the hallway. Resident #84 entered his room and shut the door. At 4:47 p.m. an unidentified dietary aide entered the room to bring the resident's roommate a room tray. Resident #84 was in the restroom and his wheelchair was in the doorway to the bathroom. At 4:48 p.m. an unidentified CNA entered the room and observed Resident #84 alone in the restroom. The CNA entered the restroom and assisted the resident. At 5:01 p.m. the unidentified CNA assisted Resident #84 out of his room and back into the dining room. On 5/20/26 at 5:57 p.m. Resident #84 was in his wheelchair in the commons area. He did not have his lap buddy on. 3. Record review The fall care plan, revised 4/25/26, documented that Resident #84 was at risk for falls related debility, weakness and altered balance with poor safety awareness. According to the care plan, Resident #84 needed prompt response to all requests for assistance. Interventions initiated on 3/4/26 directed staff to anticipate and meet the resident's needs; ensure his call light is within reach and encourage the resident to use it for assistance as needed; educate the resident/family/caregivers about safety reminders, what to do if a fall occurs and causation of the falls; follow the facility fall protocol; and, review information on past falls and attempt to determine cause of falls, record possible root causes and alter/remove any potential fall contributing factors if possible. Interventions revised on 3/16/26 directed staff to provide the resident with a motion electronic alarm and ensure the device is in place as needed. Interventions revised on 3/23/26 directed staff to ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in his wheelchair; ensure flooring surface was even and free floor clutter; provide glare-free light, a working and reachable call light, and a bed in low position at night with his personal items within reach. According to the the revised 3/23/26 interventions, Resident #84 needed to be evaluated for and supplied with appropriate adaptive equipment or devices and re-evaluate as needed for continued appropriateness and to ensure least restrictive device or restraint. Interventions initiated on 4/17/26 directed staff to place a sign in his room to remind Resident #84 to use the call light so he did not fall and provided him with anti-rollback brakes to increase safety with transfers. Interventions initiated on 4/25/26 identified Resident #84 was to use a lap buddy (a wheelchair positioning device) when out of his room and in his wheelchair. According to the intervention, staff was to ensure it was in place every 15-minutes and release it every two hours for safety. a. Fall on 4/6/26 - unwitnessed The 4/6/26 incident report was provided by the DON on 5/21/26 at 11:53 a.m. The incident report documented Resident #84 had an unwitnessed fall on 4/6/26 at 8:30 a.m. According to the incident report, he was ambulating without assistance and lost his footing when he fell and obtained a skin tear to his right scapula (back). The incident report revealed the immediate action/intervention following the fall was to remind him to use his call light. The 4/7/26 interdisciplinary (IDT) risk note documented the resident told the staff he was trying to go to the bathroom. The IDT risk note documented the root cause of the fall was the resident's attempt to use the bathroom and he had a recent room change. The note documented interventions put in place were to remind staff to place assistive devices within reach when he was in bed and remind staff to ensure motion alarm was in place and functioning properly. According to the IDT note, new interventions included offering the resident a urinal as needed and informing therapy and restorative nursing of the fall. The note documented therapy and restorative was notified of the incident. -The fall documentation did not identify the size or severity of the skin tear to his back. -The fall documentation did not identify if his call light was within reach or if his motion sensor was on and working properly, if the resident was in bed or in his wheelchair prior to his fall or when the resident was last toileted or if he was incontinent at the time of the fall. b. Fall on 4/7/26 - unwitnessed The 4/7/26 incident report was provided by the DON on 5/21/26 at 11:53 a.m. The report documented Resident #84 had an unwitnessed fall at 10:30 p.m. According to the incident report, he was ambulating without assistance, confused and lost his footing when he fell. The report documented the resident told the staff he had tried to get up. The 4/8/26 progress note identified Resident #84 was found parallel to the bed on the floor (on 4/7/26). An assessment was completed, no new injuries were found and he was assisted back to bed. According to the note, Resident #84 was very impulsive, would not use his call light and was very unsteady while up. The 4/8/26 IDT risk note documented staff added velcro to his bedside alarm and he was going to move to the long term care side of the facility. The note documented therapy and restorative was notified of the incident. -The fall documentation did not identify when the resident was last toileted or if he was incontinent at the time of the fall or if the resident was last checked on by staff. c. Fall on 4/11/26 - witnessed The 4/11/26 incident report was provided by the DON on 5/21/26 at 11:53 a.m. The report documented the nurse and CNAs were in shift report when Resident #84 walked out of his room holding his shoes when he fell next to the wall without injury. The report identified the resident fell at 6:15 a.m. The 4/13/26 IDT risk note documented the root cause of the witnessed fall on 4/11/26 was very poor safety awareness and impaired cognition. According to the risk note, Resident #84 was in a transition process for the staff and the resident to get to know each and for staff to know his routine after he moved into a new room. The note identified the intervention after the fall was to remind staff of the resident's increased fall risk and provide more frequent checks on him, especially in the early morning hours and around 10:00 p.m. The note documented therapy and restorative was notified of the incident. d. Fall on 4/14/26 - witnessed The 4/14/26 incident report was provided by the DON on 5/21/26 at 11:53 a.m. The report documented Resident #84 was witnessed to stand up out of his wheelchair in the dining room at 6:33 a.m. The wheelchair moved backwards and the resident fell on his buttocks without injury. The 4/16/26 IDT risk note documented the root cause of the fall. According to the note, Resident #84 stood up from his wheelchair without locking his breaks first and the wheelchair rolled backwards. The identified intervention was to screen him for an anti-roll back device on his wheelchair for safety. The note documented therapy and restorative was notified of the incident. e. Fall on 4/16/26 - witnessed The 4/16/26 incident report documented Resident #84 fell in his room at 7:50 p.m. The report documented the resident was attempting to ambulate without assistance. The fall was witnessed by a CNA. He was assessed by his nurse and assisted back into his wheelchair. The resident received a 5 centimeter (cm) skin tear on his right elbow as a result of the fall. The 4/30/26 IDT risk note for the fall on 4/16/26 documented Resident #84 stood up from his wheelchair and took one step and fell to the floor. According to the note, the resident said he was trying to go to the bathroom. The note documented the interventions after the fall included ensuring his call light was within reach; frequently reminding the resident to utilize the call light system and to wait for staff to assist. The note documented the staff were reminded to avoid leaving the resident in his room alone, encourage him to participate in activity of choice and sit in the commons area of the facility, socializing with other residents or watch television. The note documented therapy and restorative was notified of the incident. -The interventions directing staff to avoid leaving the resident in his room alone, encourage him to participate in activity of choice and sit in the commons area of the facility, socializing with other residents or watch television was not included in the residents care plan (see care plan above). -The fall documentation did not identify when the resident was last toileted or if was incontinent at the time of the fall. -The IDT note identified the resident's 4/16/26 fall was reviewed by IDT two weeks after the fall and after the resident had multiple falls (see below). f. Fall on 4/23/26 - unwitnessed The 4/23/26 nursing note identified Resident #84 was found next to his wheelchair, laying on his right side. He was bleeding from his right eye brow and he had a lump on his right cheek bone. The resident was alert and was able to be turned on his back so pressure could be applied to his eye brow laceration. He was assessed back into his wheelchair and wound care was provided to the laceration. The second nursing note on 4/23/26 identified Resident #84 was sent to the hospital for an evaluation of his head injury at 7:10 p.m. and returned back to the facility at 9:45 p.m. According to the note, a CT (computed tomography) scan of his head and neck and there were no underlining concerns. The 4/23/25 incident report documented the 4/23/26 fall occurred at 6:45 p.m. in the dining room and was unwitnessed. According to the report, factors of the fall included poor memory, confusion, gait imbalance and ambulating without assistance. The 4/24/25 at 12:23 a.m. skin check identified Resident #84 had bruising/hematoma right lateral back of thigh, down to his right lower leg. The 4/24/26 IDT note documented Resident #84 had poor safety awareness and was not able to say what he was doing that led to the unwitness fall on 4/23/26. The note indicated the interventions put into place after the fall was for staff to encourage the resident to sit in the commons area where he is more visible to staff and encourage the resident to attend activities of choice. The note documented therapy and restorative was notified of the incident. The 4/26/26 post fall evaluation note documented the 4/23/26 fall was witnessed by a CNA in his room that resulted in injuries to a right eye laceration, and bruising to his arm, leg and back and a visit to the emergency room. According to the evaluation, the resident was wearing shoes at the time of the fall and his bedside light was on and his bathroom and his personal light was sounding when he was found. -The fall documentation documented two different scenarios of the 4/23/26 fall. The progress note and the incident reported documented the fall was unwitnessed. The incident report documented the resident fell in the dining room. The post evaluation documented he was in his room and his fall was witnessed by a CNA. -The fall documentation did not identify if he was offered an activity or another location that would be more supervised/visible by staff, prior to the fall or if the resident was continent at the time of fall or when he was last toileted. g. Falls on 4/24/26 witnessed and unwitnessed The 4/24/26 nursing note identified the resident had another fall on 4/24/26. According to the note, Resident #84 was sitting in his wheelchair taking his clothes off when the nurse entered the room. The resident started to lean forward, when his wheelchair cushion slid forward at an angle and he started to fall. The note documented the nurse was able to assist him to the floor. The staff assisted him back into his wheelchair and then into bed. The 4/24/26 incident report was provided by the DON on 5/21/26 at 11:53 a.m. The report identified the fall was witnessed at 8:30 p.m. and the resident was not injured as a result of the fall. The 4/30/26 IDT risk note documented the witnessed fall on 4/24/26 at 8:30 p.m. root cause was the sliding forward of his wheelchair cushion when he leaned forward. According to the note, Dysum (non-slip material) was placed under his wheelchair cushion to keep it from sliding. The note documented therapy and restorative was notified of the incident. The 4/24/26 nursing note documented the resident was found on the floor next to his bed without injury. The 4/24/26 incident report identified the fall was unwitnessed and Resident #84 was found on the floor in his room at 11:30 p.m. He was not able to give staff a description of the fall. According to the report, the resident was assessed and assisted to his wheelchair and near the nursing station to be monitored closer. The 4/25/26 nursing note documented the therapy department recommended a lap buddy due to his frequent falls and orders for the lap buddy were requested with his hospice physician. The 4/25/26 restorative note documented the restorative nurse aide placed a lap buddy on Resident #84's wheelchair and gained verbal consent from the resident's representative. The 4/30/26 IDT risk note for Resident #84's 4/24/24 unwitnessed fall was provided by the DON on 5/21/26 at 11:53 a.m. The report identified the fall was reviewed on 4/30/26 with IDT. The note documented the resident rolled out of bed. The intervention discussed in the IDT review was to place a motion alarm to alert staff when the resident attempted to get out of bed unassisted, place bed in lowest position and encourage staff to do frequent rounds to ensure resident safety. The note documented therapy and restorative was notified of the incident. -The fall documentation did not identify if his motion alarm was in place, working properly and sounding when the resident rolled out of bed or the resident was last checked on, toileted and if he was continent at the time of the fall. h. Fall on 4/26/26 - witnessed The nurse progress note documented a CNA brought the resident to a recliner near the nurses station and transferred him to a recliner and walker. According to the note, 15-minutes had passed and the CNA then told the nurse Resident #84 fell earlier that night. The resident was then assessed by the nurse without injury. The 4/26/26 incident report documented Resident #84 had an assisted staff fall on 4/26/26 at 1:00 a.m. The report documented a CNA notified the nurse the resident had a fall after the incident occurred. The 4/30/26 IDT risk note was provided by the DON on 5/21/26 at 11:53 a.m. The report documented a staff member was walking by Resident #84's room when she heard his motion alarm and saw the resident mostly out of bed. She entered the room and the resident grabbed her and would not let her go so she lowered him down to the floor without injury. The interventions documented after the floor were Ensure the motion alarm is in the proper place and functioning properly. Ensure call light is within reach and frequently remind the resident to utilize the call light system and wait for staff to assist. Ensure bed is in the lowest position -The fall documentation did not identify the resident was assessed by a nurse before he was moved off the floor and into a reclining chair by the CNA or if the bed was in a low position. i. Fall on 4/28/26 - witnessed The 4/28/26 incident report was provided by the DON on 5/21/26 at 11:53 a.m. The report identified Resident #84 had another fall. The report identified the fall was witnessed on 4/28/26 at 3:15 p.m. According to the incident report, a nurse was sitting at the computer at the nursing desk when she heard a gasp and commotion. The nurse got up saw Resident #84 on the floor of the commons area, laying on his left side and in front of his wheelchair. The foot petals were on the wheelchair. The report indicated the resident was brought back to the facility from an outside provider and staff was not notified that he returned. The incident report documented the resident had a large skin tear on his upper left arm that was bleeding and measured 7 cm long and 8 cm wide. The 4/30/26 IDT risk note documented the 4/28/26 fall root cause. According to the note, he was left unattended in the commons area after he was returned from an outing with an outside provider/care team. The facility staff was not aware that he had returned to the facility and placed in the common area. The note documented the facility worked with the outside care team to communicate with the facility staff when the resident was returned to the facility so the facility could ensure oversight and supervision. The note indicated the staff would be encouraged to place the resident in a reclining chair in the common area for comfort. The note documented therapy and restorative was notified of the incident. 4. Staff interviews The DON, the MDS coordinator and the therapy director were interviewed on 5/21/26 at 9:38 p.m. Resident #84 repeated falls and intervention, clarification of the fall on 4/23/26 that resulted in the resident going to the hospital, and the above observations were reviewed. The DON said on 4/23/26 the resident fell in the dining room and not in his room. She said the fall was witnessed by a family member of another resident and was not witnessed by the staff. She said the investigation did not identify where the staff was when he fell in the dining room. The DON said the investigation did not include staff or the family member's interview. She said the investigation was not clear if the family member actually witnessed the fall or if they were the ones who found the resident in the dining room. She said she did not know what the resident was doing prior to the fall, if he needed to use the restroom or when he was last toileted. The therapy director said she was made aware of the repeated falls, but did not receive orders from his outside provider/care team to evaluate him for therapy until 4/28/26, after the resident had the 10 falls in April 2026. The MDS coordinator said there was a long process to approve and receive orders from his outside care team. The DON said the facility should have reviewed the concern and delay with the medical director to help with the timeliness of the request. The therapy director said therapy was able to evaluate the resident on 4/29/26. The DON said the facility could have looked into one to one supervision to help decrease the risk of falls while the facility was waiting on therapy orders. The DON said Resident #84 would remove the lap buddy but should be encouraged to use it. She said based on observations made on 5/19/26. The DON said the staff should have asked him if he needed to use the restroom and provided assistance when they observed him leave the dining room table, go down the hall and enter his room. The MDS coordinator said some of the April 2026 fall interventions were not care planned to ensure staff communication. The MDS coordinator said one of the nurses told her that Resident #84 liked to sit in the reclining chair and a drink/snack. She said the resident seemed to enjoy the fall intervention. She said she would add it to the care plan and spread the information to other staff that work with him. She said she would continue to encourage staff to let her know what interventions were working to help prevent falls. The DON said there were patterns to the falls that were not fully identified. She said the investigations needed to be more thorough and include relevant information such as when Resident #84 was last toileted and checked on. She said the investigations should have included what the staff was doing at the time of the unwitnessed fall and who witnessed the falls. She said interviews with the staff who were working with Resident #84 at the time of the fall would help identify more factors and information related to falls. The DON and the MDS coordinator said thoroughly completed investigations could help prevent recurrence of the falls. The DON the resident has had no new falls since 4/28/28 but she would implement fall training to help decrease Resident #84 and other residents' risk for falls. 5. Facility follow up The fall in-service conducted on 5/21/26 through 5/26/26 was provided by the DON on 5/26/26 at 11:49 a.m. (after the survey exit) via email. The inservice identified the 29 members of the nursing department who were educated on fall prevention techniques and communication to include identification of routines, preferences, toileting needs and abilities, motivation to more and need for supervision. The inservice directed staff to communicate and document the observations of residents they were working with. II. Failure to ensure safe water temperatures A. Professional reference According to the Consumer Product Safety Commission (CPSC) Safety Alert, Avoiding Tap Water Scalds, retrieved on 5/27/26 from https://www.cpsc.gov/s3fs-public/5098.pdf The majority of injuries and deaths involving tap water scalds are to the elderly and children under the age of five. The U.S. Consumer Product Safety Commission (CPSC) urges all users to lower their water heaters to 120 degrees Fahrenheit (F). B. Facility policy and procedure The Test and Log Hot Water Temperatures policy, undated, was provided by the DON on 5/22/26 at 12:47p.m. via email The policy read in pertinent part, The facility must ensure that the residents' environment remains free of accidents as much as possible and each resident receives adequate supervision assistance to prevent accidents. For burn prevention, federal guidelines advise you to keep domestic water temperatures below 120 degrees Fahrenheit although this temp can still cause burns if exposure reaches 5 minutes. C. Observations and resident interviews The tap hot water temperatures from resident rooms were obtained on 5/21/26 between 9:15 a.m. and 9:50 a.m. The hot water in each resident room ran for approximately one minute prior to taking the water temperature. The hot water temperatures were as follows: -At 9:19 a.m. the water temperature from the sink in room #E6 registered at 120 degrees F. One resident who resided in room #E6 said the water took a while to warm up and he liked it hot. -At 9:23 a.m. the water temperature from the sink in room #F1 registered at 123 degrees F. -At 9:26 a.m. the water temperature from the sink in room #F2 registered at 122 degrees F. One resident who resided in room #F2 said the water got pretty hot. -At 9:31 a.m. the water temperature from the sink in room #A12 registered at 128 degrees F. One resident who resided in room #A12 said the water got pretty hot. -At 9:41 a.m. the water temperature from the sink in room #A5 registered at 129 degrees F. -At 9:48 a.m. the water temperature from the sink in room #B13 registered at 128 degrees F. One resident who resided in room #B13 said the water took a while to get hot and should get hotter faster. -At 9:50 a.m. the water temperature from the sink in room #B5 registered at 128 degrees F. D. Record review The resident room water temperature log for February 2026, March 2026 and April 2026 was provided by the DON on 5/21/26 at 4:48 p.m. The water temperature log documented water temperatures were taken monthly in one resident room in each hall. In February 2026 the hot water temperature ranged from 107 degrees F to 114 degrees F. In March 2026 the hot water temperature ranged from 107 degrees F to 115 degrees F. The water temperature logs documented the facility's most recent water temperature audit was conducted on 4/10/26, with hot water temperatures ranging from 107 degrees F to 113 degrees F. E. Staff interviews The maintenance assistant was interviewed on 5/21/26 at 1:35 p.m. The maintenance said the hot water tanks were usually set at 113 degrees F. He said the water temperatures ranged between 105 degrees F and 113 degrees F. He said they should keep water temps under 120 for safe resident use. He said he obtained the temperature of the water in the sink in room #A12 today (5/21/26) at 12:00 p.m. He said the resident sink water was 128 degrees F, which was too hot for a resident room. He said looked at the water heater and it was leaking, which was potentially affecting water temperatures. He said he turned the water heater temperature down. He said in the past there was a drip, but the drip stopped. He said with the 5/21/26 identification of the leak, the facility learned they need a new hot water heater. The DON was interviewed on 5/21/26 at 5:00 p.m. The DON said the hot water heater had a significant leak identified by maintenance on 5/21/26. She said there had not been any burns or injuries related to the hot water. F. Facility follow-up An email provided by the DON on 5/26/26 at 2:20 p.m. (after the survey exit) documented a plumber inspected the hot water heater and determined the bottom of the heater was rusted and needed to be replaced. According to the email, the maintenance department adjusted the temperature valve to compensate for the deficiency and are doing two hour checks to ensure it was staying in the appropriate temperature range until the heater could be replaced.

Based on record review and interviews, the facility failed to provide and document sufficient discharge preparation for two (#111 and #12) of two residents reviewed for a safe and orderly discharge out of 41 sample residents. Specifically, the facility failed to ensure a written discharge bed hold notice was provided to Resident #111 and Resident #12 or their representative completed at the time Resident #111 and Resident #12 were transferred to the hospital. Findings include: I. Facility policy and procedure The Bed Holds and Return policy, revised October 2022, was provided by the director of nursing on 5/20/26 at 6:55 p.m. It read in pertinent part, All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided with written notice about these policies at least twice: well in advance of any transfer (in the admission packet); and at the time of transfer (or, if the transfer was an emergency, within 24 hours). The written bed-hold notices provided to the residents/representatives explain in detail: the duration of the state bed-hold policy, if any, during which the resident is permitted to return and. resume residence in the facility; the reserve bed payment policy as indicated by the state plan (for Medicaid residents); the facility policy regarding bed-hold periods; the facility per-diem rate required to hold a bed (for non-Medicaid residents), or to hold a bed beyond the state bed-hold period (for Medicaid residents); and the facility return policy. II. Resident #111 A. Resident status Resident #111, age greater than 65, was admitted on [DATE] and discharged to the hospital on 3/12/26. According to the May 2026 computerized physician orders (CPO), diagnoses included acute kidney failure, and congestive heart failure. The 3/27/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. B. Record review The 3/22/26 progress note documented Resident #111 was transported to the hospital emergency room at 11:43 a.m. per the on-call doctor. The 3/22/26 nursing progress note revealed Resident #111 received an update from the power of attorney (POA) the resident was admitted to hospital. Review of the electronic medical record (EMR) failed to show a written bed hold form was completed with the resident or the POA upon transfer to the hospital. A request for the bed hold form for Resident #111 5/21/26. The social service director (SSD) said she did not have a bed hold form for Resident #111 (see interviews below). III. Staff interviews Registered nurse (RN) #2 was interviewed on 5/21/26 at 2:05 p.m. RN #2 said he always asked for help with discharges, because he did them infrequently. He said he has someone from administration look over his work for discharges. He said when a resident was discharged to the hospital a bed hold form needed to be completed. He said a staff member from administration provided the forms. He said he did not know why residents had to sign a bed hold form, and he always assumed the resident's bed was always held . The SSD was interviewed on 5/21/26 at 2:20 p.m. The SSD said Resident #111 was transferred to the hospital on 3/22/26. She said a bed hold form was not provided to the resident when she was discharged . She said the facility had not utilized this form as they should. She said it had been the standard to hold the bed open for the resident until they find out the disposition of the resident. She said despite the facility holding the bed, they still needed to have a signed bed hold form. The SSD said it was the resident's right to be informed of the requirements of the bed hold policy. III. Resident #12 A. Resident status Resident #12, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the May 2026 CPO diagnoses included acute and chronic respiratory failure, pulmonary hypertension and respirator virus. The 5/19/26 MDS assessment revealed Resident #12 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He was dependent on mobility with the use of a wheelchair. B. Record review The nursing progress note, dated 5/13/26, revealed Resident #12 discharged to the hospital for shortness of breath. Review of Resident #12's EMR did not reveal a bed hold notice was provided when Resident #12 was transferred to the hospital on 5/13/26. C. Staff interview Licensed practical nurse (LPN) #2 was interviewed on 5/21/26 at 11:50 a.m. LPN #2 said the assistant director of nursing (ADON) reviewed the bed hold policy with her today (5/21/26). She said the ADON explained to her the importance of completing the bed hold form when residents were sent to the hospital. She said the form was just added to the discharge packet. She said Resident #12 did not have a bed hold form prior to leaving for the hospital on 5/13/26.

Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to prevent and treat pressure injuries for one (#9) of six residents reviewed for pressure injuries out of 41 sample residents.Specifically, the facility failed to ensure staff consistently implemented care planned interventions for Resident #9, who had an unstageable pressure injury to her right heel.Findings include:I. Professional referenceAccording to Basic Nursing third edition; [NAME] S. Treas, [NAME], [NAME] H. [NAME] (2022), page 1214-1215, Healthy people regularly shift position to maintain comfort. However, many patients are unable to move without assistance. They require a change of position at least every two hours to prevent skin breakdown, muscle discomfort. People who are immobile are more prone to pressure injury as a result of reduced circulation, impaired oxygen exchange to the tissues and edema.According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline, [NAME] Haesler (Ed.), Cambridge Media: [NAME] Park, Western Australia; 2014, retrieved from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf on 5/28/26,Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Bruising indicates suspected deep tissue injury. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/Stage 4 ulcers can extend into muscle and/or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.II. Facility policy and procedureThe Pressure Ulcer Skin Breakdown policy, revised April 2018, was provided by the director of nursing (DON) on 5/20/26 at 2:00 p.m. It read in pertinent part, The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers, for example, immobility, recent weight loss, and a history of pressure ulcers. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions, identify the type of an ulcer and define any complications related to pressure ulcers. Healing or prevention likely: The resident's underlying physical condition, prognosis, personal goals and wishes, care instructions, and ability to cooperate with the treatment plan make wound healing and subsequent wound prevention realistic. Healing or prevention possible: Healing may be delayed or may occur only partially; wounds may occur despite appropriate preventive efforts. Monitoring during resident visits: The physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. Healing may be delayed or may not occur, or additional ulcers may occur because of other factors which cannot be modified. Current approaches should be reviewed for whether they remain pertinent to the resident/patient's medical conditions, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident/patient or a substitute decision-maker. III. Resident #9A. Resident statusResident #9, age greater than 65, was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included osteoporosis, chronic obstructive pulmonary disease, peripheral vascular disease and anxiety. The 4/14/26 minimum data set (MDS) assessment revealed Resident #9 had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. She needed partial to moderate assistance for activities of daily living (ADL). The MDS assessment indicated the resident had a pressure injury and she had a pressure reducing mattress. B. ObservationsOn 5/19/26 at 8:59 a.m. Resident #9 was lying in bed on her back and her protective podus boot was laying on the floor next to the bed. During a continuous observation on 5/20/26, beginning at 9:21 a.m. and ending at 11:38 a.m., Resident #9 was lying in bed on her back. The resident's protective podus boot was laying on the floor next to the bed. -No staff members entered the room during the two hour and 17 minute observation. On 5/21/26 at 8:38 a.m. Resident #9 was lying in bed on her back and her protective podus boot was laying on the floor next to the bed. C. Record review The pressure ulcer care plan, initiated 10/28/25 and revised 3/11/26, revealed Resident #9 had a pressure ulcer to the right heel related to immobility. The pressure ulcer would show signs of healing and remain free from infection. The resident would have intact skin, free of redness, blisters or discoloration through the next review date. Interventions included administering treatments as ordered and monitoring for effectiveness, providing an alternating air mattress with fitness setting three continuously, assessing, recording and monitoring wound healing weekly and as needed, measuring length, width and depth of the wound where possible, assessing and documenting the status of the wound perimeter, wound bed and healing progress, reporting improvements and declines to the medical director (MD), educating the resident, family and caregivers as to causes of skin breakdown, including transfer and positioning requirements; importance of good nutrition and frequent repositioning, following facility policies and protocols for the prevention and treatment of skin breakdown, heel protectors on the resident's bilateral feet and reminding the resident and assisting the resident to turn and reposition at least frequently.A nurse skin assessment note, dated 10/25/26, revealed Resident #9's right heel had an approximately four centimeter (cm) diameter dark red and purple discoloration that was tender to the touch. No broken skin was noted to the area. The surrounding skin area was pink and blanching (turning pale or white). Recommendations were to apply skin prep to the area, float the resident's heels while in bed and place protective booties on her heels. The resident's heels were to be floated at all times to mitigate potential pressure. A nurse skin assessment note, dated 11/6/25, revealed Resident #9's right heel wound was unstageable and measured at 2.6 cm long by 3.2 cm wide and 3.2 cm deep. The resident had an air mattress placed and had heels floating.A nurse skin note, dated 1/14/26, revealed the skin to Resident #9's heel wound was dry and no drainage was noted. The wound nurse covered the area with a bordered foam dressing after measuring the wound to be 1.54 cm long by 2.11 cm wide by 0.4 cm deep. The resident removed her protective podus boots and had to be reminded to wear them. -However the care plan did not reflect the resident's refusals or removal of the podus boots (see care plan above).A nurse skin note, dated 2/17/26, revealed Resident #9's wound bed had minimal slough (soft tissue), no eschar (dead tissue) and epithelial (damage) tissue to the wound. The wound had improved. A new dressing was in place and boots were on the resident's heels. Skin issue education was provided to staff to turn the resident every two hours.-However, observations revealed staff did not consistently reposition the resident (see observations above).A nurse note, dated 5/14/26, revealed the nurse was called to Resident #9's room because the resident had removed the blue foam boot and the heel protector pad. The nurse made a foam heel cup instead of a slip-on protector covered the entire foot with a stockinette secured at the ankle to attempt to keep the dressing in place longer and reapplied foam boot. The resident stated she would leave the dressing alone.-However the care plan did not address the resident's noncompliance to leave the dressing and the podus boot on.Review of Resident #9's May 2026 CPO revealed the following physician's orders: Wound care right heel: make sure podus boots are applied and heels are floated, every day and night shift, ordered 12/19/25 and discontinued 5/8/26. Wound care right heel: make sure socks and heel protectors are on and heels are floated every day and night shift, ordered 5/8/26. IV. Staff interviewsThe infection preventionist was interviewed on 5/19/26 at 7:50 a.m. The infection preventionist said she was responsible for the wound care for the residents. She said she was alerted when a resident had a skin issue and she completed the risk assessments and the Braden scale She said she educated the staff on new interventions when needed, such as air mattresses, heel or elbow protectors, when to float heels and repositioning residents. She said Resident #9 often peeled her dressings off her heel and took her protective boots off. She said was repositioned every two hours and she was encouraged to keep her podus boots on her feet. -However, observations revealed staff were not consistently ensuring the resident's podus boot was on (see observations above).Certified nurse aide (CNA) #1 was interviewed on 5/20/26 at 11:25 a.m. CNA #1 said residents were repositioned every two hours on average. She said the nurse would let her know when a new skin injury occurred for a resident and what to do to help with the care. She said the staff kept a close eye on Resident #9 because she removed her podus boots and threw them on the floor.-However, observations revealed staff were not consistently ensuring the resident's podus boot was on (see observations above). Licensed practical nurse (LPN) #1 was interviewed on 5/20/26 at 2:02 p.m. LPN #1 said verbal education was given to the CNAs for positioning and offloading areas with pressure for residents. LPN #1 said Resident #9 was problematic because she would take her boots off. She said the resident refused to keep her heel protectors on and staff reminded her to keep them on but the resident forgot. -However, observations revealed staff were not consistently ensuring the resident's podus boot was on (see observations above). LPN #2 was interviewed on 5/21/26 at 11:50 a.m. LPN #2 said the first line of any skin redness was to use skin barriers to avoid further breakdown. She said residents were monitored every shift and staff made sure the resident was repositioned at least every two hours. CNA #2 was interviewed on 5/21/26 at 11:45 a.m. CNA #2 said the nurses would verbally tell her when a resident had a pressure wound and staff would turn the resident every two hours and use pillows for positioning.Registered nurse (RN) #1 was interviewed on 5/21/26 at 2:32 p.m. RN #1 said residents who had pressure injuries were followed by the wound nurse and sometimes the wound doctor. She said the residents required frequent turning and had pressure relieving devices to keep pressure off the site. She said Resident #9 wore protective boots but she liked to rip them off at times. She said staff did frequent checks to make sure the boots were kept on.-However, observations revealed staff were not consistently ensuring the resident's podus boot was on (see observations above). The DON was interviewed on 5/21/26 at 3:15 p.m. The DON said any reddened skin was reported to the nursing staff and monitoring began. She said barrier cream was started with repositioning. She said the wound nurse was notified and interventions put into place. The DON said interventions included pressure relieving devices, such as an air mattress for the bed, or cushion for the chair. The DON said the interdisciplinary team (IDT) met weekly to discuss any new concerns and to follow up on any current resident needs, to include skin with pressure injuries. She said the IDT brainstormed for any new interventions needed for the resident. She said the facility tried to ensure preventative measures for pressure wounds were reviewed for implementation. The DON said she was responsible for educating the staff to anticipate the needs of the resident. She said staff were getting better on how to capture the residents' refusals with documentation. She said Resident #9 continued to take off her protective boots and due to her cognition and inability to remember to keep them on, the IDT thought they would try a recliner chair as a new positioning technique. She said the resident's wound could decline from poor or inconsistent interventions.

Based on observations, record review and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease on one out of six units.Specifically, the facility failed to ensure hand hygiene was conducted appropriately during wound care for Resident #9 and Resident #55.Findings include:I. Professional reference According to The Centers for Disease Control and Prevention's (CDC) Hand Hygiene for Healthcare Workers (2/27/24), retrieved on 5/27/26 from https://www.cdc.gov/cleanhands/ hcp/clinical-safety/index.html, included the following recommendations for hand hygiene, Hand hygiene protects both healthcare personnel and patients. Cleaning your hands reduces the potential spread of germs. Clean your hands before and after changing wound dressings or bandages. Clean your hands immediately before touching a patient and after touching a patient or the patient's surroundings.II. Facility policy and procedureThe Wound Care policy, revised October 2010, was provided by the director of nursing (DON) on 5/20/26 at 6:47 p.m. It read in pertinent part, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Steps in the procedure: wash and dry your hands thoroughly. Put on exam gloves. Loosen tape, remove dressing and pull soiled gloves over the dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. Put on gloves. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. Remove disposable gloves and discard them into designated containers. Wash and dry your hands thoroughly. Wipe reusable supplies with alcohol as indicated outsides of containers that were touched by unclean hands, scissor blades). Take only the disposable supplies that are necessary for the treatment into the room. Disposable supplies cannot be returned to the cart. Wash and dry your hands thoroughly. Notify the supervisor if the resident refuses the wound care. Report other information in accordance with facility policy and professional standards of practice.III. Observations On 5/19/26 at 10:17 a.m. the wound doctor was completing wound care for Resident #55. The wound doctor donned a mask, gloves and a gown. He removed the soiled wound dressing. He then moved his glasses to the top of his head with his gloved hands, touched his mask and the resident's headboard. Without changing gloves and performing hand hygiene, he cleaned the wound with a wound spray and applied lidocaine gel (topical pain medication). With the same gloved hands, he picked up the camera and took pictures of the wound. He then used the sterile utensils brought into the room earlier to debride the wound, placed a sterile medicated packing material inside the wound bed and covered it with a bordered bandage. He opened the door of the resident's room with the same gloved hands and stepped out of the room before doffing mask, gown and gloves. He cleaned the camera with a disinfectant wipe and then washed his hands in the residents sink. -The wound doctor failed to change gloves and perform hand hygiene when his gloves became contaminated. On 5/19/26 at 10:45 a.m. The wound doctor was completing wound care for Resident #9 He donned a mask and gown and reached into his pocket for the gloves, he put the gloves on and entered the resident's room. He opened the sterile utensil package upon entering the resident room and placed this on the bedside table. He doffed the gloves he had in his pocket and put on a new pair of gloves found in the resident's room, without performing hand hygiene. He took off the soiled dressings from three different areas of the resident's foot and cleaned the areas with a wound cleanser. He then applied lidocaine gel to the heel wound. He took pictures of the wound and then used the sterile utensils to debris the wound, placed a sterile medicated packing material inside the wound bed and covered it with a bordered bandage. He doffed the gown and gloves, cleaned his camera with a disinfectant wipe and washed his hands in the resident's sink. -The wound doctor failed to change gloves and perform hand hygiene when his gloves became contaminated. IV. Staff interviewsThe wound doctor was interviewed on 5/19/26 at 11:10 a.m. He said the process for infection control was to keep dirty items from clean items. He said that was why he brought the sterile kit into the resident's room, so he would not contaminate the wound cart and to keep the wound clean. The infection preventionist was interviewed on 5/20/26 at 2:55 p.m. The infection preventionist said hand hygiene was completed between glove use, going in out of resident rooms, during incontinence care, prior to meals and when hands come in contact with soiled material. She said during wound care she would expect gloves to be changed from dirty to clean procedures with hand hygiene in between. She said she had not completed any education with outside agencies coming into the facility on hand hygiene nor PPE use. The DON was interviewed on 5/21/26 at 3:15 p.m. She said staff completed hand hygiene in between resident cares and glove use. She said outside agencies, such as the wound doctor, that came into the facility were not regulated by them. She said however, she said she would hope they followed professional standards with wound care and hand hygiene procedures.

Based on record review and interviews, the facility failed to establish an effective antibiotic stewardship program to include antibiotic use protocols and a system to monitor antibiotic use for one (#92) of two residents reviewed for antibiotic stewardship out of 41 sample residents. Specifically, the facility failed to ensure Resident #92's antibiotic therapy for doxycycline medication was reviewed for continued use on an ongoing basis.Findings include: I. Facility policy and procedure The Antibiotic Stewardship Review and Surveillance policy, revised December 2016, was provided by the director of nurses (DON) on 5/19/26 at 10:17 a.m. It read in pertinent part, Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship. As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection preventionist, or designee' The infection preventionist or designee will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. Therapy may require further review and possible changes if: therapy was ordered for prolonged surgical prophylaxis and clinical findings do not indicate continued need for antibiotic. At the conclusion of the review, the provider will be notified of the review findings. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include, symptoms, start date of antibiotics, site of the infection, total days of therapy, outcome, adverse events and stop date. II. Resident statusResident #92, age greater than 65, was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO) diagnoses included Alzheimer disease, infection with inflammation to a reaction with an internal orthopedic device and osteomyelitis. The 3/20/26 minimum data set (MDS) assessment revealed Resident #92 had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She was dependent on activities of daily living (ADL). The assessment indicated she was on an antibiotic. III. Record reviewThe May 2026 CPO revealed the following physician's order:Doxycycline 100 milligrams (mg) one tablet orally daily for osteomyelitis related to infection with inflammation to a reaction with an internal orthopedic device, ordered on 6/15/23. The nurse practitioner note, dated 1/9/25, was provided by the director of nursing (DON) on 5/20/26 at 8:30 a.m. The note revealed Resident #92 was on doxycycline as a suppressive therapy (continued use of medication) from an infected hardware to the left ankle. The medical director note, dated 1/20/25, was provided by the DON on 5/20/26 at 8:30 a.m. The note revealed Resident #92 was on doxycycline for infected hardware in the ankle, with associated osteomyelitis. On suppressive antibiotics and tolerating the medication well.-Review of Resident #92's electronic medical record (EMR) did not reveal any further documentation regarding justification or monitoring of the continued use of the doxycycline. The medication regimen review dated 7/30/25 and 2/26/26 were provided by the DON on 5/20/26 at 7:09 p.m. -The medication reviews did not reveal the doxycycline was reviewed. IV. Staff interviewsThe infection preventionist was interviewed on 5/19/26 at 1:47 p.m The infection preventionist said Resident #92 was on a prophylactic antibiotic for inflammation from an infected internal hardware. She said the nurse practitioner assessed the need for the continued medication and recommended any changes. She said she reviewed progress notes and talked to the interdisciplinary team for follow up. She she had not followed up with the antibiotic use for Resident #92 since the order was originally placed in 2023The DON was interviewed on 5/21/26 at 3:15 p.m. The DON said the facility completed medication reviews right after the interdisciplinary team meetings. She said the medical director talked to families and looked at the medical history before making any changes to the medications. She said when a resident was on antibiotics, they used the McGeers (identify and track infection) criteria and discussed each case with the physician for continued use or discontinuation. She said they had not looked at Resident #92 antibiotic regimen regularly to see if the medication continued to be appropriate. V. Facility follow-up A facsimile (fax) dated 5/20/26 which was sent to the physician, was provided by the DON on 5/20/26 at 3:30p.m. The fax documentedResident #92 was on doxycycline medication 100 mg one tablet daily for osteomyelitis related to infection with inflammation to a reaction with an internal orthopedic device. The fax documented she started the medication on 6/15/23. The fax asked the physician to review if the resident was still appropriate to be on the medication at this time, if there were any concerns or or if a risk versus benefit was needed.-However, record review revealed Resident #92's antibiotic use had not been reviewed since January 2025 (see record review above).-The facility did not provide follow-up from the physician.

Based on observation, record review, and interviews the facility failed to ensure that one (#2) of three residents were free from abuse out of four sample residents.Specifically, the facility failed to protect Resident #2 from verbal abuse by Resident #1 Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy and procedure, revised April 2021, was provided by the nursing home administrator (NHA) on 10/20/25 at 1:35 p.m. It read in pertinent part, Our residents have the right to be free from abuse. This includes but is not limited to freedom from physical abuse. 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. Incident of verbal abuse by Resident #1 towards Resident #2 on 8/22/25The facility investigation revealed that on 8/22/25 at 3:00 p.m. Resident #2 was observed upset during a card game with other residents. Resident #2 was observed hitting the table, making a fist towards Resident #1 and yelling at Resident #1 with profanity statements. Resident #1 became fearful of Resident #2 after the staff were unable to immediately redirect Resident #2 away from the card game.The investigation revealed facility staff immediately separated Resident #1 and Resident #2 and placed Resident #2 on frequent monitoring (every 15 minutes) for safety. The registered nurse (RN) assessed Resident #1 and Resident #2 and found no physician injuries. Resident #1 was tearful and agreed to see the facility's in-house counselor.The investigation documented Resident #1 was interviewed by the social services director (SSD). Resident #1 voiced that she was afraid of Resident #2 because of his explosive behavior. Resident #2 voiced that she was very afraid of Resident #2 because she had once had an abusive relationship and Resident #2's behavior brought up memories of the abuse. Resident #1 voiced that Resident #2 screamed, swung his arms, hit the table, and made accusatory statements about her. Resident #1 voiced that the activities staff eventually redirected Resident #2 to his wheelchair for the safety of everyone. Resident #1 told the SSD she would like to have a referral for counseling services.The investigation documented Resident #1 was interviewed by the SSD. Resident #2 voiced that Resident #1 criticized his card playing and yelled at him. Resident #2 expressed that he felt he was not good enough to play cards because he had difficulty with his vision, and women had more rights than men. Resident #2 voiced that he would stay in his room and not attend future activities, and voiced that he felt the facility tried to discharge him to another facility because the staff and residents hated him. The SSD documented that a referral to the in-house counselor had previously been sent and Resident #2 had declined counseling services. The SSD documented Resident #2 was placed on a behavior contract and educated regarding behavior expectations and ideas to reduce agitation.The investigation documented activities assistant (AA) #1 witness statement was documented at about 2:00 p.m. and revealed Resident #2 had been annoyed and accused another resident of cheating on the card game. Resident #2 was observed with increased agitation throughout the game. The AA documented she returned to her nearby office and then saw Resident #2 waving his arms and hearing him yelling at other residents. The AA documented Resident #2 said the other residents playing the card game cheated and skipped his turn. The AA documented that Resident #2 pointed, shook, and swung his fist while he explained his actions to the AA. AA #2 witness statement documented she observed Resident #2 make a fist toward Resident #1. The AA #2 documented Resident #2 was confused and upset, and AA #2 went for help from the SSD to redirect Resident #2. The 8/22/25 4:00 p.m. Resident #1 statement documented Resident #1 voiced that Resident #2 misunderstood her about the card game. Resident #1 voiced she remained afraid of Resident #2's anger, that she had nothing against Resident #2, and thought Resident #2 sometimes upset other residents.The facility investigation revealed that the altercation was witnessed by staff members and the altercation was substantiated by the facility.III. Resident #1 (victim)A. Resident statusResident #1, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the June 2022 computerized physician's orders (CPO), diagnoses included congestive heart disease and difficulty walking, The 7/31/25 minimum data set (MDS) assessment revealed the Resident #2 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #1 had no behaviors towards others during the review period.Resident #1 required a manual wheelchair and was dependent on staff for mobility and required substantial to maximum assistance from staff for bathing, dressing, toileting, moderate assistance from staff for bed mobility, transfers, and personal hygiene.B. Resident interviewResident #1 was interviewed on 10/21/25. Resident #1 said she remembers the incident with Resident #2. Resident #1 said she was fearful of Resident #2 because she had a history of living with verbal abuse from a former spouse. Resident #1 said after the verbal altercation, she returned to her room. Resident #1 said she did not return to her room only because she was afraid of Resident #2, but because that was her regular daily routine. Resident #1 said she requested to meet with the in-house counselor, but the counselor had not scheduled an appointment with her yet. Resident #1 said in the afternoon of the altercation, she felt comfortable returning to the dining room for her evening meal and did not feel that she changed her daily routines because of the altercation. Resident #1 said Resident #2 continued to sit at the same table when they played cards, but she made a point to sit away from Resident #2. Resident #1 said she thought other residents were afraid of Resident #2 and his outburst behaviors. Resident #1 said sometimes she observed Resident #2 in the hallways, but he sat in his wheelchair and was not threatening towards her. Resident #1 said she was not afraid of Resident #2 but was afraid of being near him if he had another outburst. Resident #1 said she still wanted to talk to the counselor because she was afraid of the outburst, had grief from the death of her spouse, and economic worries about her home in the community. Resident #1 said she had no appointment notifications and had not received any contacts or communications regarding counseling services. C. Record reviewReview of Resident 32's comprehensive care plan did not reveal the resident had a behavior, mood, or trauma care plan.The SSD progress noted, dated 8/22/25 at 4:30 p.m., the SSD followed up with Resident #2 after the altercation with Resident #1. The SSD note read Resident #2 appeared fearful and was visibly upset during the conversation. The SSD offered Resident #2 in-house counseling services and sent an email message to the counselor. Review of the October 2025 CPO did not reveal a physician's order for counseling services or behavior monitoring that were recommended after the incident on 8/22/25.IV. Resident #2 (assailant)A. Resident statusResident #1, age [AGE], was admitted on [DATE]. According to the October 2025 CPO, diagnoses included stroke with left-sided paralysis and aphasia (difficulty with speech and language).The 7/8/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. During the review period, the MDS assessment documented the resident had no physical or behavioral symptoms directed towards others, and zero days of verbal behavioral behaviors directed towards others. The resident used a manual wheelchair and was able to self-propel himself for mobility. Resident #1 required substantial assistance from staff for his activities of daily living.-However, progress notes found during the record review document Resident #1 had a history of behaviors towards others - yelling, using profanity, and making derogatory outbursts. According to the assessment, Resident #1 had no history of behaviors directed toward others. -However, a review of electronic medical record (EMR) revealed Resident #2 had verbal outbursts towards others on 4/15/25, 5/21/25 and 7/7/15.B. Resident interviewResident #1 was interviewed on 10/21/25 at 2:33 p.m. Resident #1 requested SSA #1 was also present during the interview. Resident #1 said he did not recall having any recent verbal outburst or arguments during recent activities and denied having any issues with any staff or residents in the facility. Multiple times during the interview, Resident #1 said he did not want to get anyone in trouble and asked SSA #1 multiple times if he was in trouble. Resident #1 said he used to be on a behavior contract, but said he was not aware if he was currently on a behavior contract. Resident #1 then asked SSA #1 to check for him after the interview. Resident #1 said he remembered a previous family member who was forced to leave a facility for her behavior and did not want to be kicked out of the facility.Cross reference F550: failure to treat the resident with respect and dignity. C. Record reviewResident #1's comprehensive care plan, initiated 12/10/24, included a care focus to explain what behavior was unacceptable. Pertinent interventions included: anticipating care needs and providing them before the resident becomes overly stressed, discussing behaviors with Resident #1, explaining and reinforcing why the behavior was unacceptable, using a behavior contract to help guide Resident #1 with outbursts, intervening to protect the rights and safety of others, and approaching calmly to divert to a less stimulating environment.The progress note, dated 4/15/2025 at 2:09 p.m., documented the previous SSD was called to meet with Resident #1 after Resident #1 yelled at a CNA for moving the resident's recliner. The progress note documented when the SSD went to speak with Resident #1, Resident #1 cursed and yelled at the SSD. The SSD informed Resident #1 he needed to speak in a polite manner and reminded him of his behavioral contract. The progress documented resident #1 cursed at the SSD to which the SSD told Resident #1 he would talk with him when he has calmed down and is willing to have a conversation.The MDS note, dated 4/22/25 at 7:39 p.m., documented Resident #1 was at risk for cognitive concerns related to behaviors of verbal aggression. The care plan goal will be to minimize risks and reduce episodes of verbal aggression as tolerated. The MDS note documented Resident #1 had increasing behavioral indicators have been noted through assessments, particularly verbal outbursts directed at staff. The MDS note documented the SSD planned for continued behavioral monitoring and interventions with the goal of reducing these episodes and supporting Resident #1's emotional well-being.The progress note, dated 5/21/25 at 11:53 a.m., documented the Sloor nurse and the floor CNA met with Resident #1 after interaction with the CNA where Resident #1 cursed out the CNA. The progress note documented Resident #1 said he was upset with the CNA because he spent too long waiting for assistance off of the commode. The progress note documented the SSD checked logs and saw residents waited five minutes from the time the call light was pressed. The Progress note documented Resident #1 became aggressive, then the SSD reminded Resident #1 of his behavior contract and told Resident #1 if he had one more aggressive episode that the staff would have to look at a facility that more meets the residents needs. The progress note documented the director of nursing was aware.The progress note, dated 7/7/25 at 1:24 p.m., documented the current SSD spoke with Resident #1 about how he approached other staff and residents in the facility. The progress note documented the SSD told Resident #1 he needed to use his manners, using please, thank you, excuse me as an example. The progress note documented Resident #1 agreed to use his manners when approaching othersThe progress note, dated 8/25/25 at 5:22 p.m. (after the abuse occurred), documented the SSD, SSA #1, the assistant NHA and the activities director (AD) met with Resident #1 to review an updated behavior contract. The progress note documented Resident #1 became visibly upset at the start of the meeting and immediately questioned whether he was being discharged ; the SSD reassured him that he was not being discharged and that the purpose of the meeting was to review the updated behavior contract. The progress note documented Resident #1 expressed frustration, and stated no other residents were receiving behavior contracts.The progress note documented Resident #1 was asked three separate times to review the updated behavior contract. Each time, he declined and repeatedly requested to speak with a former staff member who is no longer part of the social services department. After the third attempt to engage Resident #1 to review the contract, the assistant NHA informed Resident #1 he was free to go to dinner. The SSD, the AD, SSA #1, and the assistant NHA all signed the behavior contract noting that Resident #1 refused to sign.The nursing note, dated 8/28/25 at 4:04 p.m., documented new orders for Resident #1 to start escitalopram 10 milligrams (mg) by mouth once per day for aggression and anxiety.-However, no updates were made to Resident #1's care plan to assess and monitor Resident #1's behaviors after starting a psychotropic medication. V. Staff interviewsThe SSD was interviewed on 10/21/25 at 11:23 a.m. The SSD said she sent a referral for Resident #2's counseling request to the counselor by email. The SSD said the in-house counselor sent her a status report after every visit that included the names of residents she evaluated. The SSD said the status report messages were not part of Resident #2's EMR. The SSD said the counselor was a contracted social worker who provided in-house counseling to residents and visited the facility every Wednesday. The SSD said she communicated with the counselor using email messages, and the counselor kept records in her own external system. The SSD was unable to locate documentation Resident #2 had received counseling services after the referral for services was placed. The SSD said she worked together with the counselor to update resident care plans when necessary. The SSD said the counselor provided feedback by text message on 10/20/25 (during the survey) and the counselor said she had made several attempts to see Resident #2 and said Resident #2 was either participating in a facility activity, was getting her hair done, or had declined the services. The SSD said the counselor did not make appointments with residents and was unsure if Resident #2 had been notified she had missed evaluations with the counselor.The MDS coordinator was interviewed on 10/21/25 at 9:06 a.m. The MDS coordinator said she was responsible for initiating resident baseline care plans, which were required to be reviewed and discussed with residents and/or family representatives. The MDS coordinator said members of the interdisciplinary team (IDT) team were responsible for updating care plans when residents needed changes to their care. The MSD coordinator said IDT members could monitor residents for changes by attending the daily IDT meetings or by reading the 24-hour report, which was a daily log of all resident EMR entries. The MSD coordinator was unable to locate a behavior or mood care plan for Resident #1. The MDS coordinator was interviewed again on 10/21/25 at 1:45 p.m. The MDS coordinator said target behaviors are identified by talking with floor staff. Behaviors would include yelling or outbursts. For depression, we talk with family about what depression symptoms they have, and if they are previously on an antidepressant. She said the facility has a psychiatric quality assurance representative that speaks with the medical director, they also discuss with the physician, and in IDT. She said she was the one responsible for updating the care plan when a new medication is added and she was not sure why Resident #1 did not have a psychotropic medication focus added to his care plan when the antidepressant was ordered. She said Resident #2's quarterly review was planned for 10/21/25 , and she planned to update Resident #1's care plan today. She said she planned to educate staff to include a care plan when they receive a new order for a psychotropic medication so that the care plan is updated faster to reflect changes for each resident. She said she was not part of the discussion for Resident #1's medication, but she was usually involved in similar discussions during IDT meetings. She said they had discussed it in the past, but he declined. She said nonpharmacological interventions for Resident #1 would be in his behavior care plan and she also planned to add additional nonpharmacological interventions and behavior tracking when she created the psychotropic medication care plan. Certified nurse assistant (CNA) #1 was interviewed on 10/21/25 at 10:34 a.m. CNA #1 said she was familiar with Resident #1. She said she had observed Resident #1 with behaviors such as throwing himself into his chair or trying to tip the sit-to-stand equipment. CNA #1 said Resident #1 responded well when he was approached quietly and in a friendly manner. CNA #1 said if Resident #1 had escalating behaviors, she would step in to help Resident #1 de-escalate his behavior with redirection to a quiet or calm activity. CNA #1 said she received annual training for abuse prevention and reporting.

Based on observations and interviews, the facility failed to ensure care for residents was provided timely and in a manner that maintained or enhanced the residents' dignity for one (#1) of three residents reviewed for dignity out of four sample residents.Specifically, the facility failed to ensure Resident #1's behavior contract was not used as a threat. Findings include:I. Facility policy and procedureThe Resident rights policy, revised February 2021, was provided by the nursing home administrator (NHA) on 10/20/25 at 1:34 p.m. It read in pertinent part, 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; be free from abuse, neglect, misappropriation of property, and exploitation; be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms; self-determination; communication with and access to people and services, both inside and outside the facility; exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; 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.II. Resident #1A. Resident statusResident #1, greater than 65, was admitted on [DATE]. According to the October 2025 computerized physician's orders (CPO), diagnoses included stroke with left-sided paralysis and aphasia (difficulty with speech and language).The 7/8/25 MDS assessment revealed the resident was cognitively intact with a brief interview for mental statu s(BIMS) score of 15 out of 15. The resident was dependent on staff for bathing, toileting, footwear and lower body dressing. Resident #1 required substantial assistance with oral hygiene, personal hygiene and upper body dressing.The resident used a manual wheelchair and was able to self-propel himself for mobility. Resident #1 required substantial assistance from staff for his activities of daily living.According to the assessment, Resident #1 had no history of behaviors directed toward others. -However, a review of electronic medical record (EMR) revealed Resident #2 had verbal outbursts towards others on 4/15/25, 5/21/25 and 7/7/15.B. Resident interviewResident #1 was interviewed on 10/21/25 at 2:33 p.m. Resident #1 requested social services assistant (SSA) #1 was also present during the interview. Resident #1 said he did not recall having any recent verbal outburst or arguments during recent activities and denied having any issues with any staff or residents in the facility. Multiple times during the interview, Resident #1 said he did not want to get anyone in trouble and asked SSA #1 multiple times if he was in trouble. Resident #1 said he used to be on a behavior contract, but said he was not aware if he was currently on a behavior contract. Resident #1 then asked SSA #1 to check for him after the interview. Resident #1 said he remembered a previous family member who was forced to leave a facility for her behavior and did not want to be kicked out of the facility.C. Record reviewResident #1's comprehensive care plan, initiated 12/10/24, included a care focus to explain what behavior was unacceptable. Pertinent interventions included: anticipating care needs and providing them before the resident becomes overly stressed, discussing behaviors with Resident #1, explaining and reinforcing why the behavior was unacceptable, using a behavior contract to help guide Resident #1 with outbursts, intervening to protect the rights and safety of others, and approaching calmly to divert to a less stimulating environment.The behavior contract, dated 11/27/24, documented Resident #1 had behaviors of yelling, hitting the table with my hand, hat or drink, and demanding my own way. The contract documented if Resident #1 expressed the listed behaviors, he would be removed from the environment and placed in a calm environment until he was able to resolve the situation in a more appropriate manner. The contract listed goal dates for managing Resident #1's behavior of 11/28/24 to 12/28/24. -However, the behavior contract remained in place with no updated goal date.The progress note, dated 5/21/25 at 11:53 a.m., documented the social services director (SSD), the SSA, the floor nurse and the floor CNA met with Resident #1 after interaction with the CNA where Resident #1 cursed out the CNA. The progress note documented Resident #1 said he was upset with the CNA because he spent too long waiting for assistance off of the commode. The progress note documented the SSD checked logs and saw residents waited five minutes from the time the call light was pressed. The Progress note documented Resident #1 became aggressive, then the SSD reminded Resident #1 of his behavior contract and told Resident #1 if he had one more aggressive episode that the staff would have to look at a facility that more meets the residents needs. The progress note documented the director of nursing (DON) was aware.The progress note, dated 8/25/25 at 5:22 p.m., documented the SSD, the SSA, the assistant NHA and the activities director (AD) met with Resident #1 to review an updated behavior contract. The progress note documented Resident #1 became visibly upset at the start of the meeting and immediately questioned whether he was being discharged . The SSD reassured him that he was not being discharged and that the purpose of the meeting was to review the updated behavior contract. The progress note documented Resident #1 expressed frustration, and stated no other residents were receiving behavior contracts.The progress note documented Resident #1 was asked three separate times to review the updated behavior contract. Each time, he declined and repeatedly requested to speak with a former staff member who was no longer part of the social services department. After the third attempt to engage Resident #1 to review the contract, the assistant NHA informed Resident #1 he was free to go to dinner. The SSD, AD, SSA, and assistant NHA all signed the behavior contract noting that Resident #1 refused to sign.III. Staff interviewsSSA #1 was interviewed on 10/20/25 at 2:53 p.m. SSA #1 said they were not sure why Resident #1 appeared concerned about being kicked out of the facility. SSA #1 said they were aware Resident #1 had behaviors of verbal outbursts and cursing at staff and they were aware Resident #1 had a behavior contract, but SSA #1 said to their knowledge Resident #1 was not at any risk of being discharged against their will.The social services director (SSD) and the MDS coordinator were interviewed together on 10/21/25 at 11:32 a.m. The SSD said to her knowledge, Resident #1 was the only resident in the facility who had a behavior contract. The MDS coordinator said the purpose of the contract was to hold Resident #1 accountable for his actions since he was alert and oriented. The SSD said she started working in the facility June of 2025 and she was not involved in writing the initial behavior contract, but was involved in updating his updated behavior contract on 8/22/25. The SSD said she did not want Resident #1 to feel he was at risk for being kicked out of the facility due to his behavior, and that was not the intention of the behavior support plan she created on 8/22/25. The SSD said she was not aware Resident #1 was unsure whether or not he was still on a behavior contract. The SSD and the MDS coordinator said they did not know why the behavior contract was not changed and why the contract remained in place after the specified goal date.The SSD and the MDS coordinator said they were not aware of the interaction Resident #1 had with the SSD previously working at the facility and do not know why he would tell Resident #1 he would not be able to stay at the facility if he did not follow his behavior contract The SSD said she planned to re-approach Resident #1 after the interview to ensure the resident was aware his new behavior support plan was not meant to be used as a punishment and he was not at risk for discharge from the facility for failure to follow the behavior contract.

Based on observations, record review and interviews, the facility failed to ensure two (#2 and #1) of three residents out of five sample residents received dental services timely.Specifically, the facility failed to:-Identify and refer Resident #2 to the dentist timely after she lost her left upper canine tooth; and, -Resident #1 was offered routine dental care. Findings include: I. Facility policy and procedure The Emergency Dental Care policy, revised April 2007, was provided by the assistant director of nursing (ADON) on 10/1/25 at 6:49 p.m. It revealed in pertinent part, Emergency dental care is available on a twenty-four hour basis. Should a resident need emergency dental care, the dental consultant shall be notified so that arrangements for the emergency care can be made. Social services shall contact the consultant dentist to set up the appointment. (Note: Should social services be unavailable, the charge nurse shall contact the consultant dentist.) Emergency dental services included to treat an episode of acute pain in teeth, gums, or palate, broken, or otherwise damaged teeth, or any problem of the oral cavity appropriately treated by a dentist that requires immediate attention. II. Resident #2 A. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included history of a motor vehicle accident, fracture of the right pubis, fracture of the sacrum, fracture of the fifth lumbar vertebra, anemia, hypothyroidism and hypertension. The 9/23/25 minimum data set (MDS) assessment revealed Resident #2 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of ten out of 15. Resident #2 was independent with oral care. She required supervision and cues with toileting, dressing, and personal hygiene. Resident #2 required substantial assistance with footwear. B. Resident interview and observations Resident #2 was interviewed on 10/1/25 at 11:18 a.m. Resident #2 said she thought her tooth fell out about a month ago. Resident #2 said no accident occurred, the tooth just fell out while she was eating. Resident #2 said she told a staff member the tooth fell out and even kept the tooth for a little while to show them. Resident #2 said sometimes the staff helped her brush her teeth and sometimes she was able to brush them herself. Resident #2 said she also thought she told her daughter about her tooth. During the interview, it was observed the Resident #2 was missing her left canine tooth. C. Resident #2's representative interview Resident #2's representative was interviewed on 10/1/25 at 3:47 p.m. She said Resident #2 showed the representative her tooth sitting on her bedside table when she visited Resident #2 on 9/4/25. She said at first Resident #2 wanted to see her dentist, but about a week later Resident #2 told her she did not want to go anymore. The resident's representative said she called the facility to ask about what dental services they offer inside the facility, but did not report the tooth had fallen out during the phone call. The resident's representative said she would have wanted somebody to assess Resident #2's mouth and intervene if there was an infection or some other issue. D. Record review Resident #2's activities of daily living (ADL) care plan, initiated 6/20/25 and revised 7/9/25, revealed Resident #2 had deficits related to multiple fractures. Interventions related to oral care revealed Resident #2 required moderate to dependent on one staff assist with oral care in order to maximize independence. Resident #2's certified nurse assistant (CNA) Kardex (staff directive tool), dated 10/1/25, revealed Resident #2 required moderate to dependant assistance with oral care. Review of Resident #2's CNA task list for oral care, dated from 9/1/25 through 10/1/25, revealed Resident #2 required a range from substantial assistance to set up and clean up assistance only. -Review of Resident #2's electronic medical record (EMR) did not reveal documentation regarding the resident's missing tooth, despite documentation indicating the staff had assisted the resident with oral care. -Review of Resident #2's photo in the EMR revealed the resident had both canines at the time of the photo (see observations above). E. Staff interviews Registered nurse (RN) #2 was interviewed on 10/1/25 at 3:22 p.m. RN #2 said she was informed a few minutes ago that Resident #2 was missing a tooth, but did not now Resident #2 lost a tooth prior to this shift. RN #2 said any staff member who found a missing tooth in a resident's room or any potential injury without a known origin should report what they found to the nurse assigned to that room so the nurse can follow up. RN #2 said the nurse should complete an assessment to make sure there were no infections or complications requiring a change in the care plan. RN #2 said she planned to complete an oral assessment after the interview. CNA #2 was interviewed on 10/1/25 at 5:29 p.m. CNA #2 said She said they were able to see which residents need assistance with ADLs and transferring based on the whiteboard with a privacy cover for each resident in the room. CNA #2 said Resident #2 required cues and set up for personal hygiene and oral care. CNA #2 said she was working on the hall for Resident #2 at the time of the survey, but normally she worked in a different hall and had not noticed Resident #2 was missing a tooth. CNA #2 said if she saw a resident lost a tooth or if she was not sure if the nurse knew, she would tell her hall nurse so that they could complete an assessment. CNA #2 said she recently did a training related to oral care. CNA #3 was interviewed on 10/1/25 at 5:33 p.m. CNA #3 said she worked at the facility for the last six months and regularly worked the hallway Resident #2 lived on. CNA #3 said she could check the Kardex or the care plan for the ADL needs for each resident. CNA #3 said Resident #2 required assistance with set up and cues for oral care and personal hygiene. CNA #3 said she recently completed an education about providing oral care. CNA #3 said she had not noticed that Resident #2 was missing a tooth. CNA #3 said if she did notice a resident was missing a tooth, she would contact the nurse right away so that the nurse could follow up with that resident. The nursing home administrator (NHA) and the director of nursing (DON) were interviewed together on 10/1/25 at 5:01 p.m. The NHA and the DON said they were not aware Resident #2 was missing a tooth until the time of the survey. The DON said she did not know why no staff were aware Resident #2 lost a tooth, and she expected any CNA to inform the hall nurse for a resident if a broken or missing tooth was found and she expected any nurse to complete and document an assessment in order to ensure the resident was offered dental services if they wanted and to prevent an infection. The NHA said the facility recently completed education on providing oral care, but they planned to include new education to educate staff on communicating changes in a residents condition. III. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the October 2025 CPO, diagnoses included Alzheimer's disease with late onset, dementia and other diseases classified elsewhere, unspecified severity and dysphasia (difficulty swallowing). The 7/24/25 MDS assessment revealed Resident #1 had short and long term memory problems. A staff assessment identified her cognition was severely impaired. According to the MDS assessment, Resident #1 was rarely to never was able to understand others or make herself understood. She was dependent on staff for all ADL, including oral care. The MDS assessment did not identify the resident had a loose or broken tooth. -However, the resident's care plan indicated the resident's teeth were in poor condition (see record review below). B. Resident #1's representative interview Resident #1's representative was interviewed on 10/1/25 at 2:37 p.m. The resident's representative said she came to the facility on 9/3/25 to visit Resident #3 and noticed that Resident #1 was missing most of a tooth. She said Resident #1's lip was drooping where the tooth had been and there was a small broken piece of her former tooth that remained in place. She said she reported the broken tooth to the facility and they placed her on antibiotics. The representative said she was concerned that no one else noticed Resident #1's broken tooth. She said the last time Resident #1 went to the dentist was three years ago. She said the facility had not offered for the resident to see the dentist. C. Record review The vision, hearing, speech and dental care plan, revised 7/31/25, identified Resident #1's teeth were in poor condition. Pertinent interventions, initiated on 7/29/25, directed staff to notify the physician of any concerns and assist the resident with appointments. The 7/15/25 long-term care quarterly evaluation documented the resident had her own teeth. According to the evaluation, her teeth were not assessed and/or there was no information. The evaluation indicated oral care was not performed on Resident #1 was because she was independent. -However the 7/24/25 MDS assessment documented to the resident was dependent with her oral care. A 9/3/25 concern/grievance card was provided by the nurse manager/assistant director of nursing (NM) on 10/1/25 at 5:58 p.m. The grievance card was created by Resident #1's representative on 9/3/25. According to the grievance card, Resident #1 had a broken tooth in the front of her mouth and the representative was not notified. The 9/3/25 nursing note documented Resident #1's representative alerted social services that Resident #1 had a cracked tooth. According to the note, staff would monitor the resident for any signs of infection or increased mouth pain. The 9/3/25 skin check note identified an exam of the resident's mouth on 9/3/25 revealed Resident #1's upper left tooth was missing and the tooth beside the missing area was red and inflamed around the base of the neighboring tooth. A 9/3/25 facility investigation was provided by the facility on 10/1/25. The investigation documented there was an unknown time frame or cause found during the investigation as to reasoning/incident surrounding the missing tooth. The representative of Resident #1 told the nursing home administrator (NHA) that she wanted to make sure that Resident #1's dental issues were not being neglected. According to the investigation, the staff had not noticed the missing tooth because there was no change in her eating or signs of pain/discomfort. The investigation indicated the resident was provided antibiotics due to her high risk for infection. The 9/5/25 nursing note documented Resident #1 returned to the facility (after her dental appointment) after her broken tooth was extracted. The extracted area of the mouth was swollen and had five out 10 pain with use of the non-verbal pain scale. A 10/1/25 email was provided by the NHA on 10/1/25 at 3:28 p.m. The email documented the list of residents who were seen in-house by the dental hygienist during the hygienist's last two visits. The review of the provided March 2025 and June 2025 resident lists identified Resident #1 was not seen by the hygienist. Review of Resident #1 electronic medical record (EMR) did not identify the resident was seen by or offered dental services prior to her 9/5/25 appointment. D. Staff interviews The social service director (SSD) and the MDS coordinator were interviewed together on 10/1/25 at 3:57 p.m. The SSD said Resident #1's representative reported Resident #1 had a missing tooth. The SSD said the representative was upset about the missing tooth and she wanted someone to look at her mouth in case there was an infection. The SSD said the NHA was made aware of the concern. The SSD said she would usually ask residents' representatives if they had any dental concerns during care conferences. The SSD said if a representative had dental concerns then a dental appointment would be scheduled. She said if a resident required outside dental services, the facility driver would schedule an appointment and assist the residents to the appointment. She said she did not know if there was a set schedule for a resident to receive dental services. She said dentist appointments and the dental hygienist exams were usually based on request. The MDS coordinator said the nurses do a quarterly head to toe check and then request a dental appointment if they saw a concern but residents should be routinely offered and seen for dental services. The MDS coordinator was interviewed a second time on 10/1/25 at 4:28 p.m. The MDS coordinator said resident representatives should always be informed of a resident change of condition. She said Resident #1 was not able to make her needs known and staff and need staff to anticipate her needs. She said Resident #1 was not able to do any of her ADLs and was dependent on staff for eating and oral care. She said the staff should be providing her with oral care at least a day and should have routine contact with her mouth. The MDS coordinator said the nurses examine residents' mouths quarterly and as needed. CNA #1 was interviewed on 10/1/25 at 5:05 p.m. C.N.A #1 said he was the resident's regular CNA. He said he did not notice she had a missing tooth until it was reported to him on or just after 9/3/25. He said it was very hard to see into her mouth. He said she never opened her mouth fully when he brushes her teeth and she would often try to bite down on the tooth brush. He said he tried to brush her teeth very gently so she does not fracture or chip a tooth. He said she frequently grinded her teeth. RN #1 was interviewed on 10/1/25 at 5:40 p.m. RN #1 said he was Resident #1's regular nurse. He said he was not aware she had a missing or broken tooth prior to 9/3/25. He said he could not determine if the resident's tooth broken was a recent break or if it had been broken for a while. He said when he reviewed her mouth after it was reported to him, it was not bleeding, swollen, or had evidence of sharp edges. He said the resident would often grind her teeth. The medical records director was interviewed on 10/1/25 at 5:59 p.m. The medical records director identified herself as the scheduling coordinator. She said she helped coordinate dental services/appointments after she received requests from the nurses or social services. She said residents were usually seen at minimum once a year for dental services. She said most residents have biannual and annual dental services for preventive care. She said SSD was responsible for tracking when a resident would need to be seen by a dental provider. She said all residents should have the option to see the dental hygienist who could come to the facility. The medical records director said she would get a copy of residents to be seen by the dental hygienist. She said she did not think Resident #1 had been on the list to be seen. The NHA, the MDS coordinator and the NM were interviewed together on 10/1/25 at 6:02 p.m. The NHA said Resident #1's representative contacted her on 9/3/25 and told her that Resident #1 was missing a tooth. The NHA said she started an investigation and could find any staff member who could tell what happened to the tooth. The NM said the review of the resident's mouth identified Resident #1's left upper front tooth was significantly broken. The NHA said she interviewed CNA #1 who told her it was hard for staff to look at her teeth because she clamped down and would not open her mouth wide. The NHA said Resident #1's representative was upset because she felt that someone should have seen that the resident's front tooth was no longer there. The NHA said Resident #1 was not seen by the dental hygienist. The NHA said part of the problem was because of staff turnover. She said the facility had three different social services directors over the last year. She said the facility also needed to improve their ancillary tracking process. She said the facility identified the concern a few weeks ago and would implement a new tracking spreadsheet for ancillary services on 10/2/25. The NHA said the new tracking system should help ensure residents were seen by dental services one to two times a year. She said there was no documentation in the resident's EMR that had been found to identify Resident #1 was offered dental services. The NHA said the resident should have been routinely assessed by the dental hygienist to help ensure dental care, reduce infection risk and risk for swallowing a broken tooth. The NHA said the resident likely swallowed the broken tooth. She said the resident would not have been able to spit out or take out a tooth that had fallen out and was in her mouth and the tooth was not located or reported to be found on the floor.

Based on record review, and interviews, the facility failed to periodically update resident contact information for one (#2) out of three residents reviewed out of five sample residents.Specifically, the facility failed to obtain and Resident #2's power of attorney's (POA) phone number. Findings include:I. Resident #2A. Resident statusResident #2, age greater than 65, was admitted on [DATE]. According to the September computerized physician orders (CPO), diagnoses included history of a motor vehicle accident, fracture of the right pubis, fracture of the sacrum, fracture of the fifth lumbar vertebra, anemia, hypothyroidism and hypertension.The 9/23/25 minimum data set (MDS) assessment revealed Resident #2 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of ten out of 15. Resident #2 was independent with oral care. She required supervision and cues with toileting, dressing, and personal hygiene. Resident #2 required substantial assistance with footwear.B. Record reviewThe power of attorney declaration form, dated 7/15/25, revealed Resident #2's POA changed from her daughter to her son. -However, review of Resident #2's electronic medical record (EMR) on 10/1/25 at 2:00 p.m. did not reveal the resident's POA's contact information.C. Staff interviewsThe social service director (SSD) was interviewed on 10/1/25 at 3:00 p.m. The SSD said she was unable to find the phone number for Resident #2's POA in the EMR. The SSD said she started working for the facility in June 2025. She said Resident #2's son visited often and received in person updates, but the SSD said she would not be able to call Resident #2's POA if an emergency occurred. The SSD said she would try the contact information of the daughter (who was no longer the POA) listed in the Resident #2's electronic medical record. Registered nurse (RN) #2 was interviewed on 10/1/25 at 3:22 p.m. RN #2 said she was not able to find the phone number for Resident #2's son/POA in the EMR. RN #2 said she saw Resident #2's son earlier today and RN #2 said she would have updated the contact information if she was aware it was missing. RN #2 said if Resident #2 had an emergency, she would have to try to contact the other family since she did not have any way to contact the resident POA.The nursing home administrator (NHA) and the director of nursing (DON) were interviewed on together on 10/1/25 at 5:01 p.m. The NHA and the DON confirmed the phone number for the POA was not in the EMR. The NHA said the son and the daughter members were in dispute of who should have POA for Resident #2. The NHA said she remembered a new POA form was completed in July 2025 and the phone number was probably missed when updating the information. The NHA said he contacted the staff member assigned to medical records. The NHA said the staff member reviewed Resident #2's EMR and was not able to find the phone number for the POA. The NHA said she planned to find the contact information and include the phone number in the EMR as soon as possible.The NHA was interviewed again on 10/1/25 at 5:36 p.m. The NHA said the resident's POA information was added to the EMR. the medical record. The NHA and the MDS coordinator were interviewed together on 10/1/25 at 6:02 p.m. The MDS coordinator said having the phone number for the new POA was important because staff needed to be able to contact him in case of an emergency. The MDS coordinator said the new POA for Resident #2 did not call often, but did visit in person frequently. The MDS coordinator said typically, the SSD or the social services assistant would obtain and enter the contact information on admission or on request. The MDS coordinator said she thought the phone number was missed when the facility received new paperwork assigning a new resident representative. The MDS coordinator said the SSD had just started at the facility around the time they received the new POA declaration form, and she may not have known at the time that it was her responsibility to update the facesheet.

Based on interviews and record review, the facility failed to ensure one (#1) of three residents out of six sample residents received prompt efforts to resolve grievances. Specifically, the facility failed to timely address, communicate and attempt to resolve concerns related to not receiving a hair cut for Resident #1. Finding include:I. Facility policy and procedureThe Grievance/Complaints, Filing policy, revised April 2017 was provided by the assistant director of nursing (ADON) on 10/1/25 at 5:58 p.m. The policy read in part, Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The administrator will make prompt efforts to resolve grievances to the satisfaction of the resident and or representative. Grievances and/or complaints may be submitted orally or in writing, and maybe filed anonymously. Upon receipt of the grievance and/or complaint, the grievance officer will review the and review and investigate the allegations and submit a written report of such findings to the administrator within five working days of receiving the grievance and/or complaint. The administrator will review the findings with the grievance officer to determine what corrective actions, if any, need to be taken. The resident or person filing the grievance and/or complaint on behalf of the resident, will be informed verbally and in writing of the findings of the investigation and the actions that will be taken to correct any identified problems.The Grievance/Complaints, Recording and Investigating policy, revised April 2017 was provided by the ADON on 10/1/25 at 5:58 p.m. The policy read in part, All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievances. Upon receiving a grievance and complaint report the grievance officer will begin an investigation into the allegations. The grievance officer will record and maintain all grievances and complaints on the resident grievance complaint log. The resident grievance/complaint investigation report will be filed with the administrator within five working days of the incident. II. Resident #1Resident #1, age greater than 65, was admitted on [DATE]. According to the October 2025 computerized physician's orders (CPO), diagnoses included Alzheimer's disease with late onset, dementia and other diseases classified elsewhere, unspecified severity and dysphasia.The 7/24/25 minimum data set (MDS) assessment revealed Resident #1 had short and long term memory problems. A staff assessment identified her cognition was severely impaired. According to the MDS assessment. Resident #1 was rarely to never able to understand others or make herself understood. She was dependent on staff for all activities of daily living (ADL) and used a wheelchair. III. Resident representative interviewResident #1's representative was interviewed on 10/1/25 at 2:37 p.m. The representative said Resident #1 kept her hair short and she was scheduled for a hair cut every six weeks at the facility but then the hair cuts stopped. She said for months, she requested to have Resident #1's hair cut. She said the only communication she received was that if a resident was in a wheelchair, the resident would not be able to get a haircut until the facility hired a new beautician. The representative said she brought up the need for a hair cut during care conferences and with any staff member she spoke with. She said it took four months and her getting upset with staff in order for Resident #1 to get a hair cut. IV. Record reviewThe mobility and self-care deficit care plan interventions identified Resident #1 was dependent on staff for her personal hygiene, used a Broda chair (specialty wheelchair) for mobility that staff propels and bolster foot positioning device, and required the use of a hoyer lift to transfer from surface to surface (7/29/25).The 7/7/25 social service note documented Resident #1's representative requested during care conference that Resident #1 was placed on a consistent haircut schedule every six to seven weeks.-However, there was no documentation indicating the resident was placed on a consistent haircut schedule until September 2025.A 9/3/25 concern/grievance form was provided by the ADON on 10/1/25 at 5:58 p.m. The grievance card created by Resident #1's representative on 9/3/25. According to the grievance card, Resident #1 had been waiting for a hair cut for four months. The 9/3/25 nursing note documented the nursing home administrator (NHA) met with Resident #1's representative on 9/3/25 her concerns about Resident #1's hair being too long. According to the note, the NHA informed the representative that they have hired a new beautician who should be starting shortly.The 9/4/25 nursing note documented the beautician would cut Resident #1's hair when she arrived for duty after her facility onboarding. According to the note, the NHA was notified of the representative's concerns on 9/2/25 and contacted the representative. The note indicated the social service director (SSD) was already helping her resolve the concerns.V. Staff interviewThe facility's beautician was interviewed on 10/1/25 at 3:20 p.m. She said the Resident #1 was placed on a every four week haircut schedule. She said her hair was cut on 9/10/25. The SSD and the MDS coordinator were interviewed together on 10/1/25 at 3:57 p.m. The SSD said Resident #1's representative told her a couple times that she wanted Resident #1 to have a haircut. The SSD said Resident #1's representative would routinely schedule Resident #1 a hair cut with the facility's beautician but there was a gap in time that the facility did not have one. She said Resident #1 would not be able to go to an outside beautician because of her large wheelchair, the need for a hoyer lift to transfer her from surface to surface and the facility bus did not take residents to non-medical appointments. The SSD said in August 2025, the representative said she wanted Resident #1 to have a hair cut but was told there was no other option other than the facility hiring a new beautician. The SSD said she thought that maybe an in-house staff member could cut the resident's hair but she did not if that thought was pursued or someone coming in to cut hair temporarily. The SSD said she was not the facility's SSD prior to July 2025, so if the resident's representative was asking for a hair cut for Resident #1 before July 2025, she would not know. The SSD said the representative expressed that she was wanted Resident #1's hair cut during the July 2025 care conference. The SSD said the representative asked again for a hair cut in August 2025. The SSD said the representative was told the facility need to hire a new beautician and there was no option for a haircut until one was hired. The MDS coordinator said looking for a back up or temporary beautician to help out would have been a good and necessary resource for the facility to have. The SSD said she did not fill out a grievance form or start the grievance process when Resident #1 expressed concerns about Resident #1 was receiving a hair cut as requested. The SSD said in the care conferences she would review the care plan with the resident and/or their representative. She said if a family expressed a concern or had a complaint shared during a care conference, she would make a note regarding the concern but it would not go further than that. She said she would not fill out a grievance form unless the resident or their representative asked her to. The MDS coordinator said the SSD was in training and learning her role and the grievance process. The MDS coordinator said in the future, resident and representative concerns brought to social services would be something the SSD would help facilitate and follow up with the grievances/requests so any concerns and needs could be addressed. The MDS coordinator said the facility wanted residents and their representatives to feel comfortable and have a voice in resident care and services. She said it should be the responsibility of the facility to communicate efficiently with the residents and their representatives. The NHA and the MDS coordinator were interviewed together on 10/1/25 at 6:02 p.m. The NHA said the former beautician continued to call in and then resigned. The NHA said she was not sure how long the facility went without a beautician to cut residents' hair. She said she was not aware that Resident #1's representative had concerns about Resident #1 not receiving a haircut. She said she did not receive a grievance form regarding the concern until 9/3/25. She said she followed up with the representative on 9/4/25. The NHA said if she received a grievance form or was made aware of the concern, she would have followed up sooner with the representative. She said she did not know if the facility would have been able to provide a haircut sooner for Resident #1, but she would have followed up with the representative and looked at potential options. The NHA said the facility needed to tighten up the grievance process. The NHA said if a resident or their representative expresses a concern or a request, the facility needs to address it and communicate back to the family or resident. The NHA said concerns identified in a care conference should have been addressed on a grievance form using the grievance process so the concerns could have been followed up with. The NHA said the SSD had been learning a lot but still needed to have on-going training on the grievance process. The NHA said she would update the grievance form to add concerns addressed in the care conferences. She said she would also review and address the grievance process in the next quality assurance and improvement meeting.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents were provided the care and services necessary to ensure a safe discharge from the facility to the community out of seven sample residents. Specifically, the facility failed to:-Allow Resident #2 to return to the facility after an unplanned discharge to the hospital;-Provide documentation made by Resident #2's physician, including the specific resident needs the facility could not meet, the facility's efforts to meet those needs and the specific services the receiving facility would provide to meet the needs of the resident which could not be met at the current facility; and,-Reassess Resident #2 for readmission after he was stabilized at the hospital and ready to return to the facility.Findings include:I. Facility policy and procedureThe Transfer or Discharge, Facility-Initiated policy, revised October 2022, was provided by the assistant director of nursing (ADON) on 8/21/25 at 11:31p.m. The policy read in pertinent part, Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. Each resident will be permitted to remain in the facility and not be transferred or discharged unless;-The transfer discharge is necessary for the resident's welfare and the resident's needs can not be met in this facility; and,-The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident. Residents who are sent emergently to an acute care setting, these scenarios are considered facility initiated transfers, not discharges, because the residents return is generally expected. Residents who are sent emergently to an acute care setting, such as a hospital, are permitted to return to the facility. If discharge is initiated by the facility after an emergent transfer to the hospital, the reason for the discharge is based on the resident status at the time the resident seeks to return to the facility and not at the time the resident was transferred to acute care. Should a resident be transferred or discharged for any reason, the following information is communicated to the receiving facility or provider: The specific resident needs that can not be met; the facilities attempt to meet those needs; and, the receiving facilities services that are available to meet those needs. Should the resident be transferred to discharge for any of the following reasons, the basis of the transfer or discharge is documented in the resident's clinical record by the resident's attending physician. The transfer discharge is necessary for the residents welfare and the resident's needs cannot be met in the facility. Should the resident be transferred or discharged for any reasons the basis of the transfer discharge will be documented in the resident's clinical record by a physician, the safety of the individuals of the facilities endangered due to the clinical behavior status of the resident or the health of the individuals in the facility would otherwise be endangered. If the facility determines that the resident can not return to the facility, the medical record would indicate that the facility made efforts to determine if the resident still required the services of the facility and was eligible for Medicare skilled nursing facility or Medicaid nursing facility services; ascertain an accurate status of resident's condition, which can be accomplished via communication between the hospital and facility staff and/or through visits by the facility staff to the hospital; find out from the hospital the treatments, medications and the services the facility would need to provide to meet the residents needs upon returning to the facility. If the facility is unable to provide the treatments, medications, and services needed, the facility may not be able to meet the residents needs; and work with the hospital to ensure the residence condition needs are within the facility's scope of care, based on its facility assessment prior to the hospital discharge.II. Resident statusResident #2, age greater than 65, was admitted on [DATE] and discharged to the hospital on 7/31/25. According to the July 2025 computerized physician orders (CPO), diagnoses included non-traumatic acute subdural hemorrhage, reduced mobility, mild cognitive impairment of uncertain or unknown etiology, repeated falls, need for assistance with personal care, unspecified lack of coordination and generalized muscle weakness.The 7/15/25 minimum data set (MDS) assessment identified Resident #2 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment indicated the resident required partial to moderate physical assistance for transferring from surface to surface, bed mobility and walking. The MDS assessment documented Resident #2 used a motorized wheelchair. III. Resident representative interviewResident #2's representative was interviewed on 8/20/25 at 5:10 p.m. The representative said Resident #2 was initially admitted to the facility from the hospital after a fall, for therapy and long-term placement. He said Resident #2 was sent back to the hospital two weeks later. He said he was told that Resident #2 was sent to the hospital related to a fall at the facility. He said he later learned that the facility felt Resident #2 had a psychotic episode. He said Resident #2 was not evaluated by his physician before the facility determined he had a psychotic episode and sent him out. He said he felt the facility dumped him at the hospital. The representative said the hospital and the facility had a conference together that he was not invited to. He said he was then informed by the hospital that the facility was not going to allow Resident #2 to return to the facility and it was inappropriate for them to not allow him to return. The resident representative said he was never provided a notice of discharge or information on the discharge appeal process. He said she was never told that he could try to appeal the facility's decision. He said he just knew that Resident #2 was not welcome back at the facility. The representative said he was never recommended or referred to other facilities. He said Resident #2 was currently at another facility and had not had any problems there.Cross reference F628 for failure to provide an appropriate discharge process.IV. Record reviewThe cognition care plan, initiated 7/29/25, identified Resident #2 was at risk for cognitive decline related to mild cognitive impairment. According to the care plan, he could make his needs known but his hearing difficulties were a potential barrier for communication. Interventions, initiated 7/29/25, included approaching Resident #2 in a calm, quiet manner and offering reassurance before initiating care or providing direction, ensuring the resident was safe, re-approaching at a later time when it was safe/less distressing to the resident if he had increased confusion, frustration or agitation and asking for assistance from a different staff member.The discharge care plan, initiated 7/29/25, identified Resident #2 was a long-term care resident with no intent to discharge. Interventions, initiated 7/29/25, included providing local agency referrals as appropriate when the resident/responsible party asked about discharge and waiting for the resident/responsible party to initiate conversation regarding discharge. -Review of Resident #2's comprehensive care plan revealed the resident did not have a care plan for a risk of behaviors, or wandering/elopement.The 7/21/25 nursing progress note documented Resident #2 was near the back door and requested to walk to the Veterans Affairs facility (VA) or just go for a walk around. The note identified he was upset that he was at his current facility and wanted to go to the VA. According to the note, the resident was redirected back to his room. He told the staff he would try to contact the VA to come and get him. The note indicated Resident #2 was told why he was in nursing care and he voiced understanding. The admission/discharge report was provided by the nursing home administrator (NHA) on 8/19/25 at approximately 11:00 am. The report indicated Resident #2 discharged to the hospital on 7/31/25. The report did not identify if he returned to the facility. The 7/31/25 administration note documented Resident #2 was at the hospital.-Review of progress notes did not identify why the resident went to the hospital or incidents occurring on or before 7/31/25 requiring hospitalization. -Review of progress notes did not indicate that Resident #2 had been formally discharged from the facility. -Review of progress notes did not identify the resident's physician documented the safety of the individuals in the facility were endangered due to the clinical behavior status of Resident #2. The 7/31/25 wandering assessment documented Resident #2 was at moderate risk for wandering.-Review of assessments did not identify the resident was evaluated for wandering/elopement prior to 7/31/25. The 7/31/25 at 6:35 a.m. incident report for elopement was provided by the NHA on 8/20/25 at 4:35 p.m. The report documented Resident #2 eloped by using the door at the end of the hall. According to the report, the staff ran after the resident, attempting to coax him back inside. Resident #2 ran, fell and became violent. The risk assessment indicated he started to swing at anyone who tried to stop him. The report identified the resident was placed in a chair and wheeled backwards inside the facility while he attempted to hit and bite staff. The assessment revealed the resident was able to go out the same door again. The staff followed the resident, contacted his physician and requested a physician's order to send the resident out to the hospital. The assessment identified Resident #2 remained calm as long as the staff did not approach him or attempt to bring him back into the facility. The 7/31/25 hospital final transcript documented Resident #2 was brought to the emergency department (ED) by emergency medical services (EMS) for a possible fall at his living facility and he was somewhat combative with them in the morning (7/31/25). According to the transcript, EMS reported to the hospital that Resident #2 was fine with them. The transcript identified Resident #2 arrived at the hospital without complaints or signs of trauma on exam and likely had some behavioral issues and dementia and may or may not have fallen. The transcript revealed there did not appear to be evidence of an acute emergency condition that would necessitate hospitalization or suggest a need for immediate inpatient treatment given their lack of red flags for serious illness and he remained stable in the emergency department. The hospital transcript revealed the hospital attempted to transfer Resident #2 back to his living facility but the facility declined to have him return due to his combativeness to staff members. The transcript documented the ED requested help from the hospital case managers to determine a proper disposition and to communicate with the resident's living facility. According to the transcript, Resident #2 would be discharged from the hospital but the hospital did not know where he would be discharged to. The involuntary discharge notice, dated 7/31/25, was provided by the NHA on 8/20/25 at 4:53 p.m. The discharge notice indicated Resident #2 would be discharged to the hospital effective 7/31/25. The notice documented the facility was pursuing immediate discharge of Resident #2 from the facility in the interest of his safety and wellness, as well as the safety and wellness of other residents who resided at the facility. According to the discharge notice, the facility determined that they were no longer able to provide the level of care that Resident #2 required due to his unsafe behavior of physical and verbal aggression. The involuntary discharge notice included the resident's right to appeal the discharge and the appeal process. V. InterviewsLicensed practical nurse (LPN) #1 was interviewed on 8/19/25 at 3:34 p.m. LPN #1 said staff tried to redirect residents with combative behaviors. She said if the behaviors continued, the facility would call an ambulance for assistance. She said Resident #2 was combative and was trying to leave the facility on 7/31/25. She said he was swinging at staff, was not redirectable and was not safe to be around the staff. LPN #1 said a certified nurse aide (CNA) told her Resident #2 went out the back door (on 7/31/25). LPN #1 said she caught up with him on the other side of the building. She said she and other staff members were following him and always had eyes on him. She said his pants were on backwards and he fell. She said he was assisted to a wheelchair but then he started to swing at them. LPN #1 said he punched her in the chest and another nurse in the stomach. She said they were able to bring him back inside the facility but he walked out of the facility again, walked around and then sat under a tree. She said Resident #2 refused to come back into the facility so they called EMS. LPN #1 said when he saw the ambulance approaching him, he started to walk away. She said when EMS approached him, he started to swing at them too. LPN #1 said she Resident #2 said he wanted to leave the facility when he was trying to hit the staff outside. She said he had additionally said he wanted to leave the facility the day before (7/30/25). LPN #1 said she contacted the ADON, the director of nursing (DON) and the NHA to report what happened. She said another nurse involved in the incident left a message for Resident #2's representative that he went to the hospital. LPN #1 said the representative called her back and asked why Resident #2 was sent to the hospital. She said she told the representative Resident #2 was aggressive with staff and they could not keep him at the facility. She said Resident #2 was no longer a resident at the facility.The hospital case manager was interviewed on 8/19/25 at 4:24 p.m. The hospital case manager said the facility contacted the hospital and said Resident #2 was having a psychotic episode and was violent towards a staff member. She said Resident #2 was pleasant at the hospital, had no behaviors and only required Tylenol. She said he had a sitter with him at the hospital related to his dementia and risk of him wandering off. She said he only needed to be redirected to where the restroom was. The hospital case manager said Resident #2 was calm, watched television, slept and went on walks with the sitter. The hospital case manager said a psychiatric team reviewed Resident #2 and felt he did not have a psychotic episode at the facility. She said the psychiatric team felt his behaviors were more dementia related. She said Resident #2 was medically cleared by the hospital physician to return to the facility. She said the hospital contacted the facility but the facility refused to accept him back because of his aggression towards a staff member. She said the facility told the hospital that the 7/31/25 incident with Resident #2 was the first time he had any related behaviors at the facility. The hospital case manager said she told the facility that with it only being the first incident and he was medically and psychologically cleared, they needed to take Resident #2 back. The hospital case manager said the facility did not notify the ombudsman or tell the resident's representative what happened. The hospital case manager said further communication with the facility was difficult because they kept passing off the phone to staff who said they did not know about the situation and were not there at the time so the hospital set up a conference call with the facility and the frequent facility visitor to discuss Resident #2's discharge. The hospital case manager said the facility continued to refuse Resident #2's return to the facility. She said the hospital had to find him another facility to go to. She said Resident #2 had to stay at the hospital for two to three more days until he was accepted by and transferred to another facility. A frequent facility visitor was interviewed on 8/20/25 at 12:05 p.m. The visitor said the facility left Resident #2 at the hospital and did not allow him to return to the facility. She said the facility told the resident's representative that he went to the hospital but the representative was not told why or that the resident would not be permitted to return to the facility. She said Resident #2 was confused, walked out of the facility and then fell on his buttocks without injury. The visitor said she went to the hospital to see Resident #2 on 7/31/25. She said she spoke with the resident and he said he went to the emergency department (ED) but he did not know why. She said he told her that the facility was not listening to him. The visitor said the hospital case managers told her the facility refused to take him back because they felt he was a danger to himself and others and the facility did not want their nurses in danger. The visitor said she contacted Resident #2's representative and he was very upset because he was only told that Resident #2 went to the hospital but he was not told why or that the resident would not be permitted to return to the facility. She said he had to find out what happened from the hospital and not the facility. The visitor said she was not provided a notice of discharge for Resident #2 until 8/1/25, two days after the facility refused to have him return, and after she had to continue to ask for it.Cross reference F628 for failure to provide an appropriate discharge process. The frequent facility visitor was interviewed again on 8/20/25 at 5:05 p.m. The visitor said she did not provide Resident #2's representative with the notice of discharge and the resident's appeal rights. She said the facility should have provided the representative with the notice and rights. The visitor said the representative did not contact her to help with the discharge appeal. The NHA and the ADON were interviewed together on 8/20/25 at 4:01 p.m. The NHA said the staff could not get Resident #2 back in the facility after he walked out the facility doors a second time on 7/31/25. She said he remained in line of sight of the staff while he was outside. The NHA said the staff sent Resident #2 to the hospital so the hospital could do a medical and psychiatric evaluation and review. She said the 7/31/25 incident occurred in the early morning and the ADON was the main contact with the facility staff at the time. The ADON said LPN #1 contacted her and told her Resident #2's behavior was escalating and he punched LPN #1 in the chest, LPN #2 in the stomach and tried to get away from them and Resident #2 fell. The ADON said she suggested removing the nurses involved and approaching the situation with a new face. She said a CNA offered a wheelchair to Resident #2. The ADON said the resident calmed down enough to bring him back into the facility. She said Resident #2 was placed at a table and offered coffee. She said moments later, the resident got up from the table and went out the door again. She said LPN #1 was able to stay with him. The ADON said Resident #2 walked to the other side of the facility and then across the parking lot to another neighboring property. She said Resident #2 would not deescalate, so staff called EMS for help. The NHA said the staff told her Resident #2 had to be restrained by the police and firemen. The ADON said the physician was contacted and the facility was provided with physician's orders to send Resident #2 to the hospital. The NHA said the facility did not reevaluate Resident #2 while he was at the hospital. The NHA said the facility did not review his records at the hospital. She said the frequent facility visitor went to the hospital to see Resident #2 and she said he was calm. She said a phone conference was set up with the hospital instead. The NHA said during the phone conference with the hospital and the frequent facility visitor on 7/31/25, the facility was told Resident #2 was stable and the hospital wanted the facility to take him back. The NHA said she made the decision not to have Resident #2 return to the facility because the hospital made no medication changes. She said the facility felt that Resident #2 had a psychotic break based on his severe behaviors on 7/31/25 and he became a different person. She said that the facility told the hospital that they were not prepared or equipped to deal with psychotic episodes. She said the behavior occurred so fast without any triggers with that type of dementia. The NHA said the facility could not meet Resident #2's needs if there was a chance his behaviors would escalate and be directed towards a resident. She said she did not feel safe taking Resident #2 back. The NHA said the hospital had a caregiver stay with the resident. She said a caregiver always being with Resident #2 was not an option at the facility. She said if the hospital had adjusted the resident's medication, she might have taken him back.The NHA said the facility did not send out referrals to other facilities when they determined that they were not going to take Resident #2 back. She said she did not send out referrals because she did not know what was wrong with him so she did not feel comfortable referring him to anyone else. The NHA said she did not know what triggered his behaviors on 7/31/25. She said Resident #2 did not have elopement, exit seeking or aggressive behaviors prior to 7/31/25. She said she was not aware that he had requested to leave the facility and go to the VA. She said his desire to leave the facility and go to the VA could have been a potential trigger to his behaviors on 7/31/25. The NHA said all residents were evaluated for elopement on admission so the facility could establish a baseline and risk. The NHA said the resident should have been assessed on admission and again after he reported a desire to leave the facility on 7/21/25. The NHA said if she knew Resident #2 was expressing that he wanted to leave, she would have spoken to his representative and explored why he wanted to go to the VA instead of remaining in the facility.The ADON said Resident #2 did not have an elopement assessment until after his attempt to elope on 7/31/25. The ADON said if the facility had known he had signs of wanting to leave, they would have looked at a safety plan.

Based on record review and interviews, the facility failed to revise and implement an effective discharge plan for one (#2) of three residents reviewed for discharge planning out of seven sample residents.Specifically, the facility failed to:-Ensure the discharge planning was process was documented, including the reason for discharge in Resident #2's electronic medical record (EMR); -Notify Resident #2 and/or Resident #2's representative, in writing, of the discharge, including the reason for the move, the effective date of discharge, the location where the resident was being discharged to, a statement of the resident's appeal rights and the name, address and telephone number of the office of the state long term care ombudsman; and,-Notify the facility's ombudsman of Resident #2's discharge in writing in a timely manner.Findings include: I. Facility policy and procedureThe Transfer or Discharge, Facility-Initiated policy, revised October 2022, was provided by the assistant director of nursing (ADON) on 8/21/25 at 11:31p.m. The policy read in pertinent part, Once admitted to the facility, residents have the right to remain in the facility. Facility initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. Each resident will be permitted to remain in the facility and not be transferred or discharged unless;-The transfer discharge is necessary for the resident'swelfare and the resident's needs can not be met in this facility; and,-The safety of individuals in the facility is endangereddue to the clinical or behavioral status of the resident. Residents who are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfers, not discharges, because the residents return is generally expected. Residents who are sent emergently to an acute care setting, such as a hospital, are permitted to return to the facility. If discharge is initiated by the facility after an emergent transfer to the hospital, the reason for the discharge is based on the resident status at the time the resident seeks to return to the facility and not at the time the resident was transferred to acute care. If the facility does not permit a resident's return to the facility based on the inability to meet the resident's needs, the facility will notify the resident, and or his or her representative in writing of the discharge, including notification of appeal rights. The facility will send a copy of the discharge notice to a representative of the Office of the State LTC Ombudsman. The notice of theOffice of the State LTC Ombudsman will occur at the same time the notice of discharge is provided to the resident and the resident representative. If the resident chooses to appeal the discharge, the facility will not discharge residents while the appeal is pending. Should a resident be transferred or discharged for any reason, the following information is communicated to the receiving facility or provider: The specific resident needs that can not be met; the facilities attempt to meet those needs; and, the receiving facilities services that are available to meet those needs. When a resident is transferred or discharged from the facility, the following information is documented in the medical record: the basis of the transfer of the discharge; if the resident is being transferred or discharged because of his or needs can not be met at the facility the documentation would include the specific resident needs that can not be met; the facility's attempt to meet those needs; the receiving facilities services that are available for those needs; That an appropriate notice was provided to the resident and/or legal representative; the date and the time of the transfer or discharge; the new location of the resident; the mode of transportation; a summary of the resident overall medical physical and mental condition. Should the resident be transferred or discharged for any of the following reasons, the basis of the transfer or discharge is documented in the resident's clinical record by the resident's attending physician. The transfer discharge is necessary for the resident's welfare and the resident's needs can not be met in the facility. Should the resident be transferred or discharged for any reasons the basis of the transfer discharge will be documented in the resident's clinical record by a physician, the safety of the individuals of the facilities endangered due to the clinical behavior status of the resident or the health of the individuals in the facility would otherwise be endangered. II. Resident status Resident #2, age greater than 65, was admitted on [DATE] and discharged to the hospital on 7/31/25. According to the August 2025 computerized physician orders (CPO), diagnoses included non-traumatic acute subdural hemorrhage, reduced mobility, mild cognitive impairment of uncertain or unknown etiology, repeated falls, need for assistance with personal care, unspecified lack of coordination and generalized muscle weakness. The 7/15/25 minimum data set (MDS) assessment identified Resident #2 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment indicated the resident required partial to moderate physical assistance for transferring from surface to surface, bed mobility and walking. The MDS assessment documented Resident #2 used a motorized wheelchair. III. Resident representative interview Resident #2's representative was interviewed on 8/20/25 at 5:10 p.m. The representative said Resident #2 was initially admitted to the facility from the hospital after a fall, for therapy and long-term placement. He said Resident #2 was sent back to the hospital two weeks later. He said he was told that Resident #2 was sent to the hospital related to a fall at the facility. He said he later learned that the facility felt Resident #2 had a psychotic episode. He said Resident #2 was not evaluated by his physician before the facility determined he had a psychotic episode and sent him out. He said he felt the facility dumped him at the hospital. The representative said the hospital and the facility had a conference together that he was not invited to. He said he was then informed by the hospital that the facility was not going to allow Resident #2 to return to the facility and it was inappropriate for them to not allow him to return. The representative said he was never provided a notice of discharge or information on the discharge appeal process. He said he was never told that he could try to appeal the facility's decision. He said he just knew that Resident #2 was not welcome back at the facility. The representative said he was never recommended or referred to other facilities. He said Resident #2 was currently at another facility and had not had any problems there. IV. Record reviewThe discharge care plan, initiated 7/29/25, identified Resident #2 was a long-term care resident with no intent to discharge. Interventions, initiated 7/29/25,included providing local agencyreferrals as appropriate when the resident/responsible party asked aboutdischarge and waiting for the resident/responsible party to initiateconversation regarding discharge.The 7/21/25 nursing progress note documented Resident #2 was near the back door and requested to walk to the Veterans Affairs facility (VA) or just go for a walk around. The note identified he was upset that he was at his current facility and wanted to go to the VA. According to the note, the resident was redirected back to his room. He told the staff he would try to contact the VA to come and get him. The note indicated Resident #2 was told why he was in nursing care and he voiced understanding.The admission/discharge report was provided by the nursing home administrator (NHA) on 8/19/25 at approximately 11:00 am. The report indicated Resident #2 discharged to the hospital on 7/31/25. The report did not identify if he returned to the facility. The 7/31/25 administration progress note documented Resident #2 was at the hospital. -Review of progress notes did not identify why the resident went to the hospital or incidents occurring on or before 7/31/25 which required hospitalization. -Review of progress notes did not indicate that Resident #2 had been formally discharged from the facility on 7/31/25. The 7/31/25 at 6:35 a.m. incident report for elopement was provided by the NHA on 8/20/25 at 4:35 p.m. The report documented Resident #2 eloped by using the door at the end of the hall. According to the report, the staff ran after the resident, attempting to coax him back inside. Resident #2 ran, fell and became violent. The risk assessment indicated he started to swing at anyone who tried to stop him. The report identified the resident was placed in a chair and wheeled backwards inside the facility while he attempted to hit and bite staff. The assessment revealed the resident was able to go out the same door again. The staff followed the resident, contacted his physician and requested a physician's order to send the resident out to the hospital. The assessment identified Resident #2 remained calm as long as the staff did not approach him or attempt to bring him back into the facility. The 7/31/25 hospital final transcript documented Resident #2 was brought to the emergency department (ED) by emergency medical services (EMS) for a possible fall at his living facility and he was somewhat combative with them in the morning (7/31/25). According to the transcript, EMS reported to the hospital that Resident #2 was fine with them. The transcript identified Resident #2 arrived at the hospital without complaints or signs of trauma on exam and likely had some behavioral issues and dementia and may or may not have fallen. The transcript revealed there did not appear to be evidence of an acute emergency condition that would necessitate hospitalization or suggest a need for immediate inpatient treatment given their lack of red flags for serious illness and he remained stable in the emergency department. The hospital transcript revealed the hospital attempted to transfer Resident #2 back to his living facility but the facility declined to have him return due to his combativeness to staff members. The transcript documented the ED requested help from the hospital case managers to determine a proper disposition and to communicate with the resident's living facility. According to the transcript, Resident #2 would be discharged from the hospital but the hospital did not know where he would be discharged to.Cross reference F627 for failure to allow a resident to return to the facility.The involuntary discharge notice, dated 7/31/25, was provided by the NHA on 8/20/25 at 4:53 p.m. The discharge notice indicated Resident #2 would be discharged to the hospital effective 7/31/25. The notice documented the facility was pursuing immediate discharge of Resident #2 from the facility in the interest of his safety and wellness, as well as the safety and wellness of other residents who resided at the facility. According to the discharge notice, the facility determined that they were no longer able to provide the level of care that Resident #2 required due to his unsafe behavior of physical and verbal aggression. The involuntary discharge notice included the resident's right to appeal the discharge and the appeal process.-However, a review of Resident #2's EMR did not reveal documentation to indicate the resident or the resident's representative was notified of the discharge in writing, including the reason for the move, the effective date of discharge, the location where the resident was discharged to, a statement of the resident's appeal rights and the name, address and telephone number of the office of the state long term care ombudsman. -A review of Resident #2's EMR did not reveal the ombudsman was notified of the resident's discharge in writing in a timely manner (see frequent facility visitor interview below). V. InterviewsA frequent facility visitor was interviewed on 8/20/25 at 12:05 p.m. The visitor said the facility left Resident #2 at the hospital and did not allow him to return to the facility. She said the facility told the resident's representative that he went to the hospital but the representative was not told why or that the resident would not be permitted to return to the facility. She said Resident #2 was confused, walked out of the facility and then fell on his buttocks without injury. The visitor said she went to the hospital to see Resident #2 on 7/31/25. She said she spoke with the resident and he said he went to the emergency department (ED) but he did not know why. She said he told her that the facility was not listening to him. The visitor said the hospital case managers told her the facility refused to take him back because they felt he was a danger to himself and others and the facility did not want their nurses in danger.The visitor said she contacted Resident #2's representative and he was very upset because he was only told that Resident #2 went to the hospital but he was not told why or that he would not be permitted to return to the facility. She said he had to find out what happened from the hospital and not the facility. She said she was not provided a notice of discharge for Resident #2 until 8/1/25, two days after the facility refused to allow him to return to the facility, and after she had to continue to ask for the notice. The frequent facility visitor was interviewed again on 8/20/25 at 5:05 p.m. The visitor said she did not provide Resident #2's representative with the notice of discharge and the resident's appeal rights. She said the facility should have provided the representative with the notice and rights. The visitor said the representative did not contact her to help with the discharge appeal.The NHA and the assistant director of nursing (ADON) were interviewed together on 8/20/25 at 4:01 p.m. The NHA said the facility did not reevaluate Resident #2 while he was at the hospital. The NHA said she made the decision not to allow Resident #2 to return to the facility because the hospital made no medication changes. She said the facility felt that he had a psychotic break based on his severe behaviors on 7/31/25 and he became a different person. She said that the facility told the hospital that they were not prepared or equipped to deal with residents' psychotic episodes. She said the behavior occurred so fast without any triggers with that type of dementia. The NHA said the facility could not meet Resident #2's needs if there was a chance his behaviors would escalate and be directed towards another resident. She said she did not feel safe taking Resident #2 back.The ADON said the discharge notice was emailed to the frequent facility visitor on 8/1/25 at 1:32 p.m. The ADON said the frequent facility's visitor and the hospital told Resident #2's representative that Resident #2 was not coming back to the facility. The ADON said she did not know if the frequent facility visitor provided the resident's representative with the discharge notice or information on the appeal process. The ADON said the facility did not provide the resident or the resident's representative with the discharge notice or the rights to appeal the discharge. The NHA said Resident #2's representative did not request to appeal the discharge. She said he came to the facility and collected the resident's belongings but did not say anything about an appeal. The NHA said the discharge of Resident #2 was emergent and the frequent facility visitor was involved, so it was assumed that the frequent facility visitor provided the representative with the notice and appeal rights. She said it was not the responsibility or normal practice for the frequent visitor to give the notice.The NHA said the facility should not have assumed the representative was already given the notices and appeal rights. The NHA said she wanted to make sure Resident #2's representative knew his appeal rights. The NHA said she would make sure the resident's representative received the discharge notice and the rights to appeal.The ADON said she would send out the discharge notice and the rights to appeal process overnight (on 8/20/25).VI. Facility follow-up The ADON provided a priority overnight mail receipt for Resident #2's discharge notice and appeal rights on 8/21/25 at 10:50 a.m. According to the receipt, the discharge notice and appeal rights were to be delivered to Resident #2's representative on 8/22/25 (22 days after the resident was discharged from the facility).

Based on record review and interviews, the facility failed to ensure a copy of medical records were provided in a timely manner for one (#1) of three residents out of five sample residents. Specifically, the facility failed to ensure medical records were provided in a timely manner upon request for Resident #1 from his resident representative. Findings include: I. Facility policy and procedure The Release of Information policy, revised November 2009, was provided by the nursing home administrator (NHA) on 4/24/25 at 1:10 p.m. It read in pertinent part, The resident may initiate a request to release such information contained in his/her records and charts to anyone he/she wishes. Such requests will be honored only upon the receipt of a written, signed and dated request from the resident or representative. A resident may have access to his or her records within ____ hours (excluding weekends or holidays) of the resident's written or oral request. -The facility did not indicate on the policy how many hours the facility had to provide the requested medical records. II. Resident representative interview Resident #1's representative was interviewed on 4/23/25 at 3:45 p.m. via phone. She said she requested Resident #1's medical records from the facility in February 2025 after he passed away. She said she did not receive the records for over two weeks. III. Record review The request for access to health information was provided by the medical records director (MRD) on 4/24/25 at 11:30 a.m. The form was completed by Resident #1's representative on 2/24/25 at 3:30 p.m. The form revealed the resident's representative received the records on 3/13/25 at 11:58 a.m. -The representative did not receive the medical records for 12 weekdays after she requested them. IV. Staff interviews The MRD was interviewed on 4/24/25 at 10:20 a.m. The MRD said she did not know the time frame the facility had to provide the resident or the representative with the medical records after they were requested. She said Resident #1's medical durable power of attorney (MDPOA) requested his medical records on 2/24/25. She said the records were released to the MDPOA on 3/13/25. She said the process was to send the records to the facility's attorney and once the okay was given, the records were released to the resident or representative. The MRD said this request took a little longer because the facility had a hard time reaching the attorney because the phone number had changed. The MRD said she tried to complete medical record requests as fast as possible but did not know it needed to be completed within 24 hours except when requested on a weekend or holiday. The nursing home administrator (NHA) was interviewed on 4/24/25 at 1:50 p.m. She said she was not sure what the facility's policy indicated the time line the facility needed to provide medical records upon request. The NHA said she thought the facility had 72 hours to provide the medical records when they were requested by the resident or representative. The NHA said the facility would review the policy to ensure it matched the regulation.

Based on observations, record review and interviews, the facility failed to ensure three (#1, #8 and #6) of three residents were kept free from abuse out of nine sample residents. Specifically, the facility failed to: -Protect Resident #1 and Resident #8 from being sexually abused by Resident #2; and, -Protect Resident #6 from physical abuse by Resident #5. Findings include: I. Facility policy and procedure The Abuse Prevention, Investigation and Reporting policy and procedure, revised November 2022, was provided by the nursing home administrator (NHA) on 3/11/25 at 5:14 p.m. It read in pertinent part, To ensure to the extent possible, that every resident is free from abuse, neglect, misappropriation of resident property, and exploitation. The resident has the right to be free from abuse (including verbal, mental, sexual and physical), neglect, misappropriation of resident property and exploitation. This includes freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat a resident's medical condition. Management will take specific steps to reduce the potential for abuse to occur at the facility including, but not limited to education, monitoring and investigating thoroughly if abuse, misappropriation, neglect, or exploitation is suspected. Sexual abuse includes, but is not limited to sexual harassment, sexual coercion, or sexual assault. Physical abuse includes, but is not limited to, hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. The admissions coordinator will do a pre-assessment on all potential admissions to see if there is a history of abusive behavior. If any potential admission has a history of abusive behavior, the admissions coordinator will notify the administrator and/or the director of nursing services. The administrator will make the final determination on whether or not to admit, upon consultation with the director of nursing services and/or other appropriate personnel. The facility will conduct assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect including self-injurious behaviors. Resident to resident incident: The abusive resident will be separated from other residents for a limited period as a therapeutic intervention to reduce agitation and potential for harm and ensure the safety of other residents. Other interventions will also be considered to include, but not limited to, family assistance, change of roommates, physician review of appropriate medication(s), consult with psychology, and other interventions as outlined in the resident's person-centered plan of care. II. Sexual abuse of Resident #1 and Resident #8 by Resident #2 A. Facility investigation for sexual abuse of Resident #1 by Resident #2 on 12/18/24 The facility investigation, dated 12/18/24, documented at approximately 1:15 p.m. revealed Resident #1 was walking throughout the facility. Resident #2 invited Resident #1 into his room and closed the door. It was not normal behavior for Resident #2 to want his door closed so the staff followed them into the room. Upon opening the door, the staff member saw Resident #2 had his hand on Resident #1's crotch, over her clothing. The staff member was able to separate the two residents. Resident #1 was tearful after the event but she was not able to explain her emotions to staff due to her severely impaired cognition. The investigation documented Resident #1 was assisted back to her hallway. Resident #2 and Resident #1 were both placed on line-of-sight supervision and both residents were to be redirected from interacting with each other. Resident #1 was encouraged to participate in activities programming to prevent unsafe wandering. The interim social services director (ISSD) interviewed Resident #2 on 12/19/24. Resident #2 was defensive about the incident. He initially said he ignored Resident #1 and she was not in his room. Resident #2 was educated that Resident #1 was not able to consent to engage in sexual intimacy. Resident #2 responded by telling the ISSD that Resident #1 understood more than she let on and that he felt sorry for her when she was crying. The ISSD educated Resident #2 that his behavior was unacceptable and was not to continue. The ISSD interviewed certified nurse aide (CNA) #2 on 12/19/24. CNA #2 said she had witnessed Resident #2 inviting other female residents into his room on several prior occasions. CNA #2 said she was uncomfortable when she observed him inviting Resident #1 into his room and shutting the door. The facility substantiated the allegation of sexual abuse. B. Facility investigation for sexual abuse of Resident #8 and Resident #1 by Resident #2 on 2/22/25 The facility investigation, dated 2/22/25 documented at 1:09 p.m., revealed Resident #2 was self-propelling in his wheelchair in the common area hallway when he approached Resident #8, who was sitting in the hall in her wheelchair. The investigation documented it appeared that the residents were having a conversation. As staff approached, it was noted that Resident #2 had his hand on Resident #8's thigh and was moving his hand towards her inner thigh. Resident #8 said, No, stop! and motioned for Resident #2 to move his hand. The CNA told Resident #2 to stop and Resident #2 left the area. -Interviews later in the day revealed that the CNA who intervened in the 1:30 p.m. incident with Resident #8 did not report the incident until being questioned after the second similar incident with Resident #1 occurred at 5:30 p.m. (see below). -There was no documentation in the investigation report indicating that either resident was interviewed about the details of the incident. The second facility investigation, dated 2/22/25, documented at 5:30 p.m. Resident #1 was walking near the nurse's station and Resident #2 was self-propelling in his wheelchair behind Resident #1. As Resident #1 got closer to Resident #2 he reached out and placed his hand on the back of Resident #1's thigh and began to move his hand higher up her thigh. Resident #1 turned and tried to swat his hand away. The investigation documented her action of trying to swat his hand away did not stop him from his actions. A nearby CNA had to intervene and remove Resident #2's hand from Resident #1's leg before he was able to move his hand to her private areas. The residents were separated. The CNA took Resident #1 to a safe area and a second CNA took Resident #2 to another location. The investigation revealed Resident #1 was very tearful after the incident. The staff were unsure if the tearfulness was due to the incident or due to her baseline of having tearfulness on and off. -There was no documentation that the facility assessed Resident #1's level of tearfulness throughout the day to determine if she was more tearful than usual following the incident. -Despite Resident #2 being placed on 15-minute checks when out of his room, he was able to sexually abuse two female residents in the common area of the facility on the same day (see Resident #2's care plan below). C. Resident #1 - victim 1. Resident status Resident #1, age 81, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia with severe mood disturbance and depression. According to the 2/12/25 minimum data set (MDS) assessment, Resident #1 was unable to complete the brief interview for mental status (BIMS). The staff assessment revealed she had short-term and long-term memory deficits. The staff assessment further revealed she was severely impaired in her daily decision-making and that she had difficulty focusing her attention and was disorganized with her thinking. The MDS assessment documented that Resident #1 did not wander and could ambulate independently but needed staff assistance with most of her activities of daily living (ADL). -However, interviews and further record review revealed Resident #1 did wander (see interviews and record review below). 2. Resident #1's representative interview Resident #1's representative was interviewed on 3/10/25 at 3:20 p.m. The representative said the facility did tell him the inappropriate touching had happened twice. He said the facility was trying to keep an eye on both of the residents. 3. Observations During a continuous observation on 3/10/25, beginning at 3:45 p.m. and ending 4:36 p.m., the following was observed: At approximately 3:45 p.m. Resident #1 walked past Resident #2 in his hallway, but there was no interaction between the two residents. Resident #1 stopped to talk with other residents as she wandered the hall and then walked back up the hall to another resident unit without direct staff supervision or interaction. At 4:07 p.m. Resident #1 was sitting in a recliner in the common area eating a sucker. At 4:11 p.m. Resident #1 was sitting in a recliner in the common area with her eyes closed. At 4:21 p.m. Resident #1 was sitting in a recliner in the common area with her eyes closed. At 4:28 p.m. Resident #1 was walking around in the common area, she would stop at the nurse's station. The staff did not acknowledge her. At 4:32 p.m. Resident #1 was touching an unidentified male resident on his arm. She then placed her arm under and around his arm to walk arm and arm with him while he was walking. The social services assistant (SSA) was working with the male resident. -The SSA did not offer any prompting or cueing to Resident #1 to ensure she did not place herself in a vulnerable position while interacting with the male resident. At 4:36 p.m. Resident #1 was wandering around the nurse's station, the nurses did not acknowledge her. On 3/11/25 at 2:35 p.m. Resident #1 was wandering around the hallways and front lobby. There were no staff present. She wandered into the administrative offices and one of the administrative staff escorted her back to the nurse's station. -The staff failed to follow the interventions on Resident #1's care plan to monitor her wandering and offer meaningful activities or socialization to ensure a safe comfortable environment. 4. Record review The behavior care plan, revised on 10/28/24, documented Resident #1 had the potential for wandering and exit seeking. The care plan documented a wander guard was placed as a precautionary measure. The interventions included distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television or books, identifying patterns in her wandering and monitoring that the wander guard was functioning properly. The risk for wandering/elopement care plan, revised on 12/9/24, documented Resident #1 engaged in unsafe wandering. Pertinent interventions included staff were to engage the resident in purposeful activities, guide the resident to the recliners (but were not to put the footrest up due to her wandering) and schedule a time for regular walks. Review of Resident #1's electronic medical record (EMR) revealed that her behaviors were to be monitored. -However, the resident's EMR did not document her wandering activity or any efforts to provide meaningful activity. -Additionally, observations throughout the survey (3/10/25 to 3/13/25) revealed Resident #1 continuously wandered up and down the hallways off of the main nursing station (see observations above). The social services note, dated 11/11/24, documented that staff called Resident #1's representative about Resident #1 engaging in a kiss with Resident #2. It documented that due to Resident #1's cognitive state, the facility would be monitoring the situation closely. D. Resident #8 -victim 1. Resident status Resident #8, age greater than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included Alzheimer's disease, dementia with psychotic disturbance and depressive episodes. The 12/20/24 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 10 out of 15. The assessment revealed Resident #8 needed partial to moderate assistance with most of her ADLs. She used a wheelchair and was able to self-propel herself. 2. Record review The wandering behavior care plan, revised on 10/28/24, revealed Resident #8 had the potential to be verbally aggressive with staff and had the potential for delusional episodes. The care plan revealed that she wandered into other hallways and other resident's rooms and that her behavior may impact her behaviors. Interventions included monitoring the resident's behaviors, redirecting the resident with positive conversations and notifying the physician of increased behaviors. -A review of the resident's EMR did not reveal documentation regarding the 2/22/25 incident of sexual abuse with Resident #2. E. Resident #2 - assailant 1A. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included cerebrovascular disease (stroke), Alzheimer's disease and diabetes. The 1/3/25 MDS assessment revealed Resident #2 had moderate cognitive impairments with a BIMS score of 12 out of 15. The assessment revealed Resident #2 needed supervision or minimal assistance with most of his ADLs. The assessment revealed he used his wheelchair but was able to self-propel on his own. The assessment indicated that Resident #2 did not display inappropriate behaviors. -However, record review and interviews revealed that Resident #2 displayed sexually inappropriate behaviors on 12/18/25, prior to the assessment. 2. Record review The behavior care plan, revised 12/26/24 and 1/17/25, documented Resident #2 was at risk for potential sexual advances toward others. Interventions included discussing the resident's behavior with the resident, reinforcing why the behavior was inappropriate, diverting other residents from wandering or entering Resident #2's room and intervening, as appropriate, to protect the rights and safety of others. -The care plan was not initiated until a week after the 12/18/24 incident with Resident #1. Review of Resident #2's EMR revealed that his behaviors were being monitored. -However, the behavior monitoring did not document that he was sexually inappropriate on 2/22/25. The behavior monitoring (reviewed from 2/10/25 to 3/10/25) further revealed that the monitoring was not being done consistently. Several shifts and entire days lacked documentation of any potential behaviors or absence of behavior. The 11/11/24 social services note documented that Resident #2 had kissed a female resident. After the incident was observed, social services staff met with Resident #2 to provide education that his behavior was inappropriate because the female resident (Resident #1) was considered a vulnerable person and unable to engage in intimate relationships. The 11/13/24 nursing note documented that Resident #2 placed his hand on Resident #1's leg while she was walking and that she almost fell due to his touching. The note documented that he was instructed to avoid Resident #1 and to stop touching her. -Neither of the above incidents resulted in a care plan focused on interventions to address Resident #2's inappropriate sexual behavior towards a resident who was assessed to be unable to consent to sexual intimacy. The resident's care plan was not revised until after the 12/18/24 incident (see above). The 12/18/24 nursing note documented that Resident #1 was found in Resident #2's room and Resident #2 was touching Resident #1 inappropriately. The note documented that Resident #2 received education on keeping his hands to himself and that he told staff he understood the education. -Review of Resident #2's EMR failed to reveal documentation related to the incident on 2/22/25. An email, dated 2/23/25, was provided by the NHA on 3/11/25. The email documented communication between the facility leadership team and Resident #2's physician's office. The email revealed that the facility initiated a request for assistance to find a more appropriate placement for Resident #2 in the interest of keeping the female residents in the facility safe. The 3/4/25 social services note documented that Resident #2's representative and Resident #2 were both informed that Resident #2 was being issued a 30-day discharge notice due to his continued inappropriate sexual behavior towards female residents in the facility. -Review of Resident #2's EMR revealed Resident #2 was educated that Resident #1 was unable to engage in any type of intimate relationship and he was instructed to not pursue any type of intimate relationship with Resident #1. E. Staff interviews Registered nurse (RN) #2 was interviewed on 3/10/25 at 3:45 p.m. RN #2 said Resident #1's physician stopped her olanzapine on 3/4/25, which made her more tearful due to the lack of medications. She said Resident #1 wandered unsafely into other resident's rooms and tried to exit the facility to the outside so the staff kept an eye on her because she wandered into another resident's rooms and had gotten taken advantage of in the past. CNA #1 was interviewed on 3/11/25 at 9:00 a.m. CNA #1 said the staff were expected to monitor all residents with wandering behaviors, especially if the resident wandered off the unit. She said Resident #1 liked to wander and did not spend a lot of time in her room. CNA #1 said staff watched Resident #1 because she liked to go into other residents' rooms and tried to use their bathrooms. She said they had to watch Resident #1 when she was near Resident #2's room but that he was on 15-minute checks and was supposed to be in staff's line of sight when he was out of his room to ensure he did not interact inappropriately with Resident #1. CNA #1 said staff specifically watched for Resident #2's interactions with Resident #1 and Resident #8 since he had been sexually inappropriate with both of them. The SSA was interviewed on 3/11/25 at 11:30 a.m. The SSA said she was unaware of the incidents of inappropriate touching that occurred between Resident #1 and Resident #2. She said she did not know that staff were to monitor Resident #1 to ensure she was kept safe. The assistant nursing home administrator (ANHA) was interviewed on 3/11/25 at 4:37 p.m. The ANHA said Resident #2 was put on ongoing line of sight monitoring when he was out of his room after the 12/18/24 incident (see above). She said all staff were responsible for taking part in monitoring the resident, regardless of discipline, to make sure he did not engage in inappropriate behavior with other residents. The ANHA said Resident #2's daughter took him out to lunch after she was informed of the 12/18/24 incident (see above) and talked to Resident #2 about his behavior and told him that he could not be touching female residents. The ANHA said the resident's representative told the ANHA she believed Resident #2 clearly understood that he was not to touch a female. The ANHA said she also believed that Resident #2 understood the education he was provided because someone from adult protection services (APS) came and spoke with him and also told him he could not touch female residents who were unable to consent to the activity. The ANHA said Resident #2 told the staff, his representative and the APS worker that he understood and would stay away from the female resident he was instructed to stay away from. The ANHA said Resident #2 was issued a 30-day discharge notice because the resident continued to display inappropriate sexual behaviors and they were not able to keep the other residents safe with him in the building. The ANHA said the facility was working closely with the resident's physician's office and other outside providers to secure more appropriate living arrangements for Resident #2. 52513 III. Incident of physical abuse between Resident #5 and Resident #6 on 1/21/25 A. Facility investigation The 1/21/25 abuse investigation documented a witnessed resident-to-resident physical altercation occurred on 1/21/25 between Resident #5 and Resident #6. The staff observed Resident #5 and Resident #6 in the common area. Resident #5 lunged at Resident #6 and struck Resident #6 across the face with a piece of duct tape that was folded over upon itself. Resident #6 yelled and attempted to use a reacher (assistive device) to hit Resident #5 with no further contact made between residents. The staff separated the two residents. The staff had to physically remove and prevent Resident #5 from the continued act of physical aggression toward Resident #6. Resident #6 was assisted out of the common area and assessed for injuries. Resident #5 remained combative and attempted to hit and kick staff. Additional staff members surrounded Resident #5 to protect other residents in the area from being targeted by Resident #5. Other additional staff escorted onlooking residents and visitors out of the common area. Resident #5 sat in his wheelchair at the nurse's station while staff tried to calm him down. Staff called the resident's physician and received an order to to transport Resident #5 to the hospital for evaluation. Resident #5 was given an immediate discharge from the facility due to the inability of the facility to be able to meet the resident's behavioral health needs and keep the other residents in the facility safe from physical abuse. The facility's investigation of the incident included an interview with Resident #6. Resident #6 said he was hit with a piece of folded tape and no other contact occurred. Resident #6 said he was angry with Resident #5 after the incident. The facility investigation also interviewed other residents living in the same hall as Resident #5. The other residents on the hall said Resident #5 seemed very confused and was hard to communicate with. B. Resident #6 - victim 1. Resident status Resident #6, age greater than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included stroke and dementia. The 11/25/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He used a wheelchair for mobility and was dependent on staff to complete toileting and transfers. He required substantial/maximal assistance with bathing and dressing. 2. Record review -Review of Resident #6's EMR did not reveal documentation regarding the incident with Resident #5 on 1/21/25. Resident #6's Kardex (staff directive tool) directed staff to remove the resident to a calm safe environment and allow him to vent and share his feelings when conflict arose. Review of the comprehensive care plan, revised on 12/24/24, revealed Resident #6 had the potential for impaired psychosocial well-being and/or adjustment problems and may be at increased risk for alteration in psychosocial well-being related to continued adjustments to infection control protocol. The care plan documented he had difficulty adjusting to change and could be accusatory. It further documented that English was not his primary language. Interventions included redirecting the resident to a calm, safe environment when conflict arose and allowing him to vent/share feelings. C. Resident #5 - assailant 1. Resident status Resident #5, age greater than 65, was admitted on [DATE] and discharged to the hospital on 1/21/25. According to the January 2025 CPO, diagnoses included dementia with behavioral disturbance. The 1/21/25 MDS assessment revealed tResident #5 had short-term and long-term memory deficits and disorganized thinking per staff assessment. The resident sometimes was able to effectively express himself with verbal and non verbal expressions and sometimes understood simple direct communication. The MDS assessment indicated the resident had threatening physical and verbal behavior directed at others, wandering, and delusions. He was dependent with eating and oral hygiene and required some assistance with dressing, bathing and toileting. 2. Record review The 1/15/25 pre-admission referral documented Resident #5's spouse expressed concerns with Resident #5 having intermittent behavior outbursts at home. It documented concerns from the resident's adult daycare revealing that the resident was presenting with increasing behavioral aggression, including pushing a staff member and squeezing his spouse's arm when he did not get what he wanted. Resident #5's baseline care plan, initiated 1/18/25, documented the resident was cognitively impaired. He was unable to understand staff and was unable to communicate easily with staff. The resident was independent with mobility tasks but needed assistance with dressing and grooming. The nursing note, dated 1/21/25 at 5:35 p.m., documented Resident #5 had a change in behavior when he physically assaulted another male resident by hitting him in the face with a strip of folded-up duck tape. The staff were unable to redirect and calm the resident's aggressions so he was discharged to the hospital due to unmanaged aggressive behavior. The note documented since admission, verbal and physical aggression toward other residents and staff had been noted several times. He injured a staff member and was physically combative with another, requiring staff intervention and separation from other residents for their safety. The resident had entered other residents' rooms multiple times, sometimes taking possessions with him upon exiting. At times he entered other residents' rooms and undressed and redressed wearing another resident's clothes. He had physically touched other residents and woke them up from their sleep. Resident #5 lacked understanding and was unable to follow directions or comply with instructions. Resident #5 wandered frequently and had to be redirected several times from heading out an exit door. A wanderguard bracelet was placed on his arm to alert staff of his exit-seeking. The note documented that the resident's spouse said she was afraid of Resident #5 because he had become more paranoid and aggressive toward family members so she was expecting him to be aggressive while at the facility. The nursing note, dated 1/21/25 at 5:29 p.m., documented that at approximately 4:45 p.m., Resident #5 was observed leaning over Resident #6 hitting him with a folded-up piece of duct tape. Resident #5 did not respond to instructions from staff to stop hitting Resident #6. RN #1 had to physically hold and pull Resident #5 away from Resident #6 to stop the assault. The note further documented that when Resident #5 was pulled off of Resident #6, Resident #5 proceeded to stomp and kick the staff. RN #1 held Resident #5's hands so he could not scratch at those near him. RN #1 then placed the resident on the floor and sat behind him so he could hold on to the resident and not get injured while the resident calmed down. Once Resident #5 calmed down, nursing staff assisted him into a wheelchair. Emergency medical services (EMS) and the police were called and the resident was taken to the hospital for evaluation and treatment. D. Staff interviews RN #1 was interviewed on 3/11/25 at 2:00 pm. RN #1 said Resident #5 was confused and aggressive toward staff since he was admitted to the facility. RN #1 said he provided care to Resident #5 on multiple shifts and he was difficult to redirect. RN #1 said Resident #5's aggressive behaviors included verbal threats as well as physical aggression, such as hitting, kicking and pushing staff. RN #1 said on the day of the incident, 1/21/25, he saw Resident #5 pull tape off of the carpet in the hall that was placed there to keep and remind Resident #5 to stay away from another resident's room which he frequently wandered into. RN #1 said when he saw the resident tearing up the tape, he tried to redirect Resident #5, but the resident only became more agitated than he already was and did not follow cues to stop. RN #1 said he went down the hall to inform maintenance that the tape would need to be replaced. He said he heard a commotion and he observed Resident #5 leaning over Resident #6 and he appeared to be hitting Resident #6 repeatedly. He said he responded and separated the residents. He said he told Resident #5 that if did not stop hitting Resident #6 he would pull him away from Resident #6. RN #1 said when Resident #5 did not respond to verbal cues, he felt he was forced to separate the residents physically while the CNA removed Resident #6 from the common area for his safety. RN #1 said additional staff came quickly and got Resident #5 into a wheelchair and he stayed with Resident #5 in the nurse's station until EMS arrived. RN #1 said he was not aware if staff were informed of Resident # 5's aggressive behavior when he was admitted , but Resident #5 was aggressive towards others from the start of his admission. The ANHA was interviewed on 3/11/25 at 4:37 p.m. The ANHA said a staff member was dedicated to screening and coordinating referrals for new residents. She said the facility did not receive the referral for Resident #5 until they had already accepted him. She said the staff were notified of the needs of new residents, including behaviors, in the electronic charting system and a physical report sheet. She said that sometimes the facility did not find out about a resident's behavioral issues until after they were admitted to the facility.

Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to ensure: -Appropriate hand washing and glove usage in the main kitchen; -The cook wore a beard net while serving food; -Food was reheated appropriately; and, -Hand hygiene was offered to residents during meal times. Findings include: I. Staff hand hygiene A. Professional reference According to The Colorado Department of Public Health and Environment (2024) The Colorado Retail and Food Establishment Rules and Regulations retrieved on 4/18/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; after handling soiled equipment or utensils; before donning gloves to initiate a task that involves working with food; and, after engaging in other activities that contaminate the hands. If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. B. Facility policy and procedure The Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices policy, revised November 2022, was provided by the executive director (ED) on 4/11/24 at 11:40 a.m. It read in pertinent: Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. All employees who handle, prepare or serve food are trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. Employees must wash their hands: after personal bodily functions (toileting, blowing or wiping nose, coughing or sneezing); whenever re-entering the kitchen; and, after engaging in other activities that contaminate the hands. Contact between food and ungloved hands is prohibited. Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper hand washing. Gloves are worn when directly touching ready-to-eat foods. Food service employees are trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness. The Handwashing or Hand Hygiene policy, revised August 2019, provided by the ED on 4/11/24 at 11:40 a.m. It read in pertinent, This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing or hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing or hand hygiene. Integration of glove use along with routine hand hygiene is recognized as best practice for preventing healthcare-associated infections. Perform hand hygiene before applying non-sterile gloves and perform hand hygiene when removing non-sterile gloves. C. Observations During a continuous observation on 4/10/24, beginning at 4:40 p.m. and ending at 6:20 p.m., the following was observed: -At 4:44 p.m. dietary aide (DA) #2 prepared the meal trays going on the meal cart. He wiped his nose on the back of his glove. DA #2 did not wash his hands or change his gloves prior to picking up the resident meal tickets and sorting them. -At 4:47 p.m. DA #3 had a pair of gloves on both hands as he sorted out meal tickets that were collected from the resident's rooms. He used the same gloves to touch clean dishes and serving utensils. Without changing gloves or performing hand hygiene, he grabbed a handful of tater-tots with the gloves and placed them on a resident's plate. -At 5:59 p.m. DA #3 picked up the meal tickets with the same gloved hands and sorted them again. Without changing gloves or performing hand hygiene, he grabbed a clean plate and used his gloved hand to grab a handful of tater-tots and put them on a plate to be served to a resident. -At 6:05 p.m. DA #2 stuck his head outside of the kitchen door and sneezed. He wiped his nose on the back of his glove again and continued wiping his nose on the back of his arm from his wrist to his elbow. DA #2 walked to the handwashing sink in the kitchen and grabbed a paper towel. He used his gloved hands to wipe his nose with the paper towel. He disposed of the used paper towel and continued serving resident meals without changing his gloves or performing hand hygiene. -At 6:11 p.m. DA #2 used the same gloved hand to scratch his upper inner thigh and continued preparing trays for residents. -At 6:20 p.m. DA #3 changed one of his gloves but kept the other one on and did not wash his hands. D. Staff interviews The ED and registered dietitian (RD) were interviewed together on 4/11/24 at 10:28 p.m. The RD said the dietary staff were all new and still learning their duties and what leadership expected from them. The ED said DA #3 and DA #2 should have washed their hands and changed their gloves more often. The ED said she would provide education to the dietary staff regarding hand hygiene at the end of the survey. The RD said the gloves needed to be changed after touching something that was not for the current task. She said when DA #3 grabbed the meal tickets brought from the residents'rooms, he should have changed his gloves. She said if someone picked up something off of the floor they needed to change their gloves. The ED said any time staff changed their gloves they needed to wash their hands with soap and water in the kitchen. She said if they were not in the kitchen, staff could also use hand sanitizer between glove changes. II. Hair restraints A. Professional reference According to the Colorado Department of Public Health and Environment (2024) The Colorado Retail and Food Establishment Rules and Regulations retrieved on 4/18/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, linens and unwrapped single-service and single-use articles. B. Facility policy and procedure The Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices policy, revised November 2022, was provided by the ED on 4/11/24 at 11:40 a.m. It read in pertinent part, Hair nets or caps and beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens. C. Observations During a continuous observation on 4/10/24, beginning at 4:40 p.m. and ending at 4:51 p.m., the following was observed: -At 4:40 p.m. DA #3 was preparing meals for the short-term rehab side of the building without a beard net on. -At 4:52 p.m. the ED asked DA #3 to put on a beard net since he was cooking and plating food. D. Staff interviews The ED was interviewed on 4/11/24 at 10:28 p.m. The ED said she told DA #3 to put on a beard net because he needed to prevent potential contamination of the meal from hair. DA #3 was interviewed on 4/11/24 at 10:20 a.m. DA #3 said he was not used to wearing a beard net because he usually served the meals in the dining room and did not work as the cook. He said when the ED told him to put on a beard net he complied. III. Reheating of foods A. Professional reference The Colorado Department of Public Health and Environment (2024) The Colorado Retail and Food Establishment Rules and Regulations retrieved on 4/18/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view, Ready-to-eat time or temperature control for safety food that has been commercially processed and packaged in a food processing plant shall be heated to a temperature of at least 135 degrees Fahrenheit (F). B. Observations During a continuous observation on 4/11/24, beginning at 4:40 p.m. and ending at 6:48 p.m., the following was observed: -At 5:31 p.m. DA #4 microwaved a bowl of chicken noodle soup for three minutes. When the chicken noodle soup was done, DA #4 immediately served the bowl of steaming chicken noodle soup to a resident. DA #4 did not take the temperature of the soup prior to serving it to a resident. While the chicken noodle soup was in the microwave, DA #5 placed two hot dogs on the flat top to cook. -At 5:36 p.m. DA #5 removed the hot dogs from the flat top and immediately served them to a resident without taking the temperature. -At 5:39 p.m. DA #4 put another bowl of soup in the microwave for three minutes. He took the soup out of the microwave. The soup was steaming and he immediately served it to a resident without taking the temperature of the soup. C. Staff interviews The ED and RD were interviewed together on 4/11/24 at 10:28 p.m. The ED said the temperature of all food items needed to be taken prior to serving the food to residents. The ED said DA #4 started working in the kitchen less than a week ago and she was going to provide him more education. IV. Resident hand hygiene before meals A. Facility policy and procedure The Handwashing or Hand Hygiene policy, revised August 2019, was provided by the ED on 4/11/24 at 11:40 a.m. It read in pertinent, This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing or hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. B. Observations During a continuous observation on 4/8/24, beginning at 12:10 p.m. and ending at 12:32 p.m., the following was observed in the rehabilitation building's dining room: -At 12:10 p.m. four residents were observed in the dining room of the short-term rehab buildings. The staff did not offer residents hand hygiene before the residents were served their meals. -At 12:27 p.m. a resident self-propelled his wheelchair into the dining room placing his hands on the wheels. He went to his table and was served his plate. The resident used his hands to eat a dinner roll. The staff did not offer or encourage the resident to clean his hands before eating his meal. -At 12:32 p.m. a resident walked into the dining room carrying his portable oxygen tank and sat at a table where his lunch was placed. The staff did not offer or encourage the resident to perform hand hygiene. He sat his oxygen tank on the ground and started eating his meal. The resident used his hands to eat a dinner roll. During a continuous observation on 4/10/24, beginning at 5:08 p.m. and ended at 6:08 p.m. the following was observed: -At 5:08 p.m. Resident #20 self-propelled her wheelchair into the dining room toward her table. She used her hands to touch the wheels of her wheelchair and to adjust her positioning at the table. The resident was not offered or encouraged to perform hand hygiene after she touched the wheels of her wheelchair and before she ate her meal. Resident #20 used her hands to eat a dinner roll. -At 5:09 p.m. Resident #73 self-propelled her wheelchair into the dining room with her feet as she held her baby doll. She sat at a table in front of a bag of opened potato chips. The resident was not offered or provided hand hygiene before she began to eat the chips with her hands. -At 5:13 p.m. Resident #73 left the dining room table, touched her tablemate's wheelchair handle with her left hand, propelled her wheelchair towards the nurse in the dining room and held his hand with her left hand. The resident was not offered hand hygiene. -At 5:18 p.m. Resident #73 returned to her dining table and used her right hand to touch the shoulder of the restorative aide (RA) sitting next to her. The resident was not offered hygiene. -At 5:19 p.m. Resident #73 was served her meal. She proceeded to retrieve her utensils from her rolled napkin by placing her fingers on the eating surface of the utensils. The resident then used the spoon to eat her pudding. C. Resident interviews Resident #20 and Resident #38 were interviewed on 4/10/24 at 5:27 p.m. in the main dining room. Resident #20 said the wipes on the table were for cleaning your hands. Resident #38 said the bottle of hand sanitizer was used to clean their hands too but the staff just added the bottles of hand sanitizer to the tables on 4/10/24 (during the survey). -However, neither resident was observed sanitizing their hands nor was staff observed encouraging the residents to utilize the hand sanitizer or wipes. D. Resident group interview The resident group was interviewed on 4/10/24 at 10:03 a.m. The group consisted of five residents (#37, #16, #24, #38 and #20), including the resident council president, who were identified as interviewable by the facility and assessment. Resident #24 said there were blue packs of wipes on the dining room tables for the residents to wipe their hands before they eat. She said the staff did not offer hand hygiene to the residents before any meal. She said the blue packs of wipes were the same wipes she had in her bathroom to clean her peri-area with. Resident #16 said she only ate meals in her room and was not offered hand hygiene. She said she did not know wipes were available before meals. Resident #38 said the blue wipes were left on the tables in the dining room as long as the facility did not run out of them, which happened often. E. Staff interviews Registered nurse (RN) #1 was interviewed on 4/11/24 at 6:42 p.m. She said she did not offer the residents hand hygiene when delivering the meal trays. The NHA and DON were interviewed together on 4/11/24 at 7:46 p.m. The DON said residents needed to be offered hand hygiene before their meals. V. Facility follow-up The ED provided the facility's dietary training plan on 4/15/24 at 5:01 p.m. The training was scheduled for 4/18/24 at 9:30 a.m. It consisted of hands-on training for the dietary staff. The training included hand hygiene, glove usage and kitchen sanitation. Additional training was sent out to all facility staff in the facility's electronic training system to cover all content that was covered in the in-person training. After the training was completed the staff were required to complete a post-training exam.

Based on observations, record review and interviews, the facility failed to ensure residents received proper respiratory treatment and care for three (#37, #55 and #77) of four residents reviewed for supplemental oxygen use out of 38 sample residents. Specifically, the facility failed to: -Administer oxygen in accordance with the physician's order for Resident #55 and Resident #77; and, -Ensure Resident #37 had a physician's order for oxygen use. Findings include: I. Facility policy and procedures The Oxygen Administration policy, revised October 2010, was provided by the facility on 4/11/24. According to the policy, the purpose of the policy was to provide guidelines for safe oxygen administration. The policy read in pertinent part, Verify there is a physician order for this procedure. Review the physician's order or facility protocol for oxygen administration. Review the resident's care plan to assess any special needs of the resident. Assemble the equipment and supplies as needed. II. Resident #55 A. Resident status Resident #55, over the age of 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included chronic and obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia and paroxysmal atrial fibrillation. According to the 12/31/23 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had no behavioral symptoms or rejections of care. The assessment indicated the resident received oxygen therapy and had shortness of breath or trouble breathing with exertion and when laying flat. B. Resident observations and interview On 4/8/24 at 4:13 p.m. Resident #55 was in her room wearing a nasal cannula attached to an oxygen concentrator. The oxygen concentrator flow rate was set at 5 liters per minute (lpm). The resident said she had no concerns with her oxygen. She said weekly on Mondays she received a new nasal cannula and her oxygen flow rate was to be set at 5 lpm. The resident said 5 lpm was not a new setting. She said it had been set at 5 lpm for a while. On 4/9/24 at 10:31 a.m. Resident #55 wore her nasal cannula attached to her oxygen concentrator as she layed in bed. The oxygen concentrator flow rate setting remained at 5 lpm. On 4/10/24 at 1:47 p.m. the resident was in her room wearing a nasal cannula attached to her oxygen concentrator with the oxygen flow rate set at 5 lpm. She said she had not had recent breathing issues or episodes of shortness of breath. On 4/11/24 at 8:29 a.m. Resident #55 wore the nasal cannula attached to her oxygen concentrator and the oxygen flow rate was set at 5 lpm. B. Record review The respiratory care plan, initiated 7/21/23, identified Resident #55 was at respiratory risk related to chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia. The resident was dependent on continuous oxygen per nasal cannula. The respiratory care plan intervention, revised 1/1/24, directed staff to administer medications per physician's orders, provide oxygen via nasal cannula and titrate oxygen to maintain oxygen blood saturation levels above 90% and notify the physician of changes in status. -The care plan did not identify the resident adjusted her own oxygen settings (see interview below). The 1/13/24 CPO read Resident #55 had oxygen orders for 2 lpm continuously via nasal cannula. Observe skin integrity every shift at pressure points from the oxygen delivery device while in use on every shift related to COPD and chronic respiratory failure with hypoxia. -According to the oxygen order, staff needed to notify the physician if the resident required oxygen greater than 4 lpm. The 2/28/24 CPO read staff needed to check the resident's oxygen every shift for oxygen tubing kinks and safety issues. A 3/8/28 nursing note read Resident #55 was at 5 lpm with an oxygen saturation level of 95%. The 4/3/24 multidisciplinary care conference documentation read Resident #55 was on continuous oxygen related to COPD at 4 lpm and was doing well. The documentation read the resident had some shortness of breath with exertion. -The care conference documentation did not indicate the physician would be or was notified to change the resident's oxygen orders from 2 lpm continuous to 4 lpm continuous as identified in use per the multidisciplinary documentation. -The 4/3/24 documentation did not identify the resident's oxygen setting would be increased to 5 lpm as observed above. -Review of the resident's medical record did not identify the physician was notified of an increased oxygen need between the 4/8/24 through 4/11/24 survey observation period. The April 2024 treatment administration record (TAR) between 4/1/24 and 4/10/24 read the oxygen saturation levels ranged between 90% and 96% on continuous oxygen at 2 lpm via nasal cannula. The TAR indicated the resident's nurse checked and signed off on the resident's oxygen twice a day. -However, observations on 4/8/24, 4/9/24 and 4/10/24 revealed the resident's oxygen flow rate was set on 5 lpm (see observations above). III. Resident #37 A. Resident status Resident #37, over the age of 65, was admitted on [DATE]. According to the April 2024 CPO, diagnoses included unspecified dementia, unspecified severity without behavioral disturbances, generalized anxiety, interstitial lung disease with progressive fibrotic phenotype in diseases classified elsewhere, obstructive sleep apnea and chronic atrial fibrillation (an irregular and often very rapid heart rhythm). According to the 11/14/23 MDS assessment, the resident was cognitively intact with a BIMS score of 13 out of 15. The assessment did not identify the resident received oxygen therapy. B. Observations On 4/9/24 at 10:40 a.m. Resident #37 was in her room and wore a nasal cannula attached to a portable oxygen canister on the back of her wheelchair. On 4/10/24 at 4:58 p.m. Resident #37 was in the dining room. The resident wore a nasal cannula attached to her portable oxygen. On 4/11/24 at 7:48 a.m. Resident #37 wore a nasal cannula attached to her portable oxygen canister. The oxygen flow rate was set at 3 lpm. C. Record review The 7/6/23 physician's orders directed staff to obtain Resident #37's oxygen saturation levels every 24 hours as needed. -The physician's order did not identify the resident was on oxygen therapy. The cardiac care plan goal, initiated 8/17/23, read Resident #37 would maintain oxygen saturation levels above 90%. The care plan intervention, revised 2/15/24 read the resident was on oxygen PRN (as needed). The vital signs log identified Resident #37 saturation levels were monitored twice a month between 12/19/23 and 4/1/24. The vital signs log identified Resident #37 had been on oxygen via nasal cannula in December 2023, January 2024, March 2024 and April 2024. The resident's oxygen saturation levels were 93% or above on room air and 95% or more on oxygen via nasal cannula in December 2023 and January 2024. In February 2024, the resident's saturation levels were checked on 2/1/24 and 2/17/24. Her oxygen saturation level on room air the resident was 98% on 2/1/24 and at 93% on 2/17/24. The resident's saturation levels on oxygen via nasal cannula was at 98% when her March 2024 and April 2024 oxygen saturation level was checked by staff. -The February 2024 vital signs log documented the resident had 93% or greater oxygen saturation levels when tested on room air without oxygen via nasal cannula. The March and April 2024 medication administration records for obtaining Resident #37's oxygen saturation levels as needed were left blank between 3/1/24 and 4/11/24. The April 2024 CPO did not identify the resident had physician orders for oxygen use via nasal cannula. The April 2024 treatment administration record (TAR) did not identify the resident was monitored for oxygen use. IV. Resident #77 A. Resident status Resident #77, over the age of 65, was admitted on [DATE]. According to the April 2024 CPO, diagnoses included chronic respiratory failure with hypoxia, obstructive sleep apnea and hypertensive heart disease with heart failure. According to the 2/7/24 MDS assessment, the resident's cognition was intact with a BIMS of 13 out of 15. The assessment identified the resident received oxygen therapy. B. Resident observations and interview On 4/8/24 at 4:39 p.m. Resident #77 was in his room wearing a nasal cannula attached to an oxygen concentrator. The oxygen flow rate on the concentrator was set at 3 lpm. On 4/11/24 at 10:50 a.m. Resident #77 was in his room wearing a nasal cannula attached to an oxygen canister. The oxygen flow rate was set at 3 lpm. Resident #77 said staff set his oxygen at 3 lpm and he had not had a recent change in his respiratory needs or oxygen level settings. C. Record review The 2/1/24 physician's order directed staff to provide Resident #77 oxygen via nasal cannula every shift. -The physician's order did not specify what the resident's oxygen flow rate should be. The 2/1/24 physical therapy (PT) evaluation and plan of treatment was provided by the assistant director nursing (ADON) on 4/11/24 at 4:26 p.m. The PT evaluation read the resident needed 3 lpm of oxygen via nasal cannula. A 2/1/24 PT treatment encounter note was provided by the assistant director nursing (ADON) on 4/11/24 at 4:26 p.m. The note read Resident #77's oxygen saturation levels were 100% on 4 lpm of oxygen and 98% on 3 lpm of oxygen. According to the resident's nurse, the resident was on 2 lpm of oxygen at the hospital and the resident reported using 3 lpm of oxygen at home. The respiratory risk care plan, initiated 3/7/24, read the resident was at risk related to obstructive sleep apnea chronic respiratory failure with hypoxia, heart failure and edema. The care plan directed staff to administer medication per physician's orders, provide oxygen per nasal cannula, titrate to maintain oxygen saturation level over 90% and notify the physician of changes in status. The April 2024 TAR between 4/1/24 and 4/10/24 read the oxygen saturation levels ranged between 92% and 99% on continuous oxygen at 4 lpm via nasal cannula. The TAR indicated the resident's nurse checked and signed off on the resident's oxygen twice a day. -However, observations on 4/8/24 and 4/11/24 revealed the resident's oxygen flow rate was set on 3 lpm (see observations above). V. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 4/11/24 at 10:40 a.m. LPN #2 said the nurses and certified nursing assistants checked residents' oxygen. LPN #2 reviewed Resident #55's oxygen orders. The nurse said the resident had oxygen orders for 2 lpm. She said the resident's oxygen should not have been set at 5 lpm. She said the resident should have not been higher than 4 lpm. LPN #2 said she would notify the physician for order clarifications. LPN #2 was interviewed again on 4/11/24 at 11:38 a.m. LPN #2 said she changed Resident #55's oxygen setting to 2 lpm. LPN #2 said she thought the resident was the one who changed the oxygen setting to 5 lpm. She said she would have the resident assessed for appropriate oxygen needs and contact the physician to determine if the resident needed a higher level of oxygen than was ordered. The nursing home administrator (NHA) and the director of nursing (DON) were interviewed on 4/11/24 at 12:09 p.m. The DON said Resident #55 was changing the oxygen settings to 5 lpm. The DON said staff attempted to get a new order but the physician said her oxygen level should not be set higher. The DON said the resident said she would just continue to turn up the oxygen. The NHA said Resident #55's behavior of turning up her oxygen should have been care planned. The NHA said she would look at interventions such as educating the resident on the need for appropriate oxygen settings, offer reminders to the resident to not self adjust and provide non-pharmacological interventions when the resident felt anxious. The NHA said she would provide education for staff to monitor the resident's oxygen settings. The NHA said she would look at prevention methods so the resident could not self adjust her oxygen settings. The NHA said Resident #55 had COPD. She said if the resident received too much oxygen then she could become sick and decrease her ability to breathe. The NHA said she did not know why the resident was turning up her own oxygen. The NHA said residents' oxygen needs were assessed on admission and quarterly. She said the assessments were not documented but included respirations and review of oxygen saturation levels and oxygen orders. She said a nurse would make sure the resident was on the correct liter of oxygen to maintain a saturation level above 89%. The NHA reviewed the orders and said Resident #37 did not have an order for oxygen via nasal cannula as observed. The DON said an oxygen report identified Resident #37 used oxygen at night via CPAP (continuous positive airway pressure). The DON said the resident did not have a CPAP order. The DON said the assistant director of nursing (ADON) was in the process of identifying when and why Resident #37 was placed on oxygen via nasal cannula and provided the equipment without a physician's order. The DON said the oxygen supply company completed an audit of their oxygen equipment on 3/18/24. The DON said the supply company's audit read Resident #37 had portable oxygen equipment in place. The NHA said the resident should have had an order for the nasal cannula and documentation identifying why the resident needed the oxygen. The NHA said Resident #77's oxygen setting should not have been lower than what he had an order for. She said if Resident #77's oxygen saturation levels were consistently high, the physician should have been contacted and the order changed. The NHA said when CNAs turned the oxygen on the nurse should provide an on the spot check to make sure the oxygen was on the correct setting as oversight because oxygen was a medication. The NHA said Resident #77's saturation levels looked good so she would have his order changed. The ADON was interviewed on 4/11/24 at 4:26 p.m. The ADON said the nursing staff should check residents orders and compare the orders to the oxygen settings on every shift. The ADON said Resident #55 told staff in February 2024 she would hit them if they tried to turn her oxygen down and she would just turn the oxygen back up. The ADON said the behavior should have been care planned and staff should have been monitoring it more. The ADON said Resident #37 used to have an oxygen order but she could not find a current order for her. The ADON said she contacted the oxygen supply company and Resident #37 had been receiving oxygen via a portal nasal cannula (without an order) for the past six weeks. The ADON said Resident #77 was admitted to the facility on 2 lpm of oxygen. Then he was on 3 lpm of oxygen and saturation levels were holding steady. The ADON said the therapy notes read therapy bumped up his oxygen to 4 lpm. She said therapy could not change oxygen so a nurse must have entered the 4 lpm oxygen order on 2/1/24. -Review of provided PT notes (above) and evaluation did not identify PT felt the resident should have been on 4 lpm of oxygen. The quality assurance nurse (QAN), the NHA, the DON and the executive director (ED) were interviewed on 4/11/24 at 8:07 p.m. The QAN said oxygen management had been reviewed in the facility's quality assurance meetings. The quality assurance committee focused on ensuring residents had the right oxygen equipment assigned to them and orders matched treatment through audits. The QAN said they had identified and corrected several concerns and wrote new orders. The DON said staff turnover could have hindered sustainable changes for oxygen management concerns. The NHA said the committee needed to identify the root cause of the current oxygen concerns. VI. Facility follow up The 4/11/24 oxygen inservice education was provided by the facility on 4/11/24 (during the survey). The oxygen education was provided to 15 staff members including nursing and CNA staff. According to the education every resident that was on oxygen needed to have an order in their medical chart. Nurses and CNAs should monitor oxygen use when in the residents' rooms. CNAs should report to the nurses to ensure the oxygen was on the correct liter flow

Based on observations, record review and interviews, the facility failed to ensure the self administration of medications was clinically appropriate for two (#7 and #46) of eight residents reviewed for medication errors out of 38 sample residents. Specifically, the facility failed to implement an interdisciplinary team (IDT) approach to assess if Resident #7 and #46 were clinically safe and appropriate for self-administration of medications. Findings include: I. Professional standard According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 2016, retrieved on 4/16/24, Do not leave medications at the bedside. If you leave the medication on the bedside table, how do you know they took the medication? Someone else could come in and take or discard the medication. II. Facility Policy The Self-Administration of Medications policy, dated February 2021, was provided by the nursing home administrator (NHA) on 4/11/24 at 6:14 p.m. It documented in pertinent part, Residents deemed safe to self-administer medications will have this documented in the medical record and the individualized care plan. III. Resident group interview The resident group was interviewed on 4/10/24 at 10:03 a.m. The group consisted of five residents (#37, #16, #24, #38 and #20), including the resident council president, who were identified as interviewable by the facility and assessment. Resident #38 said the nurses left her medications in her room because the staff knew she would take her medications. She said she often self-administered her medications without staff present. Resident #20 said the night shift nurses left her bedtime medications in her room. She said she took sleeping medications and was not tired enough to take them when the nurses came by so the nurse left the medications in her room. She said the nurses also left her pain medications in her room and she self-administered her medications herself when she needed pain relief at 8:00 p.m. and 12:00 a.m. Resident #37 said if she was in the restroom when the nurse brought her medications the nurse left the pills on her counter and she self-administered her medications. Resident #16, the resident council president, said she self-administered her morning medications after breakfast without staff present. IV. Resident #7 A. Resident status Resident #7, over the age of 65, was admitted on [DATE] According to the April 2024 CPO, diagnoses included unspecified dementia, unspecified severity, with psychotic disturbance, blindness in her right and left eye, unspecified macular degeneration and anxiety disorder. The 1/13/24 MDS assessment indicated the resident's cognition was intact with a BIMS of 15 out of 15. The resident did not have behaviors of rejections of care or other related behaviors. B. Observations and resident interview Resident #7 was interviewed on 4/8/24 at 10:44 a.m. Resident #7 said she could not see well and was blind in her right eye. The resident said she put her own eye drops in her eyes. The resident pulled a small plastic bag out of her bedside dresser drawer. The bag contained two eye drop bottles, artificial tears eye drops, Prednisolone prescription eye drops and Saline nasal spray. Next to the bag in the drawer was Flonase nasal spray. The resident said she had trouble sleeping at night because of sinus problems so she put cotton tips and nasal spray in her nose herself. -At 11:03 a.m. Resident #7 retrieved an artificial tears eye drop bottle with a white cap out of the plastic bag and asked if the bottle had a red top. The resident then pulled a Prednisolone eye drop bottle out of the bag with a red top and asked if the bottle had a red top. The resident proceeded to twist off the red top of the Prednisolone eye drop bottle and place one drop of the medication in her right eye. The resident placed a drop of the artificial tears in her left eye. The resident said she could tell the color difference of the bottle caps when she held them next to each other. On 4/11/24 at 8:27 a.m. Resident #7's bottle of artificial tears was on top of her bedside dresser and the Prednisolone was in the drawer. The resident said she could not always find her eye drops because staff placed everything in the drawer and her eye drops got buried. She said staff also moved her eye drops sometimes to the other side of the room and she had difficulty finding her eye drops. C. Family interview The resident's family member was interviewed on 4/10/24 at 1:27 p.m. The family member said the resident always put her own eye drops in her eyes when she was at home. She said Resident #7 continued to administer her own eye drops at the facility. She said the resident could not always find where she last put the eye drops in her room because she could not see well at all. D. Record review The April 2024 CPO revealed the following physician's orders for Resident #7: Pred Forte Ophthalmic Suspension at 1% (Prednisolone Acetate) for one drop in right eye four times a day for ocular pain, ordered 5/29/23. Saline Nasal Spray Nasal Solution at 0.65 % to spray in both nostrils every six hours as needed for rhinitis (inflammation and swelling of the mucous membrane of the nose), ordered 6/7/23. Flonase Allergy Relief Nasal Suspension to spray in each nostril in the morning for rhinitis, ordered 10/31/23. Artificial Tears Ophthalmic Solution for drops in both eyes three times a day, ordered 11/6/23. The self care and mobility care plan, revised 1/15/24, read Resident #7 had impaired mobility, related to recent falls, blindness, weakness and did not always ask for assistance. The cognition care plan, revised 4/11/24, read Resident #7 had a BIMS score of 15 out of 15 but had episodes of confusion with an expected decline in cognitive function. -Review of the care plan did not identify the resident was deemed appropriate or safe to administer her own eye drops or nasal spray. The April 2024 medication administration record (MAR) was reviewed between 4/1/24 and 4/10/24. The MAR read the following medications were administered by a nurse: -Flonase Allergy Relief Nasal Suspension spray once a day; -Artificial Tears Ophthalmic Solution eye drops three times a day; and, -Pred Forte Ophthalmic Suspension eye drops four times a day. -However, per Resident #7, she administered her own eye drops and Flonase nasal spray and kept the medications in her bedside drawer (see observations and interview above). -According to the April 2024 MAR, the Saline Nasal Spray Nasal Solution was not administered by a nurse or known to be administered between 4/1/24 and 4/10/24. E. Staff interviews The nursing home administrator (NHA) was interviewed on 4/10/24 at approximately. She said no medications should be left in a resident's room. She said residents who administered their own medication would have to be assessed for safety and capability, have a self administration order and be able to complete their own MAR. She said she did not believe there was any resident in the facility who was assessed and ordered for self administration of medications. She said it was very rare for a resident to be able to complete the MAR. Licensed practical nurse (LPN) #2 was interviewed on 4/11/24 at 10:22 a.m. LPN #2 said she did not have any residents who had self administration medication orders. She said she was frequently Resident #7's nurse. LPN #2 said the nurse was supposed to administer her eye drops and nasal spray but the resident wanted to keep the eye drops and the nasal spray in her room because Resident #7 wanted to feel more in control. LPN #2 said it was a constant battle with the resident. She said if the resident was administering her own eye drops, she probably was not administering them in a clinically appropriate way and she would probably be getting more of the eye drops than she should. LPN #2 was interviewed again on 4/11/24 at 11:38 a.m. LPN #2 said she had moved all the eye drops and the nasal spray out of Resident #7's room. She said she had contacted the resident's family member and interviewed the resident and confirmed the resident was administering the medications herself. The resident understood why the medications could not be in her room and consented to have them removed. The resident was informed the eye drops and the nasal spray were going to be locked in the nursing cart. LPN #2 said it was normal practice to lock up the spray and the eye drops in the nursing cart. She said she was aware the medications were in the resident's room but she was trying not to upset the resident if she removed them. She said she was surprised the resident was okay that the medications would be locked up. The NHA and the director of nursing (DON) were interviewed on 4/11/24 at 12:52 p.m. The NHA said Resident #7's family member was bringing the eye drops and the nasal spray to the resident but all medications should be locked up. The DON said Resident #7 wanted the medications in her room as a sense of control. The DON said the eye drops and nasal sprays needed to be secured in the medication cart. She said the resident was probably getting more of the eye drops than was ordered by the physician. 50314 V. Resident #46 A. Resident Status Resident #46, over the age of 65, was admitted on [DATE]. According to the April 2024 CPO, diagnoses included end stage renal disease, congestive heart failure, and left lower leg amputation. According to the 10/4/23 MDS assessment, Resident #46 had no cognitive impairment with a BIMS score of 15 out of 15. The resident was not identified to complete medication administration independently. B. Observations On 4/9/24 at 8:41 a.m., Resident #46 was interviewed. During the interview, the resident had a small clear medication cup with four pills in the cup. The resident swallowed the medications over several minutes during the interview, which lasted until 8:58 a.m. No staff members were present in the resident's room between 8:41 a.m. and 8:58 a.m. when the interview took place. (cross-reference F760 for significant medication errors) C. Record Review According to the April 2024 CPO, midodrine (blood pressure medication) was ordered on 10/10/2024 to be administered three times a day at 8:00 a.m., 12:00 p.m. and 8:00 p.m. The April 2024 CPO documented it was important the resident received his morning midodrine dose before attending dialysis. The April 2024 CPO did not include an order by a physician for the resident to administer their own medications. The care plan obtained from the NHA on 4/11/24 at 6:11 p.m. failed to document Resident #46 had been assessed to safely self-administer his own medications. The April 2024 medication administration record (MAR) documented the resident received his 8:00 a.m. midodrine on 4/9/24. This was documented by LPN #1. -However, LPN #1 was not present in the room to confirm the resident took his medications. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 4/10/24 at 4:36 p.m. LPN #1 said medication orders should always be followed. LPN #1 said Resident #46 could not self-administer medications. LPN #1 said she had witnessed Resident #46 take his medications the morning of 4/9/24, however, the resident was observed swallowing medications at 8:41 a.m. without any staff members present. LPN #1 said the cup of medications the resident consumed was Resident #46's morning medications and not someone else's medications. LPN #1 then said she did not know the time Resident #46 swallowed his midodrine. The pharmacist (PH) was interviewed on 4/11/24 at 2:02 p.m. The PH said Resident #46 was not allowed to self-administer medications. The PH said it was expected that nurses witness medication administration for residents who could not self-administer medications. The director of nursing (DON) was interviewed on 4/11/24 at 5:54 p.m. The DON said medication orders should always be followed. The DON said resident #46 could not administer his own medications, and did not have a physician's order to allow self medication administration per the facility policy. The DON said medications should not be left at the bedside if the resident could not self-administer medications. The DON said she expected nursing staff to observe residents swallow medications to ensure they had been taken as part of a normal medication administration.

Based on observations, record review and interviews, the facility failed to ensure one (#1) of three residents remained free from accident hazards out of 16 sample residents. The facility failed to ensure a safe environment and prevent major injury for a resident at risk for elopement and falls. Resident #1 was let out of the facility doors by a facility visitor on 11/17/23. The resident was wearing a wander guard device but the device was not functioning properly and the wander guard system door panel did not sound an alarm to alert staff the resident was exiting the facility. The resident rolled out in the parking lot with her wheelchair and hit a parking lot bumper. Resident #1's wheelchair tipped over and the resident landed on the parking lot asphalt. A facility vendor who was outside observed the resident in the parking lot and alerted staff. The resident required hospitalization for treatment and sustained a fracture to her femur and abrasions to her head. Findings include: I. Facility policy The Wanderguard Bracelet policy and procedure, revised October 2019, was provided by the director of nursing (DON) on 1:05 p.m. According to the policy, the facility was to ensure residents at risk for elopement were assessed and remained safe within the facility. The policy read in part: (Residents) who are at risk such as those presenting with history of attempts of elopement, dementia, confusion or increased confusion and/or Alzheimer's disease wore a wander guard bracelet to alert staff of attempts at independent exit from the facility. (Residents) that are at risk for elopement are assessed by the floor nurse for the need for a wander guard bracelet on admission, quarterly and with a change of condition. Once a (resident) has been assessed as needing a wander guard bracelet, one can be placed, the device is obtained from the restorative department and the following must be completed: - The POA (power of attorney) is notified of why a wander guard is needed. - The physician is notified and a request for an order is made. - The care plan is revised to include the bracelet. - The above steps are documented in the record. Each resident who wears a wander guard bracelet will be checked every shift to ensure that the bracelet is in place. This is documented on the MAR (medical administration record). The night shift nurse will check each bracelet every night to ensure that the bracelet is operational and document on the MAR. Anytime a resident is confused, is either attempting to leave the facility and makes his way outside, is to immediately have a wander guard bracelet applied to ensure safety of the resident. Restorative nurses re-assesses for appropriateness of devices quarterly, with change of condition and PRN (as needed). They care plan the use of the device. The Falls and Fall Risk, Managing policy, revised October 2019, was provided by the director of nursing (DON) on 1:05 p.m. The policy read in part: Based on previous elevations and current data, the staff will identify interventions related to the resident specific risks and causes to try to prevent the resident from falling and to try and minimize complications from falling. II. Resident status Resident #1, over the age of 65, was admitted on [DATE] and discharged to the hospital on 11/7/23. According to the January 2024 admission record, diagnoses included Alzheimer's disease, unspecified, dementia in other diseases classified elsewhere, unspecified severity, with agitation, depressive episodes, unspecified macular degeneration, acquired absence of the left leg above the knee, unilateral primary osteoarthritis of the right knee, diastolic (congestive) heart failure. The 11/3/23 minimum data set (MDS) assessment identified Resident #1 had severe cognitive impairment cognitively intact with a brief interview for mental status (BIMs) score of three out 15. According to the MDS assessment, the resident's disorganized thinking and inattentive behavior were continuously present. The MDS assessment identified Resident #1 required a wheelchair for mobility. III. Record review The November 2023 comprehensive care plan identified Resident #1 needed assistance with self care and mobility. The resident had a history of falls and exit seeking behaviors. The November 2023 comprehensive care plan for Resident #1 identified: -Had delusional episodes and hallucinations; -Had poor safety skills and safety awareness; -Had behaviors of restlessness, and wandering, -Had agitation with exit seeking episodes; -Was impulsive; and, -Believed she was staying in a hotel and packed her belongings stating I have to be ready to move. Interventions directed staff to: -Monitor behaviors and symptoms; -Provide positive distraction; -Encourage activities; -Validate feelings; -Encourage mobility; -Provide reassurance of safety; and, -Monitor for increased agitation; -The care plan did not include the resident's use of a wander guard or direct staff how to manage the wander guard, including frequency of ensuring Resident #1's wander guard was in proper working condition. The patient summary report read staff were to ensure the resident's wander guard bracelet was on and functioning every shift and staff were to answer the alarm promptly and attempt to redirect. The 6/27/23 computerized physician orders (CPO) read IDT (interdisciplinary team) review deems that it is necessary to apply a wander guard bracelet to the resident for unsafe exit seeking behaviors and poor safety awareness. The assistive device form was provided by the facility on 1/2/23. The form identified Resident #1's wander guard function was checked on 6/14/23, 7/6/23 and 7/29/23. On 8/31/23 the battery was changed and was now working.-The assistive device form did not identify the wander guard function was checked in September 2023. According to the form, the batteries to Resident #1's wander guard had to be changed on 10/4/23 and on 10/17/23. -The assistive form did not identify Resident #1's wander guard checked for function between 10/18/23 and 11/17/23, ensuring the wander guard was operational. The October 2023 treatment administration record (TAR) identified the wander guard was in place daily. -The October 2023 TAR did not identify the wander guard was checked for function, ensuring it was operational. The November 2023 TAR identified the wander guard was in place daily between 11/1/23 and 11/17/23. -The November 2023 TAR did not identify the wander guard was checked for function, ensuring it was operational. The 11/3/23 fall risk evaluation identified Resident #1 was at risk for falls. -Review of Resident #1's record did not identify the resident was assessed for elopement or had a wander risk assessment in place. The 11/6/23 unannounced wander/missing resident drill record form identified the facility conducted a drill simulating a missing resident, actions and time it took the staff to find the missing resident. According to the record, nine staff participated in the drill and the resident was found in six minutes. The 11/17/23 nursing note read a certified nurse aide (CNA) entered the facility at 3:30 p.m. and said a resident was in the parking lot in the front of the facility. According to the note, staff ran out the facility and found Resident #1 in the parking lot on her back. The note identified the resident fell out of her wheelchair. The nursing note read Resident #1's left side of head was bloody and her right leg was twisted. Emergency personnel were called and Resident #1 was taken to the hospital at 4:00 p.m. The 11/17/23 at 3:30 p.m. risk management report was provided by the facility on 1/2/24. The note read the quality assurance manager (QAM) was called to assist staff in the front parking lot of the facility. Resident #1 fell off the sidewalk and onto the parking lot. The resident was seated on her bottom with a CNA holding her head while other staff members took her vitals. Resident #1's right leg was curled inwards and there was a noted protrusion (bulge) to her posterior knee which was visible through her pants. The resident was complaining that her leg was burning and requested to get up off the ground. The resident was encouraged to take deep breaths and relax. The resident was crying and staff continued to encourage her to calm down as they held her hands and talked to her. The QAM called 911 at 3:43 p.m. for emergency transportation to the hospital for an evaluation and treatment. The medical durable power of attorney (MDPOA) was notified of the resident's fall, possible fracture and transportation to the hospital. The paramedics arrived at the facility at 3:55 p.m. and initiated pain relief. The resident was assisted onto the gurney for transportation and left for the hospital at 4:10 p.m. The risk management incident report read there was an obvious protrusion of the femur, just above the resident's right knee. According to the report, the protrusion did not break through the skin. Resident #1 had a large abraded (scraped) area to the left side of her forehead. The risk management incident report identified wandering as a predisposing situation factor that contributed to the 11/17/23 incident. The risk management incident report read the wander guard was cracked and not functioning. The batteries to the wander guard were dead and did not send a low battery signal to the computer system. The 11/17/23 facility investigation included the following staff witness statements: The witness report of the certified nurse aide with medication authority (CNA/MA) read Resident #1 was found face down with her head and shoulders over the bumper. Her left side of her face was bloody. She was rolled out of the (puddle) of water. The resident screamed not to be moved. The resident was pale, her leg looked bad and crooked. The witness report of CNA #5 read the resident was face down on the asphalt and her left side was bloody. The resident was screaming when her leg was moved. The resident was in much pain and her leg did not look right. The witness report of CNA #6 read she was not sure how the resident got outside because the resident did not know how to work the door. The CNA saw the resident a few minutes before the incident. The resident was by the doors and the CNA asked Resident #1 to come with her. The CNA assisted the resident down the hall to a table. Resident #1 flipped out of her wheelchair face down with the wheelchair on top of her. Registered nurse (RN) #2 attempted to straighten the resident's leg which was bent at the knee. The resident's bone could be felt through her pants. RN #2 told the CNA there was someone lying in the parking lot. She observed the resident on her back between two cars. The resident's leg was twisted at an odd angle. The staff proceed to take the resident's vital signs. The witness report of restorative nurse aide (RNA) #2 read after RNA #2 learned of Resident #1's fall, she tested the wander guard of Resident #1 on 11/18/23. The battery to the wander guard was dead which was why there was not an alert when the resident exited the facility on 11/17/23 and why the wander guard did not show up on the wander guard door monitoring system. The restorative department completed regular checks on the wander guards once or twice a month. The battery in Resident #1's wander guard was checked and replaced on 10/4/23 and on 10/17/23. The 11/18/23 communication note read the QAM received a call from Resident #1's MDPOA. The MDPOA informed the facility that Resident #1's femur was severely broken and she was in much pain. The QAM told the MDPOA the facility was investigating the incident and the CNAs were with her shortly before the accident. According to the note, the MDPOA was tearful and said she already ordered the cake for the resident's upcoming birthday. A wander guard check sheet was provided by the facility on 1/2/23. The wander guard check sheet identified weekly checks were conducted between 11/28/23 and 1/2/23 to determine if the wander guards in the facility and assigned to a resident were working properly. The 12/11/23 unannounced wander/missing resident drill record identified a second drill to find a missing resident was conducted on 12/11/23. The drill was conducted after the 11/17/23 incident with Resident #1. The record identified three staff members who participated in the drill and the resident was found after two minutes. The staff participation of the drill was low because the resident used in the drill was not a wandering risk (unlike Resident #1). The drill record read additional education would be provided to staff in January 2024. The 12/22/23 therapy note (over a month after the resident was discharged from the facility) read Resident #1 had an unwitnessed fall on 11/17/23. Staff were educated through a monthly all staff meeting through dial my call to remind staff to be aware of any residents exiting through doors and question and assist the resident to prevent potential injuries. The staff were informed of increased documentation and were educated on the wander guard system (see above). -However, some staff were not educated after the 11/17/23 incident (see staff interviews below). The wander guard system manual documented if a battery was low it would alternate between green and red. If a low battery indicator light was displayed on the wander guard, the batteries must be replaced within a week. Batteries were to be replaced when a low battery message was displayed (on the door panel) or when identified during routine tests with the magnetic wand (fob). The wander guard system manual read a low battery fault would appear when the device (wander guard) reaches a low battery state. The battery should be replaced as soon as possible before the battery was too depleted to power the device. Devices could fail due to moisture, electrical surges or other environmental factors. The wander guard system manual identified batteries were expected to last eight months under normal use. If the resident continually exercised the wander guard, the battery life would be less. The wander guards should not be stored more than 10 feet from the wander guard installation (exit door panels). The wander guards should be routinely checked for low batteries. The wander guard system set up procedure was provided by the facility on 1/2/23. The wander guard system procedure outlined steps on how to set up a new wander guard. IV. Observation The wander guards of Resident #2 and Resident #3 were tested on [DATE] at 10:15 a.m. The wander guards were attached to the bottom of the resident's wheelchairs. RNA #1 scanned both of the wander guard pendants with a fob. The indicator light on the wander guard flashed green identified the wandering guard was functioning properly. V. Staff interview The DON was interviewed on 1/2/23 at 10:40 a.m. The DON said after an incident such as a fall, the facility conducts an investigation. The staff looked at potential contributing factors such as the new medications or environment. She said the nurse or the CNA would look at the scene right after the fall and attempt to identify any environmental causation factors. The incident would then be reviewed in the next morning meeting with the interdisciplinary (IDT) so the whole team was aware of the concerns. The resident would be assessed for any appropriate safety devices and training of use as appropriate. The DON said the facility conducted a weekly risk management meeting to review incidents and find the root causes. She said the facility reviewed the video camera recording Resident #1's fall on the parking lot on 11/17/23. The DON said the video records showed a visitor letting the resident out of the facility from the main entrance. She said the resident was wearing a wander guard when she went out the door. The facility checked and determined the wander guard system was working properly but she was not she if Resident #1's wander guard was working when she went out the door and out to the parking lot. The DON said after the incident, the facility sent out a call to staff through a call system to remind staff to not to just open the doors for residents wanting to go outside. The DON said after the incident, the facility checked and ensured other residents' wander guards were working properly. The QAM was interviewed on 1/2/24 at 11:02 p.m. The nursing home administrator (NHA) entered the interview while in progress. The QAM said RN #2 informed her she was needed outside in the parking lot. The QAM said she went outside and saw Resident #1 lying in the parking lot with her head on the lap of a staff member. The resident had gone off the curb of the sidewalk with her wheelchair and hit the bumper of a parking space. Resident #1 was crying in pain while attempting to get up and said her leg was burning. The QAM said she could see there was a deformity to the resident's upper knee cap. She said they attempted to calm the resident down, took vitals, covered in blankets to help make her comfortable and called 911 informing them of a possible fracture to the resident's leg. The QAM said the ambulance arrived at the facility at 3:55 p.m. and Resident #1 was taken by ambulance to the hospital at 4:10 p.m. The QAM said the resident's MDPOA called her on the evening of 11/17/23 and told her Resident #1 had a fracture to her femur. The QAM said the resident's family member asked her if the resident was outside alone for a length of time. The QAM said she told the family member the facility was reviewing video camera footage but the interviewed CNAs said they were providing ADL care to the resident shortly before she went outside. She said the resident did not return to the facility. She said the resident did not return to the facility after the 11/17/23 accident. The NHA said the facility provided a timeline of the events to the resident's family. The QAM reviewed the facility investigation. Resident #1 had a wander guard attached to the bottom of the wheelchair that did not work when she exited the building on 11/17/23. She said video footage showed Resident #1 was at the front door at 3:10 p.m. CNA #6, entered the facility, spoke to the resident and redirected her down the hall to a location the resident liked to sit at. The QAM said at 3:20 p.m. the video footage showed the resident exited the facility when a visitor opened the front entrance doors. The visitor let the resident out the door and then walked away. She said there was a red stop sign on the entrance door that read to not let residents out of the door but the visitor let the resident out anyway. She said she did not recognize the visitor as someone who routinely was at the facility. The QAM said a facility vendor notified staff that a resident had fallen in the parking lot. The QAM said the CNA/MA was first to get to the resident at 3:30 p.m. The QAM said after the incident, staff were interviewed and the maintenance report was pulled to make sure the wander guard system attached to the doors were routinely checked. The maintenance report identified the wander guard system door panels were checked on 10/24/23 and then again on 11/17/23, after the incident. The QAM said all the wander guards in the facility were working with door panels on 10/24/23. The only concern identified was the wander guard of Resident #1 was not communicating with the door panel on 11/17/23 and did not sound the alarm when the resident exited the facility on 11/17/23. The wander guard did not sound the alarm after it was brought back into the facility after the resident went to the hospital. The QAM said after the incident the resident's wander guard and a crack in the plastic from edge to edge but felt the crack occurred when the resident fell and the wander guard caught the wheel of the wheelchair. The QAM said maintenance requests were reviewed and there was no requests or identified concerns regarding the wander guard of Resident #1. The QAM said Resident #1 wander guard was checked again on 11/18/23 and there was no battery power. The QAM said when there was a low battery the wander guard computer system was notified. The restorative department reviews the wander guard system and tests all the wander guards to ensure the wander guards were working. The restorative aides checked the wander guard one to two times a month and replaced the batteries as needed. The restorative department documented when they checked the wander guards for each resident who used the wander guards. The QAM said Resident #1's wander guard was last checked by the restorative department on 10/4/23 and 10/17/23 when her battery needed to be changed (see above). The QAM and the NHA said there might be a way to pull a report from the wander guard system tracking low batteries and alarm notifications but was not sure how. The NHA said she would follow up. The QAM said on 11/18/23 all staff received a call through the facility's call system to review the wander guard system procedure (see above). The 11/17/23 incident was reviewed in the risk management team meeting and again in the morning meeting with the IDT. The NHA said post incident notes were usually added to the resident's medical record in the progress notes for follow up but the resident was not going to return to the facility so the notes were not added. The QAM said a note was added to the resident chart on 12/22/23 (see above). The QAM said she did know why the therapy note was not added until 12/22/23. The NHA said the restorative department recently made improvements to the wander guard tracking documentation by creating a new spreadsheet format that streamlined and clarified the tracking and documenting process. The QAM said the restorative nursing aides (RNAs) increased the frequency of checking each wander guard after the 11/17/23 incident. She said the wander guards were now checked weekly. The QAM said another change after the 11/17/23 incident was the removal of excess signs at the front entrance to distract the eye. She said the main sign left at the front door as people were exiting was the stop sign with notification not to open the door for residents. The sign was now more centralized and easier to focus on without the other visual clutter. The NHA was interviewed again on 1/2/24 at 1:40 p.m. The NHA said the wander guard system vendor was contacted and an instruction webinar was set up for 1/3/23 to review all the components of the system including retrieving wander guard reports and notifications. The DON was interviewed on 1/2/24 at 3:05 p.m. The DON reviewed the record of Resident #1 and said the resident did not have an assessment for her wander guard but should have. The DON said Resident #1 should have been care planned for her wandering and elopement risk. The resident should have been care planned to direct staff on the resident's use of a wander guard, why the wander guard was in place and interventions to distract her from exit seeking. The DON said she was in process of training staff on the steps to take when a resident was determined to need a wander guard. The physical therapy assistant (PTA) was interviewed on 1/2/24 at 3:22 p.m. The PTA said she was responsible for overseeing the restorative department since November 2024. She said when a resident was at risk for elopement, a wander guard would be placed on the resident on a device the resident would use for mobility such as a wheelchair. When a resident with a wander guard to the exit of the facility, the wander guard would signal to the wander guard system door panel and an alarm would sound to alert all staff to the resident. The PTA said before she took over restorative oversight and before the 11/17/23 incident with Resident #1, the RNAs checked the batteries of the wander guards once a month. She said RNA #1 would document the monthly wander guard battery checks on each resident who used the wander guards. The PTA said after the 11/17/23 incident, she checked the wander guards weekly to ensure the wander guards were in place, functioning properly and to determine if batteries needed replacement. The PTA said the facility currently had four residents that used a wander guard. She said each wander guard would be checked by use of a wander guard fob. The fob would be placed next to the wander guard. If there was a green flashing light, the wander guard was working. If there was no green light, the wander guard batteries would need to be replaced. The PTA said she was taught that if a resident's wander guard battery was low, the resident's name should appear on the door panel. The PTA said the only way she knew to see when a battery was low was to physically check the wander guards or the door panels. She said on 1/3/23 she was scheduled to attend a webinar to learn if there were more ways to use the wander guard system more efficiently. She said until she receives additional training, she would continue to keep physically checking the wander guard system. The PTA said RNA #1 last checked all the wander guards on 12/27/23. RNA #1 was interviewed on 1/3/24 at 10:06 a.m. The RNA said the restorative department was responsible for checking all the wander guards. She said she has been a restorative aide for the past three years. RNA #1 said before the 11/17/23 incident, the wander guards were checked monthly. The RNA said wander guards were now checked weekly. She said she checked each wander guard with the fob but she could also go to all the exit doors and check the door panel. The RNA said the last time Resident #1's wander guard was checked before 11/17/23 was October 2023. She said on 10/4/23 the wander guard fob showed Resident #1's wander guard batteries were low so she replaced them. The RNA said on 10/17/23 a nurse informed her the wander guard was not working. The RNA said the batteries were dead so she changed them on 10/17/23. RNA #1 said the batteries in the wander guards usually lasted a while so she was surprised to have to change the batteries after a couple of weeks. She said she was provided the wander guard manual on 12/27/23 and read batteries could drain quickly if the resident was frequently near the exit and within the wander guard system radius. RNA #1 said if a wander guard indicator light would flash green and red during a fob test, the wander guard was low and the batteries would need to be changed within the week. RNA #1 said she would check the door panels every time she went through the doors to identify if the wander guard system was registering a wander guard low battery. She said she remembered seeing a low battery warning for Resident #1 on the door panel but could not remember if the warning was in October 2023 or the beginning of November 2023. She said the low battery warning on the door panel would remain on the door panel until it was physically cleared from the panel. She said she did not clear the door panel. RNA #1 said she has not received additional wander guard education from the facility after the 11/17/23 incident. She said RNA #2 had printed instructions on how to set up wander guards and handed the procedure to her and the maintenance director. RNA #1 said the instructions were provided to her before the 11/17/23 incident. The RNA said she and RNA #2 took it on themselves to start checking the wander guards more frequently after the 11/17/23 incident. The maintenance service director (MSD) was interviewed on 1/3/24 at 12:37 p.m. The MSD said she checked the wander guard door panels monthly to make sure the system was operating properly. She said she completed a webinar training this morning (1/3/24) and learned more about the wander guard system. She said she learned the wander guard system could be attached to the call light system in the facility and scan all the wander guards in the facility every 60 minutes. Since the systems could link, it allowed the facility to pull a report on how often the residents with the wander guards were near the exit doors. The MSD said the wander guard system could be set up so the facility's computer system so if there was a problem with the wander guard, the nurses and anyone else on the computer would get a notice of the wander guard problem. The MSD said currently the doors did not automatically lock when a resident with a wander guard was too close to the door. She said the facility was in the process of setting up the wander guard system to allow the doors to lock and not just sound an alarm. The MSD said the facility was in process of determining who could clear the door panel notifications of a low wander guard battery so only she and the administration could clear the notifications. The DON was interviewed on 1/3/24 at 12:58 p.m. The DON said verbal education was completed on 11/17/23 with the staff of duty at the time of Resident #1's incident. The DON said the QAM reminded staff to make sure they always knew where all the residents were an elopement risk. The DON said the facility had an elopement drill before 11/17/23 and again after 11/17/23 (see above). The DON said the restorative aides received training on how to properly check the wander guard system and inform the maintenance staff if a problem was identified. Registered nurse (RN) #1 was interviewed on 1/3/24 at 1:20 p.m. She said she did not have any residents with a wander guard in her hall and did not check if the wander guards were working. She said if a resident with a wander guard was too close to the door, she would try to find something for the resident to do in their room or in another part of the facility. She said if a resident continued to try to exit the doors, she would contact the family to see if they had additional ideas or could come into the facility to redirect the resident. Licensed practical nurse (LPN) #1 was interviewed on 1/3/24 at 1:39 p.m. The LPN said she did not have residents on her hall with a wander guard. She said she had not had elopement training but if she saw a resident go to the door she would ask the resident where they were going, walk with them away from the door and periodically check on the resident and the door. LPN #3 was interviewed on 1/3/24 at 1:44 p.m. He said he did not have a resident with a wander guard on his hall but if he did the resident should be monitored. He said if a resident continued to exit seek, the facility would place a wander guard on the resident. CNA #3 was interviewed on 1/3/24 at 2:32 p.m. He said if a resident tried to exit the facility with a wander guard, an alarm would sound. He said if the alarm sounded he would check the doors and redirect the resident. The NHA and the DON were interviewed again on 1/3/24 at 2:41 p.m. The NHA said during the 1/3/24 webinar, the facility learned the wander guard system could be improved by linking it to the call light system. The NHA said they were working on a way to lock the doors when a resident with a wander guard was close. She said the system currently did not lock the door, it only sounded an alarm. The NHA and the DON said if the doors locked when a resident with a wander guard was too close to the doors, then a visitor could not have let the resident out of the facility. The DON said the staff would have ongoing wander guard training to improve the frequency of checking the wander guards. She said all nursing staff should make sure the wander guards were operating properly. The DON said a broader education on the wander guard system would be conducted with the restorative department. She said wander guards were checked monthly before 11/17/23 and then checked weekly after the 11/17/23 incident but felt the wander guards should be checked daily. She said she would instruct staff to check all wander guards daily. The NHA said she wanted the nurses to check wander guards daily. She said the nurses would be provided a wander guard fob so they could make sure every day the wander guards were all functioning. The DON said she

Based on observation, record review and interviews, the facility failed to ensure that all residents were free from abuse, neglect, and exploitation, for two residents (#14 and #420) in two allegations of abuse of five allegations reviewed out of 26 sample residents. Specifically, the facility failed to provide adequate supervision and effective interventions to prevent repeated incidents of resident-to-resident verbal altercations between Residents #14 and #420. Resident #420 and Resident #14 were roommates at one point in time while living in the same facility. As time went by the two stopped getting along, and Resident #14 moved to a new room on the opposite side of the facility. Still Resident #420 continued to target Resident #14 when he saw him in common areas. Resident #420, based on documentation in the resident's records, was very angry and specifically targeted Resident #14 and some other female residents who also lived in the facility. Several residents expressed not liking the way Resident #420 treated them and other residents in the facility. For Resident #420 being in the same space with Resident #14 triggered increased anger. The facility documented two significant events of verbal abuse from Resident #420 towards Resident #14 where Resident #420 launched verbal attacks upon Resident #14. Both of these events, one occurring on 9/22/22 and the other on 10/22/22, were seemingly unprovoked per facility documentation. Facility documentation in both resident records and in the facility's incident investigations revealed that in neither of the incidents listed above did Resident #14 provoke Resident #420 in any way to start the verbal altercation. Resident #420's verbal abuse of Resident #14 increased to the point where Resident #14 expressed feeling bullied and unsafe living in the facility while Resident #420 also lived in the facility. On 9/22/22 Resident #14's mother got involved to step between the two residents as Resident #420 wheeled his manual wheelchair in close proximity to Resident #14 while yelling, threatening and waving his arms in a threatening manner, all directed towards Resident #14. On 10/22/22 Resident #420 again chased Resident #14 down and followed Resident #14 outside to yell and verbally threaten Resident #14. Resident #420 tried to hold back Resident #14's power wheelchair to prevent Resident #14 from getting away from him in the altercation. However, Resident #420 did not let go of Resident #14's wheelchair as he pulled away and Resident #420 fell out of his manual wheelchair and fractured his hip, for which he required surgical intervention to repair the fracture. Resident #420 was discharged after this incident. Findings include: I. Facility policy The Abuse Prevention, Investigation, and Reporting policy, dated November 2022, was provided by the nursing home administrator (NHA) on 12/19/22 at 9:02 a.m. It read in pertinent part: The resident has the right to be free from abuse (including verbal, mental, sexual and physical), neglect, misappropriation of resident property and exploitation. Management will take specific steps to reduce the potential for abuse to occur at Larchwood Inns including, but not limited to education, monitoring and investigating thoroughly if abuse, misappropriation, neglect, or exploitation is suspected. Verbal abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. II. Resident #14 A. Resident status Resident #14, under the age 65, was admitted on [DATE]. According to the December 2022 computerized physician's orders (CPO), diagnoses included multiple sclerosis, depression, and quadriplegia (paralysis of all limbs). The 9/28/22 minimum data set (MDS) assessment revealed the resident had intact cognition as evidenced by a brief interview for the mental status (BIMS) score of 13 out of 15; did not present with inattention or disorganized thinking during conversations; and was not verbally or physical aggressive towards others. The resident did not walk and used a power wheelchair to get around the community independently. The resident needed extensive to full assistance from staff to complete activities of daily living (ADLs) including transferring from surface to surface. The resident was on daily antidepressant medication. B. Record review The resident comprehensive care plan, dated 9/22/22, revealed the resident had a care focus for behavior, which documented Resident #14 had a history of paranoia and verbal aggression towards others. The resident often accused others of stealing his belongings. Additionally the resident had the potential for impaired psychosocial well being related to adjusting to lifestyle changes of facility life. This caused the resident to have difficulties getting along with a roommate. Relevant interventions included: Provide education on resident rights; Listen to resident concerns and address timely; Offer opportunities for interaction with other residents with similar interests. -There was no care focus or interventions to help staff work with Resident #14 prevent reoccurrence of verbal alterations initiated by Resident #420 towards Resident #14 (see below). III. Resident #420 A. Resident status Resident #420, age [AGE] years old, was admitted on [DATE] and discharged on [DATE] to the hospital for surgery then to another long term care facility. According to the October 2022 CPO, diagnoses included diabetes mellitus, heart failure, and history of stroke. The 9/13/22 minimum data set (MDS) assessment revealed the resident had intact cognition as evidenced by a brief interview for the mental status (BIMS) score of 14 out of 15; did not present with inattention or disorganized thinking during conversations; and was verbally aggressive towards others. The resident did not walk and used a manual wheelchair to get around the community independently. The resident needed extensive to full assistance from staff to complete activities of daily living (ADLs) including transferring from surface to surface. The resident was not on any antipsychotic medications. B. Record review The resident comprehensive care plan, dated 4/5/22, revealed the resident had a care focus for behavior, which documented episodes of cursing and yelling at staff and other residents. Interventions included: Monitor for significant changes in daily participation; Listen to concerns and address them timely; Offer counseling services as needed; Notify physician of unexpected changes in behavior; Offer reassurance; Follow up as needed with roommate; Ensure Resident #420 has preferred staff. If resident #420 becomes verbally/physically aggressive, ensuring he is in a safe position/place; Get another staff member to assist as appropriate and provide one to one observation-staff to be within line of sight of the resident as needed. -There were no patterns of verbal aggression or interventions identified in relation to Resident #420's verbal aggressions towards other residents. Additional care plan focuses included: mood disorder, which documented Resident #420 had verbal aggression, which appeared to be a symptom of depression; and a potential for impaired psychosocial wellbeing and or adjustment to lifestyle changes when moving into the facility, which included problems getting along with a new roommate. Relevant interventions included: Notify physicians in changes in mood; Encourage socialization; reassure resident safety when concerned with others; Listen to concerns and address them in a timely manner; Redirect when requesting personal information about another resident; Review need for psychotropic medication as needed. IV. Resident interviews Resident #420 was no longer in the facility and an interview with the resident was not possible. Resident #14 was interviewed on 12/22/22 at 4:22 p.m. Resident #14 said he did not feel staff acted to protect him the day Resident #420 chased me down. Resident #14 said staff saw Resident #420 yelling and waving his hands around but did not respond until it was too late. Resident #14 said on 10/22/22, Resident #420 was at the end of the hall, he came at me and started yelling and waving fists around like he was going to hit me. Resident #14 said he decided to get out of the situation by putting his electric wheelchair into drive to get away from Resident #420. Resident #14 said Resident #420 thought he could hold me back with one arm but he flipped out of his wheelchair and he broke his leg. I went past him and did not say anything to him because it would have made things worse. Resident #14 said staff did not respond to the incident until Resident #420 was on the floor and had to be sent to the hospital. Resident #14 said after the event was over the staff told him Resident #420 broke his leg when he fell out of his wheelchair. Resident #14 said he did not think he was in the wrong; because he was just trying to get out of the situation when Resident #420 was trying to hold him back. No one can hold back an electric chair with one leg and one arm. Resident #14 said Resident #420 had been making smart remarks to him for the past several months leading up to the 10/22/22 incident. At first they were friends, but when Resident #420 went out for surgery over the summer (mid-June and July 2022) and came back to the facility things changed, and that was when the bullying began. Resident #14 said since Resident #420 moved to a new facility he felt safe living in the facility, and was relieved that no one was going to attack him any longer. V. Resident to resident altercations Review of Resident #14 and Resident #420's incident investigations revealed the following information: A. 9/6/22 altercation Resident #14-a behavior occurrence note dated 9/6/22 at 11:25 p.m. documented, Staff heard yelling from residents' room. Resident and his roommate were yelling at each other about the roommate's television being too loud. Resident was trying to sleep. Both men were yelling obscenities at each other. Resident #14 stopped when asked, but started again when his roommate continued to mutter and yell. Resident #14 did stop after being asked to several times. Neither one is able to physically approach the other due to mobility (when out of their wheelchairs). They agreed to stop and discuss with social services in the morning. Resident #14-a behavior occurrence note dated 9/7/22 at 12:16 p.m. documented, Follow up regarding roommate disagreement.Roommates were arguing and cussing at each other related to television and music choices. Roommate and Resident #14 were offered a different room/roommate, roommate refused but Resident #14 agreed and was showed room options and plans to move were placed. Staff will continue to monitor behaviors and redirect as needed. B. 9/8/22 altercation Resident #420-a behavior occurrence note dated 9/8/22 at 2:23 p.m. documented in part, Resident #420 yelled at his roommate during lunch in the commons area. This writer spoke with Resident #420 regarding inappropriate behavior and anger management dealing with other residents and staff. Resident denies yelling at staff and treating them rudely. Resident #420-a behavior occurrence note dated 9/9/22 at 10:11 a.m., late entry, documented, Spoke with Resident #420 concerning outburst and inappropriate behavior in the common area. Resident #420 was very angry and resisted taking any responsibility calling others liars. Resident #420 complained about other people in the facility. This writer explained that was their home also and they have rights to be comfortable and secure in their home. Resident #420 stated maybe he would just move out. C. 9/14/22 altercation Resident #420 a behavior occurrence noted dated 9/14/22 at 8:30 p.m. documented, Resident #420 observed screaming at another resident today during lunch due to dislike for increase in television (TV) volume. Resident did request politely that she not turn up the TV, but was instigated by the other resident. She was observed turning up the volume to television while looking at him. She then proceeds to return to her table stating, 'I'm sorry but it's just got to be done. These ladies here could not hear.' Situation escalated quickly, as resident shouted, '(Expletive) you, you (expletive)!' 'You don't run this place!' This RN (registered nurse) to immediately intervene and de-escalate the situation. Resident extremely red in the face and agitated as he was moving towards television to turn it down. He continued yelling and now directing at this RN, 'I don't want to talk to you, or anyone! You got that?' D. 9/22/22 altercation A verbal altercation occurred on 9/22/22 from 4:30 p.m. to 4:54 p.m. The facility reported an allegation of verbal abuse between two residents and filed an online police report to the local police revealing Resident #14 as the victim and Resident #420 as the assailant. The facility incident report read Resident #14 (resident name) and his mother were on the back patio visiting. At the conclusion of the visit. Resident #14 escorted his mother to the front door when Resident #420 came around the pillar in the commons area and began to yell at resident #14 and his mother stating 'I'm going to knock you out.' Resident #420 counted to yell and curse at Resident #14. Resident #14's mother was afraid that something was going to happen and stepped in front of her son. Resident #420 continued to curse and make threats towards Resident #14. Facility staff arrived, instructed Resident #420 to stop yelling, and intervened allowing Resident #14 and his mother to leave the area without further incident. Resident #420 continued to make comments that he was going to 'beat the (expletive) out of Resident #14' 'I can inflict damage on him' 'I can hurt him real bad.' The residents were separated by staff members and Resident #420 will be in line of sight by a staff member while out of his room. Resident #14 was interviewed on 9/22/22 at 5:00 p.m., just after the incident. Resident #14 said he felt that Resident #420's words placed him in harm. Staff interviews revealed no staff witnessed what led up to the verbal altercation. Resident interviews revealed several residents were aware that Resident #420 had a temper and was verbally aggressive towards other residents, including Resident #14 and the ladies who were watching television in the common room. Resident #420 was interviewed on 9/22/22 at 5:22 p.m. just after the incident. Resident #420 said Resident #14 made threats two weeks ago and was lucky that he did not beat the (expletive) out of Resident #14 for it. Resident #420 denied threatening Resident #14 but added that he could inflict harm on Resident #14 and hurt him. Resident #45 was interviewed on 9/23/22 at 11:21 p.m. Resident #45 remembered a lot of yelling and name calling during the verbal altercation between Resident #420 and #14; and said she did not like it but was getting used to their verbal aggressions. E. 9/29/22 altercation Resident #420-a behavior occurrence note dated 9/29/22 at 8:14 a.m. documented Resident #420 was yelling for help at the breakfast table. Resident #420 was cussing and asked if another resident could be moved, after the other resident propelling backward in her wheelchair and lightly bumping into Resident #420's wheelchair. Resident #420 was angry. Staff were not able to redirect Resident #420, he just became increasingly more angry, so staff removed the other resident who was the target of Resident #420's anger from the area. Resident #420-a mental health note dated 10/12/22 late note entry documented, Resident angry and frustrated, but unable to articulate why. Asked him about his increased aggression and verbal abuse towards others. He claims to 'not remember', has very little insight into how his behavior affects others. Is able to talk about feelings in the moment, but unable to apply them to real life/next day scenarios. F. 10/22/22 altercation resulting in physical injury A verbal altercation occurred on 10/22/22 at approximately 2:30 p.m. between Resident #420 and #14. The facility reported an allegation of verbal abuse between the two residents revealing Resident #14 as the victim and Resident #420 as the assailant. The facility incident report documented, On 10/22/22 at approximately 2:30 p.m., staff were called out to the back patio. Resident #420 and Resident #14 had been in an altercation and Resident #420 had fallen out of his manual wheelchair. When staff attempted to move Resident #420 he cried out in pain in his left hip. Resident was sent to the emergency room for assessment. An investigation into the events leading up to Resident #420 falling out of his wheelchair revealed Resident #420 started a verbal attack on Resident #14, and in Resident #14's attempts to distance himself from this verbal abuse he engaged his power wheelchair and took off. Before leaving the area Resident #420 grabbed onto Resident #14's power wheelchair and did not let go as Resident #14 pulled away. This caused Resident #420 to fall out of his chair and injure himself. Resident #14 was interviewed on 10/22/22, just after the incident. Resident #14 said Resident #420 started yelling stuff and he tried to get away but Resident #420 followed him and grabbed the back of his power wheelchair. Resident #14 said he told Resident #420 to let go and he moved forward and saw Resident #420 on the ground when he looked back. Resident #14 said he went inside to get staff help. Resident #14 was interviewed a second time on 10/22/22 at 3:10 p.m. Resident #14 said Resident #420 was harassing and threatening him. He attempted to get away from Resident #420 by going outside, but Resident #420 followed him to the patio and would not stop badgering him. Resident #14 said Resident #420 was calling him names and threatened to knuckle him up. Resident #14 said he did not realize Resident #420 had a hold of the back of his wheelchair and when he moved forward Resident #420's wheelchair tipped over and Resident #420 fell on the ground. Resident #14 denied any instances of physical altercation between the two of them. Staff interviews revealed no staff witnessed what led up to the verbal altercation, the verbal altercation, or how Resident #420 ended up on the ground. Resident interviews revealed several residents were aware that Resident #420 had a temper and was verbally aggressive towards other residents, including Resident #14 and the ladies who were watching television in the common room. Resident #420 was interviewed the day after the event at the hospital after undergoing surgery to repair a hip fracture. Resident #420 recalled reaching out to grab Resident #14's wheelchair but did not recall anything that occurred after that. Resident #420 did not comment on the verbal alteration he had with Resident #14. Other resident interviews revealed: -Resident #45 said Resident #420 had a bad temper and was always cursing at other residents including Resident #14. All Resident #14 was doing, at the time, was going outside to enjoy the sunshine. -Resident #40 said Resident #420 had a bad temper. On 10/22/22 Resident #420 was watching Resident #14 as he went from the dining room table to the back patio and he followed. Resident #40 said he tried to stop Resident #420 from going after Resident #14 but by the time he got to the patio, Resident #420 was already on the ground. He did not see what happened. -Resident #27 said Resident #420 was yelling something at Resident #14 and following Resident #14 outside. Resident #27 did not see what happened. Resident #14-a mental health counseling note dated 10/26/22 at 4:41 p.m. documented, Resident #14 needed to process feelings related to an altercation he had with another resident. He felt attacked and bullied and unsafe by this other resident. This person is not currently in the building for a few days. Was able to process feelings around it. Will see him again. He gave writer permission to tell the social services director (SSD) he felt unsafe and threatened. Resident #14-a mental health counseling note dated 11/3/22 at 4:57 p.m. documented, Resident #14 processing feelings from recent altercation. Verbalized feeling relief that he will not be at risk for being bullied again by that resident. Processed feelings and emotions. VI. Staff interviews The SSD was interviewed on 10/22/22 at 3:33 p.m. The SSD said Residents #14 and #420 were roommates, but they started to have disagreements and the facility offered each the opportunity for a room move. Resident #14 took the offer and moved to an entirely different unit to distance himself from Resident #420. The two were also distanced in the dining room but still had verbal altercations. Resident #420 was presented with a behavioral agreement. The behavioral contract asked for Resident #420 to sign an agreement that he would interact with others in a dignified manner, and refrain from verbal altercations including making threatening comments, cursing or yelling at other residents. The contract also asked Resident #420 to refrain from physically aggressive acts, such as raising his arms or hands in a threatening manner towards others, and requesting staff assistance to handle conflicts. This contract was signed by Resident #420 on 9/26/22. The SSD said Resident #420 signed the behavioral agreement without concern because he felt the agreement actions were things he was already doing, and did not need to change his behavior because he was not the one in the wrong. Both residents were offered in-house counseling services and were participating in regular individual counseling sessions. In the interim, staff were instructed to provide Resident #420 with every-15-minute checks, interventions and redirection when observed to present with any aggressive behaviors towards other residents. The interdisciplinary team (IDT) met to discuss interactions between Residents #420 and #14 and felt the established interventions were sufficient to protect the residents from repeated verbal abuse.

Based on record review, observations, and interviews, the facility failed to ensure two (#60 and #47) of four residents reviewed for pressure injuries received care and services, consistent with professional standards of practice, to prevent development and promote healing of pressure injuries, out of 26 sample residents. Resident #60, who was at risk for wound development due to immobility, admitted to the facility on [DATE] with diagnoses of cerebral infarction (stroke), hemiplegia/hemiparesis (paralysis), enteral feeding, dysphagia and excoriation to her coccyx/sacrum. Resident #60 developed and redeveloped wounds to her sacral area (see record review below). On 11/16/22 Resident #60 developed a stage 3 wound to her coccyx/sacrum. The facility failed to complete weekly wound assessments in their entirety to promote wound healing from 11/16/22 to 12/9/22. The registered nurse/wound nurse (RNWN) said she completed wound treatments every Monday, Wednesday and Friday and the facility had a wound protocol which they followed (see interview below). However, review of Resident #60's physician orders revealed the facility failed to implement wound care orders. The facility's wound protocol documented four different treatments that could be utilized if a resident had a stage 3 wound and staff interviews revealed they would review the progress notes and apply whatever dressing the RNWN previously applied (see interview and record review below). Review of Resident #60's treatment administration record (TAR) revealed no documentation of any treatment being provided for the months of October, November or December of 2022. Furthermore, the facility failed to implement preventative measures (air mattress) for Resident #60 in a timely manner until 12/9/22, three weeks after the wound development. Additionally, the facility failed to ensure weekly wound assessments were completed for Resident #47. Findings include: I. Professional references A. Pressure ulcer classification According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline, [NAME] Haesler (Ed.), Cambridge Media: Osborne Park, Western Australia; 2014, retrieved from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf on 12/27/22, pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Bruising indicates suspected deep tissue injury. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/Stage 4 ulcers can extend into muscle and/or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. B. Pressure injury interventions According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline, [NAME] Haesler (Ed.), Cambridge Media: Osborne Park, Western Australia; 2014, from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf (12/9/21), Skin assessment is crucial in pressure ulcer prevention because skin status is identified as a significant risk factor for pressure ulcer development. The skin can serve as an indicator of early pressure damage. Skin and tissue assessment underpins the selection and evaluation of appropriate preventive interventions. Interventions for Prevention and Treatment of Pressure Ulcers: Five sections of the guideline present interventions that are used for both prevention and treatment of pressure ulcers. Nutrition, repositioning and early mobilization, addressing heel pressure, support surfaces and medical device management are all areas of care that are implemented both as a preventive measure, and to promote healing of existing pressure ulcers. Nutrition for Pressure Ulcer Prevention and Treatment Multivariable analyses of epidemiological data indicate that a poor nutritional status, indicated by low body weight or poor dietary intake among other signs, is a factor that impacts upon pressure ulcer risk. All individuals at risk of pressure ulcers should have their nutritional status screened. A comprehensive assessment should be conducted where risk of malnutrition is identified, and in individuals with existing pressure ulcers. Repositioning and Early Mobilization Repositioning involves a change of position in the lying or seated individual, with the purpose of relieving or redistributing pressure and enhancing comfort. Repositioning and its frequency should be considered in all at-risk individuals and must take into consideration the condition of the individual and the support surface in use. Repositioning should maintain the individual's comfort, dignity and functional ability. Repositioning to Prevent and Treat Heel Pressure Ulcers Heel pressure ulcers are a challenge to prevent and manage. The small surface area of the heel is covered by a small volume of subcutaneous tissue that can be exposed to high mechanical load in individuals on bedrest. It is important to conduct regular inspection and correct positioning in order to relieve heel pressure while avoiding potential complications such as Achilles tendon damage, foot drop and deep vein thrombosis (DVT). Support Surfaces Support surfaces are specialized devices for pressure redistribution and management of tissue load and microclimate. The importance of using a high specification pressure redistribution support surface in all individuals at risk of pressure ulcers or with existing pressure ulcers is highlighted. Medical Device Related Pressure Ulcers Individuals with a medical device in situ are at a high risk of pressure ulcers related to the device. These pressure ulcers often conform to the pattern or shape of the device and develop due to prolonged, unrelieved pressure on the skin, often contributed to by associated moisture around the device, impaired sensation or perfusion and/or local edema, as well as systemic factors. Assessment of skin that is placed at risk due to a medical device is highlighted. II. Facility policy and procedures The Wound Care Standards policy and procedure, reviewed in October 2022, was provided by the director of nurses (DON) on 12/21/22 at 9:51 a.m. It revealed, in pertinent part, Residents are assessed as to the current status of their skin. A plan of care is established and updated as needed for prevention of skin breakdown and/or for treatment of existing wounds in order to heal them if possible and prevent infection. The treatment program for a pressure ulcer then entails: assessment and documentation of each pressure ulcer is to be done upon discovery of the ulcer; weekly by the wound team; PRN with any significant change in the wound. Assessment of the pressure ulcer must include the following: a. Stage, b. Location, c. Size: measurement of the length, width and depth (if any) of the ulcer, d. Color of the wound base, exudates color and consistency, and approximate volume of the wound drainage, e. Necrotic tissue (if present): slough or eschar, stated in terms of approximate percentages, f. Tunneling and/or undermining, g. Infection: presence or absence of signs of local wound infection: erythema, induration, purulent drainage, h. Pain: assess presence of pain associated with the wound both with or without dressing change, i. Healing (when present): indicators of healing include the presence of granulation tissue (fragile beefy red healing tissue composed of small blood vessels and connective tissue) or epithelialization tissue (thin silvery epidermal tissue), j. Surrounding skin: color, appearance and integrity of the area. Pressure ulcers must be monitored daily. III. Resident #60 A. Resident status Resident #60, age less than 70, was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), the diagnoses included hemiplegia and hemiparesis (paralysis) following cerebral infarction (stroke) affecting left non-dominant side, hypertensive heart disease with heart failure, type 2 diabetes mellitus with diabetic chronic kidney disease, dysphagia (discomfort or difficulty swallowing), and received enteral feeding. The 9/13/22 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. It also revealed that she needed extensive assistance with activities of daily living and bed mobility. She was at risk for developing a pressure ulcer, having moisture associated skin damage, no unhealed pressure ulcers were present, no turning/repositioning program in place, and the treatment for her skin was a pressure reducing device for the bed and application of ointments/medications. B. Observation On 12/21/22 at 9:00 a.m., the RNWN was observed providing wound care to Resident #60. The resident was lying in bed. The nurse pushed the call light for assistance with repositioning the resident in bed. Certified nurse aide (CNA) #2 came in to assist. They positioned the resident on her left side. The resident's dressing was removed and scant serous (thin, watery) drainage was observed. The resident's wound bed to the coccyx had 90% slough tissue and 10% granular tissue to the distal edge of the wound. Attached to the proximal edge of the coccyx wound, was a smaller wound to the upper right sacrum (the wound bed was red). There were no signs and symptoms of infection noted. The wound care nurse cleansed the wound with a wound cleanser, then applied a hydrocolloid (autolytic debridement dressing) dressing and then covered it with a foam dressing. The wound nurse did not measure the wound. C. Record review The care plan, initiated 9/20/22, identified the resident had a potential for worsening skin integrity related to immobility/acute decline in activities of daily living secondary to recent hospitalization /illness. It also revealed that the resident had excoriation to her coccyx upon admission. The interventions that were put in place were as follows: use caution when transferring or moving in bed (use lift device/turn sheet); assess/report/record to the physician any skin condition, presence of any new areas; and weekly skin check by nurse. -The care plan did not include frequent repositioning/offloading, treatment, a pressure reducing bed, or when the air mattress was implemented. The clinical notes for Resident #60 revealed a skin assessment on 9/7/22, with a Braden scale score of 16, mild risk for developing pressure injury, and describing the resident's coccyx area as being red but fully blanchable and a skin barrier was applied. No wound orders for the skin barrier were found in the resident's chart, and no measurements of the area were documented as performed. Wound care notes for the coccyx area on 9/14/22 and 9/16/22 revealed the area was improved with mild excoriation. Skin barrier spray and a foam border pad was applied. No wound orders for either the skin barrier spray or the foam border pad were found in the resident's chart. A wound care note on 9/19/22 revealed no open areas to bilateral gluteal area, skin barrier was applied. -There was no note to document a coccyx area wound was found. A wound care note on 10/3/22 revealed a wound to the right gluteal area, measuring 0.3 x 0.3. Skin barrier was applied, then a foam border patch. -Assessment of the wound was lacking units of measurement and staging of the wound. A wound care note on 10/10/22 revealed that the right gluteal wound was closed, skin barrier applied and foam border pad applied. A wound care note on 10/17/22 revealed a deteriorated 1.0 x 1.0 partial thickness wound with distal border blue/red, skin protectant barrier and foam pad applied. -No location of the wound was identified and no units of measurement were identified with assessment of the wound. A wound care note on 10/21/22 revealed the right gluteal area was mildly excoriated over 3.0 x 3.0 area, cleansed and skin barrier swab applied, and foam border dressing applied. -There was no note regarding how the area was being cleansed and no units of measurement were found. A wound care note on 10/28/22 revealed that the right gluteal area was improving, and the wound bed had pink/red granulation and epithelialization. -No measurement of the wound or wound care was found. A wound care note on 11/2/22 revealed a coccyx wound was improving. -No documentation of the right gluteal area was found. A wound care note on 11/4/22 revealed that the coccyx wound was closed and the right gluteal wound was improving with excoriation, 0.1 x 0.3 open mild maceration. -No wound care documentation and units of measurement in assessing the wound were found. A wound care note on 11/7/22 revealed that the bilateral gluteal areas were improving and that a skin barrier and foam border dressing were applied. -No wound care orders were found. A wound care note on 11/9/22 revealed gluteal excoriation was improving and a skin barrier was applied. -No wound care orders or measurement of the wound were found. A wound care note, within the clinical notes, on 11/16/22 revealed that the coccyx wound had reopened. A blue/black spot 0.7 x 0.7 was noted on the coccyx and another the same size on the right sacrum with partial thickness wound surrounding the wound with tissue maceration, cleaned, skin barrier applied to the entire area and covered with foam border dressing. -No units of measurement in assessing the wound, wound care orders, or bilateral gluteal area wound assessment were found. A wound care flow sheet initiated on 11/16/22 revealed an assessment for a right sacrum wound. -Only two entries had been entered: 11/16/22 and 11/18/22. Both entries were incomplete: missing documentation in the wound stage, tunneling, pain, and other information sections. A wound care flow sheet initiated on 11/16/22 revealed an assessment for a coccyx wound. -The wound care flow sheet revealed an assessment of the coccyx wound on: 11/16/22, 11/18/22, 11/25/22, 11/28/22, 12/5/22 and 12/14/22. -All entries were missing documentation in the pain and other information sections of the assessment. -The 11/18/22, 11/25/22, 11/28/22, 12/5/22, and 12/14/22 entries were missing documentation in the tunneling section. -The 11/25 and 11/28/22 entries were missing the wound staging assessment. -The 12/14/22 entry was not completed or signed, only revealing that the wound had deteriorated. No other entries were found. A wound care note, within the clinical notes, on 12/9/22 revealed that there were two wounds: 0.8 x 0.4 stage 3, coccyx wound with yellow slough in the wound bed, and excoriation on the right sacrum. The wound was cleaned, skin barrier applied, and covered with a border foam dressing. -No units of measurement in assessing the wound or wound care orders were found. A wound care note on 12/14/22 revealed that both wounds had deteriorated, the coccyx wound was 0.8 x 0.4 x 0.1 open, no slough but blue discoloration. Right sacrum 0.8 x 0.5 blue/red non-blanching, skin barrier applied with border foam dressing. -No units of measurement in assessing the wounds or wound care orders were found. A nursing note on 12/15/22 revealed a Braden scale score of 14, indicating a moderate risk for developing a pressure ulcer. A wound care note on 12/21/22 revealed that the sacrum and coccyx wounds were both improving slowly. The sacral wound bed had red/pink granulation tissue with scant areas of maceration. The coccyx wound had red/yellow granulation buds apparent and yellow slough in the wound bed. A hydrocolloid with foam border dressing applied. -No wound care orders were found and the wound was not measured. The wound measurements documented in the wound and clinical notes did not include if the measurements were in millimeters, centimeters or inches. The CPO for December 2022 included an order for skin/wound care per facility protocol PRN (as needed). No specific orders were noted for Resident #60's coccyx and sacrum wounds. An order was added on 12/9/22 for an air mattress to the resident's bed for off-loading and comfort. Review of the treatment administration records (TARs) for October, November and December 2022 revealed a skin/wound care per facility protocol, as needed, order starting 9/6/22, and no documentation of staff performing the treatment was noted. The medication administration record (MAR) for December 2022 revealed no administration record of the wound cleanser being used to treat Resident #60's wounds. The Wound Care Standards policy and procedure, revised in October 2019 and last revised in October 2022, was provided by the director of nurses (DON) on 12/21/22 at 9:51 a.m. It revealed, in pertinent part, Ulcer Care. Initial care of the pressure ulcer involves debridement, wound cleansing, the application of dressings. Treatment product categories protocol for stage 3 wounds: hydrocolloid (absorbent) dressing, should not be used with heavy exudate wound or if infection is present, hydrogels (absorbent), foams and alginates. The policy revealed that in the absence of the wound nurse, it is the responsibility of the staff nurse to assess pressure ulcers on a daily basis. If a dressing is in place and it is not due to be changed, evaluate the status of the dressing, the area surrounding the ulcer for possible complications such as infection or maceration of skin. Initial the TAR and document any findings. Complete treatments as ordered on TAR and initial when completed, assess wound and document. There was no further documentation in Resident #60's record to reflect the care the facility was providing to prevent wound development or interventions to prevent wound development. D. Interviews Licensed practical nurse (LPN) #3 was interviewed on 12/21/22 at 5:20 p.m. She said that the wound care orders were found in the resident's chart. She acknowledged there were no orders, she could not locate them. She said that she looked at the last wound care nurse's note, and applied whatever dressing the wound nurse last applied. She said that she was not able to assess the wounds, it was outside her scope of practice, that a registered nurse needed to assess wounds. The registered nurse/wound nurse (RNWN) was interviewed on 12/22/22 at 9:43 a.m. She said Resident #60 admitted with excoriation to her coccyx and staff applied a skin barrier, the excoriation would get worse, then it would get better. She said Resident #60's coccyx wound healed and then reopened on 11/16/22 and it was documented as a stage 3 pressure ulcer. She said that she did 90% of the wound care at the facility (every Monday, Wednesday and Friday), and that the staff nurses should know what wound care to provide because she reported to them when she provided wound care. She said the facility had a wound protocol which she followed (see above). She agreed that residents with wounds should have specific wound care orders for staff to follow. She acknowledged that she was behind on weekly documentation of wound care and that it needed to include measurements, characteristics of the wound, and if the wound was healing or deteriorating. 38503 IV. Failure to ensure weekly wound assessments were completed for Resident #47 A. Resident #47 status Resident #47, age 79, was admitted on [DATE]. According to the December 2022 computerized physician orders (CPO), diagnoses included fracture of the right ulna (wrist), fracture of the left and right patella (knee), chronic obstructive pulmonary disease, hypertension, and pressure ulcer of the left and right heel. The 12/2/22 MDS assessment revealed Resident #47 was cognitively intact with a BIMS score of 15 out of 15. She required extensive one to two-person assistance with most activities of daily living (ADLs). She did not exhibit behaviors or reject care. Resident #47 was at risk of developing pressure ulcers/injuries. Two unstageable pressure injuries were present upon admission. She had a pressure reducing device for her chair and bed, pressure ulcer/injury care and application of dressings to her feet. B. Observation The registered nurse/wound nurse (RNWN) was observed providing wound care to Resident #47's bilateral heels on 12/21/22 at 8:45 a.m. She said the resident was admitted with deep tissue injury (DTI) to her bilateral heels. She said the resident was non-compliant with care, and often refused treatments, such as heel booties, L'Nard boots and floating of her heels. The resident had a geo mat (foam) on her bed which she used to float her heels in bed. The resident's right heel was calloused with a dark dry center. The resident's left heel was calloused, dry and boggy. The wound nurse applied skin prep to the resident's heels. The wound nurse did not measure the resident's wounds to her heels. C. Record review The care plan, initiated 11/26/22, revealed Resident #47 had a potential for impaired skin integrity related to immobility/acute decline in ADL function secondary to her recent hospitalization /illness. The resident's Braden (a tool used for predicting pressure ulcer development) score was 16 on admission (15-18=mild risk, 13-14=moderate risk, 10-12=high risk and less than 9=severe risk). Interventions included to administer medication/treatments as ordered and note/report any side effects or complications, float heels, and weekly skin checks by the nurse. Review of the December 2022 CPO revealed Resident #47 had orders to apply skin prep to her bilateral heels every shift (twice daily) and to offload pressure to her heels. Review of the weekly wound reports and weekly clinical notes from 11/14/22 to 12/21/22 revealed staff did not document weekly assessments to include wound measurements, wound characteristics, and/or if the wound improved or deteriorated. The documentation for the left heel was completed on 11/14/22 and 11/16/22. The documentation for the right heel was completed on 11/14/22, 11/16/22, and on 11/28/22 which documented the wound was healed. D. Staff interviews The RNWN was interviewed on 12/21/22 at 9:30 a.m. She said at one point Resident #47's right heel DTI/callous healed on 11/28/22 but then redeveloped on 11/30/22 due to her skin condition ichthyosis (a group of skin disorders characterized by dry, scaly, or thickened skin). She acknowledged Resident #47 did not have weekly wound assessments completed for the past few weeks. She said she was behind on her weekly documentation of wounds. She said she was the only wound nurse and occasionally another registered nurse (RN) would fill in for her when she was off. She said residents with pressure ulcers needed to have a weekly assessment completed to include measurements and documentation if the wound was healing or deteriorated. She said if she did not complete one it would fall on the floor nurses to complete. The director of nursing (DON) was interviewed on 12/22/22 at 1:41 p.m. She said the wound nurse usually completed weekly documentation of wound care. She said the weekly wound assessments needed to include measurements, description of the wound, drainage, signs of infection and if the wound was healing or deteriorating.

Based on record review and interviews, the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents for one (#1) out of three sample residents. Specifically, the facility failed to prevent a fall off of the toilet in the bathroom with injury for Resident #1 on 7/10/22 at 11:10 p.m. The resident was left on the toilet by herself where she fell forward and struck her head on the ground resulting in a contusion on the left side of her forehead. Upon assessment, the resident's injuries consisted of a contusion on her left forehead, a skin tear to her left wrist and a skin tear to her right elbow. The injuries were identified and neurological examination revealed the resident was unable to track the nurse's finger and was unable to form coherent sentences. The resident was sent to the hospital on 7/11/22 at 10:51 a.m. for further examination due to deterioration of her neurological condition. She was diagnosed with a subarachnoid hemorrhage (brain bleed) and a subdural hematoma (buildup of blood on the surface of the brain). She returned to the facility on [DATE], was admitted to hospice services and passed away on 7/20/22. Cross-reference F684 Quality of Care. Findings include: I. Facility policy and procedure The Fall/Accident Assessment Prevention and Management policy, revised October 2019, was provided by the director of nursing (DON) on 9/13/22 at 1:00 p.m. It read, in pertinent part: The goal of the facility is for elders to remain as free from falls and accidents as possible, and for the potential for injury to be as minimal as possible. All residents are assessed by nursing for fall risk potential with the fall risk assessment. Elders (residents) are assessed for fall risk upon admission to the facility, quarterly and with a change of condition. Elders at risk for falls have a care plan in place with interventions to reduce the potential for injury from falls. When an elder falls or is involved in another type of incident, the following interventions occur: -The staff member who is first on the scene notifies the nurse on duty. -The elder is not moved until assessed by the licensed nurse. -The nurse does a complete assessment of the elder to determine whether injury is noted or suspected. Vital signs are obtained, including orthostatic BPs (blood pressures). -First aid is administered PRN (as needed). -Neuro (neurological) checks are initiated if head injury is known or suspected. -The physician is notified of the incident and the assessment findings. If the elder experienced significant injury, the physician will be called, otherwise notification by facsimile is acceptable. -The nurse is to notify the family/POA (power of attorney). If there is not significant injury the call may be placed during daytime hours. -The nurse is to complete an incident report and a nurses note. The fall will be recorded on the 24 hour report. Elders are to be monitored and assessed for at least 72 hours post fall for complications. -The nurse makes an acute care plan to include any immediate interventions to treat injury, assess for injury, and to add any interventions to attempt to further prevent injury from fall. II. Resident #1 A. Resident status Resident #1, age 92, was admitted on [DATE] and passed away on 7/20/22. According to the July 2022 computerized physician orders (CPO), the diagnoses included urinary tract infection, Alzheimer's disease, unilateral primary [CONDITION(S)], [CONDITION(S)], general anxiety, [CONDITION(S)], spinal stenosis, chronic pain, history of falling, and dementia. The 5/6/22 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status score of eight out of 15. She required limited assistance of one staff member with mobility, transfers, dressing and personal hygiene. She required supervision with eating and toileting. B. Record review On 6/25/22 the resident suffered a fall in the bathroom while attempting to wipe herself. According to the nursing note and the incident report, the resident attempted to stabilize herself using her wheelchair which was not locked which caused the wheelchair to shift and the resident lost her balance, falling on her left side. The resident was assessed and no injuries were noted. The fall was witnessed by the certified nurse aide (CNA) and the resident did not hit her head. The post fall assessment dated [DATE] revealed an intervention to make sure the resident's wheelchair brakes were locked and to remind her to call for help. An interdisciplinary team note to review the fall dated 6/29/22 revealed additional interventions including orders for occupational therapy to improve wheelchair safety and wheelchair modification to include anti-rollback bars to be added. A fall care plan (undated) revealed the resident was at risk for falls related to impaired balance, [CONDITION(S)], [CONDITION(S)], malaise, [CONDITION(S)], impaired mobility, history of falls, impaired vision, and occasional bowel and bladder incontinence. Interventions (undated) included: anticipate and meet needs, be sure call light is within reach and encourage use, respond promptly to all requests for assistance, coordinate with appropriate staff to ensure a safe environment with: floors even and free from spills or clutter, adequate glare free light, ensure she is wearing appropriate footwear when ambulating or up in wheelchair. She prefers to wear shoes. Keep personal items in reach. She has a hi/lo bed for positioning. Assess prior history of falls. Nurse to document fall risk per protocol and alert staff of potential for falls. The resident's most recent fall risk assessment was dated 5/4/22 and revealed the resident scored an eight on the fall risk scale where a score of ten or more indicated high risk for falls. A nursing note dated 7/11/22 at 12:00 a.m. revealed the resident had suffered a fall at 11:10 p.m. on 7/10/22. The CNA had assisted the resident to the toilet and while she was making the resident's bed, the resident fell face down onto the floor. The nurse entered the room and the resident was lying face down on the floor and was found to have a contusion on her left forehead, a skin tear to her left wrist, and a skin tear to her right elbow. She complained of pain near her right hip, but otherwise the head to toe exam was unremarkable. The resident was assisted into her wheelchair and then to bed. She was responding to voice, but could not track with her eyes. She spoke, but could not form a sentence and was unable to follow verbal commands. An ice pack was applied to her forehead and dressings placed on the skin tears. Neurological checks were initiated. The resident's family was notified by telephone and the resident's physician was notified by fax. The resident was given pain medications and allowed to rest. A nursing note dated 7/11/22 at 5:28 a.m. revealed frequent checks were made on the resident throughout the night and neurological checks continued with vital signs remaining consistent, though her blood pressure was elevated at 145/98 (normal 120/80). The resident was responsive but unable to follow verbal directions, she was hard of hearing and confused at baseline. When asked to squeeze the nurse's hands, the resident responds I don ' t know but is able to move her arms and hands. The resident was unable to track the nurse's finger, though it was unknown if she understood the request. Pupils were reactive to light. Large hematoma on her forehead with bruising and swelling spreading to her eye. Ice was applied throughout the night with resident compliance. Information to be passed along to oncoming day shift nurse and continue to make frequent checks. A nursing note dated 7/11/22 at 6:30 a.m. revealed the resident had fallen on the previous shift. The resident had a hematoma to her left temporal area with visible bruising that appeared to be draining to her left eye. The resident was conscious but not alert. She was slurring her words and was not able to follow commands. She was not able to follow commands to assess her field of gaze and her eyelids had to be manually opened to assess her pupil response. Her pupil size was 2 mm (millimeters) and was fixed at that time. She was not able to follow commands to grasp hands, but her hands were moving and she pulled the covers up over herself as if she was cold. An icepack was placed on her temporal hematoma to assist in the swelling. She remained lying down in bed, neuro checks continued and she would be monitored for safety and comfort throughout the day. A nursing note dated 7/11/22 at 10:17 a.m. revealed the resident's power of attorney was contacted and gave verbal consent to send the resident to the hospital for treatment. The resident continued to exhibit confusion beyond her normal baseline. The resident's physician was informed and also gave a verbal order to send the resident to the hospital to be treated for the head injury to the left temporal area and any other potential injuries. The resident claimed she could not hear anything and was not responding to verbal communication. She could verbalize that she did not know where she was and she could not hear anything. Pupils were fixated at 2 mm. The resident continued to fail the field of gaze test with no tracking. The resident left the facility with EMTs (emergency medical technicians) at 10:51 a.m., approximately 11.5 hours after the fall, initial injury and initial assessment which indicated head trauma. Cross-reference F684. Review of the post fall assessment and CNA information revealed the resident had asked for privacy in the bathroom and her wheelchair was not within reach. A new intervention of stand by assistance in the bathroom and not leaving the resident alone was put into place. -Records or documentation of the neurological checks for the resident was requested, though could not be located by the facility. C. Hospital records Review of the resident's hospital emergency department notes revealed the resident was diagnosed with subdural hematoma, subarachnoid hemorrhage, and an underlying urinary tract infection. The resident was a do not resuscitate (DNR) and it was decided to forgo surgical intervention to honor the resident's wishes. The resident returned to the facility on [DATE], was admitted to hospice services, and passed away on 7/20/22. III. Staff interviews CNA #1 was interviewed on 9/13/22 at 12:35 p.m. She stated when a resident fell , the staff member who found the resident made sure the resident was safe, asked them what happened, then called for a nurse. She stated the nurse assessed the resident for injuries and vital signs and neurological checks if the resident hits their head. She stated if the resident was not injured, the staff get the resident up off the floor and check on them frequently. CNA #2 was interviewed on 9/13/22 at 12:40 p.m. She stated when a resident fell , the CNA got the nurse on duty and the nurse assessed the resident for injuries. She stated the resident could not be moved until a nursing assessment was completed. She stated she knew a resident was a fall risk by observing if the resident tried to get up on their own or had alarms. She stated if a resident was a known fall risk, the staff checked on them often and reminded them to use their call light. CNA with medication aide authority (CNA-Med) #1 was interviewed on 9/13/22 at 12:50 p.m. She stated if a resident fell , she called out for the nurse on duty and would make sure the resident was safe. She stated the nurse would come and complete an assessment and the resident was never left alone until the assessment was completed. Licensed practical nurse (LPN) #1 was interviewed on 9/13/22 at 12:55 p.m. She stated she was new and had not had a resident fall since she started. She stated she would assess the resident's vital signs, skin, neurological status and check for injuries. She stated she would consult with another nurse if there were any injuries or suspected injuries and would document a note related to the fall. She stated she would inform the resident's family and the physician. LPN #2 was interviewed on 9/13/22 at 1:00 p.m. She stated when a resident fell , the resident was assessed to ensure there was no injury and if during daytime hours during the week, management was informed. She stated the physician would be informed by phone immediately if there was head involvement or injury and neurological checks would be performed if the resident hit their head. She stated the neurological checks should be documented in the nursing note and then on a paper form according to the neurological check schedule. She stated she had taken care of Resident #1 frequently and she was very good about calling for help and asked for toileting frequently. She stated if a resident fell and hit their head, she would have called the physician immediately. LPN #3 was interviewed on 9/13/22 at 1:15 p.m. She stated when a resident fell , the nurse assessed the resident for injury and pain. She stated the resident was not left unattended until the nursing assessment was completed and then the resident was assisted up off the ground safely. She stated if the fall was unwitnessed or head injury was known or suspected, the nurse would complete neurological checks on the resident according to schedule. She stated the staff would help the resident off of the floor if there were no injuries observed. She stated the resident would then be monitored for 72 hours. She stated if there was injury or neurological tests were abnormal, the physician would be called immediately for orders or additional direction. The director of nursing (DON) was interviewed on 9/13/22 at 2:06 p.m. She stated if a resident fell , the nurse would assess the resident for injuries or pain. If an injury was found, the nurse would call the physician to inform them of the fall and injury to get orders for treatment. If the resident had no injury, the nurse could fax the physician. She stated the nurse would also call the resident's family or representative. She stated the nurse would document a note in the chart related to the fall, assessment and any actions taken and continue charting for follow up monitoring for 72 hours. The nurse and the CNA both complete post fall assessments or reports which were then reviewed by the interdisciplinary team. She stated fall risk assessments were completed upon admission, quarterly and with a change of condition. She stated, upon review of Resident #1's fall, the nurse should have called the physician due to the head contusion and abnormal neurological exam results. She stated the two other nurses who cared for the resident before she was hospitalized could have called the physician sooner. The nursing home administrator (NHA) was interviewed on 9/13/22 at 2:51 p.m. She stated she would expect staff to follow the fall policies of the facility related to all resident falls. She stated she would expect the staff to respond immediately to a fall, perform an assessment and treat the resident according to policy and physician orders. She stated the physician and family should be notified of falls and the physician should be called immediately if the resident suffered injury. She stated appropriate interventions should be implemented to prevent further falls and staff should ensure that interventions were always in place. She stated if a fall results in head involvement, neurological checks should be completed and documented. The resident's physician and facility medical director (MD) was interviewed on 9/13/22 at 3:23 p.m. She stated when Resident #1 fell , she should have been called immediately as the resident did hit her head and there was a contusion and neurological tests were abnormal.

Based on record review and interviews, the facility failed to ensure residents received treatment and care which met professional standards of practice, was consistent with comprehensive assessments, and comprehensive care plans for one (#1) out of three sample residents. Specifically, the facility failed to prevent a fall off of the toilet in the bathroom with injury for Resident #1 on 7/10/22 at 11:10 p.m. The resident was left on the toilet by herself where she fell forward and struck her head on the ground resulting in a contusion on the left side of her forehead. Upon assessment, the resident's injuries consisted of a contusion on her left forehead, a skin tear to her left wrist and a skin tear to her right elbow. The injuries were identified and neurological examination revealed the resident was unable to track the nurse's finger and was unable to form coherent sentences. The resident was sent to the hospital on 7/11/22 at 10:51 a.m. for further examination due to deterioration of her neurological condition, which was 11.5 hours after the initial fall and injury. She was diagnosed with a subarachnoid hemorrhage (brain bleed) and a subdural hematoma(buildup of blood on the surface of the brain). She returned to the facility on [DATE], was admitted to hospice services and passed away on 7/20/22. Cross-reference F689 Accidents. Findings include: I. Facility policy and procedure The Fall/Accident Assessment Prevention and Management policy, revised October 2019, was provided by the director of nursing (DON) on 9/13/22 at 1:00 p.m. It read, in pertinent part: When an elder falls or is involved in another type of incident, the following interventions occur: -The staff member who is first on the scene notifies the nurse on duty. -The elder (resident) is not moved until assessed by the licensed nurse. -The nurse does a complete assessment of the elder to determine whether injury is noted or suspected. Vital signs are obtained, including orthostatic BPs (blood pressures). -First aid is administered PRN (as needed). -Neuro (neurological) checks are initiated if head injury is known or suspected. -The physician is notified of the incident and the assessment findings. If the elder experienced significant injury, the physician will be called, otherwise notification by facsimile is acceptable. -The nurse is to notify the family/POA (power of attorney). If there is not significant injury the call may be placed during daytime hours. II. Resident #1 A. Resident status Resident #1, age 92, was admitted on [DATE] and passed away on 7/20/22. According to the July 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/6/22 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status score of eight out of 15. She required limited assistance of one staff member with mobility, transfers, dressing and personal hygiene. She required supervision with eating and toileting. B. Record review A fall care plan (undated) revealed the resident was at risk for falls related to impaired balance, [CONDITION(S)], [CONDITION(S)], malaise, [CONDITION(S)], impaired mobility, history of falls, impaired vision, and occasional bowel and bladder incontinence. Interventions (undated) included: anticipate and meet needs, be sure call light is within reach and encourage use, respond promptly to all requests for assistance, Coordinate with appropriate staff to ensure a safe environment with: floors even and free from spills or clutter, adequate glare free light, ensure she is wearing appropriate footwear when ambulating or up in wheelchair. She prefers to wear shoes. Keep personal items in reach. She has a hi/lo bed for positioning. Assess prior history of falls. Nurse to document fall risk per protocol and alert staff of potential for falls. The resident's most recent fall risk assessment was dated 5/4/22 and revealed the resident scored an eight on the fall risk scale where a score of ten or more indicated high risk for falls. A nursing note dated 7/11/22 at 12:00 a.m. revealed the resident had suffered a fall at 11:10 p.m. on 7/10/22. The CNA (certified nurse aide) had assisted the resident to the toilet and while she was making the resident's bed, the resident fell face down onto the floor. The nurse entered the room and the resident was lying face down on the floor and was found to have a contusion on her left forehead, a skin tear to her left wrist, and a skin tear to her right elbow. She complained of pain near her right hip, but otherwise the head to toe exam was unremarkable. The resident was assisted into her wheelchair and then to bed. She was responding to voice, but could not track with her eyes. She spoke, but could not form a sentence and was unable to follow verbal commands. An ice pack was applied to her forehead and dressings placed on the skin tears. Neurological checks were initiated. The resident's family was notified by telephone and the resident's physician was notified by fax. The resident was given pain medications and allowed to rest. A nursing note dated 7/11/22 at 5:28 a.m. revealed frequent checks were made on the resident throughout the night and neurological checks continued with vital signs remaining consistent, though her blood pressure was elevated at 145/98 (normal 120/80). The resident was responsive but unable to follow verbal directions, she was hard of hearing and confused at baseline. When asked to squeeze the nurse's hands, the resident responded I don ' t know but was able to move her arms and hands. The resident was unable to track the nurse's finger, though it was unknown if she understood the request. Pupils were reactive to light. Large hematoma on her forehead with bruising and swelling spreading to her eye. Ice was applied throughout the night with resident compliance. Information to be passed along to oncoming day shift nurse and continue to make frequent checks. A nursing note dated 7/11/22 at 6:30 a.m. revealed the resident had fallen on the previous shift. The resident had a hematoma to her left temporal area with visible bruising that appeared to be draining to her left eye. The resident was conscious but not alert. She was slurring her words and was not able to follow commands. She was not able to follow commands to assess her field of gaze and her eyelids had to be manually opened to assess her pupil response. Her pupil size was 2 mm (millimeters) and was fixed at that time. She was not able to follow commands to grasp hands, but her hands were moving and she pulled the covers up over herself as if she was cold. An icepack was placed on her temporal hematoma to assist in the swelling. She remained lying down in bed, neuro checks continued and she would be monitored for safety and comfort throughout the day. A nursing note dated 7/11/22 at 10:17 a.m. revealed the resident's power of attorney was contacted and gave verbal consent to send the resident to the hospital for treatment. The resident continued to exhibit confusion beyond her normal baseline. The resident's physician was informed and also gave a verbal order to send the resident to the hospital to be treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident claimed she could not hear anything and was not responding to verbal communication. She could verbalize that she did not know where she was and she could not hear anything. Pupils were fixated at 2 mm. The resident continued to fail the field of gaze test with no tracking. The resident left the facility with EMTs (emergency medical technicians) at 10:51 a.m., approximately 11.5 hours after the fall, initial injury and initial assessment which indicated head trauma. -Records or documentation of the neurological checks for the resident were requested, though could not be located by the facility. C. Hospital records Review of the resident's hospital emergency department notes revealed the resident was diagnosed with subdural hematoma, subarachnoid hemorrhage, and an underlying urinary tract infection. The resident was a do not resuscitate (DNR) and it was decided to forgo surgical intervention to honor the resident's wishes. The resident returned to the facility on [DATE], was admitted to hospice services, and passed away on 7/20/22. III. Staff interviews CNA #1 was interviewed on 9/13/22 at 12:35 p.m. She stated when a resident fell , the staff member who found the resident made sure the resident was safe, asked them what happened, then called for a nurse. She stated the nurse assessed the resident for injuries and vital signs and neurological checks if the resident hit their head. She stated if the resident was not injured, the staff got the resident up off the floor and checked on them frequently. CNA #2 was interviewed on 9/13/22 at 12:40 p.m. She stated when a resident fell , the CNA got the nurse on duty and the nurse assessed the resident for injuries. She stated the resident could not be moved until a nursing assessment was completed. She stated she knew a resident was a fall risk by observing if the resident tried to get up on their own or had alarms. She stated if a resident was a known fall risk, the staff checked on them often and reminded them to use their call light. CNA with medication aide authority (CNA-Med) #1 was interviewed on 9/13/22 at 12:50 p.m. She stated if a resident fell , she called out for the nurse on duty and would make sure the resident was safe. She stated the nurse would come and do an assessment and the resident was never left alone until the assessment was completed. Licensed practical nurse (LPN) #1 was interviewed on 9/13/22 at 12:55 p.m. She stated she was new and had not had a resident fall since she started. She stated she would assess the resident's vital signs, skin, neurological status and check for injuries. She stated she would consult with another nurse if there were any injuries or suspected injuries and would document a note related to the fall. She stated she would inform the resident's family and the physician. LPN #2 was interviewed on 9/13/22 at 1:00 p.m. She stated when a resident fell , the resident was assessed to ensure there was no injury and if during daytime hours during the week, management was informed. She stated the physician would be informed by phone immediately if there was head involvement or injury and neurological checks would be performed if the resident hit their head. She stated the neurological checks should be documented in the nursing note and then on a paper form according to the neurological check schedule. She stated she had taken care of Resident #1 frequently and she was very good about calling for help and asked for toileting frequently. She stated if a resident fell and hit their head, she would have called the physician immediately. LPN #3 was interviewed on 9/13/22 at 1:15 p.m. She stated, when a resident fell , the nurse assessed the resident for injury and pain. She stated the resident was not left unattended until the nursing assessment was completed and then the resident was assisted up off the ground safely. She stated if the fall was unwitnessed or head injury was known or suspected, the nurse would do neurological checks on the resident according to schedule. She stated the staff would help the resident off of the floor if there were no injuries observed. She stated the resident would then be monitored for 72 hours. She stated if there was injury or neurological tests were abnormal, the physician would be called immediately for orders or additional direction. The director of nursing (DON) was interviewed on 9/13/22 at 2:06 p.m. She stated if a resident fell , the nurse would assess the resident for injuries or pain. If an injury was found, the nurse would call the physician to inform them of the fall and injury to get orders for treatment. If the resident had no injury, the nurse could fax the physician. She stated the nurse would also call the resident's family or representative. She stated the nurse would document a note in the chart related to the fall, assessment and any actions taken and continue charting for follow up monitoring for 72 hours. She stated, upon review of Resident #1's fall, the nurse should have called the physician due to the head contusion and abnormal neurological exam results. She stated the two other nurses who cared for the resident before she was hospitalized could have called the physician sooner. The nursing home administrator (NHA) was interviewed on 9/13/22 at 2:51 p.m. She stated she would expect staff to follow the fall policies of the facility related to all resident falls. She stated she would expect the staff to respond immediately to a fall, perform an assessment and treat the resident according to policy and physician orders. She stated the physician and family should be notified of falls and the physician should be called immediately if the resident suffered injury. She stated appropriate interventions should be implemented to prevent further falls and staff should ensure that interventions are always in place. She stated if a fall results in head involvement, neurological checks should be completed and documented. The resident's physician and facility medical director (MD) was interviewed on 9/13/22 at 3:23 p.m. She stated when resident #1 fell , she should have been called immediately as the resident did hit her head and there was a contusion and neurological tests were abnormal. -The nursing staff who cared for the resident on 7/10/22 and 7/11/22 could not be reached for interview.

Based on interviews and record review, the facility failed to ensure freedom from abuse and neglect for five (#31, #47, #49, #50, #87) of 27 residents reviewed out of 44 sample residents. Resident #31, who had severe dementia and was dependent for activities of daily living (ADLs), was physically and verbally abused and neglected by certified nurse aide (CNA) #8, who rammed her fingers into a table, refused to take her to the bathroom, and was verbally abusive during care provision. CNA #8's abuse and neglect of Resident #31 was observed and reported by fell ow CNAs. Resident #31 was unable to express how those experiences made her feel. Resident #47, who needed extensive assistance with transfers, was neglected and received injuries in the shower room when CNA #1 banged and scraped her shin on the bath bed, then transferred her from her wheelchair to the bath chair without using a gait belt or locking her chair brakes. As a result, Resident #47 fell and injured her hand, ankle and shin. Further, Resident #47 said in an interview that she had recently been left unattended on the toilet for half an hour. She said both incidents hurt. Resident #87 reported that a night nurse was rough and threw her into bed like a rag doll during a transfer. She said she was not hurt and not afraid of the nurse, but she did not like to be treated that way. Residents #49 and #50 suffered resident-to-resident abuse during a physical altercation. Both residents sustained bruising and skin tears to their wrists and hands. Findings include: I. Facility policy and procedures The Abuse Prevention, Investigation and Reporting policy, dated March 2017, was provided by the nursing home administrator (NHA) on the afternoon of 8/23/21. The policy documented in pertinent part that management would take specific steps to reduce the potential for abuse to occur including, but not limited to, education, monitoring and investigating thoroughly if abuse, neglect or exploitation was suspected. In addition, incidents would be reviewed to determine if abuse was suspected, and if suspected, it would be investigated thoroughly. The facility would ensure staff patterns to meet the needs of the resident, and to assure that the staff assigned had knowledge of the individual residents' care needs. New staff were assigned to work with an employee during their orientation period to become accustomed to the residents. The supervision of staff would be ensured to identify inappropriate behaviors such as derogatory language, rough handling, and ignoring residents while giving care. Employees who suspected abuse were to immediately intervene to protect the residents. Any alleged employee suspect would be removed from contact with any resident and put on administrative leave during the investigation. If evidence was found to support abuse or neglect, the employee would be terminated. II. Resident #31 A. Resident status Resident #31, age 88, was admitted on [DATE]. According to the 6/17/21 significant change minimum data set (MDS) assessment, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 6/17/21 MDS assessment further documented Resident #31 had severe cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. No behavioral symptoms or care rejection were documented. The resident used a wheelchair for ambulation and needed extensive assistance with bed mobility, transfers (by two or more staff), dressing, and toilet use. The resident was frequently incontinent and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . B. Resident observations Resident #31 was observed throughout the survey, conducted 8/22/21 from 6:05 to 9:30 p.m., and 8:00 a.m. to 6:00 p.m. on 8/23, 8/24, 8/25 and 8/26/21. She used a wheelchair and was often in the common areas, pleasantly confused, and visiting with others. C. Interviews Certified nurse aide (CNA) #4 was interviewed on 8/26/21 at 10:42 a.m. She said she had reported abuse, but the allegations did not get passed along and nothing gets done. She said some staff were kind of rude to residents with dementia and Alzheimer's. She said she had reported but it was not addressed. She said CNA #8 was refusing to take Resident #31 to the bathroom. When Resident #31 would ask, CNA #8 would say no. She said she had reported to her supervisor and nothing had happened. I've watched (CNA #8) ram her (Resident #31's) fingers into the table and instead of saying 'sorry' she said 'well?' She said that happened last Tuesday. She said every time CNA #8 was in the room with Resident #31 she got angry that she had to provide her cares. Just Tuesday (two days prior) we wheeled her out and (Resident #31) said she needed to go to the bathroom, and CNA #8 said, 'I already took you.' We've reported before and nobody seems to care. It's rude. And you don't want to get backlash for reporting things. I've reported multiple times. I assumed someone reported from the new nursing class. What if she's doing that to other residents? We just don't know. The quality assurance nurse manager (QANM) was interviewed on 8/26/21 at 11:27 a.m. and the above allegations were reported to her. She said she was in the process of investigating, and that one of the CNAs who witnessed it called off and was not working, another CNA who witnessed it was working in the facility that day. She said CNAs #15 and #16 who reported were not working in the facility that day. She said CNA #16 yelled at CNA #8 and CNA #15 was a witness; CNA #5 saw CNA #8 refuse to take a resident to the bathroom. She said she definitely considered it abuse and neglect. She said it was reported to her late Tuesday afternoon, about 6:30 p.m., when CNA #4 came to her and reported and said she had already reported to CNA #3 and the assistant director of nursing (ADON). The ADON said she was already working on it. The first thing we do is make sure the residents are safe, and CNA #8 was suspended pending the investigation. The QANM said she and the SSD were finishing up their investigations and just typing up their notes now. Copies were requested. CNA #5 was interviewed on 8/26/21 at 11:53 a.m. She said Resident #31 constantly asks to go to the bathroom and she told CNA #8 she was capable of going, knew when she needed the bathroom, was really easy to work with, and if she had to go to the bathroom she knew when she had to go, but the CNA #8 said, I just changed her, it's okay. CNA #5 said she told CNA #8 you don't have to be mean to her, she's really nice. I said there's no reason for you to be rude to her. (Resident #31) said something to her like 'you're too pretty to have this attitude,' and CNA #8 said 'this is why I don't like her.' She said it in front of the resident. It was Tuesday around lunch time. She says stuff like that in front of residents, talks a lot about her personal stuff around residents, how her day's going, cussing. It's been going on but about six months. CNA #5 said she talked to CNA #4 about it, and was told CNA #4 had already reported her and I know other people have reported her multiple times but I personally have not. She said she reported to CNA #3, their lead CNA and then CNA #4. She said the facility had talked to CNA #8 and gave her multiple warnings. She did have to take an abuse test online but they had not been monitoring her, which she knew because she worked with her most of the time. I don't see her being rough, it's more like the way she talks to them, like with (Resident #31), she'll just say 'Roll' (as in roll over), so then the residents get confused and upset and she gets upset. It's more like she doesn't know how to talk to the residents. It's verbally abusive but I've never seen her being rough like physical abuse. D. Facility investigation During an interview on the evening of 8/26/21, the QANM provided undated, untimed interviews with CNAs #5, #15 and #16 conducted by lead CNA #3. The QANM said they had substantiated abuse by CNA #8 and she would be terminated. CNA #5 reported that on 8/24/21 she had a disagreement with CNA #8. Resident #31 was saying she needed to go to the restroom and CNA #8 told the resident she had already changed her, that she was okay and did not need to use the restroom. CNA #5 ended up taking Resident #31 to the restroom herself, respecting the resident's wishes. CNA #15 reported she did not believe that CNA #8 treated Resident #31 kindly. She was told by coworker CNA #16 that one time she was taking care of Resident #31's roommate and overheard the way she was speaking to Resident #31 and told CNA #8 not to talk to her in that manner. CNA #15 also stated that CNA #8 would say she toileted/provided personal care to residents and when CNA #15 checked on those residents it was found to be untrue. CNA #16 reported there was a time when she was in Resident #31's room taking care of Resident #31's roommate and CNA #8 was taking care of Resident #31. She had a rude tone and raised her voice at the resident. She could not recall what words were said. CNA #16 reported she did intervene and told Resident #31 she could not treat Resident #31 that way. After that incident, CNA #16 never heard CNA #8 speak that way to any resident again. She said CNA #8 would at times lie about changing and making beds. -No further documentation was provided by the facility related to their investigation of CNA #8 after the evening of 8/26/21. The QANM said that based on their staff interviews, abuse/neglect was substantiated and CNA #8 would be terminated. However, there was insufficient evidence they had identified the extent of the damage CNA #8 had done, the number of residents affected, or how long her abusive behavior had been going on. III. Resident #47 A. Resident status Resident #47, age 87, was admitted on [DATE]. According to the August 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to her 6/30/21 MDS assessment, she was cognitively intact with a BIMS score of 15 out of 15. No mood or behavioral symptoms were documented. She needed extensive two-plus person assistance with transfers, and extensive assistance with dressing and toilet use. She had range of motion impairments to upper and lower extremities on one side, and used a wheelchair for ambulation. B. Facility investigative report of neglect incident Review of abuse/neglect documentation revealed on 7/10/21 at 10:30 a.m., CNA #1 was assisting Resident #47 transfer from her chair to the bath chair before a bath. The bath chair moved out from behind the resident causing her to slide to the floor. The CNA did not use a gait belt during the transfer. The resident was assessed by the floor registered nurse (RN), who assisted the resident back into her wheelchair via gait belt transfer with max assist. Later in the afternoon at approximately 3:45 p.m. the nurse rechecking the resident at the request of the restorative nurse aide noted bruising and increased swelling to the resident's left wrist and left foot. The resident was sent to the hospital for follow-up X-rays, which showed no fractures. A nursing progress note dated 7/10/21 at 7:57 p.m. documented in part that the resident did not report pain or discomfort immediately after her fall. However, the registered nurse documented, Restorative aide came to notify this RN of resident (complaint of) pain to (left) hand with ROM (range of motion) exercises. This RN to assess resident at (3:24 p.m.) Resident verbalizes pain to (left) hand. She is also observed with 2+ pitting [CONDITION(S)] to her (left lower extremity). (Right lower extremity) noted with trace [CONDITION(S)]. Resident complained of discomfort to left ankle/foot with ROM. A nursing progress note on 7/11/21 at 3:20 a.m. documented, Res returned at approximately 8PM from (local hospital emergency department); per after visit summary, xrays show no fractures. Affected area on left wrist and ankle were elevated and applied ice. The resident's daughter, who was with her at the hospital, reported the resident had a sprained ankle. On 7/11/21 at 4:31 p.m. documented the resident complained of left wrist pain, Rates pain 7/10 currently and is requesting PRN (as needed) Tylenol. The facility investigation revealed the resident was care planned for one-person assistance with a gait belt for all transfers. -The CNA failed to use a gait belt. The CNA failed to lock the bath chair before the transfer, and the resident was wearing regular socks, instead of shoes or non-slip socks, during the transfer. The CNA was re-educated after an investigation was conducted, and trained on policies and procedures related to transfers, lifts and gait belt usage. -However, although the care plan documented one-person assistance, the MDS assessment (see above) documented the need for two-plus-person assistance with transfers. C. Resident interview Resident #47 was interviewed on 8/25/21 at 11:44 a.m. about the incident on 7/10/21. She said the CNA accidentally pushed her left leg into the bath bed and it's still healing. She removed a Band-Aid from her left lower shin, said, It's just a skinned area, and revealed a quarter-sized abrasion that was red around the edges. She said after the incident in 7/10/21 her hand hurt badly on her affected left side, but her wrist and ankle were healing. She said CNA #1 had not bathed her since then. I'm sure it scared her. Resident #47 said she was not afraid or angry, but it hurt. She said she didn't mean to hurt me. I said I wouldn't say 'Ow-ow-ow' if it wasn't hurting me. The resident said that was why she wore a gait belt around her waist all the time now, because before they weren't putting the gait belt on me. In fact if they take it off, I ask them to put it back on. It makes me feel safer. She said the nurses in the facility were nice people, there's just not enough of them. I think they need a little bit more help. (Cross-reference F725, sufficient nursing staffing.) Resident #47 said she was left on the toilet for about half an hour one day last week in the afternoon. The CNA kept saying she was so sorry, and the resident replied, It's okay, it just hurt (her bottom). The CNA told her another resident fell and she had to help her. If they have emergencies, call light response takes them a bit longer, and I can understand that. Resident #47 did not recall the CNA's name. D. Facility follow-up The QMNM documented a warning statement on 7/13/21 for CNA #1 regarding failure to use a gait belt during a transfer resulting in a six-month probation, and a skills check-off for resident care and transfer technique, also on 7/13/21. Training regarding transfer expectations in the bath area, sit-to-stand and max-lift transfers and gait belt usage was provided for CNA #1 on 7/13/21 and 7/14/21. -There was no evidence of further supervision of CNA #1. The facility failed to ensure Resident #47 was free from neglect when she suffered injuries on 7/10/21 in the shower room. IV. Physical abuse between Resident #49 and #50 Resident #49 and Resident #50 were a married couple who were residing in the same room on E Hall at the time physical abuse between the two occurred on 7/28/21. A. Resident #49 1. Resident status Resident #49, age 90, was admitted on [DATE]. According to the August 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/1/21 minimum data set (MDS) assessment revealed the short-term memory was not coded and the long-term memory coded the resident had deficits. She was moderately impaired for daily decision making. There was no brief interview for mental status (BIMS) score completed on this MDS. This MDS documented the resident displayed physical behaviors directed towards others, verbal behaviors directed towards others and behaviors not directed towards others during one to three days during the seven-day lookback period. She received seven days of anti-anxiety medications and hypnotics during the seven-day lookback period. The MDS documented the resident required extensive assistance of one for bed mobility, transfers, ambulating in her wheelchair, dressing, eating, toileting, personal hygiene and bathing. 2. Record review The care plan dated 7/7/21 related to mood documented Resident #49 had the potential for mood decline as evidenced by accusatory screaming, calling out and being difficult to redirect. It documented the resident was vision and hearing impaired, which exacerbated the resident's anxiety. Her spouse reported the resident had made negative comments as her health declined. It documented the resident yelled out comments such as Is there arsenic in those pills, there should be, Just shoot me, or You're abusing me when staff was providing proper care, when someone just entered the room or when no one was in her room at all. It documented the resident was physically aggressive, hit staff during care and was difficult to redirect. On 7/19/21, this care plan was updated to reflect the resident had been started on [MEDICATION(S)] (medication) for anxiety and depression. On 8/4/21, this care plan was updated to reflect the resident had been ordered [MEDICATION(S)] for a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . -The care plan was not updated on 7/28/21 in relation to a physical altercation between Resident #49 and her husband, Resident #50. The care plan dated 7/7/21 related to psychosocial well-being documented Resident #49 continued to have difficulty adjusting from the community to long term care status with increased episodes of anxiety, resulting in verbal outbursts which were disruptive towards other residents and may be impacting the resident's psychosocial well-being. This care plan was updated on 7/28/21 and documented, Due to increased potential for physical and verbal aggression towards spouse, they are no longer rooming together which decreases their time together. Interventions included encouraging participation in activities of interest, introduce Resident #49 to others with similar interests and encourage and provide individualized activities for the resident's room as needed. The care plan dated 7/7/21 related to behavior documented Resident #49 was irritable and had episodes of physical aggression. It documented she reached out, attempting to grab or touch anyone that was near, such as her spouse. It documented Resident #49 and her spouse would argue at times and would push each other's hands away, resulting in staff visibly seeing the residents' irritation with each other. The resident's spouse stated this was Resident #49's baseline anxiety due to her sensory impairments. It documented Resident #49 was verbally aggressive as evidenced by the resident screaming and yelling at staff. It documented she was demanding with unrealistic expectations of staff. She screams ouch and help as an anticipatory response to any ADL (adult daily living) or request for assistance. It documented, on 7/21/21, Resident #49 entered into a behavioral agreement to ensure the safety and dignity of others. She agreed to be respectful towards staff and to no longer spit, throw items at, scream while proper care was being provided, threaten to harm others and to use the call light instead of screaming and yelling. It was updated on 7/28/21 and documented physical aggression towards her spouse, resulting in injury to both Resident #49 and her spouse, Resident #50. It documented visits with her spouse would be monitored for safety as needed. B. Resident #50 1. Resident status Resident #50, age 89, was admitted on [DATE]. The August 2021 CPO documented the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/6/21 MDS assessment revealed the resident had a BIMS score of 14 out of 15 and was cognitively intact for daily decision making. It documented the resident displayed physical behaviors towards others during one to three days during the seven-day lookback period He required limited assistance from one for ambulating with his walker. He required extensive assistance of one for bed mobility, transfers, dressing, toileting and personal hygiene. 2. Record review The care plan dated 7/7/21 related to psychosocial well-being documented Resident #50 had the potential for impaired psychosocial well-being and/or adjustment problems related to recent lifestyle changes, as he was used to caring for his spouse with minimal interaction with others, as the two were rooming together. This care plan was updated on 7/28/21 and documented that due to the increased potential for physical and verbal aggression towards his spouse, they are no longer rooming together, which decreased their time together. The care plan dated 7/7/21 related to behavior documented Resident #50 had episodes of irritation towards others, which could lead to physical aggression such as hitting a staff member's hand away while they were trying to assist him. It documented he also pushed his spouse's hand away while she was trying to reach or grab out towards him. This care plan was updated on 7/28/21 and documented there was physical aggression towards his spouse, resulting in injury to both Resident #50 and Resident #49. It documented Resident #50 was immediately transferred to a different room following the physical abuse altercation between the two. It documented an intervention of visitation with his wife to be observed for safety as needed. C. Initial facility investigation The facility's abuse investigation related to the resident to resident physical abuse between Resident #49 and Resident #50 was provided by the social services director (SSD) the morning of 8/24/21. The investigation documented a physical abuse investigation was filed on the State Agency related to resident to resident abuse between Resident #49 and Resident #50. This incident was reported to the State Agency on 7/28/21 by the social services director (SSD) at 10:00 p.m. Resident #49 and Resident #50 were spouses who resided together on E Hall. This physical abuse occurred in Resident #49's and Resident #50's room on 7/28/21 at 8:40 p.m. The facility's abuse investigation documented a certified nurse aide (CNA) heard Resident #49 calling out, Help me, help me, so the CNA walked into their room and heard both residents yelling at each other. Resident #49 was calling out for the CNA to move the call light clipped on her shirt to her collar of the shirt, which was done. As Resident #49 continued to yell out, the CNA observed Resident #50 reaching out with his right arm and swatting his wife's back, as they were lying next to each other in twin beds that had been pushed together. Resident #49 was lying on her side, turned away from Resident #50 when he hit her. Resident #49 then retaliated and reached back with her left arm and swatted her husband, hitting his right hand/arm. It was documented both residents were yelling, as both were very hard of hearing. It was documented Resident #50 grabbed and squeezed Resident #49's hand, digging his nails into her hand. Resident #49 started screaming, Abuse, abuse, he's hurting my arm. Call a doctor, call a lawyer. At one point during the physical altercation, Resident #50 sustained a skin tear to his hand. It documented both residents made contact with each other during the incident. Both of the residents sustained injuries, as a few hours later, staff noticed some bruising on the back of Resident #49's left wrist. The residents were immediately separated by the CNA who observed the physical abuse between the two residents. The CNA called for a nurse, who moved Resident #50 to another room in E Hall, where he still resides. Nursing staff assessed both residents for injury. The police department and Adult Protective Services were notified of the incident. D. Staffing training The SSD was interviewed on 8/26/21 at 9:52 a.m. She said the facility had conducted an all staff training on abuse on 7/2/21. The staff development coordinator (SDC) provided documentation on 8/26/21 that facility staff completed two separate abuse trainings in 2021. She said a CMS (Center for Medicaid and Medicare) course on abuse had been presented to all staff on 2/5/21. She said another training on abuse and behavior management had been presented to all staff on 7/5/21. She said both trainings lasted approximately 45 to 60 minutes each. E. Staff interviews The SSD was interviewed on 8/26/21 at 9:52 a.m. She essentially re-iterated what occurred between Resident #49 and Resident #50 on 7/28/21. (see above initial facility investigation). She said both residents still reside in separate rooms on E Hall and neither resident currently had a roommate. She said, following the initial investigation she filed the evening of 7/28/21, she was asked by the nursing home administrator (NHA) to begin the official facility investigation, which began 7/28/21 at 11:20 a.m. She said both Resident #49 and Resident #50 had cognitive deficits and she interviewed the residents separately. She said she interviewed Resident #50 first because she was the alleged victim. She said she then interviewed Resident #50, the CNA who witnessed the abuse, the nurse who assessed the residents and the only resident who was awake at the time of the abuse. She said initially, Resident #49 kept murmuring she wanted to die, but once the residents were separated, both appeared to be calmer and their anger seemed to have dissipated. The SSD said the facility did substantiate the allegation of resident to resident abuse, as it was witnessed by a CNA. She said because staff were not involved in the abuse and because there were no prior incidents of abuse between the two residents, the facility did not expand the investigation further. She said Resident #49 and Resident #50 were still able to visit each other, if they chose to do so, with staff monitoring both resident's mood and behavior and would chart on the visits by exception. She said, because Resident #49 had displayed continued anxiety and behaviors, the resident has not focused much on wanting to be with her husband. She said Resident #50 had been coming out of his room more often and was becoming more social since he stopped sharing a room with his wife. She said the facility was allowing the couple to visit, per their initiation, but neither resident were really asking for visits, which are very minimal. She said a few times, Resident #50 would go to the doorway of his wife's room and look into the room to check on her, but does not go into her room and will return to his room or the common dining area on E Hall. She said the couple's daughter has been focusing on stabilizing her mother's level of anxiety and is very involved in her parent's care, but due to the daughter's declining health issues herself, it limits her ability to come into the facility as often as she used to. She said the daughter still kept in frequent contact with staff via telephone. She said the daughter was fine with her parent's current living arrangement, but did ask staff if her parents would ever be able to room together again. She stated the facility answer was they would have to wait and see. The staff development coordinator (SDC) was interviewed on 8/26/21 at 1:56 p.m. She said a CMS course on abuse had been presented to all staff on 2/5/21. She said another training on abuse and behavior management had been presented to all staff on 7/5/21. She said both trainings lasted approximately 45 to 60 minutes each. She said if the facility substantiated any abuse allegation, additional education should have been provided to the staff, if requested of her. She said facility administration had not requested additional training be provided in the area of abuse, so she had not provided any additional staff training into abuse since 7/5/21. The nursing home administrator (NHA), director of nursing (DON) and quality assurance nurse manager (QANM) were interviewed together on 8/26/21 at 8:03 p.m. The NHA said they had developed an action plan to identify and prevent abuse in the facility. The NHA said it was a standard for their quality assurance (QA) program. She said the facility would monitor and discuss any issues with the SSD. All three being interviewed said they had not identified any trends related to abuse that were concerning prior to the start of the recertification survey beginning 8/23/21. The NHA facility reviewed any allegations of abuse during the 24-hour report every weekday and did not wait an entire month for QA to review the occurrences. The NHA said the facility was unaware of any abusive behaviors between Resident #49 and Resident #50 when they lived at home. She said the facility asked Resident #50 several times if he wanted to move into a different room because Resident #49 was so verbally abusive, but he declined. She said they were concerned that Resident #50 was not getting enough rest and he could just shut her off if he were in a different room. The DON said the facility had contacted the local mental health center's crisis line several times due to Resident #49's behaviors, but were denied services due to the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the facility attempted different things with Resident #49, such as different headphones, different music, bringing the daughter in visit with the resident, and one-on-one staff monitoring when needed. The NHA said the facility had looked into alternative placement , but the facility was not accepting new admission due to low staffing. She said many medication adjustments had been made for Resident #49 by the facility's medical director and they saw a bit of a trend of improvement and then further adjustments were needed. She said the facility has looked into geri-psych placements since the abuse altercation between the two residents. She said the facility did not foresee the altercation and felt the husband was just trying to keep his wife quiet when the altercation began. V. Resident #87 A. Resident status Resident #87, age greater than 65, was admitted on [DATE]. According to the August 2021 CPO diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 8/10/21 MDS assessment the resident was cognitively intact with a BIMS of 15 out of 15. Moods included trouble falling/staying asleep, feeling tired or having little energy, poor appetite or overeating. She had no behaviors. She required extensive assistance of two persons for bed mobility and transfers and extensive assistance of one person for locomotion and toileting. B.Resident interview Resident #87 was interviewed on 8/23/21 at 9:41 a.m. She said that one night she had a run in with one of the nurses. She said that the nurse was rough with her when transferring her into bed and that she tossed her into bed like a ragdoll. She said the nurse was impatient and rushed. She said she told the nurse that she did not like being treated that way. The resident said the facility was short staffed, however; that did not mean that they had the right to treat people like that. She said she brought it to another nurses ' attention the following day. She said she was not afraid of the nurse and that she was still taking care of her when she was on duty. C.Staff interviews Registered nurse (RN) #5 was interviewed on 8/23/21 at 11:05 a.m. She said that she remembered that Resident #87 did mention something about negative staff treatment during a care conference meeting. She said that from w[TRUNCATED]

Based on resident and staff interview and record review, the facility failed to provide two of seven sample residents (#1 and #2) the care and services necessary to attain and/or maintain their highest practicable level of physical, mental and psychosocial well-being. Specifically, the facility failed to assess residents' condition, address symptoms, and follow physician orders related to: -A change of condition for resident #1 when she experienced nausea and vomiting and was unable to swallow her medications, and eat or drink sufficient amounts, for several days; -Implementation of a condom catheter for resident #2 in keeping with resident request and two physician telephone orders. These failures contributed to: -Resident #1's prolonged discomfort from nausea, vomiting, inability to swallow, and pain. She was hospitalized [DATE] for seven days and required treatments and procedures for pain, nausea, dehydration, [MEDICAL CONDITION] embolism, [MEDICAL CONDITION], and dysphagia. -Resident #2 experiencing discomfort and embarrassment because staff reportedly failed to provide adequate incontinence care, and then delayed implementing the physician-ordered condom catheter he requested as a result. The findings included: 1. Resident #1 Resident #1, a [AGE] year-old female, was admitted to the facility on [DATE]. She was hospitalized [DATE] and was readmitted on [DATE]. [DIAGNOSES REDACTED]. a. Resident Status (prior to hospitalization ) Minimum Data Set (MDS): According to the resident's 4/26/13 annual MDS, she had a BIMS (cognition) score of 13, indicating she was cognitively intact, and had no behavioral symptoms. She required extensive assistance with bed mobility, transfers, dressing, and toilet use. She was independent with ambulation using a power wheelchair, and always continent of bowel and bladder. Her [DIAGNOSES REDACTED]. She exhibited complaints of pain and difficulty with swallowing. medication orders [REDACTED] Review of physician orders revealed the resident was on over ten medications, including medications for cardiac arrhythmia, hypertension, pain and diabetes. Specifically, the orders read: -[MEDICATION NAME] 0.125 mg tab every evening (noted as typically given at 5 p.m.), hold for apical heart rate less than 50, started 5/4/12 for [MEDICAL CONDITION]. -[MEDICATION NAME] CD 180 mg cap daily for hypertension, started 11/7/12. -[MEDICATION NAME] 100 mg tab QHS (every night at bedtime) for [MEDICAL CONDITION], started 5/29/12. -[MEDICATION NAME] 600 mg tab BID (twice daily) for pneumonia, started 5/4/12. -KCL 10 meq, two tabs every morning for potassium replacement, started 9/28/12. -[MEDICATION NAME] 20 mg 1.5 tabs every morning for [MEDICAL CONDITION], started 9/28/12. -Losartan/HCTZ 100/25 mg tab daily for hypertension, started 4/3/13. -Mag-Ox 400 mg tab daily supplement, started 3/13/13. -[MEDICATION NAME] HCL 1000 mg tab film coated BID for diabetes, started 5/2/13. -[MEDICATION NAME] daily and Senna S twice daily for constipation, ordered 5/10/12. -[MEDICATION NAME] 10 mg tab every morning for polymyalgia rheumatica, started 5/4/12. -[MEDICATION NAME] 150 mg capsule gelatin coated BID for [MEDICAL CONDITION] reflux disease, started 10/16/12. -[MEDICATION NAME] 80/4.5 mcg 2 inhalation BID for prevention, started 5/30/13. -Tylenol [MEDICATION NAME] coated 500 mg, two tabs QHS for pain, started 8/21/12. Care Plan: The resident's care plans (prior to her hospitalization ) noted in pertinent part the following problems: -5/1/13 "Pain management r/t polymyalgia with [MEDICATION NAME], [MEDICAL CONDITION] d/t DM (due to diabetes mellitus). Res would like to remain on low dose [MEDICATION NAME] permanently no matter SE (side effects). Says she would rather be pain free. Res has scheduled and PRN (as needed) medications." -5/1/13 "H/O (history of) pneumonia and trouble breathing - has oxygen. Scheduled inhalers and [MEDICATION NAME] BID (twice daily) ... Administer meds as ordered and assess for side effects and effectiveness." -5/1/13 "Diabetes mellitus II with scheduled medications ... Administer meds as ordered and monitor for side effects." -5/17/13 "Meal intakes are below estimated needs. Weight loss. Res reports occasional [MEDICAL CONDITION] swallowing problems, and does not want food intervention. Resident tends to fall asleep at meals. Hx of c/o (history of complaints of) food not tasting good. Complications: potential for weight fluctuation r/t [MEDICAL CONDITION]. Hx of refusing supplement. Strengths: above IBW (ideal body weight). Feeds self. Makes needs known. [MEDICATION NAME] swallow study on 2/2/10 showed no aspiration. See speech therapy screens. Likes buttermilk and Activia yogurt." Resident goals...Resident will consume at least 45% average of meals, with no significant weight loss... Interventions (in pertinent part were): Monitor intakes and weight per facility protocol. Monitor swallow and request speech therapy screens as needed. Offer snacks. Wake resident as needed to continue eating." Nutritional Assessment: According to the resident's 5/3/13 nutritional assessment, the resident's fluid needs were 1950 ccs per day. b. Change of Condition Record Review: Record review revealed resident #1 complained of an inability to swallow and to keep anything down for several days prior to her hospitalization [DATE]. During this time, the resident refused some and then all her medications, including medications for pain, hypertension, and cardiac arrhythmia. Her food and fluid intake also declined. (1) Nurses' notes documented: -On 6/23/13 at 6:45 a.m., "Res refused all HS oral meds due to GI upset & not feeling well. V/S BP 123/67, P78 R16 T98 02 sat 92% on RA." -On 6/23/13 at 5:24 p.m., "Res refused all meds today r/t 'can't swallow well' and res reports 'I don't think they will stay down.' VS: BP 140/64; P 84, R 18, T 98.2, 02 sat 93% @ RA." -On 6/24/13 at 5:29 p.m., "Res c/o not 'being able to swallow very good,' declines to take her medicine, reporting she does not feel they will 'stay down'. This nurse has had no reports of emesis this shift, visualized small amount of thick sputum in emesis basin, res' VS WNL. Late entry for 6/23/13 - Res refused meds during day shift for same reason as stated above. No reports of emesis, VS WNL." -On 6/25/13 at 12:39 p.m., "MD faxed 6/23/13 for an office visit to examine open area to right lower leg, appointment made 6/27/13 at (3:45 p.m.), res notified." There was no documentation the physician was notified at this time of the resident's reports of nausea, inability to swallow, or medication refusals." -On 6/26/13 at 6:50 a.m., "Res discharged to ... hospital at (7:35 p.m.) on 6/25. Res was c/o N/V, hadn't taken medications in 4 days, and son was worried about her. (Physician) came to see resident and decided to send her to the ER. Res was admitted to (hospital) medical floor with dx N/V dehydration." -On 6/29/13 at 12:31 p.m., "Late entry for 6/25/13 - Res refuses meds again this shift due to she does not feel she can swallow the pills and keep them down. No reports of emesis, thick sputum in the emesis basin. VS WNL. Res reports she is 'just tired.' She reports she has drank some tea and some water, 'the tea goes down better' and has eaten 'a little bit of soup, and some pudding, and some cereal with bananas.' VS WNL: BP 106/52, P60, R20, T98.4, 02 sat 93% @ RA." 6/25/13 (5:30 p.m.) "Res son ... in facility to visit res; he came to the nurses' station demanding res go to the ER right now. This nurse assessed res, obtained VS: BP 136/100, P88, T100.2, R28, shallow, 02 sat 93% @ RA. Res was reporting at that time (with her son in the room) 'You know I have been like this all day, since Friday night (6/21/13).' That was not the report this nurse had received. Res stated on 6/25/13 am, 'I'm feeling a little better today, I might try to go down to the dining room sometime.' When res' son was here she appeared worse, and after her son left the facility CNAs reported res was resting and breathing normally." "(Physician's) answering service notified via phone call from this nurse, Dr. on call ... returned call, report given on res' condition, (dr. on call) advised he would come in and assess res." (2) Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Review of resident #1's MAR for 6/1-6/30/13 revealed her medications from 6/22 through 6/25/13, four days prior to hospitalization , were noted as either "held," or "refused." "Routine Meds Notes," where nurses documented the reasons for not giving medications, stated in pertinent part as follows: -6/22/13, 8 a.m., [MEDICATION NAME] CD, "held AM meds due to GI upset." -6/23/13, 8 a.m., [MEDICATION NAME] CD, "refuses all am meds r/t 'too difficult to swallow pills today.'" -6/24/13, 8 p.m., [MEDICATION NAME], "not feeling well." -6/24/13, 8 a.m., [MEDICATION NAME] CD, "res reports 'I don't think I should try the pills because they won't do me any good if I throw up.'" -6/25/13, 8 p.m., [MEDICATION NAME] CD, "res does not feel she can swallow the pills and keep them down." (3) Food and Fluid Intake Records The resident's meal intakes for 6/13, where fluid intake was also documented, revealed the resident consumed less than half her necessary fluids on 14 out of 25 days. On 6/23, she was documented to drink only 50ccs of fluid, on 6/23 she was documented to drink 990ccs, on 6/24 she was noted to drink 310ccs, and on 6/25/13 she was noted to drink 340ccs. Her meal intake during 6/13 was low, especially from 6/22 through 6/25/13. Specifically, the resident ate no breakfast, lunch or dinner on 6/22; she ate 10% of breakfast and dinner and 20% of lunch on 6/23; no breakfast or lunch and 10% of dinner on 6/24; and no breakfast or dinner and 15% of lunch on 6/25/13. Interviews: (1) Resident #1 was interviewed at 10:45 a.m. on 7/3/13 regarding her condition prior to hospitalization [DATE]. She stated, in pertinent part: -"I haven't been able to swallow properly for a long long time, but it got to where I couldn't swallow at all. I'd just sit and gag and gag and gag. I'd gag until I felt everything was coming out, and then I'd spit out just a little bit of thick phlegm. This is how I got so dehydrated. There were at least four days where I didn't swallow anything. I'd try but I couldn't. The nurses had to hear me gagging - it was loud ... " -"I didn't take any pills, any meds whatsoever for over a week I'm sure - in my state of mind I can't be 100% sure - but every time they'd come and ask 'Do you want your meds today?' I'd say, 'What good would it do? I can't swallow them.' ... (My nurse) said, 'I didn't know you were sick.' I got angry and said, 'There's no way you couldn't know.' (It was a) swallowing problem - I'd just gag until I felt I couldn't gag any more ..." -The resident said, "I was asking in a quiet way that wouldn't upset anyone, was what I was trying to do ... I was becoming very disoriented on Tuesday night (6/25/13) ..."You have no idea how scary it was. For at least a week I didn't swallow anything." (2) The resident's family member/power of attorney was interviewed by phone on the morning of 7/9/13. He said, "On Friday night 6/21/13 (the resident) became very ill, vomiting, and was sick all night. Saturday was the same. (Family members) stopped in to visit, but nobody reported to them that Mom was ill. Her vomiting and illness continued Saturday, Sunday, Monday and Tuesday. ... At 4:45 p.m. on Tuesday 6/25/13, I visited and Mom was looking (very ill)." c. Facility Failures Record review and interview revealed nursing staff failed to adequately monitor, assess, and recognize resident's change of condition and failed to communicate this change and the resident's medication refusals to the physician as expected. (1) See nurses' notes above. Although nursing documented the resident's symptoms and medication refusals, there was no documentation that the resident's condition was comprehensively assessed 6/22 through 6/25/13. Vital signs were taken, but there was no evidence the resident's decline in food and fluid intake was considered and no evidence that staff communicated with the physician about the resident's complaints and sought interventions to address them. Finally, there was no evidence staff attempted to address her symptoms, in particular, her swallowing difficulties and GI upset. The resident had an order for [REDACTED]." The resident also was documented as receiving Tylenol once 6/22 - 6/25/13, on 6/25/13 at 8:27 p.m. (although per nurses' note above, she was discharged at 7:35 p.m.) Resident #1 was interviewed on 7/3/13 at 10:45 a.m. about the facility's response to her condition 6/22 - 6/25/13. She stated in pertinent part, that the certified nurse aides (CNAs) would run and get her something to spit in "but that was as far as actual help went." She said, "They should have called the doctor but they didn't." She further stated that when she put on her call light, staff would check on her roommate but not on her. (2) The resident's family member, interviewed by phone in the morning on 7/9/13, said during his visit to the resident on 6/25/13 at 4:45 p.m., he reported the resident's condition to facility staff, who said they had already called the doctor's office and could not get an appointment until Thursday afternoon at 3:30 p.m. He said he located the resident's doctor and asked him to stop in and visit resident #1. He said resident #1 told him she would push her call light for help and they would visit with her roommate and then leave; this happened repeatedly over the weekend (6/22 and 6/23/13). She told him she felt (awful) and said 'They just left me here.'" (3) See nurses' notes and MAR indicated [REDACTED] Although the resident missed four days of medications, including her [MEDICATION NAME], and [MEDICATION NAME] and Losartan (antihypertensives), nurses did not adequately document, report or follow up shift to shift, or communicate with the resident and her family about the resident's repeated refusals to take her medications, starting 6/23/13. Review of the facility policy on "Administration of Medications" revealed it required in pertinent part: "The nurse must enter an explanatory note on the MAR indicated [REDACTED]. (Note: The attending physician must be notified when two (2) doses of medication are refused or withheld.)" Review of the facility's pharmacy policy and procedure, revised 3/13, provided in pertinent part: "If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time ... an explanatory note is entered ... If two consecutive doses of a vital medication are withheld or refused, the physician is notified." There was no evidence on the MAR indicated [REDACTED]. d. Resident Status 6/25/13 On 6/25/13 (untimed) the resident's physician noted: "Pt (with) N&V x 4 days, poor intake. (No) meds x 4 days, including [MEDICATION NAME] for PMR (illegible) DM. Nursing unable to provide IV access, thus (transferred) to (hospital), IV fluids, IV steroids, (illegible)." The resident was discharged to the hospital in the evening on 6/25/13. She was hospitalized for [REDACTED]. Hospital Documentation revealed: (1) The emergency department report dated 6/26/13 read in pertinent part: "This elderly female presents with several days of nausea and vomiting and is feeling uncomfortable from her chronic conditions and appears a bit dehydrated as well ... Final impression: (1) Nausea with vomiting, (2) Polymyalgia rheumatica, (3) Dehydration." -"She has not been able to take her regular medications which helped control numerous comorbid conditions including polymyalgia rheumatica and hypertension and diabetes ... has had significantly decreased urine output in recent days." (2) The internal medicine progress note dated 6/25/13 read in pertinent part: "Assessment/Plan: Nausea & vomiting, 4 days duration, no meds x 4 days. Polymyalgia rheumatica, stable on [MEDICATION NAME] 10 mg daily, but no meds since Friday. So will start with IV [MEDICATION NAME] (corticosteroid anti-[MEDICAL CONDITION]) til resuming diet, then back to usual dose. Pain due to coming off steroids abruptly. Diabetes mellitus..." -"General appearance - dehydrated, anxious and chronically ill appearing ... mucous membranes dry thin skin, poor IV access." -The resident was noted as given [MEDICATION NAME] for nausea on 6/26 and 6/27/13. (3) The hospital discharge summary (dated 7/1/13) documented in pertinent part: She "presented with a 4 day hx (history) of nausea and vomiting. She was admitted and treated w/ IV (with intravenous) fluids and antiemetics. Because of abdominal pain a CT (computerized tomography) abdomen was obtained which was negative for GI (gastrointestinal) process but demonstrated PE (pulmonary embolism) and [MEDICAL CONDITION] infarct in RLL (right lower lobe of the lung). A fu (follow up) venous doppler confirmed right leg [MEDICAL CONDITIONS]. The patient was started on [MEDICATION NAME] and [MEDICATION NAME]. Because of dysphagia a speech evaluation was obtained and subsequently GI eval w/ EGD (Esophagogastroduodenoscopy). She had a Schatzke's (lower [MEDICAL CONDITION] mucosal) ring dilated. After this procedure she was able to tolerate her diet w/o difficulty. It was felt that she could return to (the long term care facility)." (4) A SLP (speech language pathologist) evaluation note 6/27/13: "Pt referred for swallow eval w/ c/o dysphagia for last several years. Pt resides at (LTC facility) and was admitted with 3-4 day hx of nausea and vomiting. Pt currently on liquid diet. Pt seen at bedside, alert and interactive. Pt reports feeling 'miserable' and was tearful during my visit. She reports ongoing issues with swallowing difficulties. She reports frequent [MEDICAL CONDITION] pain, mid-sternal discomfort with fluids and solids. Pt reports reflux and that 'my esophagus doesn't work.' Pt trialed with water but demonstrated immediate grimacing, clutching her chest and retching with some post prandial reflux observed. Pt did cough several times during trials as well. Impressions: Pt with obvious [MEDICAL CONDITION] discomfort/dysphagia, query presbysophagus vs. stricture vs. ? Pt likely having some pharyngeal involvement r/t esophagus with possible airway penetration. Pt may benefit from GI consult or esophagram ..." The SLP noted on 6/29/13, "Pt seen for f/u visit ... s/p EGD and [MEDICAL CONDITION] dilation yesterday ... Impressions: Pt appears much improved following procedure yesterday although w/ some mild continued symptoms. Pt appears safe for diet upgrade and would recommend pureed diet to start [MEDICAL CONDITION] (upright in chair, alternate fluids/solids). Can ADAT (advance diet as tolerated) after that but will likely do best with mech soft/soft diet ultimately." The SLP noted on 6/30/13 ...Pt appears to have responded well to GI intervention. The resident was discharged back to the facility on [DATE] with diet orders of "no restrictions (may return to usual diet)." e. Staff Interviews A CNA who provided care for resident #1 was interviewed at 4 p.m. on 7/3/13. The CNA said, "The last day before she went to the hospital, it was like she was trying to cough up phlegm. She said, 'I'd feel better if I could cough this phlegm up.' She said she thought she'd gotten most of it up and out, and didn't want to go to dinner. Other than that don't recall ... I think it was on a Tuesday. She was doing pretty good with drinking. She had quite a bit of fluid in her room - there were no reports of swallowing difficulty." Two other CNAs who provided care for resident #1 were interviewed the afternoon of 7/3/13 and said they did not recall the resident having nausea, vomiting or swallowing difficulties before she went to the hospital. The licensed practical nurse (LPN) who provided care for resident #1 on the day shift prior to her hospitalization was interviewed at 10:30 a.m. on 7/8/13. She said, in pertinent part: -"Over the days I worked - she's done this before where she'll go two to two and a half days where she can't swallow. She had her esophagus stretched years ago and she said her doctor didn't want to do that again, but they did do that again this last hospitalization . She said she didn't want to swallow her pills. She said she was drinking iced tea and water but mostly iced tea because she liked it. One of the CNAs said she was drinking some of those Sobes but she didn't take her pills." -"I called (the physician's office), I think it was Monday (6/24/13) or Tuesday (6/25/13) two weeks ago and talked to Dr (name) and he came in later that evening. That's when he decided to send her in to see what was going on because she hadn't taken her pills. It had been three days. Tuesday morning she said she was feeling better but she didn't want to take her pills because they came back up anyway. I didn't see any emesis or have reports of emesis - I saw thick sputum in her emesis basin. Her vitals were within normal limits, nothing was out of character for her ..." -"She does take [MEDICATION NAME] and [MEDICATION NAME]. I can't remember all her meds. She has some BP meds, I think ... and she has one diabetic med ..." -"I now know that if it's greater than two consecutive times (missed medications), we're supposed to let the doctor know and let the family know. I didn't know she wasn't eating anything because she was telling me she was eating. She was telling me she'd had some cereal with bananas for breakfast, and then she had some soup. They brought her broth; she said she'd had some banana pudding one night. I thought she was eating. Dietary couldn't find where it was recorded what she was eating..." -"She was afraid her pills wouldn't go down because of her esophagus, or that they'd come back up. I didn't realize she'd not taken her pills the day before I was there. Typically when somebody is saying they can't swallow their pills I'd definitely notify the doctor if it was more than one time." -"I reported to the night nurses she didn't take her pills - I think the prior night nurse reported to me when I came on - I was with her 3 days. I saw her drinking some tea when I went in there. She seemed to do okay, seemed to be swallowing okay, was taking small sips, and it didn't seem to come back up. I saw where she had eaten the banana pudding - there was an empty container on the tray - a little sputum in her emesis basin - about a quarter size ..." -"In hindsight I should've called that doctor on Monday morning (6/24/13) and talked to her doctor and told him what was going on and called her family and then seen if (the PCP) wanted to see her, come in. I wouldn't have called Sunday because most of the time it's not the regular doctor - I can call the on call doctor ...I'd given a note to the receptionist because they said she should really go see the doctor so I talked to the receptionist - she said she's already got an appointment (but the appointment was for something else). I probably didn't call the doctor myself, but it was just so busy." -"I kind of talked to (one of the CNAs), who told me she seemed to be eating and drinking, maybe not as much, but softer, easier to swallow things." f. Action taken during survey The director of nursing (DON) was interviewed at 3:30 p.m. on 7/8/13. She said resident #1 "has on occasion done the exact same thing, refusing meds, not eating, then she feels better ... I began an investigation because of the resident's hospitalization ... I wrote up three nurses total as a result." The DON said the facility policy stated nurses should report to the physician when a resident had refused or missed two consecutive medications (see policy above). The DON demonstrated that she had issued warning statements to two RNs (on 7/3/13 and 7/5/13) and the LPN (undated), completed "Medication Discrepancy Reports" on 6/26/13, and re-educated all nursing staff on 7/5/13. The DON documented the following in the warning statements issued to the nurses involved: "Resident ... was ill these 4 days (6/22-6/25/13). She refused all PO meds, c/o difficulty swallowing and N/V. Her meal intake and fluid intake for the 4 days decreased to almost nil. The nurse failed to notify the physician and family of a change of condition. The nurse also failed to notify the physician that resident had not taken vital medication for >2 consecutive doses." 2. Resident #2 Resident #2, a [AGE] year-old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. Resident Status MDS: According to his 6/12/13 admission MDS, he had a BIMS (cognition) score of 15 indicating he was cognitively intact, and no behavioral symptoms. He required extensive two-plus-person assistance with bed mobility, transfers, dressing, and toilet use. He had an external condom catheter, was occasionally incontinent of bladder and frequently incontinent of bowel. He used a power wheelchair for ambulation. Orders: According to physician's orders and medication administration review, the resident was taking [MEDICATION NAME], a diuretic, 40 mg three times daily, for [MEDICAL CONDITION], beginning 6/5/13. Care Plan: The resident's 6/12/13 care plan for bowel and bladder function identified "condom catheter r/t persistent overflow incontinence ... Staff to change as needed per protocol. Staff to provide catheter care per facility protocol." physician progress notes [REDACTED]. The resident's primary care physician noted on 6/4/13, "Pt has been admitted from his residence ... He has many needs. His doctor was very concerned about him. He is now in a safer environment. He has concerns regarding urination ... Assessment/Plan: Urinary incontinence ... Advised that a foley catheter is not indicated. Given the choice between Texas (condom) catheter and depends. He chose depends." -On 6/26/13, the physician noted, "Today (resident's) biggest concern is his inability to control urination. This is NOT a new problem. He wants to restart a condom catheter ... Given the choice between Texas (condom) catheter and depends. He chose condom catheter." Physician Orders: -Physician telephone orders on 6/26/13 at 2 p.m. noted, "Restart condom catheter per pt. wishes. Dx (diagnosis) = urinary incontinence." -Physician telephone orders on 6/28/13, no time noted, documented: "Condom Cath: Dx Persistent Overflow Incontinence." b. Failure to follow physician orders for condom catheter use Record Review: Treatment Administration Record (TAR): The resident's TAR documented the condom catheter as a PRN FYI order during 6/13. The condom catheter was never documented as being implemented. However, under "Treatment Notes," nurses had documented under "Foley Cath Care" the following: -6/1/13 at 10 p.m., "condom cath" -6/2/13 at 10 a.m., "res has condom catheter, replaced x 3 this shift 6a-6p" -6/3/13 at 10 a.m., "res has condom catheter, replaced x 2 this shift, 6a-6p" -6/4/13 at 10 a.m., "condom cath care" -6/7/13 at 10 a.m., foley cath care was initialed but there was no note. Interdisciplinary Team Notes: IDT notes documented in pertinent part as follows: -6/1/13 "condom catheter is intact draining w/ yellow urine." -6/2/13 "condom catheter is patent." -6/5/13 "condom catheter removed and attends provided per request." -6/12/13, the social services director noted, "complaints that staff was not answering his light fast enough." -6/14/13, MDS initial assessment review noted, "resident needs a maxi-lift with two for all transfers ... bladder and bowel incontinence ... diuretic use." -6/19/13, MDS care plan conference notes, the resident's family/representative "asks why the catheter was dc'd. Restorative explains caths are used for skin breakdown, [MEDICAL CONDITION], but not for incontinence. Res c/o staff not answering the call light helping fast enough especially during the day, nsg will fu ... Res states he would be more social if he had a catheter. Res and son state res has seen a urologist, and the treatment made things worse. Res has been on [MEDICATION NAME] for at least 2 years. Res says he can't use a urinal without staff help. Nsg offers to take the urine problem to an IDT meeting to find a solution and res agrees. Res has no control of urine. Son says res retains quite a bit of urine, so nsg suggests a new urology appointment. Res wants to be dry. Res says staff checks every 2 hours, but they hardly get out the door before he is wet again ... Son says the two big issues are the catheter and the roommate (the resident changed roommates)." -6/27/13, "New order for condom cath for urinary incontinence per res wishes." -6/28/13, "Condom cath dx: persistent overflow incontinence." Resident Interview: Resident #2 was interviewed on the morning of 7/3/13. He said call light response wait times were sometimes as long as 30 minutes, and he pointed to a large clock on the facing wall that he referred to. He said he was tired of sitting in urine, and that staff checked and changed him every two hours but that was not often enough. He said when he rang his call light by the time staff arrived, it was too late. He said he was embarrassed to leave his room, participate in activities, and sit at the table in the dining room, if he was wet and smelling of urine. During a follow-up interview on the afternoon of 7/3/13, the resident said he had requested a physician order for [REDACTED]. c. Action taken during survey Observations on 7/3/13 at approximately 6 p.m., the resident's door was closed. A CNA said the nurse was applying the resident's condom catheter. During a follow-up interview at 2:30 p.m. on 7/8/13, the resident said, "The condom catheter is working better. I don't have to lie in urine anymore." Staff Interviews: The DON was interviewed the afternoon of 7/3/13 about the resident's condom catheter order. She said staff had probably not implemented the order, probably because they were unfamiliar with condom catheters. She said they were in stock and she would follow up. A CNA who provided care for resident #2 was interviewed on 7/3/13 at 4 p.m. He said he had never heard resident #2 complain about call light response. The CNA said he would check on the resident more often for toileting and changing assistance. An LPN who worked with resident #2 was interviewed at 10:30 a.m. on 7/8/13. Regarding resident #2's condom catheter, she said she had not heard him complain about call light response or about incontinence. She said she had not heard any requests for him to have a condom catheter. "Yesterday he didn't say anything about not having a catheter or having it changed or anything. From what I've seen he does get changed more than every two hours, but not necessarily in the afternoon after lunch ... I know the CNAs try to answer the lights as soon as they can. But I do look down there (in the hallway) and six lights are going off - he doesn't like the urinal because he said he can't always make it." -The LPN checked the computer and said, "There is no order for catheter care, and the order on the TAR says PRN, FYI so we need to get that order changed." In a follow-up interview at 3:30 p.m. on 7/8/13, the DON was asked about the inaccuracy of the treatment record (PRN, FYI) and lack of condom catheter instructions on the treatment record. She said the issue was already being addressed, and that she knew the condom catheter had been implemented. Although the facility staff was aware of

Based on observation, record review and family and staff interview, the facility failed to provide supervision and assistive devices to keep three of three sample residents (#1, #2, #3) safe from falls. Although residents were assessed at high risk for falls, and/or had a history of [REDACTED]. Residents #1 and #2 sustained additional hip fractures. The findings included: A. EXPECTATIONS 1. Professional Reference regarding Fall Prevention According to the Hartford Institute for Geriatric Nursing Fall Prevention Nursing Standard of Practice Protocol, updated January 2008, in part: "The highest fall incidence occurs in the institutional long-term-care setting, where 50% to 75% of the 1.63 million nursing-home residents experience a fall yearly. Falls rank as the eighth leading cause of unintentional injury for older Americans and were responsible for more than 16,000 deaths in 2006." "Intrinsic risk factors to fall (include): -Advancing age, especially if older than 75 -History of a recent fall -Specific co-morbidities: dementia, hip fracture, type II diabetes, Parkinson's disease, arthritis, and depression." "Institute general safety precautions according to facility protocol, which may include: -Referral to a falls prevention program -Use of a low-rise bed that measures 14 inches from the floor -Use of floor mats if patient is at risk for serious injury -Easy access to call light -Use of personal or pressure sensor alarms -Increased observation and surveillance -Regular toileting at set intervals and/or continence program; provide easy access to urinals and bedpans." "Identify specific patients requiring additional safety precautions and/or evaluation by a specialist or: -Those with impaired judgment or thinking due to acute or chronic illness -Those with osteoporosis, at risk for fracture -Those with current hip fracture." 2. Facility Policy/Procedure The facility policy for "Fall/Accident Assessment, Prevention and Management," dated March 2010, provided in pertinent part: "Elders are assessed for fall risk upon admission to facility. Elders at risk for falls have a care plan in place with interventions to reduce the potential for injury from falls. Newly admitted elders assessed as being at high risk for falls will be placed on the 'Star Program.' With the stars as indicators, all staff members will be alerted to the fact that these residents may be at increased risk for falls. Interventions to be put into place for these residents are as follows: -Upon review of the elder's record prior to admission, the RN assessor will be alerted to conditions that put a person at increased risk for falls (i.e. infectious process, mental dx, h/o falls). He/she will relay this information to the Admissions Coordinator so that the elder can be admitted into a room as close as possible to the nurse's station. The MDS Coordinator will insure that an acute care plan is in place for risk for falls. -If the resident was on alarms at the hospital, they will be placed on the resident immediately. Otherwise, the admitting nurse upon completion of the admission assessment, will complete a wander guard assessment for placement of alarms on bed and WC if he/she feels that they are warranted. The nurse will also explain precautionary measures to elder/family. Upon further assessment, the nurse, with input from therapy and CNA staff, will determine whether a low bed with a fall mat is appropriate. (Hip precautions may be in place.) -LTC elders with an infection may be included in the Star Program when deemed appropriate (i.e. presence of other risk factors such as dementia or h/o falls with infectious process)." B. RESIDENT FAILURES 1. Resident #1 Resident #1, a closed record review, was an [AGE] year-old female admitted to the facility from the hospital on [DATE], and discharged back to the hospital on [DATE]. Her [DIAGNOSES REDACTED]. a. Resident Status on Admission Review of the resident's physician discharge instructions, dated 12/13/10 at 2 p.m., revealed [DIAGNOSES REDACTED]. She was to have "hip precautions - CGA (contact guard assist), dressing change every two days, staples out 12/23/10, 50% wt. bearing." According to the 12/13/10 hospital transfer summary form, the resident was to have assistance with bathing, dressing, mobility, ambulation, transfers, and toileting. Her physical safety devices were front wheeled walker. She was noted to have stress incontinence, and was alert but forgetful. Her activities were up to chair and rehabilitation. Surgeries were listed as 12/9/10 left hip nailing. The facility's Nursing Admission Assessment, dated 12/13/10 at 4 p.m., documented in pertinent part: -The resident had short-term and long-term memory problems and cognitive difficulty in new situations only. She was usually able to understand others and make herself understood. Her vision was impaired, and it was noted that she had a behavioral symptom of wandering. -The resident was noted as continent of bladder, and used briefs, but that urinary continence had deteriorated. -The resident needed one-person assistance with transfers, extensive assistance with ambulation, and limited assistance with toileting. However, she was also noted as bedfast and using a wheelchair. In the assessment narrative, it noted the resident was admitted to the hospital after an intertrochanteric fracture of the left hip, post fall 12/8/10. b. Fall following admission - pain - right hip fracture The resident's family member was interviewed by phone on 1/10/11 at 10 a.m. The family member said that on 12/13/10, she had checked her mother (resident #1) into the facility, gotten her settled, met two aides and the admitting nurse, and was leaving when she heard the resident calling her name. She told another aide to check on her mother, and went to the nurses' station and "they said they'd get someone to help her - I don't know if that's when she fell . It's possible she tried to take herself to the bathroom. I left at 6 p.m., and got the call an hour later that she'd fallen and was back in bed." According to the fall report, dated 12/13/10 at 7:30 p.m., the resident had a "Bed-Fall" ... "Has ROM (range of motion) to Rt (right) leg (with) no severe pain (with) movement. Does (complain of) ache to right thigh." She fell at the foot of her bed "attempting to walk by bed." The resident reported she was "Going to get a drink of water." Review of the Interdisciplinary Progress Notes revealed a nurse documented at 10:48 p.m. on 12/13/10, that the resident was "admitted during the day with left hip nailing. Dresg (sic) to left hip dry and intact. 5 minutes after nurse assessed res(ident), she attempted to amb (ambulate) around her bed and fell to her buttock. No bruising or abrasions or any sign of injury other than sore right thigh. Applied ice and gave her a pain pill. Resident is watching the ball game on TV. Will continue to monitor right leg and faxed Dr re above info. B/P 110/60, pulse 85, resps 18 and sat 93% on 2L. Temp is 97 before her fall. After fall B/P 108/60, pulse 90, resps 22 with sat of 95% on 2L. Cont to be confused. Daughter ... called re above. Agrees with plan. Will reassess with Drs if X-ray is warranted in am. Placed sensor pad to bed after fall and daughter agrees." On 12/14/10 at 2:37 a.m., the nurse noted the resident was "calling out and confused. Complained of butt pain but no more thigh pain. Medicated again for pain. Sensor pad active." On 12/14/10 at 10 a.m., another nurse noted, "Call to Dr's office at 9 a.m. with a request for a portable X-ray of pt's right hip r/t pain and a fall last evening, rt. hip is internally rotated. Received an order for [REDACTED]." On 12/14/10 at 11:30 a.m., the nurse noted, "Results of right hip X-ray = impression: intertrochanteric fracture is present with avulsion of the lesser trochanter. Varus angulation of the fragments is present. Pelvic ring visualized is intact. Code: Undiagnosed fracture of a major bone/pelvis. ... Daughter notified and spoke with patient about the need to go back to the hospital. (Pt has dementia.) Waiting for orders to transport back to (local) hospital." On 12/14/10 at 1:10 p.m., the nurse noted "call to Dr's office and received an order to transport to (local) hospital. Call for a non-emergent transport at this time. Family present in room." The resident did not return to the facility after her 12/14/10 hospitalization . c. Facility failure to adequately address resident's risk for falls on admission Review of the resident's acute care plans revealed that, although the resident was admitted to the facility at 4 p.m. on 12/13/10 with risk factors for falls (hip fracture, bladder infection, dementia and visual impairment - see hospital discharge and nursing assessment above), interventions to reduce the resident's risk for falls and injury from falls were not promptly implemented. (1) Review of her initial acute care plan, dated 12/13/10, revealed it read: "Risk for falls related to history, pain, weakness, impaired balance, and general deconditioning. The goal was "safety and follow up need for X-ray to right leg - will have decreased potential for injury from falls over the next 30 days." Interventions were: "Sensor pad to bed, follow up with Dr re need for X-ray 12/14. Nurse to document fall risk per protocol and alert staff of potential for falls. Keep call light within easy reach and enc(ourage) use of call light. Place on star program for falls." The above interventions, referencing the need for "X-ray of the right leg," indicated the acute care plan and the safety interventions it included were not implemented promptly after admission, but after the resident had fallen, approximately three and a half hours after admission. Even then, the care plan did not identify the resident's need for assistance with transfers and other activities of daily living (ADLs), did not address her weight bearing status, and did not include additional safety interventions indicated by the resident's high risk for falls, such as alarms, lowered bed, fall mats, and increased supervision (see standards of practice and facility policy above). Finally, the interventions developed included encouraging the resident to use her call light, an intervention that failed to take into consideration her forgetfulness (see hospital discharge above) and other cognitive difficulties (see nursing admission assessment above). (2) Review of the Fall Risk Assessment revealed it was completed on 12/13/10 at 10:31 p.m. The resident was assessed at 18, high risk for falls (a score of 16 or higher indicated high risk), due to confusion, elimination with assistance needs, one or two previous falls, visual impairment, attempts at unsafe transfers, gait and balance problems, and medications including analgesics and diuretics. The assessment, like the acute care plan above, was completed after the resident's admission and several hours after the resident's fall in the facility. The risks identified in the assessment were not incorporated and addressed in the resident's 12/13/10 acute care plan. (3) Another acute care plan was developed 12/14/10, but it, too, failed to include interventions to minimize the resident's risk for falls due to her confusion, visual impairment, gait and balance problems. It read, in pertinent part: "Decline in independence with ADLs r/t (activities of daily living related to) hip fx (fracture) due to fall at home, lives at (a local assisted living facility)." Interventions noted the resident was "50% wt (weight) bearing." d. Interviews (1) The resident's family member was interviewed on 1/10/11 at 10:00 a.m. The family member said that after the resident fell , staff put in place "an alarm, low bed, fall mats on each side ... Later, not before. I don't want them to wait until someone has a fall to put precautions in place. I want them to assume someone with a broken hip is a fall risk." The family member said the resident had "quite a bit of memory issues. She couldn't remember to use the button to call the nursing staff." The resident's family member/power of attorney, was interviewed by phone on 2/1/11 at 9:30 a.m. She said she recalled the resident was admitted to the facility at about 5 p.m. The facility called at 7:30 or 8 that night to report the resident's fall. "I was under the impression myself that it had just occurred." She said the resident was in another long-term care facility and the family member did not expect the resident would ever get back to her assisted living apartment. (2) The clinical coordinator was interviewed the evening of 1/11/11. She said the day the resident was admitted was very busy. Asked why fall precautions were not put in place sooner for resident #1, she said, "We usually put tab alarms and/or sensor pads in place when residents are at risk for falls. I believe that (the admitting) nurse was in the process of getting the alarms to put them in place (when the resident fell ). In hindsight, having it in the room available would have been better. We put a star outside their door so we know they're a fall risk - the star was in place. It was less than three or four minutes, and (the nurse had) just gone in there to assess her ... We put people closer to the nurses' station (when they are at high risk for falls)." (Observation of the resident's former room revealed it was near the nurses' station.) (3) The Director of Nursing (DON) and Nursing Home Administrator (NHA) were interviewed the evening of 1/11/11. The DON said if residents have alarms in the hospital "we'll use them here." She said assessments were done in the hospital, and charts were reviewed by a facility nurse. The NHA said the resident was in pain, then fell , at the assisted living facility. "Her fall risk factor was dementia - putting alarms on an agitated person with no other history of falls" can agitate residents more. "You have to look at (each resident) as an individual." During a follow-up phone interview on 2/1/11 at 1:30 p.m., the DON was asked about hip precautions (see hospital discharge note above) and what that instruction entailed. She said the facility had no policy per se, and that therapy usually provided more specific recommendations to staff after assessing the resident. She later faxed a copy of "Total Hip Arthroplasty Anterior Approach Precautions" which gave the following instructions: "1. Do not extend hip - straighten hip excessively. 2. Do not abduct hip - move leg to the outside excessively. 3. Do not externally rotate hip - turn leg outwardly." An instruction sheet that appeared to be written for residents stated, "Do not bend over past 90 degrees. Do not cross your legs. Do not turn leg inward." The DON said if a resident was a fall risk upon admission, their assessing nurse notified staff before the resident arrived at the facility, added on the notification form that they were to be placed on the Stars program, and monitored for unsafe practices. The DON said resident #1 had not had bed or chair alarms in the hospital. In summary, the facility failed to promptly implement safety interventions after admission for a resident known to be at high risk for falls. 2. Resident #2 Resident #2, an [AGE] year-old male, was admitted to the facility on [DATE] with diagnoses, per the face sheet, including aftercare for healing traumatic fracture (left hip fracture with surgical repair 10/23/10), history of falls, depressive disorder, insomnia, hypertension, senile dementia, and cardiac pacemaker. a. Resident Status on Admission Admission nurses' notes, dated 11/6/10 at 2:26 a.m. (stet), documented the resident was admitted from the hospital for a syncopal fall at home resulting in a left femoral neck fracture. He underwent L-Hip ORIF (surgical repair) 10/23. Past medical history included left eye blindness, hypertension, atrial fibrillation, coronary artery disease, mild headaches, and dementia. Surgeries included pacemaker, right total knee and right hip replacement. He needed extensive assist with bed, ambulation and transfers. Nurse's notes on 11/7/10 noted the resident was on antibiotics for [DIAGNOSES REDACTED] and had a Foley catheter. (An 11/5/10 [DIAGNOSES REDACTED] culture was negative and nurses requested the physician discontinue the antibiotic.) Review of the resident's fall risk assessment, dated 11/6/10, revealed the resident scored 10, low risk. Review of the assessment revealed no mention of the resident's current healing fracture of the left (L) hip, his dementia, or his antihypertensive and antidepressant medications (with potential side effects of vertigo, dizziness, confusion, and gait abnormality). According to his 12/5/10 MDS, resident #2 was severely cognitively impaired. He needed extensive two-plus-person assistance with bed mobility, transfers, and toilet use; and extensive one-person assistance with ambulation, dressing and personal hygiene. He was unsteady and needed balance assistance with moving from a seated to standing position, moving on and off the toilet, and transfers between bed and wheelchair. He was frequently incontinent of urine and occasionally incontinent of bowel. He had range of motion limitations on one side to his lower extremities, and used a walker or wheelchair for ambulation. He had experienced occasional, mild pain during four out of five days. He was coded to have had no falls before or after admission (but see admission notes above). Although assessed at low risk for falls, the facility developed an acute care plan on 11/6/10, identifying the resident as at risk for falls related to "history, pain, weakness and impaired balance and general deconditioning. Fall at home with hip fx (fracture)." Interventions were document fall risk, alert staff of potential for falls, keep call light within easy reach and encourage use of call light. The care plan failed to address the resident's visual impairment and severe dementia (see MDS above) that made the interventions of "keeping call light within easy reach" and encouraging its use inappropriate. b. Fall after admission - re-fracture L hip - facility response On 11/23/10, a care conference note documented the resident was building strength and endurance in therapy. He was working on balance, and able to stand about one minute unassisted. He was noted to have short-term memory problems. (1) 11/26/10 Fall with injury: On 11/26/10 at 6:06 p.m., a nurse noted the resident was found on the floor flat on his back, lying beside his roommate's bed. He had tried to walk and fell and hit his head on the bed. He had a laceration to his left occipital area, reported severe pain to his left hip and shoulder, and was unable to move his left hip. He was transported to a local hospital for evaluation. According to the fall report, he fell at 5 p.m., was "walking self - light off." On 11/28/10, he was readmitted to the facility from the hospital with an inoperable left hip fracture. His Foley catheter was discontinued in the hospital as he had a urinary tract infection (UTI). He was prescribed Levaquin for the UTI according to physician orders. Facility response: On 11/30/10 at 9:20 a.m., a late entry for 11/28/10 noted a tab alarm was placed on the resident's wheelchair and bed to help prevent rising without assist "as he has had 2 falls that have resulted in a fx." The resident's 12/7/10 care plan identified a status [REDACTED]. The interventions were: "Nurse to document fall risk per protocol and alert staff of potential for falls. Keep call light within easy reach and enc(ourage) use of call light." Facility's failures: -The care plan did not reference the tab alarm, placed 11/28/10 (see above). -There was no evidence of a re-assessment of the resident's fall risk after the resident experienced a fall with hip fracture and additional falls afterward in the facility. The DON was interviewed by phone on 2/1/11 at 1:30 p.m. and asked why the resident's fall risk had not been reassessed after he fell [DATE]. The DON said fall risk assessments were updated quarterly and with a significant change, and the resident had not yet been in the facility for 90 days. She said the resident had not had a significant condition change per the MDS requirements. -There was no documentation the facility initiated bladder assessments and retraining after the resident's catheter was removed on 11/28/10 during his hospitalization . c. Additional incidents - 12/23/10, 12/29-12/30/10 (x 3), 1/3/11 1) 12/23/10 On 12/23/10 at 10 a.m., nurse's notes documented: "Res with sit down type of fall today unwitnessed. Says 'I tried to stand up and slid down. I'm sorry.' Also related he was transferring from his w/c (wheelchair) to his bed. Res was sitting on the floor beside his bed with his urinal lying on the floor beside him. Full ROM (range of motion) to all extremities wnl (within normal limits) for res. Some pain in his L hip which was also previously present. Stood well to chair and transfers to toilet and bed." According to the fall report, dated 12/23/10, the resident was found at 9 a.m. The resident's activity at the time of the fall was noted as: "? Voiding - Tx (transfer) to bed - both." A physician progress notes [REDACTED]. X-rays taken of (left) hip - no change in fracture. ...S/P L (status [REDACTED]." -Neither the fall report nor nurses' notes documented whether or not the resident's chair alarm was sounding, or if it was checked. -There was no documentation that the resident's 12/7/10 care plan was updated or that the resident's toileting plan was reviewed. 2) 12/29 and 12/30/10 -On 12/30/10 at 3:26 a.m., nurse's notes documented that at around 9:45 p.m. (12/29/10), the resident's alarm sounded and staff found him with his "feet on the floor, fall mat was pushed aside by his feet, bottom was at the edge of the bed, upper part of the body across the bed. Resident was crying, stated he did not have anybody to help him. Reminded resident about the call light. Notes written in big letters were attached to the curtain and wall to remind resident to use call light and call for help. Assisted back to bed, urinal was provided." -On 12/30/10 at 6:31 a.m., the nurse noted, "Resident was already in the wheelchair, ready for breakfast, CNA (certified nurse aide) checked on the resident at (6 a.m.), bathroom call light was on, resident was on the floor, sitting position, no apparent head injuries, noted about 11 cm long abrasion across the back. Denies pain, but crying. Day shift RN ... filled out the incident report and notified the PCP (physician) by fax. Body audit done, care plan updated." --There was no evidence a fall report was completed on the 3:26 a.m. incident above. --The fall report documented at 6 a.m. did not match the nurse's note above, in that it was noted "call lt (light) not on," and the resident's injury was noted as a "6 cm scratch to back from rubbing/hitting on w/c leg. Superficial - no bleeding." The resident was noted as found in the rest room after self transferring. It was not noted in the fall report or nurse's note whether or not the bed alarm or chair alarm sounded, or if they were checked. -On 12/30/10 at 2:16 p.m., the nurse noted the resident was "seen several times today leaning forward in his w/c as if he was picking something up or fidgeting with his foot pedals and was wandering trying to find his 'red truck.' He has had several unsafe transfer falls lately and wife asked if there is anything more we can do. Discussed a self releasing lap belt alarm for res and she agreed. Faxed the doc. awaiting orders." No physician response was noted. -On 12/30/10 at 5:35 p.m., a nurse noted, "Res found sitting on the floor in his bathroom. He was tearful and said he was stupid. Reassured him he was not stupid. He just forgets to call for help but it is important not to get up without help as he did. We have reinforced several times today that he should not do this. We also attempted to get him more active with activities. None of these efforts were effective." The fall report, dated 12/30/10, documented the fall above occurred at 4:45 p.m., "Res sitting on floor facing commode (with) commode riser chair knocked over. ,Sitting upright." The resident was noted to have no injuries except that his nose was slightly red and running, although he said he did not hit his nose. There were no other apparent injuries. The resident was noted to state: "I'm stupid," "I fell ," "I hit my head." --It was not noted in the fall report or nurse's note whether or not the resident's alarm was sounding, or checked, or if the call light was on or not. --There was no evidence the facility increased supervision of the resident to prevent further falls after he began self-transferring unsafely, in order to keep him safe. 3) 1/3/11 On 1/3/11 at 1:27 a.m., a nurse noted the resident "tried to get out from B-hall exit door looking for his pickup, confused, called wife and after a few minutes of conversation he realized that he has a room in this facility, assisted back to his room and went to bed early ... sent fax to (physician) for order of wander guard bracelet." The resident's care plan on 1/3/11 identified "risk for unsafe unsupervised elopement from facility." The intervention was a wander guard bracelet placed on the cross bars under his wheelchair to monitor for unsafe unsupervised exits from the facility, with nursing to monitor every shift that it was properly placed and functioning properly. Staff was instructed to distract the resident with activities or snacks. On 1/3/11 at 9:16 a.m., a nurse noted "As per IDT (interdisciplinary team) meeting on 12/30/10 it was determined to start a 3 day trial of voiding pattern with resident. I have started this today to go through 1/4/11 and have instructed hall nurse and CNA on hall as to the process. I also requested for them to pass onto the noc (night) shift this information so we can have good carry through. He has dx of hx of falls and senile dementia and very poor memory. I also spoke with his wife this A.M. regarding placement of w/g (wander guard) bracelet on cross bars of his w/c to monitor for unsafe unsupervised exits from building and she stated, 'thank you, anything that will keep him safe.'" At 10:30 a.m., the nurse noted the wander guard was placed. On 1/4/10, it was noted the resident was toileted every two hours, and was "compliant to procedures." -See above; the resident's catheter had been removed in the hospital 11/28/10; this was the first documentation regarding a bladder assessment. On 1/6/11 at 1 p.m., a nurse noted, "Chart reviewed R/T mult(iple) falls. Noted that res had UTI (urinary tract infection) 11/27/10 on labs and his prealbumin was low. Res treated w Levaquin and dc'ed 12/3/10. R/T recent falls faxed Dr. for labs and geomat for bed to prevent skin breakdown r/t low prealbumin and decreased sensation to pressure/pain. Also refaxed multiple notifications and requests that were not answered." On 1/8/11 at 12 noon, the dietary manager noted in part, "There is concern regarding falls, with a trial of toileting pattern, and a request for a self-releasing seat belt. A wander guard was added due to res's wandering. Goal is adequate intakes and stable wt." On 1/11/11 at 12:11 p.m., a nurse noted, "Refaxed doctor for order to have alarm in bed and a self-releasing seatbelt for safe, supervised transfers. Call to doctor office to notify them that a couple of faxes were coming." A follow-up note from the Director of Nursing reiterated that the requests were "refaxed several times and that they need to be responded to today." On 1/11/11 at 2 p.m., the DON noted the following in nurses' notes: -"Review of res' record regarding safety/falls and interventions put into place since admission: Res. admitted [DATE]. Initial fall assessment done on admission rated res. at a '10-Low Risk' for falls. An acute care plan was made to address the risk. No specific interventions were warranted initially. -Review of nursing and therapy documentation from 11/5/10-11/26/10 (date of his first fall), reveal no attempts at self-transfer, and PT (physical therapy) note of 11/17/10 rated his overall safety fair to fair+. Although safety training is always a goal with therapy, reading through their notes reveals that it was not one of their primary concerns with this resident. -Res. had his first fall on 11/26/10. He was sent to the hospital and was diagnosed with [REDACTED]. Upon his return to the facility, alarms were placed on his bed and wheelchair and he was put on a hi-lo bed with a fall mat. -He did not have another fall until 12/23/10. At that time, staff and wife determined that res. would benefit from encouragement to attend more activities. Staff were also instructed to insure that his urinal is always within his reach. -On 12/30/10, res. had two falls in one day. Both falls were in the bathroom. The hall nurse initiated process of getting self-releasing seatbelt for wheelchair after discussing with res' wife. In ADT meeting that day, the team suggested a toileting program for resident since the last two falls were in the bathroom. -On 1/3/11 (we do not initiate voiding trials on weekends), a voiding trial was initiated. On 1/7/11, the restorative nurse evaluated the results and found that res. needs to be toileted more frequently in the morning (he takes a diuretic), so she wrote a toileting program for assistance with toileting q hour from 0800-12:00 noon, and then per facility protocol. -During IDT meeting on 1/6/11, it was also suggested that a repeat UA be done and other appropriate lab work to determine whether resident may have another UTI or another medical condition contributing to his falls." d. Resident Observations Observations on 1/10/11, revealed the resident's room was halfway down the hallway, and was not near the nurses' station. Resident #2 was observed at 3:30 p.m. lying on his back in a low bed with a fall mat on the floor next to his bed. The other side of his bed was against the wall. He said his left hip was "hurting a little," but added that it could be all in his head. (The nurse was notified that the resident was having pain, and she said she would talk with him and get him something.) e. Staff Interview The charge nurse was interviewed the afternoon of 1/11/11. Asked about fall precautions for the resident, she said he was toileted every hour from 8 a.m. to noon, and they were charting "wet, dry or voided." She said they also had in place a hi/lo bed, fall mat, pressure alarm, and an alarmed self-releasing seat belt when he was up in his wheelchair. See care plans above; the above interventions (hourly voiding until noon, hi/low bed, fall mat, pressure alarm, and alarmed self-releasing seat belt) were not noted on the resident's care plans to ensure consistent staff implementation of these safety interventions. Moreover, these safety interventions were initiated after the resident experienced falls, not as preventative measures. In summary, there was insufficient evidence of planning and implementation of adequate supervision to ensure the resident was safe and that implemented measures were effective and in working order. There was no evidence the facility developed a plan to increase supervision. The facility continued to emphasize using the call light, although nursing staff had knowledge that the resident was unable to understand, and did not use his call light. 3. Resident #3 Resident #3 (closed record), a [AGE] year-old female, was admitted to the facility on [DATE] and discharged on [DATE]