Every finding on record at Life Care Center of Colorado Springs

Based on observations, record review and interviews, the facility failed to ensure one (#18) of three residents reviewed for accidents out of 44 sample residents received adequate supervision to prevent accidents. Resident #18 was admitted to the facility on [DATE] with diagnoses of traumatic subdural hemorrhage (bleeding near the brain) with loss of consciousness status unknown, seizures, generalized muscle weakness, cognitive communication deficit, unspecified dementia and history of falls. Resident #18 was identified as a high fall risk. On 11/26/25, Resident #18 sustained an unwitnessed fall. The facility recommended implementing care plan interventions which included a call light within reach, orienting Resident #18 to his room, assisting the resident with activities of daily living (ADL), keeping the resident's bed in the lowest position, floor mats to side of the resident's bed and offering Resident #18 frequent toileting. -However, observations during the survey revealed the resident's bed was not in the lowest position and the fall mats were not at the resident's bed side. Resident #18 sustained an additional unwitnessed fall on 12/9/25, where he hit his forehead and jaw. The resident was transferred to the hospital and received glue to his forehead laceration. Upon return from the hospital, the facility recommended implementing a personal urinal to be within reach of the resident at all times. -However, observations during the survey revealed the resident did not have his personal urinal within reach. Specifically, the facility failed to ensure person-centered fall interventions were consistently implemented for Resident #18, who sustained multiple falls, including a fall with injury that required transport to the hospital for treatment of a forehead laceration.Findings include: I. Facility policy and procedureThe Fall Management policy, revised 3/11/25, was provided by the director of nursing (DON) on 2/26/26 at 2:16 p.m. It revealed in pertinent part, The facility will assess the resident upon admission, readmission, quarterly, with change in condition, and with any fall event for any fall stocks and will identify appropriate interventions to minimize the risk of injury related to falls. Fall refers to unintentionally coming to rest on the ground, or other lower level, but not as a result of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Risk refers to any external factor, facility characteristic (staffing or physical environment) or characteristic of an individual resident that influences the likelihood of an accident. Supervision/Adequate Supervision refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed This determination is based on the individual resident's assessed needs and identified hazards in the residents environment.II. Resident #18A. Resident statusResident #18, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included traumatic subdural hemorrhage with loss of consciousness status unknown, seizures, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety and a history of falling. The 1/14/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS)score of 14 out of 15. He required partial/moderate assistance with most of his activities of daily living (ADL).The MDS assessment revealed the resident had difficulty with focusing his attention. The behavior was present but fluctuated during the assessment look-back period.The MDS assessment revealed the resident had two or more falls without injury and one fall with injury since his time of admission to the facility. B. Observations On 2/24/26 at 2:54 p.m. Resident #18 was sitting in his wheelchair in his bedroom. Resident #18 was leaning forward out of his wheelchair, reaching towards the ground. Resident #18 began resting his head on the tray table in front of him. Resident #18's body began to fall forward out of the wheelchair and his legs began to buckle. Registered nurse (RN) #4 was sitting directly across the hallway at the nurses' station from Resident #18's room, however, she was not paying attention to Resident #18.At 2:56 p.m., upon prompting, RN #4 entered Resident #18's room and asked Resident #18 what he was doing. Resident #18 said he was trying to throw something away. Resident #18 was still bent forward out of his wheelchair. RN #4 had to physically intervene to assist Resident #18 back to an upright and safe sitting position. RN #4 provided a verbal reminder and educated the resident on the importance of using his call light when he needed help in his room. Resident #18 said he wanted to lay down. RN #4 told Resident #18 she would go find some certified nurse aides (CNA) to help assist him back into bed. RN #4 placed the resident's oxygen back on him and pushed the call light, remaining with the resident. At 2:59 p.m. CNA #11 answered Resident #18's call light. RN #4 told CNA #11 Resident #18 wanted to lay down and instructed CNA #11 to stay with the resident while she went to get a sit-to-stand lift. CNA #12 was coming down the hall and RN #4 asked her to assist them with Resident #18's transfer from his wheelchair to his bed.On 2/26/26 at 2:06 p.m. Resident #18 was sleeping in his bed. Resident #18's bed was not in the lowest position, his floor mats were not in place by the bed and his personal urinal was not within reach. -However, Resident #18's care plan revealed his bed was to be in the lowest position, his personal urinal was to be within reach at all times and the floor mats were to be placed at the bed side to prevent Resident #18 from falling (see record review below). C. Record review1. Care plan The fall care plan, revised 12/10/25, identified Resident #18 was at risk for falls related to impaired mobility, history of falls, impaired vision, seizures and psychotropic medication use (medications that affect behavior, mood, thoughts, or perception). Pertinent interventions (revised 12/10/25), included ensuring the resident's call light was within reach, assisting the resident with ADLs as needed, providing adaptive equipment or devices as needed, completing a fall risk assessment and orienting the resident to his room. The actual fall care plan, revised 1/23/26, identified Resident #18 had multiple falls since his time of admission, with one fall resulting in an injury. Pertinent interventions (revised 1/23/26), included ensuring the resident' bed was in the lowest position at all times (initiated 11/28/25), clipping the call light onto the resident's clothing within his reach and vision, encouraging the resident to use the urinal for urgent episodes, ensuring the resident's personal urinal was within reach at all times, placing floor mats to the sides of the bed, providing a lipped mattress and moving the resident to a room directly across from the nurses station-However, observations revealed person-centered fall interventions were not consistently implemented for Resident #18 (see observations above). 2. Fall on 11/22/25 - unwitnessed The 11/22/25 nursing progress note, documented at 1:45 p.m., revealed Resident #18 was found on the bathroom floor. Resident #18 was on the floor in the middle of the bathroom sitting upright. Resident #18 did not complain of pain and no apparent injuries were assessed by the RN. Root cause analysis was related to gait imbalance and a new intervention was implemented to offer Resident #18 frequent toileting. 3. Fall on 11/24/25 - witnessed The 11/24/25 nursing progress note, documented at 1:47 p.m., revealed Resident #18 was attempting to walk with his friend. The occupational therapist (OT) assisted the resident to the floor and notified the RN. Resident #18 was wearing his personal clothing with his shoes on. Resident #18 was educated by the RN and the OT about supervised walking with authorized personnel only and safe transferring. A CNA said she had also educated the resident on this prior to the witnessed fall. No injuries were assessed.-The progress note did not indicate what the root cause of the fall was or if the resident's fall interventions were reviewed to determine if the interventions were effective or if a new fall interventions were needed.4. Fall on 11/26/25 - unwitnessedThe 11/26/25 nursing progress note, documented at 8:09 p.m., revealed Resident #18 was seen by the nurse at 5:00 p.m. sitting in his wheelchair watching television. The director of nursing (DON) was walking past and saw Resident #18 had his call light on. The DON walked in to the resident's room and found Resident #18 sitting on the floor with his legs facing the sink and his wheelchair behind him. Resident #18 said he was trying to get his cell phone off the charger so he could put it away in the dresser drawer. Resident #18 was wearing non-skid socks at the time of the fall. The call light was pulled out of the wall socket and on the floor. The nurse completed the initial assessment with no obvious injuries and Resident #18 denied any pain. Resident #18 was assisted back into his wheelchair.-The progress note did not indicate what the root cause of the fall was or if the resident's fall interventions were reviewed to determine if the interventions were effective or if a new fall interventions were needed. 5. Fall on 12/1/25 - unwitnessedThe 12/1/25 nursing progress note, documented at 1:30 a.m., revealed Resident #18 was found on the floor in his room. Resident #18 said he rolled out of bed. Resident #18 said he did not hit his head and he landed on the fall mat. No pain was noted and the nurse completed an assessment before assisting the resident from the floor. Resident #18 was repositioned and changed in bed. The wedges and fall mats were put in place on both sides of the resident. The bed was placed in the lowest position and the resident's call light was within reach. -The progress note did not indicate what the root cause of the fall was or if the resident's fall interventions were reviewed to determine if the interventions were effective or if a new fall interventions were needed.6. Fall on 12/6/25 - unwitnessed The 12/6/25 nursing progress note, documented at 3:15 a.m., revealed Resident #18 was found sitting on the floor. The resident said he fell from the low bed. Resident #18 was assessed for injury and none were noted. Root cause analysis determined the cause of the resident's fall was toileting urgency due to a possible urinary tract infection (UTI). A urine sample was collected to verify a UTI and was sent out to validate. The 12/5/25 nursing progress note, documented at 7:09 p.m., revealed a stat (immediate) urinary analysis (UA) was collected from Resident #18 via clean catch. The urine sample was in the dirty utility refrigerator awaiting laboratory (lab) pickup. The lab was notified by the charge nurse on duty.7. Falls on 12/9/25 (two falls) - one witnessed fall and one unwitnessed fallThe 12/9/25 nursing progress note, documented at 2:17 p.m., revealed Resident #18 attempted to get out of his bed unassisted. Resident #18 was seen by the OT as he fell onto his right elbow without hitting his head. Resident #18 reported a 1 out 10 for pain to his right elbow. A head to toe assessment was performed and no injuries were noted. The nurse educated Resident #18 again, regarding the importance of calling for assistance. Resident #18 verbalized his understanding. Staff assisted the resident to the toilet before returning to bed. The 12/9/25 nursing progress note, documented at 7:24 p.m., revealed a loud thud was heard from Resident #18's room around 6:40 p.m. by surrounding staff. The CNA notified the nurse Resident #18 was bleeding. The RN walked over and saw the resident on the floor with his back towards the wall adjacent to the door with his feet towards the bathroom door. Resident #18 was attempting to sit up. Resident #18 was wearing his personal clothing and personal shoes. Blood was observed coming from the resident's right side of his face and top of his scalp. Resident #18 said he was attempting to empty his urinal and wanted to clean the mess up himself. No mess described by the resident was observed on the floor surrounding Resident #18. It was possible the resident mistook making a mess as he used a different urinal provided by his friend that evening and Resident #18 had impaired vision. Resident #18 did not utilize his call light for assistance. The resident was assessed by the nurse and then assisted by staff back into his wheelchair. Resident #18 was assessed for injuries after clearing away blood. The resident's right side of his forehead revealed a laceration, as well as a laceration to the right side of his jaw. Resident #18 said he had a 2 out of 10 for pain. Resident #18 was sent out to the hospital for evaluation and treatment. The resident required stitches and imaging for his head.8. Fall 12/10/25 - unwitnessed The 12/10/25 nursing progress note, documented at 10:17 p.m., revealed Resident #18 was found in bed but called the staff to alert them that he had slid from the bed and gotten himself back into bed. Resident #18 denied hitting his head, experiencing any new pain, or new injuries. The resident was assessed by the nurse. During the resident's neurological assessment, the nurse discovered Resident #18's heart rate and blood pressure were changing dramatically, and Resident #18 was having increased slurred speech. The nurse practitioner (NP) was present at the facility and evaluated the resident. An physician's order was placed to send Resident #18 to the hospital for further evaluation. Resident #18 was determined to be stable and sent back to the facility. 9. Fall 12/16/25 - unwitnessed The 12/16/25 nursing progress note, documented at 9:47 a.m., revealed Resident #18 sustained a fall while in the shower room. The nurse was alerted by a staff member and came to assess the resident. Resident #18 did not have any visible injuries and was alert and oriented. The resident said he was reaching to turn the water off and slid out of the shower chair onto the floor landing on his buttocks. Resident #18 was educated on the importance of asking for assistance and not to reach for objects out of his immediate reach. Resident #18 was also educated about this earlier in his room and the resident verbalized understanding at that time. Resident #18 was assisted back into the shower chair and taken back to his room. The CNA giving Resident #18 a shower had left the shower room, leaving the resident unattended for a few minutes during the incident. The CNA was educated on the facility's policy for leaving residents unattended during showers. The CNA verbalized understanding. -However during an interview with the DON (see interview below), it was revealed that Resident #18 should never be left alone in the shower room as he was a high fall risk and required high supervision to ensure the resident's safety. 10. Fall 12/31/25 - unwitnessedThe 12/31/25 nursing progress note, documented at 7:43 p.m., revealed Resident #18 was seen 10 minutes prior to his fall sitting in his wheelchair eating dinner. The resident had finished eating his dinner and wanted to get into bed. Resident #18 could not find his call light. The call light had fallen behind the left side of his wheelchair arm rest and was wrapped around the wheel. Resident #18 was wearing non-skid socks but the socks did not grip the floor to help with traction, and the resident fell to his buttocks. The bed was to the resident's left and the wheelchair was on his right. Resident #18 denied any injury or pain. Resident #18 said he was looking for the call light to call for help. The nurse assessed Resident #18 and determined no injuries were noted at this time. The resident was assisted to bed, ensuring the call light was clipped to the resident's shirt. Resident #18 was educated on safety awareness and calling for assistance. 11. Fall 1/19/26 - unwitnessedThe 1/19/26 nursing progress note, documented at 6:36 p.m., revealed the nurse was notified by a CNA that Resident #18 was on the floor. The nurse went into the resident's room to assess the resident and Resident #18 was found in the bathroom with his back leaning against the wall. The resident was wearing long sleeves, a sweater, non-skid shoes, and his brief and sweatpants were around Resident #18's knee's. The resident said he was transferring from the toilet to the wheelchair without staff assistance and slipped when the wheelchair was not locked. A head to toe assessment was performed and no visible injuries were noted. The resident denied pain or injuries at the time of the assessment. Resident #18 was transferred back to his wheelchair. The call light was clipped to the resident. III. Staff interviews CNA #7 was interviewed on 2/26/26 at 9:08 a.m. CNA #7 said Resident #18 was very impulsive when he first arrived at the facility. CNA #7 said the resident was falling all the time; however, Resident #18 had not been falling as much lately. CNA #7 said Resident #18 had been declining recently and he was unable to stand on his own currently CNA #7 said some interventions for Resident #18 would be to keep close supervision on him. CNA #7 said if she saw Resident #18 trying to get up out of his wheelchair, she would ask the resident if he needed assistance with something. CNA #7 said up until recently, Resident #18 was good at communicating his needs. CNA #7 said if she saw Resident #18 put his feet out of the bed or if he put a leg out, that was a good indicator the resident needed to use the bathroom. CNA #7 said the resident was not on a toileting schedule, but said when she was working she toileted Resident #18 every two hours.The DON was interviewed on 2/26/26 at 2:16 p.m. The DON said accidents and hazards were defined by choking, falls with major injury, elopements, burns, leaving the facility against medical advice, and abuse and neglect. She said, depending on the incident, the procedure would be for the nurses to begin documentation by immediately completing a risk assessment. She said if the event was witnessed, then staff were to take statements from the resident and anybody else involved. The DON said making necessary notifications to the provider and family would be next as part of the investigation process. The DON said the root cause analysis of an incident was important because it helped to determine the cause of the incident and how to treat immediately to ensure the incident did not happen again. The DON said the facility put a lot of interventions in place to prevent Resident #18 from falling. The DON said Resident #18 was very impulsive due to his diagnoses. The DON said Resident #18 scored high on his BIMS assessment; however, his safety awareness was not present. The DON initially recalled the CNA was in the shower room with the resident at the time of the 12/16/25 fall. However, once she reviewed the 12/16/25 event progress note, the DON discovered that the CNA had left Resident #18 alone in the shower room. The DON confirmed the CNA was outside of the shower room for a few minutes. The DON said a resident was allowed, per the facility policy, to be left alone in the shower room only if a resident was alert and oriented. She said an alert and oriented resident did not have to be attended in the shower room, but staff was to check on the resident every five minutes. The DON said the CNA was educated on 12/16/25 by the RN. The DON said a resident with a diagnosis of high falls should not be unattended in the shower room. The DON said post-fall, the RN on duty should complete the head to toe assessment (skin, pain, fall, neuro's if the fall was unwitnessed) before doing anything else with the resident. The DON said the nurses should document this in a progress note. The DON said the licensed practical nurses (LPN) could complete the initial assessment of the fall, but the RN had to be the one who completed the head to toe assessment.The DON said on the days Resident #18 had multiple falls, there was nothing more the facility could do, and the DON said she started calling staff to come and provide one-to-one supervision with Resident #18. The DON said that was why there was a significant decrease in his falls after 12/10/25. The DON said the resident's family also hired a private sitter to come in and sit with Resident #18 on the days the resident's wife could not make it or family and friends were not available. The DON said the facility attempted to offer Resident #18 a soft helmet and busy board, but his wife did not want either of those for dignity reasons. The DON said the facility arranged an appointment for the resident to see the neurological ophthalmologist. The DON said Resident #18 was complex and not appropriate for this setting. The DON said Resident #18's entire frontal lobe had been compromised and the resident was very impulsive as a result. The DON said residents had a right to fall and the facility had an obligation to try to keep the residents as safe as possible. The DON said the facility completed a high risk audit on all the residents that were high fall risks. She said the environmental audits were completed by the DON or unit manager. The DON said on grand rounds they asked staff who they thought was going to fall next, and any concerns about residents falling. The DON said CNAs could find a resident's fall interventions on the Kardex (comprehensive care tool. The DON said RNs would find interventions on the residents' care plans. The DON said CNAs did walking rounds, and fall huddles were done with all the staff. The DON said she created a fall binder back in December 2025 after the high volume of falls. The DON said the binder was placed at each nurses' station. She said the binder included a fall checklist which was a packet that each RN was to complete after a fall and give to the DON. The DON said the fall packet included a fall checklist, neurological assessment forms, resident and RN sign offs for interventions and education, and witness interview forms. The nursing home administrator (NHA) was interviewed on 2/26/26 at 6:45 p.m. The NHA said he was aware of Resident #18 being a high fall risk. The NHA said Resident #18 had a right to fall but he said he also knew the facility had a responsibility to ensure Resident #18's safety. The NHA said he was aware of Resident #18's impulsivity.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of diseases and infection on three of three units.Specifically, the facility failed to: -Ensure appropriate personal protective equipment (PPE) was worn by staff while providing care for Resident #11, Resident #9 and Resident #109, who were all on enhanced barrier precautions (EBP); and,-Staff performed appropriate hand hygiene during wound care for Resident #9.Findings include: I. Professional reference According to the Centers For Disease Control And Prevention's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), (4/2/24), retrieved on 3/2/26 , from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high-contact resident care activities. EBP may be indicated for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status, and infection or colonization with an MDRO. II. Facility policy and procedure The Infection Prevention and Control Program and Plan (IPCP) policy, revised 6/2/25, was provided by the nursing home administrator (NHA) on 2/23/26 at approximately 3:00 p.m. It read in pertinent part, Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities. Ensure associates follow the IPCP's standards, policies and procedures (hand hygiene and appropriate use of PPE) while other needs are specific to particular roles, responsibilities, and situations. III. Resident #11 A. Observations On 2/25/26 at 9:41 a.m. a sign posted outside of Resident #11's room indicated Resident #11 was on EBP. According to the resident's electronic medical record (EMR), the resident had MDRO in her urine. A small bin containing isolation gowns was under the sign outside the resident's room. Certified nurse aide (CNA) #5 entered Resident #11's room to perform incontinence care for the resident. -CNA #5 did not don (put on) an isolation gown before entering Resident #11's room. On 2/25/26 at 9:42 a.m. an unidentified CNA entered Resident #11's room to perform incontinence care for the resident. -The unidentified CNA did not don a gown before entering Resident #11's room. B. Staff interviews CNA #5 was interviewed on 2/25/26 at 10:00 a.m. CNA #5 said she went into Resident #11's room to provide Resident #11 with incontinence and perineal care. CNA #5 said she used only gloves as personal protective equipment (PPE) during resident care. IV. Resident #9 A. Observations On 2/25/26 at 9:35 a.m. there was a sign on Resident #9's door that indicated she was on EBP. The sign on the resident's door indicated gloves and a gown must be worn for resident care activities, including dressing, bathing/showering, transferring, linen changes, providing hygiene, changing briefs or assisting with toileting and device care or use, such as central lines, urinary catheters, feeding tubes, tracheostomies and wound care. PPE, including gloves, gowns, eye protection and masks, was stocked in a plastic bin directly outside of Resident #9's door. On 2/25/26 at 9:40 a.m. licensed practical nurse (LPN) #2 entered Resident #9's room to complete wound care for Resident #9. LPN #2 was assisted by CNA #3. Both LPN #2 and CNA #3 performed hand hygiene and donned gloves before providing care to Resident #9. LPN #2 removed the old wound dressing located on the resident's coccyx and to the left of the gluteal fold. -LPN #2 failed to change her gloves after removing the old wound dressing and preparing the new wound dressing to be applied. After the completion of the wound care, LPN #2 and CNA #3 provided incontinence care and a linen change for Resident #9. LPN #2 and CNA #3 changed the resident's brief and sheets, which were soiled with urine. -CNA #3 and LPN #2 failed to wear a gown during the performance of incontinence care and the wound dressing change. B. Staff interviews. LPN #2 and CNA #3 were interviewed together on 2/25/26 at 9:55 a.m. LPN #2 She said it was important to perform hand hygiene between tasks, such as when removing old soiled wound dressings before applying the new wound dressing. She said she did not want to spread bacteria or cause an infection to start and that was why hand hygiene was so important. She said after reading the EBP sign on Resident #9's door, she now realized she was required to wear a gown while providing care to the resident. She said she was not provided with education or training from the facility regarding EBP and appropriate PPE requirements. CNA #3 said she Resident #9 was completely dependent on staff. She said she provided Resident #9 with dressing assistance, oral care, personal hygiene and assistance with meals. She said she did not know Resident #9 was on EBP. She said she always wore gloves when assisting a resident to prevent the resident from getting an infection. She said she knew it was important to wash her hands before and after providing care to Resident #9. She said she did not remember receiving training from the facility regarding EBP. The director of nursing (DON) and the infection preventionist (IP) were interviewed together on 2/25/26 at 2:08 p.m. The IP said she had been a nurse for over 25 years and received her IP certification from the CDC. She said her role as the facility's IP included monitoring residents when they had an infection, making sure the residents were receiving the appropriate antibiotics by referring to the Mcgeer's criteria, infection mapping and tracking and monitoring housekeeping for dwell times. The IP said she was responsible for training nursing staff about infection control standards and protocols. She said she conducted audits on hand washing and ensured the direct care staff were wearing appropriate PPE when providing care to facility residents. She said she expected her staff to adhere to EBP measures to prevent the start or spread of an infection. The IP said nursing staff were expected to wear gloves and gowns for all high contact activity. She said LPN #2 and CNA #3 should have worn a gown when providing wound care and incontinence care to Resident #9. The DON said she would provide immediate retraining for her nursing staff regarding appropriate usage of PPE and adherence to EBP measures. The DON said LPN #2 should have changed her gloves and performed hand hygiene after removing the old soiled wound dressing from Resident #9. She said LPN #2 and CNA #3 should have worn a gown when providing care to Resident #9 because that was a part of the PPE requirements for any resident on EBP. V. Resident #109 A. Observations On 2/25/26 at 1:56 p.m. RN #4 entered Resident #109's room to give the resident a tube feeding through the resident's feeding tube. -RN #4 was wearing gloves and a mask but did not put on a gown, prior to completing the resident's tube feeding. On 2/25/26 at 3:51 p.m. there was no enhanced barrier precautions sign on the outside of Resident #9's door. -However, on 2/26/25 at 10:12 a.m. Resident #109 had an EBP sign posted on the outside of her door. The sign revealed individuals were to stop before entering the room due to EBP. Anyone entering the room was to clean their hands before entering the resident's room and when leaving the room. Providers and staff were required to wear gloves, and a gown for high contact resident care activities such as: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing brief or assisting with toileting, device care (tube feeding, central line, urinary catheter, and tracheostomy) and wound care. B. Staff interviews RN #4 was interviewed on 2/26/26 at 9:16 a.m. RN #4 said Resident #109 was not on EBP and that was why she did not wear a gown during the resident's tube feeding. RN #4 referenced her computer charting to verify and again said Resident #109 was not on EBP The IP was interviewed on 2/26/26 at 9:40 a.m. The IP said the determinants for EBP included if the resident had any type of indwelling medical device, or MDRO infection. The IP said she was just made aware of Resident #109's feeding tube and was getting ready to put the orders for EBP in, but it had been a busy week. The IP said the process for establishing EBP was determined at the time of a resident's admission. The IP said the facility's admission team would inform her of an EBP and then she added it to the resident's chart.

Based on observations and interviews the facility failed to ensure all drugs and biologics used in the facility were properly stored and labeled for one of four medications carts reviewed for storage and labeling. Specifically the facility failed to ensure over the counter (OTC) medications were discarded after the expiration date. Findings include:I. Facility policy and procedureThe House Stock Items policy, revised 9/15/24, was provided by the director of nursing (DON) on 2/25/26 at 4:05 p.m. It read in pertinent part, The facility should post the house stock medication list in an appropriate location such as medication rooms or a medication administration binder. The facility should ensure that house stock medications are stored in the original manufacturer's container. The medication name, strength, expiration date and lot number should be clearly visible.II. ObservationsOn 2/24/26 at 5:01 p.m. the medication cart on the 300 east hall was observed with licensed practical nurse (LPN) #4. The following items were found:A bottle of OTC CoQ10 100 milligrams (mg) supplement had a manufacturer's expiration date of 1/24/26.A bottle of OTC Calcium 500 mg had a manufacturer's expiration date of 1/30/26. A bottle of OTC Acetaminophen 500 mg had a manufacturer's expiration date of 12/30/25.III. Staff interviewsRegistered nurse (RN) #4 was interviewed on 2/24/26 at 4:50 p.m. RN #4 said she had worked at the facility for approximately two years. She said she was trained to write the date of when the OTC medications were opened. She said she was trained by the facility to discard the OTC medications three months after the open date that was written on the bottle. LPN #4 was interviewed on 2/24/26 at 5:01 p.m. LPN #4 said she was unsure of whether OTC medications expired 30 days after opening or according to the manufacturer's expiration date on the bottle. She said she did not know where to locate the OTC storage and expiration policy for the facility. She said she was unsure why nursing staff were writing the open date on the OTC medication bottles. She said if the expiration date on the manufacturer's bottle had passed then the medication should be discarded. The director of nursing (DON) was interviewed on 2/24/26 at 5:38 p.m. The DON said the nursing staff were expected to reference the manufacturer's date on the OTC medication bottles. She said all the nurses were trained by other bedside nursing staff. She said the facility did not provide any specific training on medication expiration dates of medications, whether the medications were from the pharmacy or OTC medications. The DON said all nursing staff should be properly trained and demonstrate competency for nursing medication tasks prior to performing medication administration. The DON said this was important to maintain resident safety. She said expired medications should not be administered to residents for safety reasons because expired medications could make a resident very sick.

Based on observations, record review and interviews, the facility failed to meet all requirements for the provision of hospice care for one (#41) of two residents reviewed for hospice services out of 44 sample residents.Specifically, the facility failed to ensure hospice notes were readily accessible, the comprehensive care plan was developed with delineation of care responsibilities established between the facility and hospice and the most current care plan from hospice was available for Resident #41.Findings include:I. Facility policy and procedureThe Facility and Hospice Agreement, signed 11/30/17, was provided by the nursing home administrator (NHA) on 2/23/26 at approximately 3:00 p.m. It read in pertinent part, Each party shall prepare and maintain complete and detailed clinical records concerning each hospice patient receiving hospice services under this agreement in accordance with its usual record-keeping procedures, and as required by applicable federal and state law and regulations and applicable Medicare and Medicaid program guidelines. Each party shall retain such records as required by applicable federal and state law. Each such record shall document that the specified services are furnished in accordance with this agreement and shall be readily accessible and systemically organized to facilitate retrieval by either party, in accordance with federal and state patient privacy laws. Hospice will document that hospice services are furnished in accordance with this agreement.II. Resident #41A. Resident statusResident #41, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician's orders (CPO), diagnoses included hypertensive heart disease (heart disease resulting from uncontrolled high blood pressure) with heart failure, palliative care and protein-calorie malnutrition.The 12/2/25 minimum data set (MDS) assessment revealed the resident was moderately cognitively intact with a brief interview for mental status (BIMS) score of nine out of 15. Resident #41 used a wheelchair to ambulate and needed partial assistance with bathing.The MDS assessment indicated the resident was receiving hospice services.B. Record reviewReview of Resident #41's February 2026 CPO revealed a physician's order for hospice services, ordered 3/22/24.A review of Resident #41's electronic medical record (EMR) revealed the most recent plan of care from the hospice services team was active from 9/19/25 to 11/17/25.-There was no current plan of care from the hospice services team in the resident's EMR.A review of Resident #41's hospice care plan, initiated 3/8/24, revealed the resident was receiving hospice services. Interventions included working cooperatively with the hospice team to meet Resident #41's needs (revised 7/19/24).-Review of Resident #41's EMR failed to reveal clinical documentation from the hospice service team's routine visits to the resident.III. Staff interviewsRegistered nurse (RN) #2 was interviewed on 2/25/26 at 5:05 p.m. RN #2 said neither Resident #41's physical chart nor the EMR had the most recent copy of the hospice services team's care plan for the certification period starting 1/17/26. RN #2 said she was not surprised the hospice notes were not updated or in chronological order in the physical chart. RN #2 said the facility's system for ensuring hospice was providing services was for the hospice staff to check in with the facility's nurses or physician if they had any concerns about Resident #41. RN #2 said the hospice staff did not have to sign into the facility, and there was no system in place to ensure hospice staff fulfilled their weekly visits. RN #2 said all hospice certified nurse aides (CNA) came to the facility on Tuesdays and Thursdays and usually helped their residents with bathing at that time, but there was no formal system for hospice staff to chart or report what care they had provided for the residents.Licensed practical nurse (LPN) #3 was interviewed on 2/26/26 at 2:46 p.m. LPN #3 said she had seen the CNA from the hospice services company earlier in the day (2/26/26). LPN #3 said the hospice CNA checked in with her before she left for the day. LPN #3 said she had seen the hospice RN the day before (2/25/26). LPN #3 said she knew the hospice staff would see Resident #41 because the hospice staff would usually check in with her. LPN #3 said she did not check the physical chart for hospice visit notes for the resident, because the physical chart was more for the hospice team.-However, neither Resident #41's electronic medical record (EMR) nor her physical chart had a visit note from either the hospice CNA or RN on 2/25/26 and 2/26/26 (see record review above).The director of nursing (DON) was interviewed on 2/26/26 at 3:32 p.m. The DON said the hospice services company was not good at communicating with the facility, but the facility was ultimately responsible for ensuring the hospice services company was providing services appropriately for the residents. The DON said the facility had been searching for other hospice services companies to work with.

Based on record review and interviews, the facility failed to ensure residents received adequate supervision and were kept free from elopement for one (#1) of three residents at risk for elopement out of three sample residents.Specifically, the facility failed to provide Resident #1 with the supervision necessary to prevent elopement. Resident #1, who had moderate cognitive impairments and had diagnoses of aphasia and encephalopathy, had a history of wandering and required an escort to his appointment off of the facility's property.On 9/9/25 at approximately 1:00 p.m. Resident #1 was scheduled for pickup by an outside medical transportation company. The resident was taken to his appointment by the transportation driver and escorted into the building. Per the clinic's notes, the resident was seen from 2:17 p.m. to 2:32 p.m., at which time the resident was discharged from the clinic and he subsequently walked away from the clinic. On 9/9/25 at 4:00 p.m. the outside transportation company returned to the clinic to transport Resident #1 back to the facility, but the driver could not find the resident. The transportation company contacted the facility and alerted them they were unable to locate the resident. Facility staff began searching the area for the resident.On 9/9/25 at approximately 6:40 p.m. (four hours after the last known sighting of Resident #1 and 2.5 hours after the resident was identified as missing) the director of nursing (DON) found Resident #1 walking on a sidewalk approximately 3.4 miles away from the clinic where he had attended his appointment.Serious harm to Resident #1 was likely to have occurred during Resident #1's elopement on 9/9/25. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 11/3/25 through 11/4/25, resulting in the deficiency being cited as past noncompliance with a correction date of 9/12/25.I. Situation of serious [NAME] 9/9/25 at approximately 1:00 p.m. Resident #1 was scheduled for pickup by an outside medical transportation company. The resident was taken to his appointment by the transportation driver and escorted into the building. Per the clinic's notes, the resident was seen from 2:17 p.m. to 2:32 p.m., at which time the resident was discharged from the clinic and subsequently walked away from the clinic. On 9/9/25 at 4:00 p.m., the outside transportation company returned to the clinic to transport Resident #1 back to the facility, but the driver could not find the resident. The transportation company contacted the facility and alerted them they were unable to locate the resident. Facility staff began searching the area for the resident.On 9/9/25 at approximately 6:40 p.m. (four hours after the last known sighting of the resident and 2.5 hours after the resident was identified as missing) the director of nursing (DON) found Resident #1 walking on a sidewalk approximately 3.4 miles away from the clinic where he had attended his appointment.II. Facility plan of correctionThe corrective action plan the facility implemented in response to Resident #1's elopement incident on 9/9/25 was provided by the nursing home administrator (NHA) on 11/3/25 at 1:11 p.m. The plan documented the following:A. Immediate action Resident #1 was returned to the facility by the DON on 9/9/25 at approximately 7:00 p.m. Resident #1 was assessed by the nursing staff and was not found to have any injuries. Nursing staff working with the resident that evening were educated by the NHA to closely monitor Resident #1 for his wandering behaviors.B. Identification of other residentsOn 9/9/25 an audit was initiated to identify all residents residing in the facility who were at risk for elopement. Identified residents' care plans were reviewed. Photographs of residents at risk for elopement were updated and their information was placed in the elopement binders at the reception desk. Audits were completed by 9/12/25.Residents with upcoming appointments were reviewed by the interdisciplinary team (IDT) and arrangements were made to have a staff member accompany each resident and ensure their appropriate assistive devices were sent with them to their appointments.C. Systemic changesOn 9/10/25 the elopement binder was updated and accurate based on residents' elopement assessments. On 9/9/25 education on the elopement policy, the elopement binder and the updated procedures for residents' appointments outside the facility was initiated for all staff and added to the orientation education. The education was completed by the DON and the NHA. Education for core staff responsible for patient care was completed on 9/12/25, and all facility staff were educated by 9/19/25.The process and procedures for residents' appointments outside the facility was updated by 9/12/25. The procedures were updated to ensure a staff member or designee accompanied all residents to their appointments, and established a chain of communication with the transportation coordinator, the NHA and the DON. Outside transportation companies were educated on the changes in the facility's processes for appointment transportation. The transportation drivers needed to check in with a facility nurse, who needed to ensure the transportation provider had the appropriate documentation and assistive equipment available for the resident before they were taken to their appointment. The transportation provider would also check in with the nurse after the resident's appointment and provide them with any documentation from the appointment. Resident appointments and escort needs were discussed daily during grand rounds and reviewed.All new admissions would be assessed for risk of elopement on admission, quarterly, and as needed with any change in condition.D. MonitoringThe DON or designee would audit the transportation requests for physician appointment forms to ensure they were completed and staff members were assigned to accompany each resident. This would be done five times per week for four weeks, at which point the frequency would be reevaluated.The DON or designee would ensure resident appointments and the staff members assigned to supervise those appointments were discussed in the facility's grand rounds. This would be done daily for four weeks, at which point the frequency would be reevaluated.The DON or designee would report the results of the audits and outcomes of their grand rounds discussions to the quality assurance and performance improvement (QAPI) committee for review by the QAPI team monthly, along with any recommendations for process changes or frequency of ongoing monitoring.III. Facility policy and procedureThe Unsafe Wandering and Elopement Prevention policy and procedure, revised 8/26/25, was provided by the NHA on 11/3/25 at 1:11 p.m. It read in pertinent part, The facility will ensure that residents are assessed to determine risk for elopement in accordance with current standards of practice and implement interventions as appropriate to mitigate the risks identified. As residents' conditions may vary throughout the day, week, month or other time period, the identification of unsafe wandering and elopement indicators is an ongoing interdisciplinary assessment process.IV. Resident #1A. Resident statusResident #1, age less than 65, was admitted on [DATE], hospitalized on [DATE], readmitted on [DATE] and discharged home with home health services on 9/20/25. According to the September 2025 computerized physician orders (CPO), diagnoses included encephalopathy (a disturbance in brain function), aphasia, dysphagia, hemiplegia and hemiparesis (weakness and paralysis on one side of the body), signs and symptoms involving cognitive functions following a stroke, alcohol dependence and epilepsy.The 9/20/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments per the staff assessment for mental status. The assessment documented the resident was independent for most activities of daily living (ADL). The assessment indicated the resident had not exhibited any wandering behavior during the assessment look-back period.B. Resident #1's representative's interviewResident #1's representative was interviewed on 11/3/25 at 11:35 a.m. The resident's representative said Resident #1 had an appointment with his neurologist on 9/9/25, so the facility had coordinated transportation for him. The resident's representative said no one supervised Resident #1 during his appointment, and when the appointment was over, the neurologist's office sent the resident back outside. The resident's representative said Resident #1 wandered away from the neurologist's office and was missing for several hours. The resident's representative said Resident #1 was a vulnerable person, as he had aphasia and dementia. She said Resident #1 did not have a history of wandering prior to admitting to the facility, and seemed like he wanted to get out of the facility and go home.The resident's representative said the facility had told her they usually had a staff member to supervise and sit with residents during their appointments. She said she had spoken with a member of the social services staff, who said Resident #1 would need supervision during his appointment and that she would be sure to let the transportation staff know about Resident #1's need for supervision. The resident's representative said Resident #1's appointment finished early and the resident was assisted back to the lobby afterward, and staff supervision would have been paramount for the resident during the period between when his appointment concluded and when the transportation services returned to pick him up.C. Record reviewThe elopement care plan, initiated 9/9/25, revealed Resident #1 was at risk for elopement. Resident #1 was disoriented and had impaired safety awareness. Resident #1 wandered aimlessly and significantly intruded on the privacy or activities of others. Pertinent interventions included adding Resident #1 to the facility's elopement book, documenting wandering behaviors and diversional interventions, encouraging the resident to participate in activities and the use of visual barriers including stop signs, ribbons and tape.-However, the care plan was not initiated until after Resident #1's elopement incident on 9/9/25.An elopement risk evaluation, dated 8/7/25, revealed Resident #1 was not at risk for elopement. The assessment documented Resident #1 did not have cognitive impairments and did not have a history of substance use disorder.-However, Resident #1's diagnoses included cognitive impairments and alcohol dependence (see above).A progress note, dated 8/8/25 at 9:27 p.m., revealed Resident #1 had acute onset dysphagia, wandering and confusion.An elopement risk evaluation, dated 8/18/25, revealed Resident #1 was not at risk for elopement.The assessment documented Resident #1 was able to ambulate independently, was recently admitted , and had cognitive impairments. The assessment documented Resident #1 did not have a history of substance use disorder.-However, Resident #1's diagnoses included cognitive impairments and alcohol dependence (see above).A progress note, dated 8/20/25 at 8:02 p.m., revealed Resident #1 was noted to be wandering around to other residents' rooms and was reoriented several times by staff. Resident #1 was pleasant with reorientation.A progress note, dated 8/21/25 at 9:00 p.m., revealed Resident #1 was reoriented to his room by a member of the nursing staff. Resident #1 was noted to be wandering around to other residents' rooms and was reoriented several times. A progress note, dated 8/31/25 at 11:48 p.m., revealed Resident #1 wandered onto a different hall in the facility and was found by staff sitting in a wheelchair. An unidentified certified nurse aide (CNA) assisted Resident #1 back into his room. Resident #1 had a history of cognitive deficits and epilepsy.A progress note, dated 9/8/25 at 11:15 p.m., revealed Resident #1 was wandering down the hallway and tended to go into other residents' rooms. Resident #1 needed redirection from staff back to his room. Resident #1 accepted redirection from the staff and was pleasant.-Despite numerous progress notes indicating Resident #1 was wandering into other residents' rooms and needed frequent reorientation, the facility failed to identify the resident as a potential elopement risk.A progress note, dated 9/9/25 at 9:34 p.m., revealed Resident #1 was evaluated on his return to the facility. Resident #1's skin evaluation did not reveal any new injuries. Staff were educated about Resident #1's tendency to wander, and were vigilant in monitoring the resident and offering redirection as needed. Staff were educated regarding appointment safety for cognitively impaired residents by the NHA. An elopement risk evaluation, dated 9/9/25 (after the resident's elopement), revealed Resident #1 was at risk for elopement. The assessment documented Resident #1 wandered aimlessly, ambulated independently, had cognitive impairments, had a history of substance use disorder and a history of actual elopement.The facility investigation, dated 9/9/25, was provided by the NHA on 11/3/25 at 1:11 p.m. and revealed the following:A timeline of events, undated, revealed that at approximately 1:00 p.m. Resident #1 was scheduled to be picked up by an outside transportation company for an appointment. The transportation driver arrived at the facility, assisted Resident #1 to his appointment and escorted him into the building. Resident #1 was seen by the neurologist and discharged at approximately 2:15 p.m., at which point the resident walked away from the hospital.-However, the neurology clinic said the resident was seen at the clinic from 2:17 p.m. until 2:32 p.m. (see interview below).At approximately 4:00 p.m. the transportation driver contacted the facility to notify the facility's receptionist they were unable to locate Resident #1 at the neurology clinic. The receptionist notified the facility's transportation coordinator and the NHA. The transportation coordinator left the facility and began to look for Resident #1 in the area surrounding the neurology clinic.At 5:02 p.m. the transportation coordinator contacted the facility and notified the facility staff they were not able to locate Resident #1. The DON and the social services director (SSD) left the facility to aide in the search for Resident #1. Facility staff also contacted the police department regarding Resident #1's status as a missing person at that time, and notified Resident #1's representative.At approximately 6:40 p.m. Resident #1 was found by the DON walking along a sidewalk 3.4 miles away from the neurology clinic. The DON was able to redirect Resident #1 into her vehicle and transport the resident back to the facility. At 7:00 p.m. Resident #1 returned to the facility, ate dinner and was assessed for any injuries by the nursing staff. Resident #1 did not have any new injuries and did not complain of any pain. An interview with Resident #1's neurology clinic revealed the resident was seen from 2:17 p.m. to 2:32 p.m. The neurology staff said they did not help their patients to ensure they had transportation after their appointments. An interview with the outside transportation company revealed Resident #1 was picked up by the transportation driver at 1:35 p.m. and dropped off at the neurology clinic at 2:02 p.m. The transportation driver was scheduled to arrive back at the neurology clinic at 4:00 p.m. to assist the resident back to the facility. The transportation company said Resident #1 was in the lobby when the driver arrived at the facility. Resident #1's transportation paperwork said he needed an escort to his appointment and that the resident's representative would be escorting him to his appointment. The transportation company said the driver spoke with two unidentified staff members at the facility who both said Resident #1 was okay to go to the appointment by himself, and if Resident #1's representative was not at the clinic, the facility would send a staff member to meet the resident at his appointment. The transportation company said their process typically involved the driver ensuring a resident's escort was available and ready prior to the appointment.V. Staff interviewsCNA #1 was interviewed on 11/3/25 at 12:40 p.m. CNA #1 said she monitored any residents displaying wandering behaviors, notified the nurse and documented the residents' behaviors. CNA #1 said Resident #1 was very confused, had dementia and had been wandering around the hallways of the facility prior to his elopement event on 9/9/25. CNA #1 said all of the nursing staff knew to monitor the resident as a result of those behaviors. CNA #1 said Resident #1 had an incident in which he was going to an appointment and someone was supposed to attend the appointment with him. CNA #1 said the transportation driver took Resident #1 to the appointment but did not stay with the resident. CNA #1 said the facility staff were wondering where Resident #1 was later that evening and found out the transportation driver could not find him.Transportation coordinator #1 was interviewed on 11/3/25 at 1:15 p.m. Transportation coordinator #1 said the facility had two transportation coordinators. He said the transportation coordinators usually received notification that a resident needed an appointment, and they would set up the resident's appointment time and date. Transportation coordinator #1 said the assistant director of nursing (ADON) helped to coordinate escorts for residents' appointments and reviewed which residents needed escorts to their appointments. Transportation coordinator #1 said the nurses filled out an appointment form, which documented the residents' physical abilities, whether or not they needed an escort, and the transportation coordinators then reviewed the form and clarified any additional information with the ADON.Transportation coordinator #1 said another transportation coordinator had contacted the outside transportation services for Resident #1's appointment, so he did not see his transportation paperwork and was not sure what was arranged. Transportation coordinator #1 said he assumed Resident #1's paperwork documented he needed an escort, but he was not sure who told the transportation driver to leave before an escort was identified. Transportation coordinator #1 said the transportation company arrived to pick Resident #1 up from his appointment at the neurologist at 4:00 p.m. and alerted the facility that they could not find the resident at 4:10 p.m. Transportation coordinator #1 said the facility staff checked the hospital's security footage and searched the area for the resident.Transportation coordinator #1 said since the incident on 9/9/25, there were more staff members involved in the transportation arrangement process. Transportation coordinator #1 said the facility provided staff escorts during all residents' appointments. Transportation coordinator #1 said the outside transportation company reviewed and signed off that they understood the changes to the facility's transportation arrangement process.Registered nurse (RN) #2 was interviewed on 11/3/25 at 2:35 p.m. RN #2 said residents were evaluated for elopement risk on admission and quarterly. RN #2 said if a resident exhibited any new wandering or exit seeking behaviors, it would prompt the nurse to perform a new elopement risk evaluation. RN #2 said if a resident was considered at risk for elopement, the nursing staff would be prompted to create an elopement care plan and pertinent interventions. RN #2 said wandering behaviors were documented in the resident's progress notes or the skilled nursing assessments in the resident's electronic medical record (EMR).RN #2 said the facility did not previously use resident escorts whenever a resident had an appointment outside the facility, but family members could join the residents if they wanted to. RN #2 said the facility started sending escorts with residents to outside appointments after Resident #1's elopement incident on 9/9/25. RN #2 said Resident #1 was confused and exhibited wandering behaviors. RN #2 said Resident #1 was not able to ambulate independently when he first admitted to the facility and primarily stayed in bed due to his altered mental status, but as the resident began feeling better he had started wandering more. RN #2 said Resident #1 wandered around the facility hallways and went into other residents' rooms, so the staff had to redirect him multiple times per day.RN #2 said he thought Resident #1's family member was supposed to go with him to his appointment on 9/9/25 but he was not sure.The social services assistant (SSA) was interviewed on 11/3/25 at 4:18 p.m. The SSA said she had received a call from Resident #1's representative on 9/8/25. She said the resident's representative had asked her to assist in scheduling the resident's neurologist appointment to an earlier date. The SSA said the appointment had been initially scheduled on 9/23/25. The SSA said she called the clinic and left a message and was waiting for a response; however, the resident's representative called back and told the SSA that she had been able to reschedule the resident's appointment for the following day herself. The SSA said the resident's representative also informed her that she would not be able to attend the new scheduled date due to her work obligations. She said the resident's representative asked that the facility provide a staff member to accompany the resident to his appointment since she was not going to be able to go with him. The SSA said she replied that she would inform the transportation department; however, since it was a late notice from the representative, it was likely that the facility would not be able to get an escort to accompany the resident. The SSA said the resident's representative said that it was okay for the resident to attend the appointment without an escort. The SSA said she informed transportation coordinator #2 and the case manager of the resident's new appointment date and the request for an escort since the resident's representative was not going to be available.The case manager was interviewed on 11/4/25 at 10:25 a.m. The case manager said she was responsible for overseeing insurance processing and occasionally managing transportation documentation, which involved setting appointments for residents admitted for skilled nursing care (speech, occupational, and physical therapy).The case manager said she overheard the SSA inform transportation coordinator #2, that Resident #1's representative had rescheduled the resident's appointment to an earlier date of 9/9/25. The case manager said she heard from the SSA that the resident's representative would not be able to attend the appointment, and requested that the facility send an escort to accompany the resident.The case manager said she did not act on this information because it was late in the day and she felt that transportation coordinator #2 was capable of managing the situation by setting up the appointment with an escort.The DON and the NHA were interviewed together on 11/3/25 at 3:08 p.m. The DON said the transportation coordinators typically arranged residents' appointments, and the nurses filled out the transportation sheet. The DON said residents with noted elopement risk needed an escort to outside appointments. The DON said if the staff were not sure if a resident needed an escort to their appointment, they could bring the issue to her so they could talk through the situation and determine if an escort was necessary. The DON said elopement risk evaluations were performed on admission and quarterly. The DON said the determination of whether or not a resident was at risk for elopement was the nurse's discretion. The DON said the social services staff audited the elopement evaluations and emailed a list of residents who were at risk of elopement to the DON. The DON said the facility nurses were trained in-house on how to fill out the elopement assessments.The NHA said Resident #1 liked to walk around the facility's halls and had aphasia, so he was not able to vocalize things. The NHA said Resident #1 knew he had an appointment the day of 9/9/25, so he sat on a bench by the front door of the facility. The NHA said the outside transportation driver entered the facility and asked the receptionist for Resident #1, and the receptionist identified the resident. The NHA said RN #2 provided the driver with Resident #1's transportation documents. The NHA said Resident #1 walked out of the building with the driver and was taken to his appointment at the neurology clinic. The DON said later on that day (9/9/25) the transportation driver could not find Resident #1, so they called the facility's transportation team. The DON said she contacted the neurology clinic, who said Resident #1's appointment had ended early and they did not know the resident's whereabouts.The DON said Resident #1 did not have any injuries after he returned to the facility on 9/9/25.The NHA said Resident #1 was assessed by the nursing staff when he returned to the facility and did not have any changes in cognition or disposition. The NHA said Resident #1's representative was scheduled to be his escort to his appointment that day, as she had previously expressed interest in accompanying Resident #1 to his appointment.-However, according to interviews with the SSA and the case manager, Resident #1's representative informed the facility she would not be able to attend the resident's appointment and she requested the facility provide an escort to the appointment for the resident (see interviews above).The DON said Resident #1's representative knew she would not be able to attend the resident's appointment because she was working that day and had called the neurology clinic to let them know Resident #1 would need help calling the transportation services for pick up after his appointment.The DON said Resident #1 had cognitive impairments and a history of wandering. The DON said before Resident #1 was able to ambulate independently, he would self-propel in his wheelchair around the facility. The DON said Resident #1 had been added to the elopement book prior to his elopement incident on 9/9/25 due to his aphasia diagnosis, but he did not have an elopement care plan. The DON said the resident was more sedate when he first admitted to the facility, so the first two elopement risk assessments were accurate. The DON said she did not believe there was anything in the facility's policy which indicated the nursing staff should have completed a new elopement evaluation when Resident #1's wandering behaviors were noted to begin, but she said it was a missed opportunity.The DON said the MDS coordinator or the social services staff would typically implement care plans for wandering and elopement. The DON said if the nursing staff identified a resident was at risk for elopement, they could also trigger pertinent interventions in the resident's care plan. The DON said Resident #1 should have had a care plan developed for his wandering prior to his elopement on 9/9/25. The DON said Resident #1 had a comprehensive nursing assessment completed on 9/3/25, at which point he was already exhibiting wandering behaviors, so those behaviors should have been included in his comprehensive care plan.The NHA said Resident #1 would walk around the facility's main floor but did not have exit-seeking behaviors.The NHA said after the incident on 9/9/25, every staff member who worked on the floor of the facility was educated on what was necessary for a resident to leave the facility, the elopement policy, and the updated procedure for resident escorts. The NHA said every morning since 9/9/25, the facility staff ensured each resident with an outside appointment that day had an escort to go with them. The NHA said if a resident was being escorted to an appointment by a family member, the family member had to go to the facility first so the facility staff could verify they were able to escort the resident.Transportation coordinator #2 was interviewed on 11/04/25 at 10:22 a.m. Transportation coordinator #2 said she tried to make sure resident escorts to outside appointments were scheduled at least a week in advance prior to their appointment date. She said she checked the resident outside appointment list daily to make sure everything was in order. Transportation coordinator #2 said she would sometimes receive late cancellations from the assigned resident escort and she would do her best to find a replacement. Transportation coordinator #2 said if she could not find a replacement escort for the resident, she would volunteer as the escort herself. Transportation coordinator #2 said she had not been aware Resident #1's representative was unable to attend his outside appointment on 9/9/25. Transportation coordinator #2 said she had not been notified by facility staff nor the resident's representative of the need for a replacement escort. Transportation coordinator #2 said on the day of Resident #1's elopement, the neurologist's office ended the appointment early because Resident #1 did not have an escort with him.

Based on observations, interviews, and record review, the facility failed to ensure one (#15) of two residents reviewed for communication out of 28 sample residents was provided appropriate treatment and services to maintain or improve their abilities. Specifically, the facility failed to provide Resident #15, who had difficulties with speech due to a stroke, with an appropriate communication tool to ensure the resident was able to effectively communicate her needs to staff. Findings include: I. Resident #15 A. Resident status Resident #15, under age 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), the diagnoses included cerebral infarction (stroke). The 3/8/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a (BIMS) score of 14 out of 15. She needed substantial assistance from one staff member for transferring and needed supervision or hands on assistance of one staff member for eating and personal hygiene. The MDS assessment indicated Resident #15 was usually understood with difficulty communicating some words or finishing thoughts but was able if prompted or given time and was able to understand others with clear comprehension. B. Observations and interview On 4/15/24 at 9:31 a.m. Resident #15 was sitting in her room pointing at her chest and using her index finger to draw a line from her throat to her chest area. Certified nurses aide (CNA) #2 asked Resident #15 if she needed something to drink or eat, Resident #15 shook her head to indicate no. CNA #2 asked Resident #15 if she needed something for her throat and the resident shook her head to indicate no and continued using her index finger to draw a line from her throat to her chest. CNA #2 asked the resident if her chest was bothering her. Resident #15 attempted to verbally communicate but was unable to pronounce words clearly. CNA #2 said she was unable to understand what Resident #15 was trying to say and left to find assistance from another staff member. CNA #2 did not return, unit care coordinator (UCC) #1 returned instead, approached Resident #15 and asked if the resident was trying to something about her throat to CNA #2. Resident #15 shook her head indicating no and looked at the ground. UCC #1 asked the resident if she wanted juice and Resident #15 shrugged her shoulders and shook her head to indicate yes. C. Record review The communication care plan, revised on 10/23/24, revealed Resident #15 had a communication problem related to cerebral infarction and unclear speech. It indicated the resident would be able to make basic needs known on a daily basis through the review date. Pertinent interventions included using alternative communication tools as needed. -The care plan did not indicate what communication tool to utilize when communicating with Resident #15. D. Staff interviews CNA #2 was interviewed on 4/15/24 at 9:35 a.m. CNA #2 said staff needed to take their time with Resident #15 when trying to understand what she was trying to communicate or find another staff member who was better at communicating with the resident. CNA #2 said Resident #15 expressed frustration in the past when she could not be understood. CNA #2 said she was not aware of any communication devices being used by staff to assist in communicating with Resident #15. CNA #1 was interviewed on 4/15/24 at 9:31 a.m. He said he was aware of Resident #15 having a communication board but had never used it with her. He said another staff member informed him of Resident #15 having a communication board and he would not have known of it otherwise. CNA#1 was unable to locate a communication board in Resident #15's room. Registered nurse (RN) #1 was interviewed on 4/15/24 at 9:40 a.m. She said Resident #15 had a communication board available to staff in her room but the resident may have thrown it away. RN #1 said she did not know why Resident #15 threw her communication board away. RN #1 said there was a communication board at the nurses station that was kept in the narcotic count book. RN #1 said she did not know how direct care staff would know to look in the narcotic count book for a communication board for Resident #15. UCC #1 was interviewed on 4/15/24 at 10:00 a.m. UCC #1 said using alternative communication tools for Resident #15 was indicated to CNAs in the Kardex (tool utilized by staff to provide person centered care). UCC #1 said the Kardex did not specify what the alternative communication tools were. UCC #1 said the care plan would be updated to specify the communication board as an alternative tool. -However, despite UCC #1 indicating the communication care plan would be updated, it was not updated prior to the end of survey on 4/16/24. The speech therapist (ST) was interviewed on 4/16/24 at 11:00 a.m. The ST said prior to 4/16/24 Resident #15 had never been on her caseload. She said she was going to assess the resident for swallowing issues. The ST said Resident #15 had not been assessed by therapy for the use of a communication board and she was unsure when the resident started using it or who recommended it to be used. Social services assistant (SSA) #1 was interviewed on 4/16/24 at 12:43 p.m. She said she was unaware Resident #15 had a communication board prior to 4/15/24. II. Facility follow up The education material that was provided to the CNAs and nurses was provided on 4/14/24 at 2:30 p.m. by the director of nursing (DON). It read in pertinent: Be aware of having difficulty communicating with Resident #15 there is a communication board taped to the inside of her closet. In addition, one is always available on the nurses cart.

Based on observations, record review and interviews the facility failed to ensure one (#55) of one resident received treatment and care in accordance with professional standards of practice out of 28 sample residents. Specifically, the facility failed to ensure Resident #55 was assisted with applying her compression stockings to treat her bilateral lower leg edema. Findings include: I. Facility policy and procedure The Anti Embolism (compression) Stocking Application policy, revised 9/8/23, was received by the director of nursing (DON) on 4/16/24 at 10:43 a.m. It read in pertinent part, The facility will provide anti embolism stocking application in accordance with professional standards of practice. The services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet the professional standards of quality. The facility will utilize [NAME] (nursing) procedures for anti embolism stocking application. The Anti Embolism stocking application checklist, undated, was provided by the DON on 4/16/24 at 10:43 a.m. It read in pertinent part, To apply knee-length anti embolism stockings according to standard of care; -Insert your hand into the stocking from the top, grasp the heel pocket from the inside, and turn the stocking inside out; -Position the stocking over the patient's foot and heel; -Grasp a few inches of the stocking and begin pulling it up around the patient's ankle and calf; -Continue pulling the stocking up the patient's leg using short pulls, alternating from the front to the back, until the bottom of the stocking's band falls one to two inches below the knee; -Smooth out wrinkles in the stocking; -Make sure the patient's toes are visible through the toe inspection area; and, -Document the procedure. 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 pain in fingers, low back pain, pain in the shoulder and congestive heart disease. The 3/10/24 minimum data set (MDS) assessment revealed Resident #55 was cognitively intact with a brief interview for mental status (BIMS) score of 15 of 15. Resident #55 was independent with putting on her shoes and socks and dressing her upper and lower body. -However, the resident needed assistance in applying her compression stockings. B. Resident interview and observations On 4/11/24 at 10:30 a.m., Resident #55 said staff did not help her put on her compression stockings. She said the stockings helped control the swelling in her feet. She said she was unable to pull them up on her own. Resident #55's feet were observed to be swollen. She was wearing slippers that went over the top of her foot and had open heels to accommodate the swelling in the resident's feet. On 4/15/24 at 9:15 a.m., Resident #55 had slippers on her feet and her feet were swollen. Resident #55 was in the hallway outside her room and asked certified nurse aide (CNA) #1 to assist her. She said staff would not help her put on the compression stockings. CNA #1 said he did not know the resident. He said he did not feel comfortable applying the compression stockings because her feet were so swollen. CNA #1 spoke with licensed practical nurse (LPN) #1. LPN #1 said staff was supposed to put her compression stockings on every morning. CNA #1 said he needed larger stockings because the stockings for Resident #55 were too small to fit over her legs due to the increased swelling. The unit care coordinator (UCC) #1 walked up to where CNA #1 and LPN #1 were talking in the hall. UCC #1 said Resident #55 was supposed to put the stockings on herself. Resident #55 said she was unable to pull the stockings up on her own because it was too difficult for her to do. Resident #55 said she previously told staff but no one helped her apply the compression stockings. On 4/16/24 at 9:15 a.m., Resident #55 was in her room and was observed without her compression stockings on. Resident #55 said staff had not offered to assist her in putting her compression stockings on. She said staff did not help her with the stockings on 4/13/24 or 4/14/24. III. Record review Review of Resident #55's medical records revealed a physician's order, dated 4/9/24, which read in pertinent part, Please give resident compression stockings to wear during the day while awake. The edema care plan, initiated on 3/9/21 revealed the resident had edema related to her diagnosis of congestive heart failure. -A review of the comprehensive care plan did not reveal an updated intervention to include the 4/9/24 physician's order for compression stockings. IV. Nursing interview The DON was interviewed on 4/16/24 at 9:45 a.m. The DON said Resident #55 had a history of refusing to wear compression stockings. The DON was unable to find documentation in April 2024 that Resident #55 refused to wear the compression stockings. The DON said the physician's order for compression stockings was entered incorrectly and did not prompt the staff to assist the resident with the compression stockings. The DON said because the physician's order was not correctly entered, it did not prompt the staff to document when they assisted the resident in putting on the compression stockings. She said when UCC #1 confirmed the physician's order on 4/9/24 she should have clarified the order to ensure it was entered correctly. The DON was interviewed again on 4/16/24 at 10:40 a.m. The DON said staff had just helped Resident #55 apply the compression stockings. The DON said she clarified the physician's order for the resident to have compression stockings applied and removed daily. The DON said she updated Resident #55's care plan to include the application of the compression stockings and to apply the compression stockings and monitor Resident #55's edema.

Based on record review and interviews, the facility failed to ensure one (#1) out of three sample residents reviewed for falls, received adequate supervision and assistance to prevent accidents. Specifically, the facility failed to ensure: -Resident #1 received adequate supervision during the occupational therapy treatment to prevent an avoidable fall with injury; and, -Post fall nursing assessment of Resident #1's injuries was done timely and appropriately by a registered nurse. Findings include: I. Resident status Resident #1, age 79, was admitted to the facility on [DATE]. According to the computerized medical record, diagnoses included hemiplegia and hemiparesis (paralysis) following cerebral infarction (stroke) affecting right dominant site, cerebellar stroke syndrome, depression and anxiety. The 9/6/23 minimum data set (MDS) assessment revealed Resident #1's cognition was moderately impaired with a brief interview for mental status (BIMS) score 11 out of 15. No behavioral symptoms or rejection of care were noted. She required one person limited assistance with bed mobility, dressing and toilet use, two staff limited assistance with transfers, and was independent with eating. Medications included an antidepressant and anticoagulant. II. Record review A. Care plan The comprehensive care plan review revealed the following: -(Resident) is at risk for falls r/t (related to) impaired mobility, psychotropic medication use and impaired cognition with decreased safety awareness. Date Initiated: 9/2/23 Interventions included: Assist with ADLs (activities of daily living) as needed. Call light within reach. Complete fall risk assessment. Orient resident to room. Provide adaptive equipment or devices as needed. -(Resident) has hemiplegia/hemiparesis affecting right dominant side r/t (related to) cerebral infarction. Date Initiated: 9/19/23 Interventions included: Discuss with resident/resident and family any concerns, fears, issues regarding diagnosis or treatments. PT (physical therapy), OT (occupational therapy), ST (speech therapy) evaluate and treat as ordered. B. Interdisciplinary notes On 9/3/23 a registered nurse documented: CVA (cerebrovascular accident) with right sided weakness and decreased sensation. HX of A-fib and HTN (history of atrial fibrillation and hypertension). Slight BLE (bilateral lower extremities) edema elevation as tolerated .Pt (patient) currently with right sided weakness and requiring limited assist with transfers . Pt (patient) currently on ASA (aspirin) and eliquis (a blood thinner medication that reduces blood clotting) for DVT (deep vein thrombosis) prevention .Pt (patient) currently cooperative with all cares and therapies at this time. On 9/10/23 an occupational therapist documented in the Occupational Therapy Treatment Encounter Note the following: Patient completed toilet routine with min A (minimum assistance) for transfer from toilet to standing utilizing 3-in-1 commode and grab bars and min A (minimum assistance) for clothing management to promote ind (independence) in the toileting routine. Patient completed self-care tasks seated in w/c (wheelchair) in front of sink with SBA (stand-by-assistance) for safety. Patient participated in functional mobility tasks with FWW (front wheeled walker) across various obstacles requiring CGA (contact-guard-assistance) and vc's (verbal cues) to slow down and pick up feet. Patient fell toward L (left) side requiring dep A (assistance) to transition back into w/c (wheelchair). Therapist discussed fall with nurse and PT (physical therapist) and provided first aid (band-aid) to tip of 3rd digit. Patient benefited from fall prevention training focused on body awareness and foot placement with teach back method to enhance carryover. -The occupational therapist failed to inform the nurse of Resident #1's fall and failed to ask for an assessment. (see nursing note below and interviews) On 9/11/23 a registered nurse documented: This nurse was told by the day shift nurse on 300 hall of the resident's finger looking swollen and bleeding. Other information gathered at the time, which this writer was unaware of, is the resident had a fall with therapy the day prior. When entering the room, the POA (power of attorney), (spouse) explained his wife had a fall with therapy the day prior and had a swollen finger on the right and was having pain to the left shoulder. ROM (range of motion) decreased on left shoulder, ROM (range of motion) of finger WNL (within normal limits). This nurse examined the residents skin focusing on the shoulder, elbows, hips/buttock, and head. When questioned the resident was not able to recollect how she fell nor whether she struck an object during. Resident did state she did not think she struck her head. No other injuries were noted at the time of assessment. This nurse had shift nurse call to gain orders for X-rays for hand as well as shoulder. Awaiting results of X-ray. MD (physician) was notified. On 9/11/23, a follow-up note by a registered nurse revealed: Pt (patient) alert and oriented x2-3 (person, place, time), periods of forgetfulness. Pt (patient) will ask the same questions multiple times. Unable to remember that she had already asked the questions. Easy to re-orient. Husband at bedside 24hours a day. No c/o (complaints) of chest pain or discomfort noted at this time. History of hypertension . Pt (patient) a 1 (one) person assist with transfers and ADL's (activities of daily living). Needs queuing at times. Weakness to right side due to previous CVA (cerebrovascular accident). Pt (patient) fell this weekend working with therapy and has been c/o (complaining) of shoulder pain. New orders for stat x-ray to left shoulder, elbow and hand .Pt (patient) c/o (complained) of 10/10 pain to left shoulder from fall. PRN (as needed) Tylenol given with positive effect. On 9/11/23 a physician documented: Lost balance while attempting to transfer. fell .According to report the patient is reportedly stable with respect to contusion of left ring finger w/o (without) damage to nail init. Swelling of distal phalanx .With regards to cerebellar stroke syndrome the patient has been stable. Patient has significant dizziness which she reports has been present since stroke, fits with patient's stroke location. Patient has good days and bad days, this does hinder mobility and puts her at higher risk for falls. The 9/11/23 radiology report revealed no acute fracture or dislocation of left shoulder, elbow and hand. On 9/13/23 a nurse practitioner documented: Lost balance while attempting to transfer. fell . Pain and reduced ROM (range of motion) to L (left) shoulder .The patient is reportedly stable with respect to pain in left shoulder. Pain since fall patient reports mod (moderate)/severe, unable to lift arm actively above 90 degrees when was prior to fall full ROM (range of motion). Pain prevents full passive ROM (range of motion), on palpation pain is worst just lateral of acromion process. X-ray neg (negative) .Pain in left shoulder. No medication changes with respect to (resident's) pain in left shoulder. Continue to monitor. MRI (magnetic resonance imaging). Pain and movement pattern suspicious for rotator cuff injury. Tylenol. Patient should be careful not to push herself too hard while injury being evaluated. The 9/26/23 magnetic resonance imaging (MRI) report revealed the following: 1. Acute mildly displaced distal clavicle fracture practically at the acromioclavicular joint. 2. Full-thickness retracted tear of the anterior supraspinatus tendon insertion with associated disuse atrophy of the supraspinatus muscle suggesting that the injury is chronic. 3. Longitudinal split tear of the biceps tendon at the upper bicipital groove level and possibly within its intra-articular course. On 9/29/23 a nurse practitioner documented: Discharge to home today. Patient feels like she has made progress here and is safe to go home .The patient is reportedly stable with respect to pain in left shoulder. Slow but reasonably full AROM (active range of motion) today on my rounds. MRI (magnetic resonance imaging) results show full-thickness or practically full thickness tear of the anterior supraspinatus tendon insertion. Tendon retracted almost to the acromioclavicular joint level. Distal defect measures approximately 13 mm (millimeters) in anteroposterior dimension. Reactive intraosseous cystic changes along the posterior supraspinatus and anterior infraspinatus insertion as well as subscapularis insertion. III. Interviews The director of rehabilitation (DOR) was interviewed on 11/7/23 at 8:48 p.m. He said he was aware Resident #1 fell during occupational therapy treatment on 9/10/23. He said the occupational therapist (OT) did not call a registered nurse to assess Resident #1 after the fall in therapy room. He said the OT was a new staff member in the facility and was not aware of the facility policy to immediately call for a nurse to assess resident's injuries after a fall. He said according to the facility policy she should not transfer Resident #1 from the floor to the wheelchair by herself. He said the OT received a general facility and therapy orientation on her first day of employment. He said the orientation did not include post fall facility policy. He said he provided the education on the facility post fall policy and procedures for the OT immediately after the incident. Registered nurse (RN) #1 was interviewed on 11/7/23 at 10:55 a.m. She said Resident #1 had right side weakness in upper and lower extremity. She required staff assistance with stand pivot transfers, was able to stand from a toilet using a grab bar and was not allowed to walk with nursing staff. RN#1 said she was called to Resident #1's room on 9/11/23, in the morning, approximately at 8:00 a.m. She said the resident's ring finger was swollen and bleeding, and she complained of left shoulder pain. She said she called the resident's physician and stat x-ray was ordered. She said it was the facility policy a registered nurse must do a head to toe assessment after a resident's fall. She said the nurse (RN) who was on duty on 11/9/23 reported the OT came to her desk and asked for a band aid. She said the OT did not tell the RN about Resident #1's fall. The nursing home administrator (NHA) was interviewed on 11/7/23 at 11:25 a.m. She said it was the facility policy each resident after a fall must be evaluated for injuries by a registered nurse before the resident's transfer from the floor. She said the occupational therapist received additional training on the post fall policy from the director of rehabilitation.

Based on interviews, record review, document review, and facility policy review, the facility failed to protect the resident's right to be free from physical and verbal abuse by a family member (FM) for 1 (Resident #36) of 1 resident reviewed for abuse. Specifically, a staff member witnessed FM #1 yell at and shake the shoulders of Resident #36; however, this staff member did nothing. Later on the same day, it was reported FM #1 had been witnessed to forcefully hit Resident #36 on their shoulder multiple times. Findings included: Review of a facility policy titled, Area of Focus: Abuse & Neglect, reviewed 11/21/2022, specified, Residents must not be subjected to abuse by anyone. This includes but is not limited to staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, friends, or any other individuals. The policy further specified, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. A review of an Admission Record indicated the facility admitted Resident #36 with diagnoses that included muscle weakness, history of falling, pain in right and left shoulders, cognitive communication deficit, and other abnormalities of gait and mobility. A review of an Annual Exam, dated 06/08/2021, revealed Resident #36 had additional diagnoses of anoxic brain damage and altered mental status. The quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #36 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The resident required limited assistance with bed mobility, transfers, dressing, and toilet use; extensive assistance with locomotion on and off the unit; and supervision with personal hygiene. A review of a facility investigation report, dated 12/08/2022, revealed Resident #36's family member (FM #1) was observed to strike Resident #36 twice on the resident's shoulders. Per the report, FM #1 was made to leave the facility, pending an investigation, and Resident #36 was assessed and determined to have no injuries. Following the investigation, the facility determined the allegation of physical abuse by FM #1 was substantiated. During an interview on 01/17/2023 at 10:05 AM, Resident #36 stated something bad happened recently. The resident stated one of the nursing staff mistook a family member's (FM #1) mannerisms for abuse. According to Resident #36, FM #1 was not abusive, the occurrence was all wrong; it was not abuse, and the resident was not afraid of FM #1. During an interview on 01/18/2023 at 10:20 AM, Certified Nursing Assistant (CNA) #7, a hospice CNA, stated as she attended to Resident #36's roommate, FM #1 asked her why Resident #36 was no longer on hospice. CNA #7 stated FM #1 became very angry, yelled at her, and stated Resident #36 was dying and needed care. Per CNA #7, FM #1 reported they did not know the resident was no longer on hospice. CNA #7 further stated FM #1 was very animated, flailed their arms, and made statements and then would forcefully hit Resident #36 on their shoulders. CNA #7 stated that each time FM #1 hit Resident #36 on the shoulder, the resident grimaced. CNA #7 stated she was not able to calm FM #1, so she stepped out of the room to get the nurse on the hall for help. According to CNA #7, the nurse (Registered Nurse [RN] #5) admitted to her that FM #1 had yelled at her earlier. Per CNA #7, the situation got out of control and the police were called. CNA #7 stated Resident #36 did not appear to be fearful but grimaced every time FM #1 hit their shoulder. During an interview on 01/18/2023 at 10:51 AM, Licensed Practical Nurse (LPN) #6 stated she did not witness the incident involving Resident #36 and FM #1. LPN #6 stated she had not ever witnessed FM #1 being rough or cruel to Resident #36, though she had observed FM #1 become very impatient and a little loud with the resident. According to LPN #6, when Resident #36 was interviewed by the police, the resident denied feeling he/she was in danger around FM #1 and that FM #1 had struck them. LPN #6 indicated the resident did state FM #1 had pushed the resident really hard. On 01/18/2023 at 11:05 AM, an attempt to interview the police officer was made; however, a message was left, and the police officer did not return the surveyor's call prior the end of the survey. During an interview on 01/18/2023 at 11:40 AM, RN #5 stated Resident #36 was an at risk adult because of some of the interactions she had observed between the resident and FM #1. RN #5 stated FM #1 was verbally and physically aggressive at times, exhibited high anxiety with odd behavior that made her antennas go up. RN #5 stated that on 12/08/2022, FM #1 had called the facility at 4:00 AM and demanded medical information from a nurse. When FM #1 was denied the information as FM #1 was not Resident #36's representative, FM #1 became very angry. RN #5 stated on 12/08/2022 at 7:30 AM, FM #1 was at the nurse's station asking why the nurses refused to release information to them and why the resident was not ready to go on a breakfast date with FM #1. RN #5 informed FM #1 that Resident #36 was in the dining room. Per RN #5, FM #1 went to the dining room and brought Resident #36 out. RN #5 stated she observed FM #1 yell at Resident #36 and state, See, you have to tell them they have to talk to me, then FM #1 would shake the resident's shoulder. RN #5 stated after this incident Resident #36 seemed fine, FM #1 took the resident into their room, and she continued with her medication pass. RN #5 stated then later the hospice CNA (CNA #7) came to her and told her that FM #1 just hit Resident #36 two times in front of her. RN #5 stated she asked the unit manager to join her in Resident #36's room and observed the resident seated in their wheelchair and FM #1 going through [their] things. RN #5 stated she went to the administrative offices to request assistance and advised the staff that she called the police. Per RN #5, other staff members came to Resident #36's room and escorted FM #1 out of the room at that time. During an interview on 01/18/2023 at 12:30 PM, the Social Services Director (SSD) stated FM #1 became upset when CNA #7 stated she was unable to provide a shower to Resident #36, as the resident was no longer on hospice. Per the SSD, CNA #7 witnessed FM #1 become increasingly agitated and strike Resident #36 on the shoulder several times as FM #1 argued with CNA #7. The SSD reported the resident was upset because FM #1 was upset. The SSD stated she did not know the final disposition of the investigation, only that abuse occurred because FM #1 was witnessed hitting Resident #36. During an interview on 01/18/2023 at 3:49 PM, FM #3 stated FM #1 was pretty volatile, got very angry one day, and became inappropriately physical with Resident #36. During an interview on 01/19/2023 at 10:06 AM, the Director of Nursing (DON) stated she had been in the role of DON for about three weeks. The DON stated if abuse was suspected or there was a report of abuse, the allegation would immediately be reported to the Executive Director (ED), who was the Abuse Coordinator. The DON further stated she would ensure the resident was in a safe place and the alleged perpetrator was removed from the facility. The DON stated she was not involved in the incident involving Resident #36 and the FM #1 on 12/08/2022. During an interview on 01/19/2023 at 10:39 AM, the ED stated if abuse was suspected or reported, the staff would ensure the threat was removed, or the residents separated if it was a resident-to-resident incident. The ED further stated if she was in the building she would go to the area and talk to everyone to get the picture, and if not in the building she would talk to the witness or reporter on the telephone. The ED stated she would determine next steps based on the findings of assessments and would initiate the report to the State.

Based on interviews, record review, and facility policy review, the facility failed to ensure a resident with a new mental health diagnosis was referred for a level two pre-admission screening and resident review (PASRR) for 1 (Resident #49) of 1 sampled resident reviewed for PASRR. Findings included: A review of a facility policy titled, Pre-admission Screening and Resident Review (PASARR), dated as issued 06/06/2019 and revised 10/06/2022, revealed, A negative Level I screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. The policy also indicated, 9. As part of the PASARR process, the facility is required to notify the appropriate state mental health (SMH) authority or state intellectual disability authority when a resident with a mental disorder or intellectual disability (ID) has a significant change in their physical or mental condition. This will ensure that residents with a mental disorder or intellectual disability continue to receive the care and services they need in the most appropriate setting. 10. Referral to the SMH/ID authority should be made as soon as the criteria indicative of a significant change are evident. A review of an Admission Record revealed the facility admitted Resident #49 on 09/17/2021 with a primary diagnosis of other symptoms and signs involving the nervous system. The Admission Record indicated the resident's other diagnoses included: - anxiety, added on 04/22/2022 - delusional disorders and obsessive-compulsive disorder (OCD), added on 04/26/2022. A review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS indicated the resident had active diagnoses of anxiety disorder, psychotic disorder, and OCD. A review of a care plan, dated as initiated 06/21/2022, revealed Resident #49 had a potential for a decline in mood state related to diagnoses of delusional disorder, OCD, and anxiety. The planned interventions included administering medications as ordered and observing the resident's mood to determine if problems seemed to be related to external causes. Review of a care plan dated as initiated 09/20/2022 and revised 11/08/2022 revealed Resident #49 used psychotropic medications related to diagnoses of depression and delusional disorder. A planned intervention was to administer psychotropic medications as ordered by the physician. Review of the January 2023 Medication Administration Record (MAR) revealed that beginning on 12/22/2022, Resident #49 received Zoloft, an antidepressant medication, 100 milligrams (mg) by mouth (po) one time a day for delusional disorder and anxiety. The MAR further revealed, beginning on 01/03/2023, the resident received Abilify, an antipsychotic medication, 10 mg po at bedtime related to delusional disorders. A review of Resident #49's level one PASRR results, dated 09/23/2021, revealed no level two PASRR was required. Further review of Resident #49's medical record on 01/18/2023 revealed no other PASRR screening documentation. A review of a level one PASRR submitted on 01/18/2023 revealed Resident #49's diagnoses of other symptoms and signs involving the nervous system, delusional disorders, OCD, and anxiety disorders. During an interview on 01/19/2023 at 8:33 AM, the Social Services Director (SSD) stated a level one PASRR was completed for each resident on admission. Per the SSD, if a resident was not on any psychoactive medications, the PASRR evaluation automatically triggered that a level two evaluation was not required. The SSD indicated if a resident started on any new psychoactive medications or had a significant change in condition, she submitted an additional PASRR screen request to the state for another evaluation. The SSD stated Resident #49 was on her list to submit another PASRR screen to the state and that she submitted it on 01/18/2023. According to the SSD, when Resident #49 first admitted to the facility, the resident did not require a level two evaluation but had recently had delusions and was started on Abilify. The SSD indicated Resident #49 probably qualified for a level two evaluation now, with their current diagnoses and medications. During an interview on 01/19/2023 at 9:40 AM, the Medical Director (MD) stated he took over Resident #49's care in late December 2022. Per the MD, Resident #49 had a diagnosis of delusional parasitosis, and the use of antidepressants was validated in the treatment of this disorder. The MD further stated Resident #49 was stable with their current plan of care. During a follow-up interview on 01/19/2023 at 9:53 AM, the SSD stated Resident #49 was started on a couple psychoactive medications when their behaviors started but none were effective. According to the SSD, another level one PASRR was not done when those medications were started, and she did not have a reason for not submitting the request to the state prior to 01/18/2023. The SSD stated Resident #49 probably qualified for a level two PASRR and would be offered additional counseling services for the treatment of their mental health diagnosis once they qualified for a level two PASRR. During an interview on 01/19/2023 at 1:20 PM, the Director of Nursing (DON) stated the SSD was responsible for submitting the level one PASRR screens to the state, but she was not sure of the required timeline. The DON further stated if a resident had a new mental health diagnosis, she expected that information to be sent to the PASRR authority to see if that resident qualified for a level two PASRR and additional services. During an interview on 01/19/2023 at 1:41 PM, the Executive Director (ED) stated the SSD screened residents upon admission to see if they met the requirements for a level two PASRR. The ED further stated she was not sure what triggered another level one PASRR or what changed it from a level one to a level two screening. The ED stated, moving forward, she was going to have the medical records staff notify the SSD if they coded any new international classification of diseases codes for new diagnoses, so the SSD was aware of new diagnoses to update the PASRR screens as needed.

Based on interviews, record review, document review, and facility policy review, the facility failed to review and revise the comprehensive care plan for 1 (Resident #36) of 16 sampled residents, following a substantiated allegation of physical abuse by a family member. Findings included: Review of a facility policy titled, Person Centered Care Planning, initiated 08/16/2022, specified Each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. A review of an Admission Record indicated the facility admitted Resident #36 with diagnoses that included muscle weakness, history of falling, pain in right and left shoulders, cognitive communication deficit, and other abnormalities of gait and mobility. A review of an Annual Exam, dated 06/08/2021, revealed Resident #36 had additional diagnoses of anoxic brain damage and altered mental status. The quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #36 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The resident required limited assistance with bed mobility, transfers, dressing, and toilet use; extensive assistance with locomotion on and off the unit; and supervision with personal hygiene. A review of a facility investigation report, dated 12/08/2022, revealed Resident #36's family member (FM #1) was observed to strike the resident twice on the resident's shoulders. Per the report, FM #1 was made to leave the facility, pending an investigation, and Resident #36 was assessed and determined to have no injuries. Following the investigation, the facility determined the allegation of physical abuse by FM #1 was substantiated. A review of Resident #36's comprehensive care plan revealed there was no information or interventions implemented to ensure the resident's continued safety in the facility after there was a substantiated allegation of physical abuse perpetrated by FM #1 to the resident on 12/08/2022. During an interview on 01/18/2023 at 12:30 PM, the Social Services Director (SSD) stated there was no written directive to nursing that described the plan to keep Resident #36 safe from potential abuse by FM #1. The SSD stated she had not revised the resident's care plan at the time of the incident; she had not thought about it but would do it today (01/18/2023). The SSD repeated she would update the resident's care plan. During an interview on 01/19/2023 at 10:39 AM, the Executive Director (ED) stated the care plan was not updated at the time of the incident between Resident #36 and FM #1, as the team was waiting on a more permanent fix. The ED stated her expectation was for care plans to be updated immediately and all staff to be educated on any new interventions.

Based on interviews, record review, document review, and facility policy review, it was determined that the facility failed to provide medically-related social services by failing to monitor a resident following a substantiated abuse incident and failing to assist with discharging from the facility for 1 (Resident #36) of 1 resident reviewed for abuse. Findings included: Review of a facility policy titled, Social Services Personnel, reviewed 09/30/2022, specified, All facilities are required to provide medically related social services for each resident. The policy further specified, The facility must provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The policy specified, Procedure 14. Meet the needs of residents who are grieving from losses and coping with stressful events. A review of an Admission Record indicated the facility admitted Resident #36 with diagnoses that included muscle weakness, history of falling, pain in right and left shoulders, cognitive communication deficit, and other abnormalities of gait and mobility. A review of an Annual Exam, dated 06/08/2021, revealed Resident #36 had additional diagnoses of anoxic brain damage and altered mental status. The quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #36 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The resident required limited assistance with bed mobility, transfers, dressing, and toilet use; extensive assistance with locomotion on and off the unit; and supervision with personal hygiene. A review of a facility investigation report, dated 12/08/2022, revealed Resident #36's family member (FM #1) was observed to strike the resident twice on the resident's shoulders. Per the report, FM #1 was made to leave the facility, pending an investigation, and Resident #36 was assessed and determined to have no injuries. Following the investigation, the facility determined the allegation of physical abuse by FM #1 was substantiated. A review of Resident #36's comprehensive care plan revealed there was no information or interventions implemented to ensure the resident's continued safety in the facility after there was a substantiated allegation of physical abuse perpetrated by FM #1 to the resident on 12/08/2022. During an interview on 01/17/2023 at 10:05 AM, Resident #36 stated something bad happened recently. The resident stated one of the nursing staff mistook a family member's (FM #1) mannerisms for abuse. According to Resident #36, FM #1 was not abusive, the occurrence was all wrong; it was not abuse, and the resident was not afraid of FM #1. Resident #46 further commented that they did not want to be in the facility, since FM #1 was banned from the facility. Per Resident #36, they wished for FM #1 to visit the facility, so that FM #1 could assist the resident in packing their belongings to leave the facility. Resident #36 reported they wanted to move in with FM #1, once FM #1 got an apartment. A review of Resident #36's Progress Notes revealed the last Psychosocial Note entered by social services was dated 11/11/2022. The note indicated the resident was interviewed for their cognition and mood state and displayed no behaviors during the review period. During an interview on 01/18/2023 at 12:30 PM, the Social Services Director (SSD) stated she was not informed of the final disposition of the abuse investigation completed for the incident on 12/08/2022 involving Resident #36 and FM #1. The SSD acknowledged the resident was upset about the situation, and the resident wanted to leave the facility to live with FM #1. The SSD was unable to provide any assessments and/or documentation as evidence of conversations she had with Resident #36 to determine the resident's mental health following the substantiated physical abuse perpetrated by FM #1, and the SSD was unable to provide documentation she assisted Resident #36 with their plans to leave the facility. During an interview on 01/19/2023 at 10:06 AM, the Director of Nursing (DON) stated she had only been in this position for a few weeks and had not been involved with the incident between Resident #36 and FM #1. The DON stated the SSD was responsible for checking on residents during morning rounds, asking staff if they have noticed any changes in the resident, and then following up accordingly. The DON stated she would not expect any further assessments to be done if there were no changes reported/observed. During an interview on 01/19/2023 at 10:39 AM, the Executive Director (ED) stated she expected the SSD to document interactions with residents. The ED further stated the SSD should check in and talk to any residents affected by abuse, and the staff needed to do a better job documenting what they did.

Based on interviews, record review, and policy review, the facility failed to assess a resident for medical contraindications and provide education on the influenza vaccine prior to the administration of the influenza vaccine for 1 (Resident #7) of 5 residents reviewed for immunizations. Findings included: A review of the facility's Influenza Vaccine & Pneumococcal Vaccine Policy for Residents, revised 12/06/2022, revealed, Procedure-Influenza Vaccine 1. Starting on October 1st and extending to March 31st, residents are offered the influenza vaccine each year, unless the immunization is medically contraindicated, or the resident has already been immunized during this time period. 2. Education is provided to the resident or the resident's representative regarding: i. The benefits and potential side effects of the immunization. ii. The resident or resident's representable has the opportunity to refuse immunization. iii. The resident and/or responsible party is provided with the vaccine information statement for the vaccine to be administered. The policy further revealed, 3. The resident is assessed for possible contraindications that may include: i. Allergy to eggs, chicken, feathers, or chicken dander ii. Hypersensitivity to other components of the vaccine iii. Acute febrile illness iv. Having received another type of vaccine within the past 14 days v. In addition, the package insert is reviewed for additional contraindications and directions. Also, the policy revealed, 7. Education, assessment findings, administration, refusal or did not receive due to medical contraindications, and monitoring are documented in the resident's medical record. A review of Resident #7's Admission Record revealed the facility admitted the resident with diagnoses that included acute respiratory failure with hypoxia, heart failure, chronic obstructive pulmonary disease, personal history of pneumonia and dependence on supplemental oxygen. A review of Resident #7's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Per the MDS, Resident #7 received the influenza vaccine on 11/02/2022. A review of Resident #7's November 2022 Medication Administration Record revealed a registered nurse (RN) administered the influenza vaccine to Resident #7 on 11/02/2022 at 9:18 AM. A review of Resident #7's medical record, including progress notes, revealed there was no documentation to indicate an assessment for medical contraindications or education regarding the benefits and potential side effects of the influenza immunization was provided to the resident prior to the administration of the influenza vaccine. On 01/19/2023 at 10:30 AM, the Infection Preventionist (IP)/RN stated Resident #7 had initially refused the flu shot, but when their roommate got their flu shot, Resident #7 decided to get one as well, so the flu shot was given to the resident at that time on 11/02/2022. The IP/RN indicated ideally, a consent form should have been completed, that showed the resident gave consent. On 01/19/2023 at 1:23 PM, the Director of Nursing (DON) indicated Resident #7 had previously requested not to have the flu vaccination but had later indicated they wanted one after seeing their roommate get one. The DON revealed a new consent form should have been completed prior to the administration of the vaccination.

Based on observations, interviews, and record review, the facility failed to have an effective infection control program. Specifically, the facility failed to: -Ensure staff offered hand sanitation prior to resident meals; -Perform appropriate source control for staff and visitors; and, -Ensure housekeeping staff completed proper hand hygiene during cleaning of resident rooms. Findings include: I. Staff not offering hand sanitation prior to serving residents their meals A. Professional reference The Centers for Disease Control (CDC) Hand Hygiene updated 5/17/2020, retrieved on 10/19/21 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html, revealed in part, Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. CDC recommendations reflect this important role. The exact contribution of hand hygiene to the reduction of direct and indirect spread of coronaviruses between people is currently unknown. However, hand washing mechanically removes pathogens, and laboratory data demonstrate that ABHR formulations in the range of alcohol concentrations recommended by CDC, inactivate [CONDITION(S)]-CoV-2. ABHR effectively reduces the number of pathogens that may be present on the hands of healthcare providers after brief interactions with patients or the care environment. The CDC recommends using ABHR with greater than 60% [MEDICATION(S)] or 70% [MEDICATION(S)] in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink. B. Facility policy The Hand Hygiene policy, revised on 12/4/2020, provided by the director of nursing (DON) on 10/14/21 at 3:45 p.m. It read, in pertinent part: Handwashing/hand hygiene is generally considered the most important single procedure for preventing nosocomial infections. The purpose is to decrease the risk of transmission of infection by appropriate hand hygiene. The facility should place wall mounted dispensers within the workflow, inside and outside of resident rooms to help them do hand hygiene at the right times. Individual pocket sized dispensers may be an alternative to wall mounted dispensers. Staff should perform proper hand hygiene with alcohol based hand rubs (ABHR) and with soap and water: -before and after all resident contact; -before applying gloves; -after removal of gloves; -after contact with potentially infectious material; -prior to eating or drinking. C. Observations On 10/11/21 at 11:24 a.m., the residents in the 100 hall dining room approximately 10 residents were not provided towelettes on their meal trays and the staff did not offer or encourage hand sanitizer or hand washing. On 10/11/21 at 11:24 a.m the staff in the 100 hall dining room did not use hand sanitizer before entering and exiting the dining room. Approximately four staff did not use hand sanitizer before or after serving the residents in the dining room. The dining room had two wall sanitizer dispensers, one by each door. On 10/11/21 at 12:24 p.m. the resident rooms did not have wall sanitizer dispensers in them and there were limited wall sanitizer dispensers available for residents' use in the hallway. There were two wall hand sanitizer dispensers available to the residents in the 100 hall. There were 12 resident rooms with two dispensers for the entire hall. There was one wall sanitizer dispenser behind the nurses station for staff. On 10/11/21 at 2:04 p.m., a volunteer was observed passing out ice cream and popcorn to the residents' rooms. He was observed entering three separate resident rooms without sanitizing his hands and did not encourage resident hand hygiene. On 10/12/21 at 2:29 p.m. housekeeper #2 was observed cleaning resident room [ROOM NUMBER]. She was observed changing out her gloves between tasks but did not use hand sanitizer before or after she changed her gloves. She did not have hand sanitizer on her cleaning cart. On 10/13/21 at 11:05 a.m., the residents in the main dining room were not provided or offered hand hygiene. The towelettes were provided, but approximately six residents who were dependent on staff out of 13 total residents in the dining room were not offered assistance to open the towelettes before their meal. On 10/13/21 at 11:32 a.m. Resident #23 was observed sitting in his wheelchair at the facility's water cooler dispenser. He was observed touching multiple plastic cups before using one cup to get a drink of water. Resident #23 put the unused cups back in the basket holding the clean cups for other residents and staff to use. Resident #23 did not use hand sanitizer prior to touching the cups or touching the water cooler spout. There was no hand sanitizer available to use at the water cooler. II. Staff and visitor source control A. Professional reference According to the CDC last updated 9/10/21, Interim infection prevention control recommendations for healthcare personnel during COVID-19 retrieved on 10/21/21, read in pertinent part, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Finfection-control-after-vaccination.html Implement Source Control Measures Source control refers to the use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Indoor visitation (in single-person rooms; in multi-person rooms, when roommates are not present; or in designated visitation areas when others are not present): The safest practice is for patients and visitors to wear source control and physically distance, particularly if either of them are at risk for severe disease or are unvaccinated. If the patient and all their visitor(s) are fully vaccinated, they can choose not to wear source control and to have physical contact. Visitors should wear source control when around other residents or HCP (healthcare personnel), regardless of vaccination status. Unvaccinated HCP, patients and visitors should be offered resources and counseled about the importance of receiving the COVID-19 vaccine. B. Observations On 10/11/21 at 9:40 a.m. licensed practical nurse (LPN) #4 was observed with her mask down under her chin talking to another staff member. She said she was drinking her coffee and put her mask over her nose and mouth. On 10/11/21 at 9:53 a.m. LPN #4 was observed with her mask down under her chin walking and talking with another staff member down the hall. She immediately placed her mask over her nose and mouth once observed. On 10/12/21 at 9:30 a.m., a registered dietitian (RD) was observed sitting in her office with her mask down under her chin. She was meeting with two family members in her office who were wearing a mask. On 10/12/21 at 11:35 a.m. the RD was observed sitting in her office with her mask down under her chin. She was meeting with two family members in her office who were wearing a mask. On 10/13/21 at 11:07 a.m. the social services director (SSD) was observed sitting behind the nurses station talking on the phone with her mask down under her chin. She was observed talking with a male resident standing next to the nurses station with her mask down under her chin. On 10/13/21 at 11:58 a.m. Resident #14 had her son visit. He wore a mask down the hall and into the dining room. He removed his mask at the dining room table and ate lunch with Resident #14 during the regular lunch time. The dining room was full with other residents and there was one other resident sitting at the same table with Resident #14 and her son. All of the residents in the dining room were eating and not wearing a mask. The residents were sitting one or two to a table and were not all six feet apart. C. Staff interviews Registered nurse (RN) #2 was interviewed on 10/12/21 at 2:45 p.m. She said she carried a pocket hand sanitizer with her so it is readily available. She said there are not very many wall sanitizer dispensers on the unit. She said it would be helpful to have a wall sanitizer dispenser outside of each room instead of carrying a pocket sanitizer. Dietary aide (DA) #1 was interviewed on 10/13/21 at 8:50 a.m. He said he carried a pocket sanitizer in his pocket to use before he entered resident rooms. He said there are not very many wall sanitizer dispensers on the hall and it would be easier to have a sanitizer dispenser on the wall outside of each room instead of carrying his own or walking down the hall to find a wall sanitizer dispenser. He said he forgot to bring his today and walked down the hall to use the wall sanitizer dispenser. The director of nursing (DON) was interviewed on 10/14/21 at 3:21 p.m. She said all of the staff have received infection control and hand hygiene training. The training covered staff hand hygiene and offering hand hygiene to residents. The staff development coordinator (SDC), who was also the infection preventionist (IP), was interviewed on 10/14/21 at 1:14 p.m. She said there were seven residents who were not fully vaccinated and 8% of the staff were not vaccinated. She said they were conducting weekly testing for the unvaccinated staff and residents. She said they offered a COVID-19 booster clinic in October 2021 and will continue to offer the clinics when available. She said all visitors were screened at the front desk and should be wearing a mask during the visit. She said visitors who were allowed to visit in the building were vaccinated and the visitors who were not vaccinated visit in the front of the building and were supervised by the front desk staff. She said Resident #14's son was fully vaccinated and should not be allowed to eat in the dining room with other residents. She said he should have his mask on at all times. She said the staff should be wearing their masks at all times in resident care areas and if they were not alone in their office. She said all staff were provided hand hygiene training at time of hire and during surveillance and periodically. She said the training includes hand hygiene for staff before and after resident care, before and after glove placement and removal, and for staff to encourage the residents to wash their hands before meals. She said staff were provided a pocket hand sanitizer to carry with them at all times. She said they were trained to keep the pocket sanitizer in a designated pocket so they were not contaminating the bottle and alternating pockets. She said the staff should be encouraging and offering hand hygiene to the residents before meals and should assist them to use the towelettes on the meal tray. She said she would consider adding more wall sanitizer dispensers on the halls but had a concern with dementia care residents having access to the sanitizer. She said she would talk to her corporate support to come up with a plan. III. Facility COVID-19 status The director of nurses (DON) was interviewed on 10/14/21 at 3:21 p.m. She said they had no COVID-19 positive residents and no COVID-19 positive staff. She said there were no presumptive positive COVID-19 residents or staff. A

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for six (#13, #272, #61, #17, #44 and #21) of seven residents reviewed out of 42 sample residents. Specifically, the facility failed to ensure: -Residents #13, #272 and #61 received assistance with showers as scheduled; and -Residents #17, #44 and #21 were repositioned in their wheelchairs timely. Findings include: I. Showers A. Resident #13 1. Resident status Resident #13, age 91, was admitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/27/21 minimum data set (MDS) assessment documented the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 13 out of 15. The MDS coded the resident required supervision/oversight with personal hygiene, which included showers. -However, the resident's care plan (below) documented she needed extensive assistance with activities of daily living (ADLs). 2. Resident interview The resident was interviewed on 10/13/21 at 2:10 p.m. The resident said that she was upset that she had not received her shower as scheduled. She said that she was supposed to have a shower on 10/6/21 and 10/9/21 and she was hoping that she would get her shower today. The resident said that when her shower was skipped it made her feel as if she was not important. She said that when she complained she was told it was due to staffing. 3. Record review The care plan, last updated 7/26/21, identified the resident had an activities of daily living (ADL) self-care performance deficit related to [CONDITION(S)]. Pertinent approaches were the resident required extensive assistance of one. The Kardex showed the resident's shower days were Wednesday and Saturdays. The bathing record confirmed the resident last received a shower on 10/2/21, and that she had not received a shower until 10/13/21. The documentation report provided by the director of nursing (DON) showed the same information, which indicated the resident did not receive her showers on 10/6/21 or 10/9/21. The September 2021 shower documentation showed the resident received a shower on 9/15, 9/22 (seven days later), and 9/29/21 (seven days later). 4. Staff interview The unit manager (UM) was interviewed on 10/14/21 at 2:50 p.m. The UM reviewed the medical record and confirmed that the resident's last shower was on 10/2/21, 12 days earlier. The UM reviewed the bath logs which the certified nurse aides (CNAs) completed and was unable to locate evidence the resident received a shower. B. Resident #272 1. Resident status Resident #272, age 73, was admitted on [DATE]. According to the October 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/22/21 MDS assessment indicated the resident was cognitively intact with a BIMS score of 15 out of 15. It indicated the resident required extensive, two person assistance for activities of daily living. It indicated the resident did not have behaviors related to refusal of care. 2. Resident interview Resident #272 was interviewed on 10/11/21 at 2:45 p.m. She said the shower schedule had changed and it had led to her missing showers. She said she recently returned from the hospital and had not had a shower since her return. During the interview, the resident's hair appeared greasy and unkempt. Resident #272 was interviewed again on 10/12/21 at 3:45 p.m. She said her last shower was on 10/1/21. She said she was out at the hospital from 10/3/21 to 10/8/21 and did not receive a shower while there. She said she wanted a shower since her return to the facility and asked a staff member but had not heard anything. She said showers made her feel better. Resident #272 said she was not offered a bed bath or any alternative to a shower. 3. Record review Reviewed from 9/13/21 to 10/11/21, the bathing record revealed the resident had received seven out of 10 showers. The record indicated one shower was missed while the resident was out of the facility and two showers were refused on 10/8/21 and 10/11/21. There was no documentation if a shower was offered at a later time or day. The resident went 12 days without a shower. The CNA task list indicated Resident #272's preferred shower days were Monday, Wednesday, and Friday. 4. Staff interviews CNA #5 was interviewed on 10/13/21 at 9:02 a.m. She said residents have showers two to three times a week and it is based off their preference. She said there is a designated bath aide who completes them. LPN #2 was interviewed on 10/14/21 at 2:46 p.m. She said Resident #272's last shower was on 10/1/21. She said the resident had refused two showers since her return from the hospital. She said if a resident refuses a shower, the staff should notify the nurse and reapproach later. She said she did not know if the resident was approached later after her refusals. The DON was interviewed on 10/14/21 at 3:05 p.m. She said when a resident refuses a shower, the nurse should be notified. She said the resident should be offered an alternative time or day and staff should try to accommodate the resident's preference. She said the facility had had changes to their bath aides and had initiated training with the bath aides on how to document and address refusals. C. Resident #61 1. Resident status Resident #61, age 78, was admitted on [DATE]. According to the October 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/21//21 MDS assessment documented the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. The MDS coded the resident required extensive assistance with personal hygiene, which included showers. 2. Resident interview The resident was interviewed on 10/11/21 at 3:30 p.m. The resident said she did not always get her shower as scheduled. 3. Record review The care plan, last updated 9/27/21, identified the resident had an ADL self-care performance deficit related to an acute hospital stay with status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The bathing record in the computerized system failed to show any showers were provided. The bath logs showed the resident refused a shower on 9/22/21, 9/29/21 and 10/2/21. Otherwise the bath log did not contain any information for Resident #61. The medical record failed to show any evidence when the resident refused a shower, that another one was offered, or that the facility attempted to determine the reason the shower was refused. The care plan failed to identify any approaches to use when the resident refused showers. 4. Staff interview The unit manager (UM) was interviewed on 10/14/21 at 2:50 p.m. The UM reviewed the medical record and she confirmed she was unable to find any documentation which showed the resident received a shower since admission. The UM said that she had just entered Resident #61's information into the electronic record for showers. The UM said if the resident refused then the nurse was to be informed so she could ask the reason. D. Performance improvement plan The DON was interviewed on 10/14/21 at 4:00 p.m. The DON said the facility had a performance improvement plan (PIP) developed on 8/9/21. She said the PIP included the resident preferences for showers, and that they had not been receiving their showers. She said the PIP was to ensure resident choice was provided and residents received their showers. She said shower sheets were printed out from each floor. She said interdisciplinary team (IDT) discussed any concerns from the forms. She reviewed the print outs and confirmed Resident #61 was not on the list, that performance improvement plan discussions had not identified showers were not completed for Resident #13, and Resident #272 had received a shower on 10/1/21. The PIP was scheduled to end in November 2021. The DON said the documentationand ensuring showers were provided was a huge struggle. II. Positioning A. Resident #17 1. Resident status Resident #17, age 70, was admitted on [DATE]. According to the October 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/3/21 MDS assessment documented the resident had moderate cognitive impairment with a BIMS score of 13 out of 15. The MDS coded the resident required extensive assistance of two with transfers, mobility, and personal hygiene. 2. Observations On 10/11/21 at 10:30 a m., the resident was sitting in his wheelchair. The wheelchair was at a 60 degree angle. -At 4:04 p.m., the resident remained in his wheelchair at a 60 degree angle. -At 5:00 p.m., the resident remained in the same position. Continuous observations were completed on 10/13/21 from 8:21 a.m. to 12:45 p.m. -At 8:21 a.m., the resident was in his room. He was in his wheelchair sitting at a 60 degree angle. -At 9:01 a.m., CNA #2 assisted the resident to the halloween movie activity. The resident was not offered any repositioning. -At 11:03 a.m., the movie was over, and he started to self propel himself out of the movie room. CNA #2 walked up to the resident and asked if he enjoyed the movie. The CNA began to assist the resident out of the movie room. The CNA did not offer to reposition the resident while he assisted the resident to the dining room. -At 11:30 a.m., the resident was sitting at the dining room table eating his meal. He had not been repositioned in his chair. -At 12:24 p.m., the resident was assisted from the dining room to his room. CNA #3 told the resident she would return to help him with a shower. The resident was not offered to be repositioned prior to her leaving the resident. -At 12:45 p.m., the resident remained in his wheelchair and had not been repositioned. 3. Resident interview The resident was interviewed on 10/13/21 at 12:30 p.m. The resident said he was unable to move himself in his wheelchair, besides with some self propelling. He said he was not offered to be repositioned frequently enough. 4. Record review The care plan, last updated 8/17/21, identified the resident had an ADL self care performance deficit related to [CONDITION(S)] and generalized weakness. Pertinent approaches included assistance of one staff member to turn and reposition the resident in bed. -The care plan failed to include the need for the resident to be repositioned while in his wheelchair. 5. Staff interviews Registered nurse (RN) #3 was interviewed on 12/13/21 at 12:37 p.m. The RN was notified the resident had not been repositioned in over four hours. She said she was not aware of how frequently the resident needed to be repositioned. She said he was at risk for pressure ulcers. CNA #2 was interviewed on 10/13/21 at 12:45 p.m. CNA #2 said the resident needed to be repositioned at least every two hours. The CNA confirmed that after the movie the resident went straight to the dining room without being repositioned. He said the resident was supposed to have a shower prior to lunch but it had not happened yet. He said after his shower he would lay him down. The director of nursing (DON) was interviewed on 10/13/21 at 12:50 p.m. The DON said the resident should be repositioned at least every two hours. She said she would provide education on the importance of repositioning. B. Resident #44 1. Resident status Resident #44, age 86, was admitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/30/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident was dependent on two staff members for transfers and required extensive assistance for activities of daily living. It indicated the resident did not have any behaviors related to refusal of care. It indicated the resident was at risk for developing pressure ulcers. 2. Observation Resident #44 was observed on 10/13/21 from 8:37 a.m. to 1:15 p.m continuously. At 8:37 a.m., Resident #44 was observed seated in her wheelchair in her room. At 8:39 a.m., certified nurse aide (CNA) #4 entered the room and asked Resident #44 if she wanted to lie down. The resident declined. Resident #44 continued to sit in her wheelchair in her room until lunch. Resident #44 ate lunch in the dining room. Resident #44 was taken back to her room at 12:32 p.m. At 1:15 p.m., CNA #4 asked the resident if she wanted to lie down and if she could check her brief and empty her catheter. The resident agreed. CNA #4 and CNA #5 used a Hoyer lift to transfer the resident and checked her brief. CNA #4 said the resident had had a bowel movement. Observations revealed the resident had not received incontinence care or repositioning assistance for more than four and a half hours. 3. Record review A Braden scale for predicting pressure sore risk was completed on 10/3/21. The resident had a score of 15 indicating a mild risk. It indicated the resident's mobility was very limited and she could not make significant position changes independently. Other risk factors included bowel incontinence, history of pressure injuries, weight loss, and diabetes. A weekly skin assessment was completed on 10/10/21. It indicated the Resident #44 had no skin issues. 4. Staff interviews CNA #4 was interviewed on 10/13/21 at 1:20 p.m. She said Resident #44 should be repositioned and her brief checked every two to three hours. Licensed practical nurse (LPN) #2 was interviewed on 10/14/21 at 11:11 a.m. She said Resident #44 was at risk for pressure injuries due to limited mobility and dependence on staff. She said the resident needed to be repositioned every one to two hours. She said she was not aware that the resident was not repositioned the morning of 10/13/21. The director of nursing (DON) was interviewed on 10/14/21 at 3:43 p.m. She said Resident #44 should be repositioned at least every two hours to reduce the risk of pressure injuries. C. Resident #21 1. Resident status Resident #21, age 82, was admitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/8/21 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of seven out of 15. She had adequate hearing, clear speech, made herself understood and understood others. She did not display any behaviors or rejection of care. She required extensive assistance of two or more people for transfers, bed mobility, dressing and personal hygiene. She used a wheelchair for mobility, but was not able to propel herself. 2. Resident interview Resident #21 was interviewed on 10/11/21 at 2:30 p.m. She was in bed on her back. She stated she was very hard of hearing and initially could not understand the questions. Communication with the resident was established by typing questions on the computer, and the resident was able to answer all questions. Specifically, she said she was frequently left in her chair for prolonged periods of time either in her room or the dining room. She said she was not able to change her position or move her wheelchair. 3. Record review The comprehensive care plan for activities of daily living (ADLs), initiated on 5/7/21 and revised on 9/27/21, revealed ADL self care performance deficits, related to impaired balance and limited mobility. Interventions included: reclining wheelchair with tall foam backrest with side huggers in place. The resident required total assistance with bathing, dressing and bed mobility. She was totally dependent on 1-2 staff members for personal hygiene and oral care. At times the resident refused to go to the dining room as well as having staff assist her to eat. The resident was transferred by Hoyer lift. -The care plan did not specify what kind of assistance the resident required when she was in a wheelchair and what her preferences were. -The resident did not have a care plan for refusal of care. 4. Observations Resident #21 was observed on 10/12/21: -at 8:00 a.m. she was asleep in front of her finished breakfast at the dining room table. Kitchen staff were observed cleaning tables. -at 9:00 a.m. she was still in the dining room, sleeping at the table. All the tables in the dining room had been cleaned. No other residents were in the dining room. -at 9:46 a.m. she was taken to her room. Resident #21 was observed on 10/13/21: -at 8:30 a.m. she was sitting upright in bed in her room in front of her breakfast tray. -at 10:44 a.m. she was transferred to a wheelchair, taken to the dining room, and was left at the table. -at 11:30 a.m. she was served her lunch meal, a Caesar salad with a muffin and two drinks in sippy cups. -at 11:59 a.m. she was taken out of the dining room to continue her lunch in her room as she had a visitor. -at 1:15 p.m. she was sleeping in her wheelchair in her room in front of the table. Her call light was on the floor behind the headboard of the bed. -at 1:40 p.m. she was taken to the dining room for a music activity. -at 3:04 p.m. she was asleep in her wheelchair during the live music activity program. -at 3:20 p.m. she was taken back to her room and left in her wheelchair facing the window with closed blinds. Her call light was on the floor behind the headboard of the bed. -at 3:50 p.m. she was asleep in the same position as above. -at 4:42 p.m. CNA#6 entered the resident's room, stated she would make the resident's bed, but would not put the resident to bed as the resident would stay in the chair for dinner. The resident reported to CNA #6 that she had been sitting in her wheelchair for 13 hours and she could not reach her phone or call light. CNA #6 stated she would assist the resident to bed. -at 5:00 p.m. the resident was transferred to bed by Hoyer lift. 5. Staff interviews CNA #1 was interviewed on 10/13/21 at 1:23 p.m. She said the resident required assistance of one to two people with bed mobility and other tasks. She said the resident was able to say what she liked and disliked. She said staff made frequent rounds to check on her position, and helped her reposition in bed every two hours. She said she assisted the resident in the morning when she came in around 6:00 a.m. As far as her preferences, she said the resident liked to stay in bed for breakfast, but attended lunch in the dining room. CNA #6 was interviewed on 10/13/21 at 4:50 p.m. She said the resident had dementia and was not always understood. She said she worked with the resident during the day and evening shift, from 2:00 to 10:00 p.m., and she usually would make the resident's bed before dinner. The resident would usually stay in the wheelchair until dinner. Today, when she was making her bed, the resident told her she had been sitting in the chair for too long, so she offered to transfer her to bed. She said the resident was dependent on staff for all ADLs. Registered nurse (RN) #1 was interviewed on 10/13/21 at 5:06 p.m. She said the resident was alert and oriented, and slightly hard of hearing. She said the resident was able to make all her needs known, she required assistance of two people with transfers, one person with other needs, and was able to eat with set up assistance only. She said she was not sure what the resident's preferred routine was, but the resident was able to say what she liked and disliked. She said the resident did not refuse care. The DON was interviewed on 10/14/21 at 3:06 p.m. She said the resident was dependent on staff members for care, and required assistance with transfers and repositioning every two hours. She said staff were expected to honor the resident's wishes regarding daily schedules and make sure that her call light was within the reach when leaving the resident in the room.

Based on record review, observations and interviews, the facility failed to ensure six (#70, #25, #52, #43, #17 and #26) of 10 residents reviewed for respiratory care were provided such care in accordance with professional standards of practice out of 42 sample residents. Specifically, the facility failed to: -Administer oxygen therapy as ordered by the physician for six of 10 residents. -Label/date oxygen tubing for six out of 10 residents. Findings include: l. Facility policy The Oxygen Administration policy, revised August 2021, was provided by the director of nursing (DON) on 10/14/21 at 3:45 p.m. It read in pertinent part, The purpose of this policy is to assure that oxygen is administered and stored safely within the healthcare center. Change oxygen supplies weekly and when visibly soiled. Equipment should be labeled with a patient name and dated when setup or changed out. All facility staff will be educated on oxygen administration, safety and storage upon hire, annually, and as indicated thereafter. II. Resident #70 A. Resident status Resident #70, age 65, was admitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 9/28/21 minimum data set (MDS) assessment, the resident was severely cognitively impaired with a brief mental status (BIMS) score of two out of 15. The resident was totally dependent on two people for transfers, bathing, toileting, eating and all activities of daily living (ADLs). The resident had limited range of motion for upper and lower extremities. He required oxygen therapy at night. B. Record review The 8/5/21 revised care plan identified the resident needed staff assistance to set up oxygen and follow the oxygen rate ordered via nasal cannula. The care plan specified a flow rate of two liters per minute (LPM) at night (NOC). The October 2021 CPO documented a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Observations and interview On 10/11/21 at 10:42 a.m. Resident #70 was lying in bed with his nasal cannula (tube to administer oxygen) on and the oxygen concentrator was set at 3 LPM. The oxygen tubing was not dated. On 10/11/21 at 4:22 p.m. Resident #70 was observed in bed with his nasal cannula on and the oxygen concentrator was set at 3 LPM. On 10/13/21 at 8:50 a.m. Resident #70 was observed in bed with his nasal cannula on and the oxygen concentrator was set at 3 LPM. On 10/13/21 at 9:45 a.m. Resident #70 was repositioned and provided personal care. He continued to have oxygen provided after staff left the room. He was observed in bed with his nasal cannula on and the oxygen concentrator was set at 3 LPM. On 10/13/21 at 12:04 p.m. Resident #70 was observed in bed with his nasal cannula on and the oxygen concentrator was set at 3 LPM. The registered nurse (RN) #2 was interviewed on 10/13/21 at 2:39 p.m. She said the oxygen order for Resident #70 read two liters per minute at night per nasal cannula. She said the nurses or the certified nurse aides could change the oxygen tubing and it should be done weekly. She said she did not label the tubing when she changed it because she knew it needed to be done weekly. She said the resident's concentrator was set at three liters and said it should be set on two liters based on his current physician order. She changed the liter flow to two liters per minute. She said the order read he should have his oxygen on at night but that meant at night or when in bed. He was in bed most of the day and had his oxygen on when in bed. She said the order did not specify while in bed but that was what it meant. She said she would ask the physician to change the order. She said she changed his oxygen tubing yesterday but did not label the tubing. She said the policy was to label the tubing but she did not label the tubing. She said if there was an order to change the tubing then staff would document it was done. She said if there was not an order then there would not be documentation to show the tubing was changed. III. Resident #25 A. Resident status Resident #25, age 69, was admitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 9/1/21 minimum data set (MDS) assessment, the resident was cognitively intact with a brief mental status (BIMS) score of 15 out of 15. The resident required extensive two person assistance with bed mobility, transfers, dressing, bathing, toileting and personal hygiene. She required oxygen therapy during the day and at night. B. Record review The 8/25/21 care plan identified the resident needed staff assistance to set up oxygen and follow the oxygen rate ordered via nasal cannula. The care plan specified a flow rate of two liters per minute (LPM) continuously via nasal cannula. The October 2021 CPO documented a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The oxygen tubing should be changed every night shift every Sunday. C. Observations and interviews On 10/13/21 at 8:46 a.m. Resident #25 was observed in bed with her nasal cannula on and the oxygen concentrator was set at 3.5 LPM. On 10/13/21 at 10:05 a.m. Resident #25 was observed in bed with her nasal cannula on and the oxygen concentrator was set at 3.5 LPM. Resident #25 was interviewed on 10/13/21 at 10:05 a.m. She said she wore her nasal cannula during the day and her oxygen flow was usually set at 3.5 liters per minute. She said the nurse helped her set up her oxygen during the day and at night. She said she was not able to reach her concentrator because it was on the floor and she was not able to get out of bed on her own. Registered nurse (RN) #2 was interviewed on 10/13/21 at 2:39 p.m. She said Resident #25 had oxygen therapy during the day and at night. She said her current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The oxygen tubing should be changed every night shift every Sunday. She said her concentrator was set at 3.5 liters per minute, and turned the flow down to 3 liters per minute. She said she was not sure why it was set at 3.5 LPM. She said they recently changed oxygen companies and she wondered if the flow raised on its own. She said a certified nurse aide was not allowed to adjust the oxygen flow because oxygen was a medication. Only a nurse could change the oxygen liter flow. IV. Resident #52 A. Resident status Resident #52, age 83, was admitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/7/21 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The resident was independent with activities of daily living, and received oxygen therapy. B. Record review The physician orders, dated 3/5/21, documented oxygen at two liters/minute continuously per nasal cannula. The orders also indicated that as of 8/10/21, the oxygen concentrator should be checked for proper functioning every shift. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no orders for the oxygen tubing to be changed. C. Observation On 10/11/21 at 2:25 p.m., Resident #52's oxygen tubing was observed connected to the concentrator. The oxygen tubing was not dated and labeled. The oxygen flow rate from the concentrator was set at 3.5 liters per minute (LPM). On 10/13/21 at 9:56 a.m., Resident #52's oxygen tubing was observed connected to the concentrator. The oxygen flow rate from the concentrator was set at 3.5 LPM. D. Interview Licensed practical nurse (LPN) #1 was interviewed on 10/13/21 at 4:41 p.m. He said the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #1 said he was unsure when the oxygen tubing was last changed and he was unsure who was supposed to change the tubing. V. Resident #17 A. Resident status Resident #17, age 70, was admitted on [DATE]. According to the October 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/3/21 MDS assessment documented the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 13 out of 15. The MDS coded the resident required extensive assistance of two with transfers, mobility, and personal hygiene. The MDS coded the resident as using oxygen. B. Record review The October 2021 CPO documented a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, last updated 8/17/21, identified the resident used oxygen related to [CONDITION(S)]. Pertinent approaches included the oxygen was to be at 2 LPM via nasal cannula continuously. C. Observations On 10/11/21 at 10:30 a.m., the resident was sitting in his wheelchair. The resident did not have the oxygen on. On 10/12/21 at approximately 2:00 p.m., the resident did not have the oxygen on. On 10/13/21 at 4:38 p.m., registered nurse (RN) #3 observed and confirmed the resident was not wearing a nasal cannula and connected to any oxygen. D. Interview The unit manager (UM) was interviewed on 10/13/21 at 5:15 p.m. The UM said the resident was wearing the oxygen at night after his recent hospitalization . She said that he had been weaning off of it; however, after reviewing the record she confirmed he had an active order for oxygen at 2 LPM. VI. Resident #43 A. Resident status Resident #43 was admitted on [DATE]. According to the October 2021 CPO, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/7/21 MDS assessment documented the resident had no cognitive impairment with a BIMS score of 15 out of 15. The MDS coded the resident required limited assistance of two with activities of daily living. The MDS coded the resident as using oxygen. B. Record review The October 2021 CPO documented a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 9/10/21, identified the resident had [CONDITION(S)]. Pertinent interventions included administer oxygen at 4 LPM via nasal cannula continuously. C. Observations On 10/11/21 at 4:30 p.m., the resident received oxygen through a nasal cannula while she was in her room. The oxygen concentrator was set at 3LPM. The tubing was not dated. On 10/12/21 at approximately 2:00 p.m., the resident's oxygen concentrator was set at 3LPM. On 10/13/21 at 4:44 p.m., an observation with registered nurse (RN) #3 revealed the resident received oxygen through a nasal cannula while she was in her room. The oxygen concentrator was set at 3LPM. The tubing continued to be undated. D. Interview The unit manager was interviewed on 10/13/21 at 5:15 p.m. The UM reviewed the medical record and confirmed the resident was to be on 4 LPM. She said that the tubing should be dated to indicate when it was changed. She said she did not know who was responsible to ensure the tubing was changed and when. She said they used to have a respiratory therapist from the oxygen company who changed the tubing weekly. The director of nursing (DON) was interviewed on 10/14/21 at 3:40 p.m. The DON said the licensed nurses were responsible to ensure the oxygen concentrator was set at the correct liter flow according to physician orders. She said the nurses were also responsible to ensure the tubing was marked and dated when changed. VII. Resident #26 A. Resident status Resident #26, age 85, was admitted on [DATE]. According to the October 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/21/21 MDS assessment documented the resident had moderate cognitive impairment with a BIMS score of 10 out of 15. The MDS coded the resident required extensive assistance with activities of daily living. The MDS coded the resident as using oxygen. B. Record review The October 2021 CPO documented a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 8/13/21, identified the resident had [CONDITION(S)]. Pertinent interventions included administer oxygen at 2 LPM via nasal cannula continuously. C. Observations On 10/11/21 at 2:20 p.m., the resident received oxygen through a nasal cannula. The oxygen concentrator was set at 3LPM. The tubing was not dated. On 10/12/21 at approximately 2:00 p.m. the resident was observed to be transferred from her wheelchair to the bed. The oxygen cannula fell on the floor, and the unidentified certified nurse aide (CNA) replaced the cannula; however, it was not dated when it was changed. Observations on 10/13/21 revealed: -At 8:58 a.m., the resident was assisted from her room to the shower without her oxygen. -At 9:12 a.m., the resident was assisted back to her room after the shower. -At 9:31 a.m., she continued to not have her oxygen cannula on. -At 10:14 a.m., the occupational therapist (OTR) spoke to the resident about positioning. The oxygen concentrator was set at 2.5 LPM, but the oxygen cannula was not on the resident. The OTR was observed to turn off the concentrator and to tell the resident she was only on it at night. The resident told the OTR she was supposed to be wearing the oxygen continuously. The OTR left to get the vitals machine. She took the resident's pulse oximetry and it was at 84. The OTR placed the oxygen cannula on the resident and told her to deep breathe. D. Interview The unit manager was interviewed on 10/13/21 at 5:15 p.m. The UM said the resident should have the oxygen concentrator set at 2 LPM. She said the resident should have had her shower with the oxygen.

Based on observations, record review and interview, the facility failed to ensure that the resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for two (#19 and #21) of five residents reviewed for quality of care of 42 sample residents. Specifically, the facility failed to: -Accurately document skin assessments, and provide care and treatments for abrasion on resident 21's right knee; and, -Have a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #19's hand. Findings include: I. Failure to accurately document skin assessments, and provide care and treatments for abrasion A. Resident status Resident #21, age 82, was admitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/8/21 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of seven out of 15. She had adequate hearing, clear speech, made herself understood and understood others. She did not display any behaviors or rejection of care. She required extensive assistance of two and more people for transfers, bed mobility, dressing and personal hygiene. She used a wheelchair for mobility, but was not able to propel herself. B. Resident interview Resident #21 was interviewed on 10/11/21 at 2:30 p.m. The resident was in bed on her back. She stated she was very hard of hearing and initially could not understand the questions. Communication with the resident was established by typing questions on the computer, and the resident was able to answer all questions. Two dressings observed on the resident's right knee. Dressing #1 was covering the entire resident's right knee, it had no date on it and it had visible stains of dark red blood about 1 centimeter in diameter. Dressing #2 located below the right knee dressing #1 and had no date on it as well. The resident stated she had a fall at home and landed on both of her knees. She believed the injuries were still healing from that fall. C. Record review Comprehensive care plan for ADLs was initiated on 5/7/21 (previous admission) and revised on 9/27/21 revealed the resident had ADL self care performance deficits, related to impaired balance, and limited mobility. Interventions included: reclining wheelchair with tall foam backrest with side huggers in place. The resident required total assistance with bathing, dressing and bed mobility. She was totally dependent on one to two staff members for personal hygiene and oral care. At times the resident refused to go to the dining room as well as having staff assist her to eat. Resident was transferred by Hoyer (mechanical) lift. -The resident had no current care plan for skin integrity. She had an old care plan for skin integrity that was initiated and revised in May 2021 during the resident's previous stay in the facility. None of the problems, goals and interventions were applicable to the resident's current stay. The admission skin assessment completed on 9/1/21, revealed the resident had an area of blanchable redness and shearing to buttocks, and multiple pin-point scabbed areas to right knee and shin. The weekly skin assessments on 9/8/21 and 9/15/21 documented the resident's skin was intact and she had no new problems. The skin assessment on 9/23/21 documented resident had ongoing wound that heals/scabs over then reopens on right knee, and blanchable redness to sacrum. On 9/29/21 skin assessment was marked as skin intact; and, On 10/6/21 skin assessment was marked as skin intact with blanchable redness to right and left buttok. -The resident's October 2021 medication administration record (MAR)/treatment administration record (TAR) and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -There were no interdisciplinary progress notes mentioning skin treatments. D. Observations Skin observations were conducted on 10/13/21 at 5:15 p.m. in the presence of licensed practical nurse (LPN) #2. Dressing #1 covering the right knee with no date on it was removed by LPN # 2. Unhealed abrasion draining sero sanguinous fluid observed under the dressing. Bright red blood was oozing from the wound. There were no visible wound edges to determine the size of the wound. Overall wound area was measured as 5 centimeters (cm) by 3 cm. The surrounding area of the wound had dark red to black blood stains on the skin. LPN #2 cleaned the wound with normal saline and applied foam dressing. Dressing #2 with no date on it was removed by LPN #2. Three bright to dark red abrasions were observed under the dressing. No drainage. The abrasions were clustered and measured as 4 cm by 1.4 cm. LPN #2 stated she will keep abrasions open to air. Coccyx observations revealed small scattered abrasions in the sacral region. LPN #2 applied barrier cream to the area. E. Staff interviews LPN #2 was interviewed on 10/13/21 at 5:30 p.m. She said she did not know the resident had an abrasion on her knee. She said the resident had no orders in place for skin treatments. She said it was not a standard of care. She said all abrasions and skin problems must be documented on skin assessment and have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she did not know why resident's skin abrasions were not documented and did not have orders for treatment. She said all dressings should be dated to ensure consistent care. LPN #2 stated she would contact the physician to obtain treatment orders for the resident's skin. The DON was interviewed on 10/14/21 at 3:06 p.m. She said skin assessment should be completed weekly and all skin issues documented unless resolved. The treatment orders should be obtained from the physician and documented on the TAR. She said she was not aware that Resident #19 did not have skin treatments for her abrasions. II. Failure to obtain a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] A. Resident status Resident #19, age 69, was admitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/3/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She had adequate hearing, clear speech, made herself understood and understood others. She did not display any behaviors or rejection of care. She required limited assistance of one person with mobility and transfers, and supervision and set up help with other ADLs. B. Resident interview Resident #19 was interviewed on 10/12/21 at 3:56 p.m. Resident #19 stated she was happy with the care she received in the facility and did not have any complaints. She said occasionally she had a discomfort in her left upper hand at the [CONDITION(S)] fistula site. But that was managed well with the lotion that CNAs (certified nurse aides) helped her to apply to her hand. She reached out to the draw and pulled a tube of lotion that read [MEDICATION(S)] 2%. She said she always kept it in her drawer and on the [CONDITION(S)] days before she left, she asked nurses or CNAs to apply the lotion to the area of the [CONDITION(S)] port. C. Record review The resident's October 2021 MAR and TAR, and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's [CONDITION(S)] care plan did not mention application of the lotion prior to the [CONDITION(S)] appointment. D. Staff interviews CNA #5 was interviewed on 10/14/21 at 2:30 p.m. She said the resident occasionally asked for help with lotion to be applied to her left hand. She said she helped the resident but was not sure what kind of lotion it was. CNA #4 was interviewed on 10/14/21 at 2:45 p.m. She said the resident was able to apply lotion to her hand by herself and sometimes asked her as well. She said she did not know what kind of lotion it was, but the resident only asked for it on the [CONDITION(S)] days before she left. LPN #1 was interviewed on 10/13/21 at 10:40 a.m. He said the resident had a lotion that was applied to her [CONDITION(S)] hand prior to the [CONDITION(S)] appointment. He said he recalled applying it a few days ago. He reviewed the orders and was not able to locate the order for the lotion. He said he will talk to the resident and would try to find out what the lotion was and where the order was for it. LPN #2 was interviewed on 10/13/21 at 5:33 p.m. She said she had more information regarding the [MEDICATION(S)] lotion. She said the [MEDICATION(S)] lotion was given to the resident at the [CONDITION(S)] center and therefore they did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said lotion will be kept at the bedside in a locked draw. The DON was interviewed on 10/14/21 at 3: 06 p.m. She said all medications should be administered by nurses and order from the physician should be obtained prior to the administration of any medications. She said she was not aware that [MEDICATION(S)] lotion was administered by CNAs.

Based on observations, record review and interviews, the facility failed to ensure that two (#17 and #29) out of five residents reviewed with limited range of motion received appropriate treatment and services, out of 42 sample residents. Specifically, the facility failed to: -Provide range of motion services to Resident #17's lower extremities, and -Provide a restorative program on a regular basis to Resident #29. Findings include: I. Resident #17 A. Resident status Resident #17, age 70, was admitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/3/21 minimum data set (MDS) assessment documented the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 13 out of 15. The MDS coded the resident required extensive assistance of two with transfers, mobility, and personal hygiene. The MDS coded the resident as having limited range of motion on bilateral lower extremities. The MDS indicated the resident was not receiving range of motion. B. Observations On 10/11/21 at 10:30 a.m., the resident was sitting in his wheelchair. The wheelchair was at a 60 degree angle. His legs were supported with foot rests. The resident was not observed to move his legs. C. Resident interview The resident was interviewed on 10/13/21 at 12:30 p.m. The resident said he did not receive range of motion exercises and he would like to receive them. He said that he was able to propel his wheelchair a bit, but was unable to move his legs. D. Record review The care plan, last updated 8/17/21, identified the resident had an activity of daily living (ADL) self care performance deficit related to [CONDITION(S)] and generalized weakness. Pertinent approaches included the resident required a mechanical lift for transfers with the assistance of two staff members. The medical record failed to show the resident received range of motion exercises on his lower extremities. E. Staff interview Restorative certified nurse aide (RCNA) #1 was interviewed on 10/14/21 at 2:00 p.m. She said the resident was not on a restorative program. She said he used to be on a program for his neck, however, it was discontinued in August 2021. Licensed practical nurse (LPN) #4 was interviewed on 10/14/21 at 11:30 a.m. She said she was a manager of the restorative program. The LPN said the resident was not on a restorative program. She said if the resident needed range of motion then it was completed by the restorative aide. She said the CNA on the floor did not complete passive range of motion. The therapy manager was interviewed on 10/14/21 at 2:30 p.m. He said the resident was not currently on physical or occupational therapy. He said the resident was discontinued from the restorative program in August 2021 for his neck. He said that the decision was made with LPN #4 and RCNA #1 when it was decided the resident was maintaining. The therapy manager said the 6/9/21 therapy notes showed his legs were within functional limits. The therapy manager said that everybody benefits from range of motion to maintain function. II. Resident #29 A. Resident status Resident #29, age 73, was admitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/16/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident did not reject the care that was necessary to achieve the resident's goals for health and well-being, and did not display any behaviors. She required extensive assistance from one person for transfers, bed mobility, dressing and personal hygiene. The resident had functional limitation in range of motion on one side of her upper and lower extremity. She used an electric wheelchair for mobility in the building. B. Resident interview Resident #29 was interviewed on 10/11/21 at 3:30 p.m. She said she was very happy with the care she received in the facility except for the restorative program. She said she had a stroke, and she was supposed to walk with the restorative aide every day. She said the treatment was missed three to four times a week because the restorative aide was working on the floor as a CNA, and had no time to provide the restorative program. The resident was upset as she was not able to walk on her own without assistance. C. Record review The comprehensive care plan revealed the resident had weakness on one side due to the stroke. The care plan was initiated on 8/23/21 (13 days after admission). The goals were to maintain optimal status and quality of life within the current limitations. Interventions included providing medications as ordered, and continuing therapy services as ordered by the physician. The resident did not have a care plan for the restorative program. According to the progress note by LPN #4 on 9/24/21, the resident was enrolled into a restorative nursing program as of 9/24/21 up to six times a week as tolerated. The order was entered on 9/24/21 to the resident's electronic medical record for the resident to participate in a restorative nursing program. The restorative program log was reviewed from 9/24/21 to 10/14/21. In September 2021, the resident participated in therapy on four out of eight occasions. In October 2021, she received six out of 13 possible sessions of therapy. No follow-up notes regarding missed therapy and offers to the resident to participate at a later time were located in the interdisciplinary progress notes. D. Staff interviews Restorative certified nurse aide (RCNA) #1 was interviewed on 10/14/21 at 2:00 p.m. She said she was the only restorative aide in the building. She said they used to have two restorative aides, but one recently left. She said on many occasions she was asked to work on the floor when the facility was short on CNAs. She said on the occasions when she was working as a CNA on the floor she was not able to provide a restorative program to residents. Since she was the only restorative aide, residents were not offered a restorative program on those days. She said management was aware of this situation. Licensed practical nurse (LPN) #4 was interviewed on 10/14/21 at 2:30 p.m. She said she was a manager of the restorative program. She said sometimes she also worked as a floor nurse and in addition she was overseeing the restorative program. As a restorative program manager her duties included monitoring the residents who were on the restorative program, making sure they had orders and were receiving appropriate therapy. She said once a week she would meet with the restorative CNA and therapy manager to discuss the course of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she did not know it was that frequently. The therapy manager was interviewed on 10/14/21 at 2:30 p.m. He said the resident was discharged from occupational and physical therapy with the recommendation for a restorative nursing program. He said he was not aware the resident missed several sessions of restorative therapy. He said lack of participation in therapy could result in decreased range of motion and eventually a decrease in physical functioning and abilities.

Based on observations, and interviews, the facility failed to ensure medication error rate was not greater than five percent. Specifically, the facility failed to administer heart failure medication to Resident #16, and failed to complete a safety check/priming of the needle prior to insulin administration to Resident #16 out of 25 opportunities, resulting in a medication error rate of eight percent. Findings include: I. Facility policy The Medication Administration policy, with no revision date, was provided by the nursing home administrator (NHA) on 10/13/21 at 10:00 a.m. According to the policy, Medications are administered in accordance with written orders of the attending physician and resident ' s schedule. A. Manufacturer's recommendations The [MEDICATION(S)] [MEDICATION(S)] package insert (2018) read in pertinent part: Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: ensuring that pen and needle work properly, and removing air bubbles. - Select a dose of 2 units by turning the dosage selector. - Take off the outer needle cap and keep it to remove the used needle after injection. - Take off the inner needle cap and discard it. - Hold the pen with the needle pointing upwards. - Tap the insulin reservoir so that any air bubbles rise up towards the needle. - Press the injection button all the way in. Check if insulin comes out of the needle tip. You may have to perform the safety test several times before insulin is seen. - If no insulin comes out, check for air bubbles and repeat the safety test two more times to remove them. If still no insulin comes out, the needle may be blocked. Change the needle and try again. - If no insulin comes out after changing the needle, your insulin pen may be damaged. Do not use this pen. B. Resident #16 status Resident #16, age under 79, was admitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the medical administration record (MAR) for October 2021, the resident was scheduled to receive the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] Pen Injection (insulin) 100 Units per milliliter (U/ml) Inject 14 unit subcutaneously two times a day. -[MEDICATION(S)] ([MEDICATION(S)] medication for heart failure) extended release, give 30 milligrams (mg) by mouth one time a day in the morning. C. Observations of medication administration On 10/13/21 at 8:20 a.m registered nurse (RN) #1 was observed during medication administration. She pulled out several blister cards and popped morning medications into a small plastic cup. When she was ready to go to the room to administer the medications, she was asked to review them on the MAR. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The review and comparison of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During insulin administration, RN #1 prepared to administer 14 units of insulin to the resident. She turned the dial on the [MEDICATION(S)] flex pen to 14 units, attached the needle and administered the insulin. She did not conduct the safety test by priming the insulin needle. Cross-reference F760 for significant medication error. The above observations were reported to the unit manager/licensed practical nurse (LPN) #2 on 10/13/21 around 8:35 a.m. II. Staff interviews RN #1 was interviewed 10/13/21 at 8:25 a.m. She repeated all the steps of insulin administration as demonstrated above and said she followed all the steps for insulin administration. The unit manager/LPN #2 was interviewed on 10/13/21 at 8:50 p.m. She said the insulin needle had to be primed prior to insulin injection to ensure that the resident received the appropriate amount of insulin. She said she would provide immediate education to all nurses on the floor and for oncoming shifts as well, and she would contact the resident's physician to report the inaccurate insulin administration. Regarding medications she said the nurse was nervous and made some mistakes as a result of that. She said the nurse was full time in the facility and always administered medications without errors. The director of nursing (DON) was interviewed on 10/14/21 at 4:30 p.m. She said the education to all nursing staff regarding proper insulin administration and priming of the needle was given on 10/13/21 (after being identified, see above). She said the insulin needle had to be primed prior to insulin injection to ensure that the resident received the appropriate amount of insulin. She said all medications should be administered as ordered by the physician.

Based on observations and interviews, the facility failed to keep one (#16) of free residents on one of two hallways free of any significant medication errors. Specifically, the facility failed to prime the flex pen insulin needles prior to administering insulin injections for Resident #16. Findings include: I. Facility standards The Medication Administration policy, with no revision date, was provided by the nursing home administrator (NHA) on 10/13/21 at 10:00 a.m. According to the policy, Medications are administered in accordance with written orders of the attending physician and resident's schedule. II. Manufacturer's recommendations The [MEDICATION(S)] [MEDICATION(S)] package insert (2018) read in pertinent part: Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: ensuring that pen and needle work properly, and removing air bubbles. - Select a dose of 2 units by turning the dosage selector. - Take off the outer needle cap and keep it to remove the used needle after injection. - Take off the inner needle cap and discard it. - Hold the pen with the needle pointing upwards. - Tap the insulin reservoir so that any air bubbles rise up towards the needle. - Press the injection button all the way in. Check if insulin comes out of the needle tip. You may have to perform the safety test several times before insulin is seen. - If no insulin comes out, check for air bubbles and repeat the safety test two more times to remove them. If still no insulin comes out, the needle may be blocked. Change the needle and try again. - If no insulin comes out after changing the needle, your insulin pen may be damaged. Do not use this pen. III. Resident #16 status Resident #16, age under 79, was admitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A. Record review According to the medical administration record (MAR) for October 2021, the resident was scheduled to receive the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] Pen Injection 100 Units per milliliter (U/ml) Inject 14 unit subcutaneously two times a day. B. Observations On 10/13/21 at 8:20 a.m registered nurse (RN) #1 was observed during medication administration. She prepared to administer 14 units of insulin to the resident. She turned the dial on the flex pen to 14 units, attached the needle and administered the insulin. -However, RN #1 failed to follow the manufacturer's recommendation to prime the insulin pen before administration of dose. The above observations were reported to the unit manager/licensed practical nurse (LPN) #2 on 10/13/21 around 8:35 a.m. III. Staff interviews RN #1 was interviewed 10/13/21 at 8:25 a.m. She repeated all the steps of insulin administration as demonstrated above and said she followed all the steps for insulin administration. The unit manager/LPN #2 was interviewed on 10/13/21 at 8:50 p.m. She said the insulin needle had to be primed prior to insulin injection to ensure that the resident received the appropriate amount of insulin. She said she would provide immediate education to all nurses on the floor and for oncoming shifts as well, and she would contact the resident's physician to report the inaccurate insulin administration. The director of nursing (DON) was interviewed on 10/14/21 at 4:30 p.m. She said the education to all nursing staff regarding proper insulin administration and priming of the needle was given on 10/13/21 (after being identified, see above). She said the insulin needle had to be primed prior to insulin injection to ensure that the resident received the appropriate amount of insulin.

Based on interviews and record review, the facility failed to ensure two (#19 and #324) of three out of 25 sample residents received adequate supervision to prevent accidents. Specifically: Resident #19: Resident #19 was transferred improperly. Although care planned for a mechanical lift transfer, the certified nurse aide (CNA) transferred Resident #19 by having the resident hold the grab bar. When the resident stood up and pivoted to transfer, her left foot turned in and she lost her balance. She sustained a femur fracture that required surgery. After readmission, the facility failed to take steps to prevent additional accidents with injury. Resident #342: The facility failed to plan and provide the resident adequate supervision. Record review revealed the facility had information on the resident's age, medical condition, functional and cognitive limitations, as well as unsafe behaviors, on and after her admission that indicated she required frequent and planned staff supervision. However, the facility failed to take timely steps to address this need. The resident was left unattended in the bathroom, stood up, and fell , sustaining a left femur fracture which required surgery. Findings include: I. Facility fall policy The facility Fall Management policy issued 6/16 and 11/16 read in pertinent part: - The patient environment remains as free of accident hazards as is possible and each patient receives adequate supervision and assistance devices to prevent accidents. - All patients will be assessed for fall indicators upon admission, readmission, quarterly, with change in condition, and with any fall event. - An individualized fall management care plan will be developed and initiated upon all patient admissions and readmissions. - The interdisciplinary team will review and revise, if indicated, all patients fall management care plans upon a fall event. II. Resident #19 and #324 A. Resident #19 1. Resident status Resident #19, age 98, was originally admitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. According to the MDS dated [DATE], the resident had a score of 4 out of 15 on the BIMS which indicated she was severely cognitively impaired. The resident required total assistance with activities of daily living which also included transfers. The care plan dated 2/26/17 identified the resident was at risk for falling. The resident required a sit to stand mechanical lift for transfers. 2. Incident 4/23/18 - improper transfer with injury A 4/23/18 nurses' note read, .CNA reported that I took resident to the rest room (sic), she'll stand and pivot well, but this time as I was transferring her off the toilet, her left foot didn't move like it normally does, and as she fell , I was holding her and led her to the ground . (Complaint of) pain to left leg . X-ray revealed the resident sustained [REDACTED]. 3. Failure to implement measures to minimize future accidents with injury The facility investigation of the 4/23/18 incident and incident follow up revealed the CNA, CNA #5, transferred Resident #19 without using the sit to stand mechanical lift as care planned because the lift was not available. Rather, when interviewed by the nursing home administrator (NHA) on 4/23/18, CNA #5 said the resident transferred by holding onto the grab bar. When the resident was done using the toilet, the resident stood up, holding the grab bar. As she pivoted to transfer, her left foot turned in and she lost her balance and the CNA lowered her to the ground. She said she did not use the sit to stand lift; she said the resident was able to hold onto the grab bar and help with transfers. Although the facility suspended CNA #5 (and ultimately terminated her) and planned staff education on proper transfers and safe use of transfer equipment, the facility failed to develop and implement a resident-specific care plan to ensure Resident #19's safety upon her return and failed to ensure all direct care staff were educated on proper transfers and safe use of the equipment. a. Resident #19's care plan Resident status on readmission was assessed by physical therapy as totally dependent for transfers (without) attempt to initiate. An initial care plan dated 4/25/18 noted the resident's fall risk and read, bed in low position, floor mat, assist with transfers, and mechanical lift. The care plan was updated 5/1/18 to read Sabina lift (a sit to stand lift that requires the resident to participate in the transfer). This care plan did not reflect either the resident's PT assessment or physician orders [REDACTED]. A 4/26/18 physician order [REDACTED]. A Hoyer lift is a lift that is employed when a resident is totally dependent and unable to participate in the transfer. And, per interview with the registered nurse (RN) supervisor on 5/3/18 at 3:25 p.m., the resident did not need a floor mat or a low bed, as she was no longer attempting to get out of bed on her own. She said that the resident required total assistance and confirmed a Hoyer lift was utilized to transfer the resident from bed to the wheelchair. b. Staff education on proper transfers and safe use of the equipment. The training records for the 4/26/18 inservice on falls, transfers and using the mechanical lifts (Hoyer and sit to stand lift) were reviewed. The records documented 50 CNAs on the list; however, only 14 CNAs signed as attending the inservice. The staff development (SDC) was interviewed on 5/8/18 at 10:00 a.m. The SDC said during the inservice on 4/26/18, she provided education on how to utilize the sit to stand (Sabina) lift, the Hoyer lift, and that all lifts required two staff members. She said the physical therapist provided the training and it had not been individualized to specific residents. After reviewing the inservice sheet, the SDC agreed not all of the CNAs were at the training which occurred the afternoon of 4/26/18. She said she provided additional training to the evening shift, but had not provided training on transfers or mechanical lifts since 4/26/18. The NHA was interviewed on 5/8/18 at 2:00 p.m. The NHA said training on falls and transfers had been planned prior to the incident involving Resident #19. The DON was interviewed on 5/8/18 at 2:00 p.m. The DON said a resident should never be transferred without a lift if the resident was assessed to require the use of a lift. She said if one was not available on a specific hallway, the CNA was expected to go to another floor to obtain the proper lift. B. Resident #324 Resident #324, [AGE] years old, was admitted on [DATE]. According to the computerized physician orders [REDACTED]. The 11/29/17 Minimum Data Set (MDS) assessed the resident as cognitively intact (15/15 on the brief interview for mental status (BIMS)) and to need 3/2 assist (extensive assist of one person with resident involved in activity but staff providing weight bearing support) with activities of daily living, including toileting and transfers. Balance during transitions of moving on and off the toilet and from seated to standing was coded 2 - not steady and only to stabilize with human assistance. She had functional limitation in range of motion, both lower extremities. Resident #324's daughter, in an interview on 5/1/18 at 11:40 a.m., said Resident #324 had resided at another facility prior to her admission and there she had been a two-person assist. She said the resident had fallen a couple of times, and was very fragile. 1. Record review the resident fell twice after admission, once with injury (fracture). Review of a 12/4/17 therapy note revealed in early (MONTH) (YEAR), the resident stumbled while standing at the sink, landing on her bottom. The resident had gotten up on her own and she was reminded to use the call light for assistance. She did not sustain an injury. Review of a 1/23/18 nursing note revealed the resident fell on [DATE] at 6:45 a.m. The note read licensed practical nurse (LPN) #1 was called to the resident's room by housekeeping. The resident was found sitting on the floor in the bathroom. She said she tried to get off the toilet and fell . Vital signs were taken and the resident was assessed by registered nurse (RN) #7. She complained of a pain level of 8 out of 10 (the worst pain) in her left hip. At 11:15 a.m., the resident was transported to the hospital for x-rays which revealed left femur fracture. The resident underwent [REDACTED]. 2. Failure to timely implement measures to minimize the safety risks Resident #324's known medical, functional, and cognitive limitations as well as behaviors presented throughout her stay at the facility. a. Resident's known and documented safety risks Record review revealed repeated documentation by therapy and nursing of the resident's medical and functional limitations, and, significantly, cognitive limitations (confusion, forgetfulness, poor safety awareness and recall, inability to follow simple instructions) and behaviors (noncompliance with call light, unassisted transfers (once with fall - see above), and impulsivity) that should have triggered frequent and planned staff supervision, including during toileting, well before her fall with fracture 1/23/18. Specifically: (1) Care plans - knowledge of resident's weakness, difficulty walking, [MEDICAL CONDITION], forgetfulness A baseline care plan on admission (11/22/17) indicated the resident was at risk for falls related to a new environment and a history of falls with interventions to assist with transfers, toileting, and ambulation. A care plan 11/24/17 indicated resident was at risk for fracture related to (r/t) a history of [MEDICAL CONDITION]. Interventions included to observe for signs and symptoms (s/s) of fracture, transfer with assistance as indicated. The resident requires assistance with all activities of daily living (ADLs) r/t muscle weakness, difficulty in walking, tremor, and [MEDICAL CONDITION]. Another care plan dated 11/28/17 indicated the resident was at risk for falls related to decreased functional ability, decreased transfers, decreased range of motion (ROM), a [DIAGNOSES REDACTED]. Interventions included to remind the resident to request assistance prior to ambulation, reinforce safety awareness, and encourage her to use the call light for assistance. (2) Therapy notes - knowledge of resident's poor safety awareness, unsafe behaviors, inability to follow instruction, noncompliance with call light The 11/27/17, 12/2/17, and 1/1/18 therapy notes read the resident displayed poor mechanics and poor recall of safety awareness and balance, demonstrating impulsivity and attempting transfer before the wheelchair (w/c) brakes were locked. The 12/4/17 therapy note indicated the resident reported she had a stumble over the weekend while standing at the sink counter and landed on her bottom. She reported she was getting up on her own when it happened. The 12/11/17 therapy note indicated while the resident was transferring to the toilet, she stood up using the grab bars without locking the w/c brakes. She had difficulty following simple instructions. The 12/12/17 therapy note indicated the resident was able to toilet with moderate assistance for dressing related to her being unable to let go of the grab bar, she called out that she did not want to be alone, she stated she had hit the call light but no one came, she was advised the call light was not on, she was inconsistent with compliance. The 12/13/17 therapy note indicated she had poor safety awareness and was impulsive and would start to sit before the w/c was in place. The 12/29/17 therapy gait training note dated 12/29/17 reads: The resident completed the Tinetti balance assessment tool with a combined balance and gait score of 18/28 (slight increase from previous score of 17/28), indicating she was a high fall risk. The 12/29/17 Modified Barthel Index assessment for functional evaluation done by therapy dated 12/29/17 documented indicated the resident scored 29, indicating she required moderate to maximum assistance with transfers. The 1/5 and 1/9/18 therapy notes indicated she forgot to lock the w/c brakes and she attempted to sit three times without regard for positioning or safety. (3) Nursing notes - knowledge of resident's forgetfulness, confusion, weakness Nursing notes dated 11/22, 11/23, 12/24, 12/26, 12/27/17, and 1/2/18 revealed documentation of the resident being forgetful. Nursing notes dated 11/24, 11/25, 12/1, 12/5, 12/15, 12/22, 12/29/17, and 1/3 and 1/6/18 document her being pleasantly confused. Nursing notes dated 11/30, 12/4, 12/5, 12/7, 12/8, and 12/31/17, documented her being alert and oriented x 1-2 (self-place) with poor short term memory. Nursing notes dated 12/2, 12/3, 12/11 and 12/18/17 document her having extreme weakness in her lower extremities requiring extensive assistance with transfers. b. Failure to respond to known and documented safety risks See care plans above. The facility failed to incorporate the resident's need for planned and frequent staff supervision in her care plans. Specifically, there were no care plan updates alerting staff to the resident's impulsivity, poor recall, unsafe behaviors (self-transfers, nonuse of the call light) and confusion, and no care plan updates instructing staff on how to address these risk factors which, coupled with her medical and functional limitations, required that staff provide frequent and planned supervision, in addition to staff assistance, to keep the resident safe. According to the director of nurses (DON) and executive director (ED), interviewed on 5/8/18 at 5:00 p.m., in addition to care plans, each resident has a care directive that is specific to the resident regarding the type and amount of assistance the resident needs. With any change in condition or adverse event, it is updated with new interventions needed to adequately take care of the resident. The care directive is both undated and unsigned. Review of Resident #324's care directive revealed it identified the resident's transfer and toileting needs (assist of one) and weakness. The note section read, in part, the resident was able to make her needs known and was a high fall risk. It also read, do not leave in bathroom unattended, Per the ED, the care directive was updated the day the resident fell (1/23/18) to include this instruction. Regardless of when the care directive was updated to read not to leave the resident in bathroom unattended, the care directive, like the resident's care plans, failed to include information on the resident's need for planned and frequent staff supervision due to her impulsivity, poor recall, unsafe behaviors (self-transfers, nonuse of the call light) and confusion. Moreover, as set forth above, the facility had information well before the resident's fall to reasonably conclude the resident was unsafe to be left unattended in the bathroom. This, too, was the conclusion of the facility's adverse event investigation which read that despite the resident's BIMS score of 15, the resident should have been monitored during toileting since her inconsistency led to poor safety awareness. 3. Staff Interviews Staff interviews confirmed the resident was unattended in the bathroom and did not use her call light for assistance in transferring off the toilet. Certified nurse aide (CNA) #5, who assisted Resident #324 to the bathroom on 1/23/18 was interviewed by the facility on 1/29/18 during its investigation of the resident's fall. In her interview, she said she assisted the resident to the restroom, transferred her to the toilet, handed her the call light and told her to call once she was finished. She said within 5 minutes she heard the resident had fallen. She said the resident had not put on the call light for help getting off the toilet. (CNA #5 was unavailable for interview as she was no longer employed at the facility at the time of survey) Housekeeper (HK) #1 who was cleaning the resident's hallway on 1/23/18 was interviewed on 5/7/18 at 9:57 a.m. She heard a resident yelling for help, went into the resident's room and found her, unattended, on the bathroom floor with her head near the door. She did not recall if the bathroom call light was on.

Based on record review and staff interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one of 32 sample residents (#34). Specifically: 1. The facility failed to adequately assess resident #34, identified with cognitive issues, for pain after a hot tea burn and verbal complaints of discomfort from the catheter. The findings include: 1. Resident #34 was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to a Minimum (MDS) data set [DATE], the resident scored four out of 15 on the Brief Interview for Mental Status (BIMS), indicating a significant cognitive impairment. He had minimal hearing and vision impairments and had moderate impairments of receptive and expressive language skills. He required extensive assistance for all activities of daily living including bathing, grooming, hygiene, and dressing. He had an indwelling Foley catheter and was occasionally incontinent of bowel. The resident received prn (as needed) medication for pain management, but currently without pain. A. Record Review 1. Care plans: The resident had a care plan dated 1/14/13 for pain related to shingles and arthritis. The care plan included approaches of the following: -administer and observe for effectiveness and side effects from as needed medication -as needed pain medication -consultation of physical therapy or occupational therapy -educate about comfort measures and discuss fears and concerns regarding pain -invite, encourage, remind and escort to preferred activities consistent with interests as a diversion from pain -monitor and report to physician signs and symptoms of pain and worsening pain -notify physician if he does not state or demonstrate relief or reduction of pain one hour after administration of pain medication -observe and report to nurse sign and symptoms of pain or worsening pain -provide comfort measures -report changes in pain location/type frequency/intensity to physician The resident had a care plan for risk of pressure ulcer dated 1/14/13 that indicated he had a potential for alteration in skin integrity for shingles, history of pressure ulcers, indwelling catheter use and pain. The care plan did not include any provisions for discomfort or pain related to the catheter. The medication administration records for May and June contained pain assessments to be completed every shift, however, all records were recorded as no pain including 5/19/13 and 6/1/13 when pain medication was administered. (See below nurses' notes regarding noted presence of pain on 5/19/13 and 6/1/13). 2. Pain medications: The resident had a physician's orders [REDACTED]. According to the May and June 2013 medication administration records, the resident received Tylenol once in May (May 19 at 4 p.m. for pain related [MEDICAL CONDITION]- see below) and once in June (June 1 for urinary pain). The administration of these two medications was recorded on the medication administration record. Nurse's documented there was effective/positive pain relief. B. Hot tea spill with blisters and nursing failed to adequately assess and monitor for pain (see interviews below about the resident's pain): -According to a nursing progress note, on 5/16/13 at 4:30 p.m., the resident had requested a second cup of hot tea, which was re-warmed in the microwave and not checked for safe temperature before serving. The resident spilled the tea on his lap and a small amount spilled onto his shirt. His clothing was removed, he was dried off and ice packs were applied to the reddened areas on his thighs. No assessment for pain or pain medication administration was completed at that time. -On 5/16/13 at 9:35 p.m. a nursing progress note stated that when changing the ice pack, the nurse noted four fluid-filled blisters on the resident's left inner thigh and five fluid filled blisters on the resident's right inner thigh. No pain assessment or administration of pain medication was completed. -On 5/17/13, an untimed nursing progress note on the resident's pressure ulcer care plan stated [MEDICATION NAME] topical [MEDICATION NAME] was to be applied to inner thigh blisters with a non-adherent cover twice daily until the blisters resolved. It also stated the resident was not to wear pants until the blisters resolved. An additional care plan approach included 1) serving fluids in sippy cups to the resident and 2) not serving the resident any liquids warmed in the microwave without testing the temperature before serving. Review of the nurse's notes and medication records from 5/16/13 revealed no pain assessment or pain medication administration was completed until 5/19/13 at 4:00 p.m. when the resident was agitated and pain medication (Tylenol) was given. No other pain medication was administered C. Catheter discomfort (also see interview below about pain with the catheter): On 6/1/13 at 4:30 a.m., a nursing note stated a new Foley catheter was inserted and stated the resident "denied pain." A nursing note on 6/1/13 at 9:41 a.m. documented the resident was complaining of having to urinate. His Foley catheter was removed. The nurse attempted to reinsert the catheter, but was unsuccessful due to the resident "crying out in pain." She noted blood tinge in the Foley catheter tubing and suspected the resident had "another urinary tract infection" because of the confusion displayed by the resident. -Although the resident was expressing pain during this procedure, the nurse did not assess the resident's pain or administer any pain medication at that time. On 6/1/13 at 1:20 p.m., a nursing note stated that the resident was attempting to get out of bed and was incontinent of bloody urine, and complained of pain "down there." Tylenol was administered at that time. 1. Observations revealed the resident had discomfort with the catheter and nursing staff did not assess the resident's pain: On 6/7/13 at 2:35 p.m., the resident was in his wheelchair by the nurses' station. The resident appeared tearful and said three times, "I hurt bad, oh it hurts." His hands were clenched in fists, he was grimacing and appeared tearful. The central supply clerk asked the resident what was hurting and he pointed to his crotch area and said "down there." The clerk responded loudly to the nursing staff approximately five feet away, "Does he have a catheter?" The nurse replied that the resident had a catheter and that he also "has a urinary tract infection again." The clerk chuckled and said, "Catheters hurt, you're just going to have to get used to that." The nurse said, "Yes, they're uncomfortable, not much you can do about it." With this observation and resident complaint of pain, the nurse did not take the resident to his room for a pain assessment and did not offer the resident pain medication. D. Interviews: On 6/4/13 at 2:00 p.m., the resident was interviewed in his room. He said he had pain "all the time" and he was "miserable with it." He said the pain was mainly from his catheter and added that "when I got burned - that hurt awful." On 6/7/13 at 2:45 p.m., the unit nurse was asked what the resident's status was and she replied, "Oh, he's ok, he just doesn't like having a catheter. He'll be fine." On 6/10/13 at 9:00 a.m., the day charge nurse said the resident had a catheter, had recurrent urinary tract infections, and had fallen three times in the last two months. She said he also had been burned by a cup of hot tea on his inner, upper thighs and his stomach. She said when the resident was burned by hot tea in May 2013, it was necessary to keep clothes off the burn areas because they were so painful. She said the resident frequently complained of discomfort and pain related to the catheter and that he was having a supra-pubic catheter later that week. She said the resident had a physician's orders [REDACTED]. Although nursing reported the resident had experienced pain, review of the pain assessments completed every shift (noted above) reflected staff was documenting the resident had zero pain in May. On 6/10/13 at 9:25 a.m., the resident was interviewed in his room. He was asked if he was in any pain at that time and replied, "It always hurts, it hurts so much down there," and pointed to his crotch area. On 6/10/13 at 10:00 a.m., the nurse aide was interviewed. She said the resident frequently complained of discomfort related to the catheter and urinary tract infections, "he's always complaining; he has a terrible time." She said he frequently attempted to go to the bathroom by himself at times which also created a problem pulling the catheter. On 6/10/13 at 11:45 a.m., the Director of Nursing was interviewed. She said she would expect 'in injury situations' that pain assessments and pain medication administration would be part of the treatment until the injury was resolved. She said any time a resident complained of pain or was agitated, she expected nursing staff to assess the resident for pain and administer pain medications as ordered. She said she also expected nursing staff to assess if the pain medication being administered was adequate, and if deemed not adequate, she would expect the resident's physician to be contacted and apprised of the need for additional pain control.

Based on record review and staff interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one of 12 sample residents (#214). Specifically: The facility failed to adequately assess, formulate a plan of care and treat resident #214 for pain after: -Identification of two stage II pressure ulcers and verbal complaints of pain from the wounds. (Cross reference F314, pressure ulcers: failure to provide necessary treatment and services). -Identification of pain [MEDICAL CONDITION] the resident's chest from [MEDICAL CONDITION]. The findings include: Resident #214 was a [AGE] year old female admitted to the facility on [DATE]. According to her face sheet, [DIAGNOSES REDACTED]. According to the admission minimum data set (MDS), dated [DATE], she scored 15 out of 15 on her brief interview for mental status (BIMS) indicating that she was cognitively intact. The MDS that during the observation period from 6/29/13 to 7/4/13, the resident was not on scheduled pain medications, she received pain medication as needed, and received non pharmacological interventions for pain. According to the MDS, a pain assessment for the resident should be conducted; however, the resident was not interviewed. A staff assessment was done. The staff assessment indicated the resident had vocal complaints of pain, facial expressions (grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw), and in the observation period had indicators of pain or possible pain at least daily. Care plans: -A wound care plan, initiated 6/27/13, documented the resident [MEDICAL CONDITION] was at risk for pressure ulcers. The one approach that addressed pain was to observe for pain and medicate as needed per physician's orders [REDACTED]. -An acute care plan, initiated on 6/28/13, noted the resident had a potential for pain related to [MEDICAL CONDITION] diagnosis. Interventions included to monitor pain and observe for behaviors that may have indicated pain. -There was no specific care plan for pain on admission or when the resident was discovered as having pressure ulcers due to complaints of pain. Nursing Notes Nursing notes dated from 7/10/13 through the date of survey on 7/24/13, documented pain as follows: -On 7/12/13 at 10:41 a.m.: Denies any shortness of breath, palpitation (sic) or chest pain, preferred [MEDICATION NAME] cream to be applied later today to chest radiated areas. -On 7/12/13 at 10:46 p.m.: Patient also complains of sore on back ...Family mentioned patient's need for an air mattress. -On 7/13/13 at 10:05 a.m.: Patient denies pain at this time. -On 7/14/13 at 12:02 p.m.: No complaint of pain. -On 7/15/13 at 11:51 a.m.: No complaint of pain. -On 7/19/13 at 10:26 p.m.: The [MEDICAL CONDITION] burn areas on her chest are drying for the most part, except for the upper left area, above her left breast which is still very moist, and an area under her right arm, which appears scabbed but very sore. -On 7/20/13 at 10:08 a.m.: Resident on scheduled [MEDICATION NAME] (sic). -On 7/23/13 at 1:35 p.m.: Denies pain. -On 7/23/13 at 3:16 p.m.: Resident tolerated treatment very well with no c/o (complaint of) pain or discomfort. -A non pressure skin condition record initiated 7/1/13 documented the presence of three wounds (none of which were on the resident's back). Each assessment had a space for pain evaluation, however, none were completed. -An audit of pain management, dated 7/9/13, indicated the resident did not have a per shift pain assessment listed on the medication administration record (MAR). Appropriate pain interventions were identified and the facility noted they added this to the MAR on 7/9/13. The audit showed the resident had an updated care plan, including non pharmalogical interventions for pain. However, review of the care plans (noted above) indicated the resident did not have a pain care plan. -Review of the MAR revealed the resident was admitted with an order for [REDACTED]. She was not documented as receiving any as needed [MEDICATION NAME] in June 2013. In July, she received [MEDICATION NAME] on 7/1/13 for 5/10 pain with 10 being the worst and 0 being no pain. She also received it on 7/3/13, 7/5/13, 7/8/13, 7/10/13, twice per her pain flow sheet. On 7/10/13, the [MEDICATION NAME] order was changed to 600 mg every eight hours scheduled. However, on 7/14/13, according to the MAR, a telephone order indicated it was decreased to 400 mg oral every four hours. Review of the notes and interviews with the director of nursing (DON) and the wound nurse (WN), see below, did not indicate why the resident's pain medication was reduced, after she complained of pain on 7/12/13 and was noted to have a very sore wound on 7/19/13. Interviews The DON, WN, interim nursing home administrator (INHA) and nurse consultant (NC) were interviewed on 7/25/13 beginning at 5:25 p.m. The DON had been out for the past week and was unaware of the new wound on the resident. The NC stated that pain was addressed in an impaired communication skills care plan. (However, this was noted as a contributing factor to decreased communication and listed no pain interventions). The NHA, DON and NC stated they not know why the resident's medication had been increased then decreased. The NC stated that the pain medication was increased on 7/14/13 to address the resident's pain. However, review of the telephone orders revealed the pain medication dose was actually reduced. The facility had conducted regular audits of pain care plans, assessments and interventions to address F309, cited during the original survey exiting 6/10/13. However, the audits did not show the facility identified the discrepancies between the MAR and pain flow sheet. Moreover, the audits did not note the resident did not have a pain care plan. The DON stated they had been working closely with the resident's pain as she had the [MEDICAL CONDITIONS] her chest. The DON stated they were so painful that they had to figure out how to clothe the resident for therapy because wearing a shirt caused her pain. The resident and family on were both unavailable for interviews at the time of survey.

Based on record review and staff and family interviews, the facility failed to ensure two (#6, #9) of 22 sample residents received sufficient preparation and orientation to ensure a safe and orderly discharge. Specifically: -The facility failed to ensure support services, including an oxygen supplier, were set up prior to a holiday discharge for resident #6, who had a history of [REDACTED]. -The facility failed to ensure resident #9 was sufficiently prepared to discharge home safely. The resident was discharged home, within hours of receiving notice of the discharge (cross-reference F203). Although home health visited the same day, discharge medications were not clearly labeled, medication orders needed clarification, and the resident missed a dose of intravenous (IV) medication. The findings include: A. Facility Policy The facility policy entitled "Discharge/Transfer of the Resident," revised June 2010, was requested and received on 10/3/11, from the nursing home administrator (NHA). The policy stated in pertinent part: Policy: - To provide safe departure - To provide sufficient information for after care of the resident Procedure: ... 3. Explain benefits of the procedure to the resident. 4. Explain safety measures of the procedure to the resident. 5. Explain the adverse effects and/or complications of the procedure to the resident ...7. Include resident's family and surrogate health care decision-makers in care planning when possible. Discharge: ...2. The attending physician is required to write a discharge order. Telephone orders are acceptable. B. Resident Failures 1. Resident #6 (closed record review) Resident #6, [AGE] years old, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review of the medical record, revealed the resident had been living at home with her husband, had a fall, and was admitted to the facility from the hospital for rehabilitation. According to the closed record, the resident was sent back to the hospital from the facility on 2/17/11, at approximately 4:35 p.m. (with a blood pressure of 34/25 and an oxygen saturation level unregistered on 5 L per oxygen mask) and was readmitted to the facility within 24 hours on 2/18/11 at 4:30 p.m. The resident was again sent to the hospital on [DATE], because of unresponsiveness (a blood pressure of 34/22 and shallow respirations before the non breather mask was put on). The resident returned to the facility on [DATE]. The resident was discharged home on[DATE], over the Memorial Day weekend. The 3/2/11 Minimum Data Set (MDS), indicated the resident's Brief Interview for Mental Status (BIMS) summary score was 11, indicating the resident was moderately impaired and she had no behaviors. The MDS indicated the resident needed extensive assistance of two or more staff members with bed mobility, transferring, dressing, and with toilet use, and needed extensive assistance of a staff member with locomotion and limited assistance of a staff member with eating and with personal hygiene. She had a catheter at times, weighed 143 pounds and was 59 inches tall. The MDS also indicated the resident had a stage II pressure ulcer with slough that was present on admission/reentry to the facility. The resident used oxygen. Record Review of Resident's Status on Admission and Discharge: The initial care plan, dated 2/15/11, indicated the resident was care planned for pain, at risk for physical injury from falls, unable to complete activities of daily living (ADLs), at risk for bleeding due to [MEDICATION NAME], and infection (urinary tract infection), incontinent of bowel and bladder, and mood and behavior (depression). Resident #6 was also care planned for being at risk for skin breakdown. The resident was not care planned for the use of oxygen. On 2/16/11, the physician ordered a Hoyer lift for all transfers. Review of the 5/11 Medication Administration Record (MAR), indicated a physician's orders [REDACTED]. The 5/11 MAR, indicated the resident was on 2 liters of oxygen on 5/30/11, the day of discharge. Review on 10/6/11 of the resident's social services notes, revealed the last note documented was on 4/8/11, regarding a care meeting. This note contained information about decreasing therapy to three times a week, having restorative therapy three times a week, wound care, and changing medications. There was no information regarding discharge or any discharge planning. (Cross reference F250; Social Services) Review of the Occupational and Physical therapy and social services notes, indicated the resident would require assistance upon discharge. These notes revealed: -4/18/11 "Pt. aware that she is being seen 3 times a week with anticipation of DC (discharge) if improvements are not observed and that the resident will require 24 hour physical care in home setting other than spouse as he has not been able to safely demonstrate needs. Informed social services of discussion." Social Services notes, revealed no evidence of any documentation on this date regarding the discussion referenced above or any documentation regarding the resident's discharge plans. -4/19/11 " . . . Explained to resident that she is currently unable to have adequate strength in order to walk with walker. Explained that therapy will discontinue skilled OT and PT services effective this week due to plateau and that patient will need WC (wheel chair) for mobility needs with use of Hoyer for all transfers. Discussed DC (discharge) options. Resident does not want to go LTC (long term care). Family unable to pay for 24 hour care needs at this time. Social Services present during conversation and to provide resident/spouse with other resources." There was no evidence of any social services documentation on this date regarding the resident's discharge or resources for discharge. -4/20/11 ". . . Pt. requires removal of w/c arm for sliding board transfer. . . . her personal w/c arm rest are not removal. . ." -4/22/11 ". . .Treating therapist/COTA feels D/C is unsafe and not recommended due to Pts functional level and level of care she will require. . . Patient aware of discharge today due to lack of progress and appeared to understand." -4/27/11 "Completed family education with Pt, husband, daughter and cousin in regards to Pts current level of function, physical requirements need for caregivers and adaptive equipment if family decides to continue with decision to D/C home. . . Pt and family was advised that this is an unsafe discharge and that long term care would be more appropriate. . . Pt and family was informed of need for hospital bed, Hoyer lift, new W/C and sliding board. Family was also referred to social services for further information regarding information questions, home health info, and was given contact info for W/C services to fit Pt for new personal W/C." Review of the Social Services notes, revealed no evidence of documentation on this date regarding the issues above for further information on home support services. -4/28/11 "Family educated that the therapist biggest concern is for safety of pt and spouse at home. Family verbalized understanding and daughter stated she wants her mother to go home with part-time care first and then transition to LTC (long term care) as needed. Pt report feeling more comfortable with spouse using the Hoyer lift than slideboard." -5/24 ". . . Pt very tearful ...at initiation of wound treatment. Pt crying and stating that the board met and is trying to think of reasons to keep me here." A "Notice of Medicare Provide Non-Coverage" was reviewed on 10/6/11. There was no date on the notice as to when it was served to the resident. Documentation on the form, indicated the effective date of the current SNF (skilled) services would end on 5/30/11. The attached SNF Determination on Continued Stay dated 5/26/11, indicated the facility had reviewed the resident's medical information on 5/24/11 and "the services furnished you no longer qualified as covered under Medicare beginning 5/30/11." The "REASON FOR DENIAL" was documented as "You have exhausted 100 days of your benefit period as of 5/29/11." Review of the Vital Sign Flow Sheet on 10/6/11, indicated the resident was on 2 liters of oxygen on 5/25 through 5/30/11. On 5/21/11, on the 6 a.m. to 6 p.m. shift, it was documented the resident's saturation level was 88% on room air. Review on 10/6/11 of the physician's notes, indicated that on 2/28/11, the physician documented the resident's [MEDICAL CONDITION] history was "significant in that she has a [DIAGNOSES REDACTED]." On 3/14/11, the physician documented that the resident "is continued on her oxygen. . . She is continued on two liters of oxygen. . ." On 4/25/11, the physician documented, "She does continue to require oxygen at 2 liters. . ." On 5/2/11, the physician documented, "Her blood pressures have been satisfactory with her continuing on the oxygen. . ." On 5/23/11, the physician documented, "We will continue her medical regimen at this point in time with the follow up to be accomplished at the next visit and also some discussion if adaptive equipment can be obtained for the patient to possibly return home. As I stated above, this will be 24/7 care for this (invalid) resident." A fax dated 6/1/11, (after the resident was discharged from the facility) and located in the medical chart, was from the facility to a medical equipment company and was reviewed on 10/6/11. According to the fax, the medical equipment and the healthcare provider company had requested information on 5/26/11, regarding the wound, physician's orders [REDACTED]. The PT notes and information included in the fax were signed and dated on 6/1/11. Interviews - Failure of Facility to Prepare the Resident for Safe Discharge: The resident's husband was interviewed per phone on 10/5/11 at 9:15 a.m. -He stated he had problems with the facility once they decided she was returning home and not transferring to their long term unit. He stated he was given "a pretty short notice" before discharge. He stated, "We were aware that she had 100 days to begin with . . .We were not given any option to stay once she ran out of Medicare days, other than on their long term care unit." -He said the facility was "no help at all" in setting things up for resident #6 at home and his daughter had to fly in early and help arrange things for them once they got home. He stated that resident #6 was discharged on a holiday and did not have help for two days. He said the resident ran out of oxygen and her oxygen saturation levels went down to 80%. He said he didn't know what else to do, but go back to the facility and get oxygen for her. He stated he did that twice, and a Certified Nurse Aide (CNA) had helped him; however, he stated he was then told by the facility never to come back. -He stated resident #6 was sent home with a catheter and a wound, which now has healed with the help of a CNA coming in the morning and in the evening. The resident's daughter was interviewed per phone on 10/7/11 at 8:40 a.m. -She stated the resident required a Hoyer lift and her father was concerned about how he was going to do that alone. -She stated that the family was led to believe by facility staff that the resident would never come home and would need to move to the facility's long term care unit. She said that they kept the resident her entire 100 days and she really didn't improve. -She said she had approached the Social Worker (SW) for help with the discharge. The SW gave her a book of resources and had stated, "Do what you want to do;" there was nothing set up in preparation for the move home. -She further stated that the facility had not set up oxygen services and resident #6 was oxygen dependent at that time. She said the facility told her the resident didn't need oxygen; that they put everyone on oxygen at first. The Nursing Home Administrator (NHA) was interviewed on 10/4/11, at approximately 8 a.m. She stated the Social Service department starts the discharge process. Possible and planned discharges are discussed every week on Tuesdays. The Social Service Director (SSD) in charge of the skilled unit and the Social Worker assistant that took care of the long term care unit were interviewed on 10/5/11, at approximately 10:00 a.m. -The SSD stated the resident was very ill and she had talked to her husband several times about skilled care. She stated it was not in the resident's best interest to go home; she needed 24 hour care 7 days a week and the Hoyer lift. She said the other social worker had talked to her husband shortly before discharge and they were thinking of long term care placement. She said the daughter, who thought resident #6 could go home, ordered all the supplies. -The SSD said that they had provided caregiver training to resident #6's spouse. "He came and got oxygen twice for his wife after she was discharged . The daughter told us she had taken care of everything." The NHA, the Director of Nursing, and the regional nurse consultant were interviewed on 10/7/11, at approximately 10:15 a.m. No comments were made and no documentation was produced that showed the facility had taken steps to ensure the resident's safe and orderly discharge. 2. Resident #9 Resident #9, age 83, was admitted to the facility on [DATE]. According to the face sheet, the resident had [DIAGNOSES REDACTED]. The resident was discharged home on[DATE]. (Cross-reference F203; untimely notice of discharge) Further review of the medical record, revealed the resident had been living at home with her husband, had a [MEDICAL CONDITION] embolism, and was admitted to the facility from the hospital for rehabilitation. Her spouse also was a resident at the facility. He, too, was discharged home on[DATE]. Resident #9 and her spouse were the responsible party for one another. a. Record Review of Resident's Status on Admission and Prior to Discharge MDS: According to the admission Minimum Data Set ((MDS) dated [DATE], the resident scored a 14/15 on her mental status test and required extensive assistance with bed mobility, transfers, dressing, toilet use and bathing. Admission Care Plans: The initial care plan, dated 6/20/11, indicated the resident was care planned for at risk for drug toxicity, increased levels of pain secondary to recent hip repair, physical injury from falls, unable to complete activities of daily living (ADLs) without assistance, at risk for bleeding due to [MEDICATION NAME], at risk for nutrition/hydration deficit and for developing pressure ulcers, and she was incontinent of bowel and bladder. Resident #9 also was care planned for discharge planning related to short-term stay. Therapy Notes: Review of the Occupational, Speech Therapy and Physical therapy notes, indicated the resident would require assistance upon discharge. These notes revealed: -Review of the weekly rehab meeting notes dated 7/23/11, revealed that the resident's discharge plan, according to physical therapy note, was to go home with her spouse providing assistance, but the spouse who also was a current resident at the nursing home wanted to transition into assisted living before going home. The occupational therapy note dated the same, indicated the resident would go home with social support from her spouse. The speech therapy note documented that the discharge plan was assisted living. The resident required standby/contact assistance of one for activities of daily living. -Review of the rehabilitation services home assessment recommendations dated 7/26/11, documented that the resident required assistance to get in/out of the home, resident was not able to get into bed, recommended a bedside commode as resident's walker did not fit into the bathroom, resident required assistance getting in/out of the shower and for safe transfer to the shower chair. Resident required assistance with meal prep and laundry. The resident had a shower chair in storage and stated that a ramp would be built. It was further recommended that the dining room chairs be removed as they had wheels, a cushion be placed on the couch to assist the resident with getting up, and it was further recommended that the dogs be contained while the resident was ambulating due to fall risk. Nurses' Notes: Review of the nurses' note dated 7/29/11 at 3:55 a.m., documented that the resident's bilateral lower extremities were red and had three plus [MEDICAL CONDITION]. The resident stated that her hip pain was 7/10 "when sitting still," but was controlled with medication. The IV was patent and flushed with ease. Review of another nurses' note dated 7/29/11 at 6:00 p.m., documented the resident verbalized anger at being discharged . Social Service Notes: Review on 10/4/11 of the resident's social services notes, revealed a note dated 6/27/11, regarding a family member's concern about the resident discharging too soon. -There were no further notes after 6/27/11, about the resident's discharge plans and support services, until 7/29/11. -The discharge note dated 7/29/11 (no time), documented that the resident was informed that an issue had come up and if they wanted to discharge home this date they could do that. It further documented that the business office would be in to discuss the issue further. The social service assistance (SSA) documented that home health was available to provide physical and occupational therapy, as well as nursing services for medication management and activities of daily living assistance, if the resident wished to go home. The resident would notify her family member of the discharge and the SSA would set up home health services. MDS: The discharge MDS, dated [DATE], indicated the resident required extensive assistance with bed mobility, transfers, dressing, toilet use and bathing. Physician Notes and Orders: A physician progress notes [REDACTED]. There was nothing documented regarding the resident discharging. Review of the physician telephone orders, revealed a clarification note dated 7/29/11 at 5:00 p.m. that read, [MEDICATION NAME] 1 gram IV every 12 hours for the next seven days, discharge to home with medications, PT, OT, RN and bath aid, INR checks, Continue [MEDICATION NAME] 1 gram IV every 12 hours for the next seven days with discharge. Review of the physician telephone orders, revealed a speech therapy order dated 7/30/11, which documented discharge from skilled speech therapy effective 7/30/11. Physician telephone orders 8/1/11, documented discharge from skilled occupational therapy services effective 7/30/11. Physician telephone orders 8/2/11, documented discharge from skilled physical therapy services effective 7/30/11. b. Interviews - Failure of Facility to Prepare the Resident for Safe Discharge: (1) Resident and Family Interviews On 10/5/11 at 11:20 a.m., the resident was interviewed at her current residence. -The resident stated that on that Friday (7/29/11), a couple came in and said they could go home now and that they had to go "today." The resident stated that it was quite a shock; it was 5:00 p.m. in the afternoon. -The resident was upset about her belongings and stated that a girl and a nurse shoved everything in plastic sacks and the sack was dropped in the middle of their living room at home. -The resident indicated she was not prepared to go home that quickly. She said she fell at home a few times and had a bad hip and had been admitted to another nursing home. On 10/3/11 at 4:45 p.m., the resident's spouse who was also resident at the facility, at the same time as resident #9, was interviewed. -He stated, "We were getting ready to go to supper and someone from the office said, good news you are going home." He stated that this was on a Friday evening at about 5-5:15 p.m. He said staff came in to pack their belongings. -He indicated that they were not yet prepared to meet the resident's needs at home. He stated that resident #9 had a history of [REDACTED]. On 10/4/11 at 9:45 a.m., the resident's daughter was interviewed. -She said the therapist had told her that resident #9 was not ready to go home yet and they should consider assisted living. She had thought they might pursue this, but then the resident was discharged . -She said that at the time of discharge, resident #9, who had bad veins, was receiving intravenous (IV) antibiotics. She said staff helped resident #9 up the steps to her house, as it was not handicap ready. The driver left the bag of resident belongings in the living room, and their medications were not set up and/or clearly labeled, and her mother did not get all her medications for the first two days. (2) Agency Interview On 10/3/11 at 5:06 p.m., the nurse at the home health agency to whom resident #9 was referred, was interviewed. -The nurse stated that resident #9's start of care was on 7/29/11. The nurse stated that upon arrival to the resident's home (approximately 6:00 p.m.), the resident's IV had infiltrated and she had to wait for the infusion company. She said the resident's discharge medication orders were confusing and the resident missed a dose of her IV antibiotics. -The nurse stated she spent a lot of time trying to get things set up. The nurse stated that the resident's family members did not feel comfortable doing any IV care or medication care. The nurse stated that there were medication discrepancies, and the resident's family member had to go out two times to get medication, and she had to call the on-call doctor to get medication and to clarify medication orders. For these reasons, she did not feel it was a safe discharge. -The nurse confirmed that the resident did have a fall after her discharge. -The nurse said the agency's last note was on 8/3/11, and she was unaware of the resident's whereabouts. Documentation from the agency was requested three times on 10/3/11, 10/4/11, and 10/10/11, but was not received. (3) Staff Interviews On 10/4/11 at 9:30 a.m., the Social Service Assistant (SSA) stated she was approached by the management staff on 7/29/11, between 3:00 and 4:00 p.m., and instructed to discharge the resident as the resident's entire stay had been denied by the insurance. She stated that the resident was discharged at about 5:30 p.m. that day. -She said the home health company was in the building and agreed to provide the resident with assistance. The SSA stated that she was not aware of home evaluation performed on 7/26/11 (see above), which identified the need for a number of home care adjustments. She said that at the time of the resident's discharge, she was not aware if the resident required any equipment. -The SSA stated that she set the resident up with everything and figured with a family member (son) being home, and home health being able to get in that night, she felt like the resident would be "ok." She said she had discussed assisted living with the resident and her spouse, but they declined this option. -The SSA acknowledged she was not completely comfortable with the resident's discharge, but did what she could at the time. On 10/4/11 at 10:35 a.m. the social service director (SSD) was interviewed. -She stated that she was not involved in the resident's discharge on 7/29/11, and learned about it only after it had occurred. The SSD stated she was aware that the resident's spouse did not feel resident #9 was ready for discharge and was aware that the resident and her spouse had been discussing assisted living placement. -The SSD stated that she would have informed staff that it was not a safe discharge for resident #9 and would have given them options to buy some time. The SSD stated she now had new forms, so that discharge will be planned at the time of admission and updated appropriately. c. emergency room Report - Post discharge: On 7/31/11, a day after discharge from the facility, an emergency report documented that the resident presented to the emergency room complaining of right hip pain, secondary to sliding out of her bed that morning. According to the documentation, the resident had a hip replacement in April 2011. The report documented that the resident had fallen out of her bed this a.m. and this was a "lift assist" (the resident required physical assistance to get up). The fire department found the resident with the lower half of her body out of bed, and she was unable to stand or get off the floor. The resident was assisted back to bed by the fire department, as she had no pain complaints at that time. The resident went to the emergency room two hours later, complaining that her right hip was very painful, with pain radiating up her groin. The resident was released back to her home.