Every finding on record at Lowry Hills Care and Rehabilitation

Based on observations and interviews, the facility failed to provide a safe, sanitary and comfortable homelike environment for seven out of 10 rooms.Specifically, the facility failed to ensure resident room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER] were in good repair.Findings include:I. Facility policy and procedureThe Safe and Homelike Environment policy, dated 2025, was provided by the nursing home administrator (NHA) on 6/4/26 at 1:04 p.m. It read in pertinent part, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility, both inside and outside, maximizes resident independence and does not pose a safety risk.II. ObservationsBetween 5/28/26 at 9:15 a.m. and 6/1/26 at 12:46 p.m. the following observations were made:Resident room [ROOM NUMBER] was observed to have spackle on the walls and was not painted.Resident room [ROOM NUMBER] was observed to have spackle on the wall.Resident room [ROOM NUMBER] was observed to have broken blinds and were intertwined together.Resident room [ROOM NUMBER] was observed to have the lower corner of the wall eroded and damaged, exposing the steel frame by the bathroom door frame. The base vinyl around the wall by the bathroom was missing and had chipped paint above it. The wall to the right of the resident's bed had two windows. The blinds in one of the two windows had bent or were missing a blind slat. The wall was painted brown with multiple white spots about an inch in width where the brown paint had been removed in some way. Behind the resident's bed, on the wall, were butterflies and birds painted or stuck on the wall, approximately one to two inches in size. Resident room [ROOM NUMBER] was observed to have broken blinds.Resident room [ROOM NUMBER] was observed to have cracked paint and peeling around the toilet. The tile was chipped around the length of the toilet and peeling. The door frame was scratched from the floor to approximately midway up the frame. The transition piece between the room and bathroom was missing and the bare floor was exposed underneath. There were tape pieces on the door inside. Resident room [ROOM NUMBER] was observed to have the paint worn off all the walls in the room.III. Resident interviewsThe resident who resided in room [ROOM NUMBER] was interviewed on 5/28/26 at 3:18 p.m. The resident said no one asked him about the birds and butterflies stickers on his wall. He said those stickers were just there when he moved in the room. The resident who resided in room [ROOM NUMBER] was interviewed on 6/2/26 at 10:15 a.m. The resident said the floor in the bathroom around the toilet had been cracked for three months. He said he let the director of nursing (DON) and the maintenance director know about it, but nothing had been done about it. The resident said the cracked floor could be a breeding ground for insects. IV. Staff interviewsThe maintenance director was interviewed on 6/1/26 at 2:01 p.m. The maintenance director said the interdisciplinary team (IDT) members toured the building for room inspection and talked to the residents to identify any repair needs. He said if the IDT members noticed anything that needed repair, they communicated to him through a reportable system set up by the management team. The maintenance director said plumbing and electricity issues were the top priorities to be addressed, followed by holes in the walls and ceiling. He said he could address the identified issues within two days unless he had to order parts.The maintenance director said resident room [ROOM NUMBER] was brought to his attention a week ago. He said the maintenance team had just finished repairs in hall 300 and they would begin in hall 400 at the end of the week.The maintenance director was interviewed again on 6/2/26 at 10:40 a.m. The maintenance director said the resident who resided in room [ROOM NUMBER] had notified him regarding the bathroom floor 10 days ago. The maintenance director said the facility had purchased the flooring materials and they would begin work on it at the end of the following week.-However, according to the resident who resided in room [ROOM NUMBER], the bathroom floor in his room had been cracked for three months (see interview above).The NHA was interviewed on 6/2/26 at 3:41 p.m. The NHA said the facility was working on the patches in residents' and were making some upgrades on the building. She said the facility had ordered some repair materials.The maintenance director was interviewed a third time on 6/3/26 at 11:33 a.m. The maintenance director said residents did not like to leave their rooms so the maintenance team was not able to paint the rooms. He said the paint drying time was estimated to be three hours. He said the maintenance team tried to paint when residents were in activities or out for dialysis. He said most of the residents did not like to move their belongings.

Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in three of six medication storage carts. Specifically, the facility failed to: -Ensure medications were labeled with the date they were opened;-Ensure medications were labeled with medication identification and resident identification; and,-Ensure expired medication were removed and discarded from the medication carts.Findings include: I. Professional reference The PharMerica (1/12/25) Abridged List of Medications with Shortened Expirations Dates, was retrieved on 6/4/26 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://pharmerica.com/wp-content/uploads/2025/01/PMC-[NAME]-Meds-with-Shortened-Expiration-Dates_012025_FINAL.pdf. It read in pertinent part, Once certain products are opened and in use, they must be used within a specific timeframe to avoid reduced stability, sterility and potentially reduced efficacy. Product-specific storage and expiration details can be found in the drug product's package insert under the 'How Supplied/Storage & Handling' section. A drug product's beyond use date (BUD) is the manufacturer supplied expiration date or the shortened date after opening, whichever comes first. These in-use medications should be labeled such that the date opened is noted, clearly visible and securely attached to a part of the package to not be discarded. This date is to be referenced when auditing to clear medications prior to expiration. The Pharmcare USA's (4/9/23) Medication Disposal Practices in Assisted Living and Long Term Care, was retrieved on 6/4/26 from https://pharmcareusa.com/education/medication-disposal-practices-in-assisted-living-ltc/. It read in pertinent part, When medications are not disposed of correctly, they can pose serious threats to both human health and the environment. Improper disposal can lead to accidental ingestions, overdose and even death. The Highlights of Prescribing Information for Fluticasone propionate and salmeterol (January 2019) nasal spray, was retrieved on 6/8/26 fromchrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/020121s045lbl.pdf. It read in pertinent part, Safely throw away the Advair Diskus in the trash one month after you open the foil pouch or when the counter reads '0', whichever comes first.The Highlights for Prescribing Information for Xalantan (latanoprost ophthalmic solution) 0.005%, for topical ophthalmic use (December 2022), was retrieved on 6/8/26 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/020597s054lbl.pdf. It read in pertinent part, Store unopened bottle(s) under refrigeration at 2 degrees celsius (C) to 8 degrees C (36 degrees fahrenheit (F) to 46 degrees F). During shipment to the patient, the bottle may be maintained at temperatures up to 40 degrees C (104 degree F) for a period not exceeding eight days. Once a bottle is opened for use, it may be stored at room temperature up to 25 degrees C (77 degrees F) for six weeks. The Highlights of Prescribing Information for Humalog (insulin lispro) injection (May 2025), for subcutaneous or intravenous use was retrieved on 6/8/26 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.accessdata.fda.gov/drugsatfda_docs/label/2025/020563s214,205747s038lbl.pdf. It read in pertinent part, Diluted Humalog for subcutaneous injection may be stored for 28 days when refrigerated at 41 degrees F (5 degrees C) and for 14 days at room temperature up to 86 degrees F (30 degrees C). When stored at room temperature, Humalog U-100 and U-200 can only be used for a total of 28 days, including both not in-use (unopened) and in-use (opened) storage time.The Highlights of Prescribing Information for Lantus (insulin glargine) injection (June 2023), for subcutaneous use (June 2023), retrieved on 6/8/26 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/021081s078s079lbl.pdf. It read in pertinent part, Store unused Lantus in a refrigerator between 36 degrees F and 46 degrees F (2 degrees C and 8 degrees C). Do not freeze. The Lantus vial you are using should be thrown away after 28 days or if the expiration date has passed, even if it still has insulin left in it.The Highlights of Prescribing Information for Incruse Ellipta (umeclidinium inhalation powder), for oral inhalation use (December 2023), was retrieved on 6/8/26 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/205382s013lbl.pdf. It read in pertinent part, Throw away Incruse Ellipta in the trash six weeks after you open the tray or when the counter reads '0', whichever comes first. Write the date you open the tray on the label on the inhaler.The Highlights of Prescribing Information for Symbicort (budesonide and formoterol fumarate dihydrate) Inhalation Aerosol, for oral inhalation use, was retrieved on 6/8/26 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/205382s013lbl.pdf. It read in pertinent part, Throw away Symbicort when the counter reaches zero ('0') or three months after you take Symbicort out of its foil pouch, whichever comes first.The Highlights of Prescribing Information for Combivent Respimat (ipratropium bromide and albuterol inhalation spray), for oral inhalation use (September 2020), was retrieved on 6/8/26 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/021747s020lbl.pdf. It read in pertinent part, Three months after insertion of cartridge, throw away the Combivent Respimat even if it has not been used, or when the inhaler is locked, or when it expires, whichever comes first.II. Facility policy and procedureThe Medication Storage policy, undated, was received from the nursing home administrator (NHA) on 6/4/26 at 1:04 p.m. It read in pertinent part, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs policy.III. ObservationsOn 6/1/26, the medication cart for the 200/300 hallway was observed with licensed practical nurse (LPN) #3. The following items were found: -One card of Midodrine (a blood pressure medication) 5 milligrams (mg), expired 4/13/26;-One card of Hydroxyzine (an antihistamine medication) 25 mg, expired 4/29/26;-One card of Hydroxyzine 50 mg, expired 5/21/26;-One card of Simvastatin (a cholesterol medication) 20 mg, expired 7/5/25;-One bottle of carboxymethylcellulose sodium 0.5% (lubricant eye drop), expired January 2026; -One bottle of Vitamin D3 125 micrograms (mcg) had no expiration date; -One bottle of Calcium citrate with vitamin D3 with an expiration date of February 2026;-One bottle of oyster shell calcium with vitamin D3 500 mcg with an expiration date of July 2025;-One bottle of Diphenhydramine (allergy medication) 25 mg with an expiration date of March 2026;-One bottle of Bisacodyl (stool softener medication) 5 mg with an expiration date of February 2026; -Four fluticasone propionate and salmeterol (medication to help with asthma and chronic airway conditions) 250/50 mcg inhalers were not labeled with the date they were opened;-Two opened bottles of lantaprost (eye drop for glaucoma) 0.005% eye drops were not labeled with the date they were opened; and,-One unopened bottle of latanoprost 0.005% eye drops was not stored in the refrigerator.On 6/1/26, the medication cart for the 100/200 hallway was observed with LPN #2. The following items were found:-One vial of Humalog insulin (short acting insulin) with an expiration date of 5/28/26; -One vial of Insulin glargine (long acting insulin) with an expiration date of 5/28/26;-Multiple unidentified pills were in the bottom of the first drawer, second drawer and third drawer of the cart with no resident identifying information or medication label;-One bottle of Guaifenesin (mucus relieving medication) 400 mg with an expiration date of March 2026;-One vial of Humalog insulin, which was not opened and not stored properly in the refrigerator; -One vial of insulin Humalog was not labeled with the date it was opened;-One package of ipratropium bromide (bronchodilator medication) 0.2% inhalation solution with an expiration date of 4/28/26;-One Incurse ellipta 62.5 mcg (long acting medication to help relax the airway) inhaler was not labeled with the date it was opened;-One card of Sertraline (antidepressant medication) 25 mg with an expiration date of 3/22/26;-One card of Zofran (anti-nausea medication) 4 mg with no expiration date; -One bottle of Aspirin (anti-inflammatory medication) 325 mg with an expiration date of May 2026;-One bottle of Vitamin D3 50 mcg had no expiration date; -Cepacol cough drops with an expiration date of May 2026;-One box of Phenazopyridine hydrochloride (urinary tract medication) 95 mg with an expiration date of December 2025; and,-One bottle of latanoprost 0.005% eye drops was not labeled with the date it was opened. On 6/2/26, the medication cart for the 400/500 hallway was observed with LPN #5. The following items were found: -One bottle of Guaifenesin 400 mg with an expiration date of March 2026;-One bottle of Aspirin 325 mg with an expiration date of May 2026;-One bottle of Loratadine (allergy relief medication) 10 mg with an expiration date of April 2026;-One bottle of oyster shell calcium 250 mg with vitamin D with an expiration date of May 2026; -One bottle of folic acid 1 mg with an expiration date of 4/20/26;-One bottle of thiamin vitamin b12 with an expiration date of 4/2026; -One bottle of Biotin (B vitamin) 5000 mcg, with an expiration date of February 2026;-One bottle of iron 65 mg with no expiration date; -One bottle of latanoprost 0.005% eye drops was not labeled with the date it was opened; -Multiple unidentified pills were on the bottoms of the cart drawers with no resident identifying information or medication label;-Two medication cards of ondansetron (anti-nausea medication) 4 mg with an expiration date of 2/3/26; -One bottle of Potassium 10 milliequivalent (mEq) with an expiration date of 4/14/26;-Methimazole 5mg with an expiration date of 5/20/26;-One card of Zofran 4mg with an expiration date of 4/21/26; -One bottle of Refresh eye drops (polyvinyl alcohol 1.4% for dry eyes) with an expiration date of May 2026;-One vial of Humalog insulin was not labeled with the date it was opened;-One vial of Humalog insulin with an expiration date of 5/28/26;-One vial of insulin glargine with an expiration date of 5/28/26;-Five budesonide-formoterol 160 mcg/4.5 mcg inhalers were not labeled with the dates they were opened; and, -One ipratropium bromide and albuterol (long acting inhaler for chronic respiratory conditions) 20 mcg/100 mcg inhaler was not labeled with the date it was opened.IV. Staff interviews The director of nursing (DON), the NHA and the regional clinical resource were interviewed together on 6/2/26 at 3:00 p.m. The DON said the night shift supervisor was supposed to audit the medication storage one time per week. She said the nurses working on the medication carts were all responsible for checking expiration dates and discarding any expired medications. She said it was important to label medications with shortened expiration dates with an opened date in order for staff to know when the medications expired and when to discard them. She said the importance of discarding expired medications was to ensure those medications were not being administered to residents.

Based on record review and interviews, the facility failed to ensure the comprehensive care plan was reviewed and revised timely to include the instructions needed to provide effective and personalized care for six (#9, #83, #104, #41, #2 and #29) of 10 residents out of 51 sample residents. Specifically, the facility failed to: -Ensure Resident #9's and Resident #83's care plans were updated with catheter care interventions;-Ensure Resident #104's care plan was updated with skin integrity/pressure wound interventions and feeding precaution interventions; -Ensure Resident #41's dementia and behavioral care plan was updated with all appropriate non-pharmacological interventions for psychotropic medications;-Ensure Resident #2's care plan was updated with specific target behaviors and interventions for the resident's use of psychotropic medications; and,-Ensure Resident #29's care plan was updated with specific target behaviors and interventions for the resident's use of psychotropic medications. Findings include: I. Facility policy and procedure The Comprehensive Care Plans policy, no revision date, was received from the nursing home administrator (NHA) on 6/4/26 at 1:04 p.m. It documented in pertinent part, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The comprehensive care plan will describe, at a minimum, the following: -The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; -Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment; -Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of Pre-admission Screening and Resident Review (PASRR) recommendations; -The resident's goals for admission, desired outcomes, and preferences for future discharge; -Discharge plans, as appropriate; -Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. If the resident is non-English speaking, the facility will identify how communication will occur with the resident. The care plan will identify the language spoken and tools used to communicate; and, -Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident. II. Failed to update Resident #9 and Resident #83's care plans with catheter care interventions A. Resident #9 1. Resident status Resident #9, age [AGE], was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included acute on chronic heart failure, benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (enlarged prostate causing urinary tract symptoms) and obstructive and reflux uropathy (blockage causing difficulty with urination). The 1/8/26 minimum data set (MDS) assessment revealed Resident #9 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #9 required substantial assistance with toileting and with transfers. The assessment revealed Resident #9 had an indwelling urinary catheter. 2. Record review The indwelling catheter related to BPH and obstructive uropathy care plan, revised 12/26/25, revealed the goal for Resident #9 was to remain free from catheter-related trauma through the review date of 8/10/26. Interventions (revised 4/13/26) included positioning the catheter bag and tubing below the level of the bladder and away from the entrance room door, enhanced barrier precautions, monitoring for signs and symptoms of discomfort on urination and frequency, monitoring for pain/discomfort due to the catheter and monitoring/recording/reporting to the physician for signs and symptoms of a urinary tract infection (UTI). -However, the care plan for Resident #9's catheter failed to include anything related to hygiene of the catheter. A review of Resident #9's June 2026 CPO revealed the following physician's order: Indwelling urinary catheter care: cleanse site with soap and water and rinse, then pat dry every shift, ordered 6/2/26 (during the survey). The 5/27/26 at 7:08 a.m. nurse progress note documented that Resident #9 had returned from the hospital the evening prior at approximately 10:38 p.m. The resident's test revealed a UTI and a foley catheter had been inserted. B. Resident #83 1. Resident status Resident #83, age [AGE], was admitted on [DATE]. According to the June 2026 CPO, diagnoses included emphysema, chronic obstructive pulmonary disease and neuromuscular dysfunction of the bladder. The 4/30/26 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS score of 12 out of 15. Resident #83 was dependent on staff assistance with toileting and transfers. The assessment revealed the resident had an indwelling urinary catheter. 2. Record review The indwelling catheter care plan, initiated 8/29/25 and revised 9/10/25, revealed Resident #83 was admitted with a Foley catheter. The goal was for Resident #83 was to remain free from catheter-related trauma through the review date of 6/29/26. Interventions included checking the catheter for kinks, monitoring for signs and symptoms of discomfort on urination and frequency, monitoring and documenting intake and output as per facility policy, monitoring for pain/discomfort due to the catheter and monitoring/recording/reporting to the physician for signs and symptoms of a urinary tract infection (UTI). -However, the care plan for Resident #83's catheter failed to include anything related to hygiene of the catheter. A review of Resident #83's June 2026 CPO revealed the following physician's order: Indwelling urinary catheter care: cleanse site with soap and water and rinse, then pat dry every shift, ordered 5/14/26. C. Staff interviews Registered nurse (RN) #1 was interviewed on 6/3/26 at 9:20 a.m. RN #1 said she was responsible for communicating information and updates about residents to the nursing management team and they updated the residents' care plans. She said the nurses were responsible for catheter care, including cleaning the catheters and flushing the catheter if needed. She said the nurses and certified nurse aides (CNA) were responsible for emptying out the catheter drainage bags and documenting the output. She said catheter care and cleaning catheters should be on the care plan, including how to clean it and how often. Licensed practical nurse (LPN) #1 was interviewed on 6/3/26 at 9:30 a.m. LPN #1 said the director of nursing (DON) implemented and updated care plans. She said she was responsible for letting the DON know about any concerns with the residents. She said the nurses were responsible for cleaning catheter tubing and it should be on the care plan. She said there should additionally be a physician's order for cleaning the catheter. The DON, the NHA, and the regional clinical resource were interviewed together on 6/2/26 at 3:00 p.m. The DON said residents with catheters should have a care plan and physician's orders that included the size of the catheter, the size of the catheter balloon, catheter cleaning every shift, the drainage bag to be replaced monthly, irrigation if necessary, securing the catheter to the stat lock (a medical securement device used to hold catheters in place), changing the catheter if leaking, pulled out or clogged and enhanced barrier precautions. She said there should be a task created for CNAs to empty and document the output of urine. The DON said Resident #9's catheter had been put back in recently and the resident's physician orders and care plan had not been updated. III. Failed to update Resident #104's care plan with with skin integrity/pressure wound interventions and feeding precaution interventions A. Resident status Resident #104, age greater than 65, was admitted on [DATE] and discharged to the hospital on 4/22/26. According to the April 2026 CPO, diagnoses included traumatic subdural hemorrhage without loss of consciousness, need for assistance with personal care, presence of left artificial hip joint, displaced trimalleolar fracture of the right lower leg and dementia. The 4/22/26 MDS assessment revealed the resident had a memory problem and was moderately cognitively impaired. The MDS assessment revealed the resident was dependent on assistance from staff for all activities of daily living (ADL). B. Record review The impairment to skin care plan, initiated 4/19/26, documented Resident #104 had impairment to her skin integrity upon admission that included right lower extremity surgical incision, left lateral thigh surgical incision, left medial distal foot wound and right heel. Pertinent interventions, initiated 4/19/26, included to encourage good nutrition and hydration in order to promote healthier skin and to monitor/document the location, size and treatment of the skin injury; report abnormalities, failure to heal, signs and symptoms of infection, and maceration (breakdown) to the physician and weekly treatment documentation to include the measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate (fluid) and any other notable changes or observations. -The care plan did not specify what the sin concern was on the resident's right heel. A review of Resident #104's 4/15/26 skin note revealed the resident had a scab on her right heel that was present upon the resident's admission to the facility. A review of the resident's 4/21/26 wound note revealed the resident had a right heel pressure ulcer after debridement (removal of tissue). -However, the care plan failed to include that the resident had a right heel scab present upon admission and failed to update the care plan accordingly after development of a right heel stage 4 pressure ulcer on 4/21/26. The nutrition care plan, initiated 4/14/26, revealed Resident #104 had potential and/or was at risk for an inability to maintain her nutrition due to a history of falls, a right lower leg fracture, severe protein-calorie malnutrition, dementia, a history of metastatic cancer, malignant neoplasm of the bone, traumatic subdural hemorrhage and femur fracture. Pertinent interventions, revised 4/17/26, included to provide and serve the diet as ordered: a regular diet, regular texture with thin liquids and feeding assistance as needed; monitor and record intake every meal and provide food in a form that was acceptable and culturally acceptable. The registered dietitian (RD) was to evaluate and make nutritional recommendations as needed. A review of Resident #104's April 2026 CPO revealed the resident's diet was changed from regular texture to mince and moist level five on 4/19/26, and from mince and moist level 5 to puree level four on 4/20/26. The speech therapy evaluation and plan of treatment, starting 4/20/26, documented Resident #104's overall presentation was consistent with suspected moderate/severe oropharyngeal (middle of the throat behind the mouth) dysphagia (difficulty swallowing) and the resident remained at an elevated risk of aspiration. A FEES instrumental assessment (fiberoptic endoscopic evaluation of swallowing) was recommended as clinically appropriate to guide diet recommendations and plan of care. Speech therapy recommended the resident be downgraded to puree solids and thin liquids with adherence to safe swallow strategies during one-to-one feeding that included small bites/sips, a slow rate of intake, sitting upright for all oral intake and liquid wash. -However, the resident's care plan failed to include the resident's elevated risk of aspiration, new diet texture orders on 4/19/26 and 4/20/26 and safe swallowing strategies as recommended by speech therapy (see care plan above). C. Staff interviews The DON was interviewed on 6/3/26 at 11:52am. The DON said the interdisciplinary team (IDT) reviewed care plans at least quarterly to update the care plans for established residents. She said the care plans should be updated in real time as changes with residents occurred. The DON said the IDT reviewed any changes in condition or hospitalization and updated the care plans during that time. The DON said Resident #104's care plan should have included the updated recommendations from speech therapy. The DON said the resident should have had a more personalized care plan for her pressure ulcer that included details about the wound and more personalized interventions. IV. Failed to update Resident #41's dementia and behavioral care plan with all appropriate non-pharmacological interventions for psychotropic medications A. Resident status Resident #41, age [AGE], was admitted on [DATE]. According to the June 2026 CPO, diagnoses included severe vascular dementia with behavioral disturbance, major depressive disorder, and stage 3 chronic kidney disease. The 2/17/26 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of two out of 15. She was legally blind, and required partial to moderate assistance with transfers and hygiene tasks. B. Record review Review of Resident #41's June 2026 CPO revealed the following physician's orders: Sertraline (Zoloft) oral tablet. Give 50 milligrams (mg) by mouth one time a day related to adjustment disorder with mixed anxiety and depressed mood, ordered 10/23/25. Quetiapine fumarate oral tablet 25 mg. Give one tablet by mouth three times a day related to severe vascular dementia with behavioral disturbance, ordered 3/4/26. The behavioral and dementia care plan, revised 4/19/24, revealed that Resident #41 had the following behaviors: frequent crying, refusing to stay in the facility, and pacing while feeling anxious. Interventions included administering medications as ordered, monitoring medication side effects and effectiveness, assisting the resident to develop more appropriate methods of coping and interacting, encouraging the resident to express feelings appropriately, providing reassurance and reorientation, explaining all procedures to the resident before starting and allowing the resident time to adjust to changes. Review of Resident #41's May 2025 medication administration record (MAR) revealed the staff were to be monitoring the resident for episodes of dementia, delusional thinking, hallucinations, and episodes of confusion causing emotional distress. Non-pharmacological interventions included offering emotional support, providing a quiet environment, allowing the resident to express feelings, and offering a snack. -However, the interventions were not added to the behavioral and dementia care plan (see care plan above). Further review of Resident #41's May 2025 MAR revealed the staff were to be monitoring the resident for the number of episodes of self-isolation and crying. Non-pharmacological interventions included redirection, repositioning, offering a snack, offering fluids, distraction, and offering activity. -However, the interventions were not added to the behavioral and dementia care plan (see care plan above). C. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 6/2/26 at 1:53 p.m. CNA #1 said Resident #41 was usually confused and moved around in her wheelchair. CNA #1 said she did not see the resident being aggressive with others, crying, trying to harm herself or saying she wanted to leave the facility. CNA #5 was interviewed on 6/3/26 at 10:29 a.m. CNA #5 said she saw Resident #41 being a little verbally aggressive toward staff members, but it did not happen too often. CNA #5 said Resident #41 did not try to hit anybody when she was mad. CNA #41 said she never saw Resident #41 crying or hallucinating. The social services director (SSD) was interviewed on 6/3/26 at 9:30 a.m. The SSD said social services was responsible for identifying depression symptoms and target behaviors and shared this information with nursing staff. The SSD said Resident #41 was on an antipsychotic medication because she wandered into other residents' rooms, had episodes of hallucinations and delusional thinking, and impaired vision, which contributed to her behaviors and frustration. The SSD said Resident #41 verbalized sadness, did not have family involvement, and she was worried about them not visiting her. The SSD said the social services department reviewed care plans, and she was aware Resident #41's interventions were not updated in her care plan. The SSD said she was working on care plans. V. Failed to update Resident #2's care plan with specific target behaviors and interventions for the resident's use of psychotropic medications A. Resident status Resident #2, age less than 65, was admitted on [DATE]. According to the June 2026 CPO, diagnoses included anxiety disorder, depression, alcohol abuse and acute kidney failure. The 4/25/26 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of seven out of 15. The MDS assessment indicated the resident had little interest or pleasure in doing things, felt down, depressed and hopeless. The MDS assessment indicated the resident had no behaviors. B. Record review The depression care plan, initiated 4/19/26, revealed Resident #2 used antidepressant medication related to depression. Interventions included administering antidepressant medications as ordered by the physician, monitoring/documenting /reporting as needed (PRN) adverse reactions to antidepressant therapy, such as changes in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts and withdrawal. -However, the specific target behaviors associated with the use of the antidepressant medication were not included on the care plan. The anxiety care plan, initiated 4/19/26, revealed Resident #2 used anti-anxiety medication related to anxiety. Interventions included administering anti-anxiety medications as ordered by the physician, monitoring/documenting /reporting PRN adverse reactions to anti-anxiety therapy, such as drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation and monitoring and recording occurrence of target behavior symptoms and documenting per facility protocol. -However, the specific target behaviors associated with the use of the anti-anxiety medication were not included on the care plan. Review of Resident #2's June 2026 CPO revealed the following physician's orders: Sertraline HCl (hydrochloride) (antidepressant medication) tablet, give 100 mg by mouth for depression one time a day, ordered 5/14/26. Buspirone HCl (anti-anxiety medication) oral tablet 5 mg, give one tablet by mouth three times a day for anxiety, ordered 4/20/26. Monitor episodes of anxiety mental-to-body (M/B) feeling worried, tearful, scratching every shift for Buspirone use. Antianxiety interventions: 1) Offer activities of choice 2) Offer emotional support 3) Redirect resident 4) Provide quiet environment 5) Allow to express feelings 6) Offer snack 7) Other (Document under progress notes), ordered 4/20/26. Monitor episodes of depression M/B isolation, tearfulness, loss of appetite every shift for Sertraline use. Nonpharmacological interventions: 1. Redirection 2. Repositioning 3. Offer snack 4. Offer fluid 5. Distraction/Offer activity 6. Other, ordered 4/20/26. -However, Resident #2's antidepressant and anti-anxiety care plans failed to include the monitoring episodes of anxiety and depression and specific interventions (see care plans above). C. Staff interviews CNA #7 was interviewed on 6/2/26 at 4:50 p.m. CNA #7 said Resident #2 was tired most of the time. CNA #7 said Resident #2 was observed crying because Resident #2 said she had been experiencing diarrhea for the past three years. CNA #7 said Resident #2 stayed in bed throughout the day and refused to eat breakfast. LPN #4 was interviewed on 6/2/26 at 4:21 p.m. LPN #4 said Resident #2 was prescribed buspirone for anxiety and sertraline for depression from the hospital. LPN #4 said Resident #2 was oriented, but scared and sometimes attempted to get out of bed. Resident #2 was agitated at times, sometimes she was drawn to herself and did not want to interact with others. LPN #4 said monitoring was not only observing for anti-anxiety and antidepressant medications adverse effects, but also monitoring for signs of anxiety and depression. The SSD was interviewed on 6/3/26 at 9:35 a.m. The SSD said Resident #2 was admitted with physician's orders for buspirone and sertraline. The SSD said Resident #2 was depressed, self-isolated, tearful, and melancholic for her past. She said Resident #2 expressed anxiety and sadness regarding the future, and wanted support.The SSD said Resident #2's target behaviors included self-isolation, low motivation to participate in activities, therapy and care. She said Resident #2 had a change in appetite and sleep pattern. She said the resident had anxiety, perseveration on things out of her control, irritability, panic attacks and refusal of activities. The SSD said she identified Resident #2's target behaviors and communicated them to the nursing staff for monitoring. She said she was not responsible for adding the identified target behaviors into residents' behavior monitoring tracking on their MARs. VI. Failed to update Resident #29's care plan with specific target behaviors and interventions for the resident's use of psychotropic medications A. Resident status Resident #29, age [AGE], was admitted on [DATE]. According to the June 2026 CPO, diagnoses included cognitive communication deficit, psychotic disorder with hallucinations due to known physiological conditions and major depressive disorder. The 3/25/26 MDS assessment revealed the resident had both short and long term memory impairments and the resident's decision making skills were moderately impaired. The resident was independent with ADLs. The assessment indicated the resident was receiving antidepressant and antipsychotic medications. B. Record review Review of Resident #29's June 2026 CPO revealed the following physician's orders: Zoloft (antidepressant medication) 100 mg by mouth one time a day, ordered 3/4/26. Risperidone (antipsychotic medication) 1 mg by mouth in the evening for dementia with psychotic disturbance, ordered 5/8/26. Review of the psychotropic medication care plan, initiated 1/13/25 and revised 7/1/25, revealed Resident #29 used psychotropic medications related to psychotic disorder with hallucinations and dementia. Interventions included administering psychotropic medications as ordered by the physician, monitoring for side effects and effectiveness every shift, consulting with the pharmacy and the physician to consider dosage reduction when clinically appropriate, at least quarterly, monitoring and recording occurrences of target behavior symptoms and documenting per facility protocol. -However, the specific target behaviors associated with the use of the psychotropic medications were not included on the care plan. Review of Resident #29's May 2026 MAR revealed staff were to monitor the resident for hallucinations. Interventions documented on the MAR included offering the resident activities of choice, offering emotional support, redirecting the resident, providing the resident with a quiet environment, allowing the resident to express his feelings and offering a snack. -However the care plan failed to include the specific target behaviors and interventions which were on the MAR (see care plan above). C. Staff interview The SSD was interviewed on 6/3/26 at 9:25 a.m. The SSD said Resident #29 received psychotropic medications for psychiatric disturbances. She said he was paranoid about dogs and was distrustful of staff. She said he was also paranoid that his brother was stealing his money. The SSD said the social services department developed the specific target behaviors and interventions for addressing residents' behaviors. She said she and the social services assistant would update the resident's care plans for the use of the psychotropic medications. The SSD said she was aware some of the residents' care plans were not specific to the individual target behaviors of each resident. She said she was working on a performance improvement plan to ensure the residents were reviewed in the psychotropic medication meetings.

Based on observations and interviews, the facility failed to be designed or equipped to assure full visual privacy for each resident for six out of 10 rooms. Specifically, the facility failed to ensure residents had privacy curtains that provided them with full visual privacy for resident room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER].Findings include:I. Facility policy and procedureThe Resident Rooms policy, dated 2026, was provided by the nursing home administrator (NHA) on 6/4/26 at 1:04 p.m. It read in pertinent part, Resident bedrooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents. All resident bedrooms will be equipped to assure full visual privacy for each resident, including ceiling suspended curtains which extend around each bed in non-private bedrooms.II. ObservationsBetween 5/28/26 at 9:15 a.m. and 6/1/26 at 12:46 p.m., the following observations were made:Resident room [ROOM NUMBER] was observed to have no privacy curtain for the bed by the room's entrance that faced the bathroom, in case the resident's roommate had to use the bathroom.Resident room [ROOM NUMBER] was observed to have no privacy curtain for the first bed by the room's entrance. Resident room [ROOM NUMBER] was observed to have no privacy curtain for the third bed.Resident room [ROOM NUMBER] was observed to have no privacy curtain.Resident room [ROOM NUMBER] was observed to have a privacy curtain, however, it was not big enough for the first bed by the room entrance. The curtain did not go around the entire bed and the resident could be seen lying in the bed.Resident room [ROOM NUMBER] was observed to have one privacy curtain between the middle resident's bed and the resident's bed by the window. There was no privacy curtain between the first resident's bed and the middle resident's bed. There was no track in the ceiling to allow for privacy curtains and no portable privacy screens were observed in the room.III. Resident interviewsThe resident who resided in room [ROOM NUMBER] was interviewed on 6/1/26 at 10:52 a.m. The resident said there should be a curtain for privacy. The resident wondered how staff would provide her care with privacy if they had to look at something on her skin. She said she had to go into the bathroom to get dressed or undressed. The resident said the staff had to do whatever was convenient for them to provide care.IV. Staff interviewsCertified nurse aide (CNA) #7 was interviewed on 6/1/26 at 11:11 a.m. CNA #7 said if there was a privacy curtain, she had to pull it while providing care to the residents in their rooms. CNA #7 said if the privacy curtain was not available, she would take the resident to the bathroom to provide care. She said if the resident could not walk, she would call another staff member for assistance to get the resident to the bathroom. CNA #7 said there was no privacy curtain between the first resident's bed and the middle resident's bed in room [ROOM NUMBER]. She said she provided care to one of the residents in the bathroom. CNA #7 said she asked one of the residents to step outside while providing care to the roommate. CNA #7 said sometimes the roommate would stay in the room throughout the care. CNA #7 said resident room [ROOM NUMBER] had not had a privacy curtain for over a year between the residents and she had not notified the facility's management team about it.Licensed practical nurse (LPN) #5 was interviewed on 6/1/26 at 12:12 p.m. LPN #5 said she closed the curtain and ensured the door was closed for privacy during resident care. She said if there was no privacy curtain, she would move the other resident to the bathroom for care or would ask the roommate if it was okay to step aside. LPN #5 said she knew there was no privacy curtain between the residents' beds in room [ROOM NUMBER], but never thought about reporting it to the management or maintenance.The maintenance director was interviewed on 6/1/26 at 2:01 p.m. The maintenance director said to ensure residents' privacy during care in their rooms, the facility installed ceiling curtains in the rooms. He said there should be three curtains separating beds for a room with three residents. The maintenance director said the privacy curtain in room [ROOM NUMBER] was caught by the bed, pulled down and ripped, damaging the ceiling. He said it happened on 5/29/26 and the facility had already ordered a new one.-However, according to the interview with CNA #7, there had been no privacy curtains in room [ROOM NUMBER] for over a year (see interview above).After realizing that there was no privacy curtain track installed in room [ROOM NUMBER] in order to hang privacy curtains, the maintenance director amended his prior statement and said he had just been made aware of the issue on 5/29/26 and was in the process of ordering a ceiling track to install the privacy curtains. The NHA was interviewed on 6/2/26 at 3:37 p.m. The NHA said she was not aware of the missing privacy curtain. The NHA said the facility ordered a portable privacy screen for temporary use. The NHA provided proof of the order documentation for the privacy screen during the interview.V. Facility follow-upOn 6/1/26 at approximately 2:30 p.m. the maintenance director provided documentation that the ceiling track for room [ROOM NUMBER]'s privacy curtains had been ordered on 6/1/26, during the survey.

Based on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (#104) of five residents out of 51 sample residents reviewed for skin assessments.Specifically, the facility failed to assess and obtain orders for the care of Resident #104's controlled ankle motion (CAM - a device that provides protection after orthopedic procedures and assists in offloading pressure) boot for her right leg.Findings include:I. Resident #104A. Resident statusResident #104, age greater than 65, was admitted on [DATE] and discharged to the hospital on 4/22/26. According to the April 2026 computerized physician orders (CPO), diagnoses included traumatic subdural hemorrhage without loss of consciousness, need for assistance with personal care, presence of left artificial hip joint, displaced trimalleolar fracture of the right lower leg and dementia.The 4/22/26 minimum data set (MDS) assessment revealed the resident had a memory problem and was moderately cognitively impaired. The MDS assessment revealed the resident was dependent on assistance from staff for all activities of daily living (ADL).The assessment documented the resident had a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device.B. Record reviewThe ADL care plan, initiated 4/19/26, documented Resident #104 had an ADL self-care performance deficit related to limited mobility, impaired balance, deconditioning, dementia, a history of falls, left femur fracture - hemiarthroplasty (partial joint replacement), right ankle fracture with open reduction and internal fixation (ORIF - a common orthopedic surgical procedure used to repair severely broken or displaced bones), subdural hematoma and subarachnoid hemorrhage (bleeding on the brain), breast cancer with metastases to the bone, psychotropic medication use, incontinence and cognitive loss. Pertinent interventions, initiated 4/19/26, included a CAM boot to the resident's lower right leg.The 4/13/26 admission note documented Resident #104 was admitted after undergoing significant orthopedic interventions in the hospital, including a left hip cemented hemiarthroplasty and a right ankle ORIF with a hindfoot nail (rod inserted through the heel). The note documented the resident's baseline dementia/intermittent delirium required a high level of care and necessitated one-on-one staff supervision on arrival to the facility. The resident had a CAM boot on her right leg and was a high fall risk.A 4/15/26 skin and wound note documented Resident #104 had an external device. The external device was a CAM boot that was present to the resident's right lower extremity. The external device was removed and the site was inspected. The staff were to observe for any discoloration on the device/cast that may indicate drainage under the device. Resident #104 was to use the CAM boot when out of bed.A review of Resident #104's April 2026 CPO revealed the following physician's orders:Weight bearing as tolerated for stand and pivot transfers every shift for the right lower extremity in the CAM boot, ordered 4/14/26 and discontinued 4/14/26. Weight bearing as tolerated for stand and pivot transfers every shift for the right lower extremity ordered 4/14/26.-The second weight bearing order did not include the resident's CAM boot.A 4/21/26 occupational therapy note documented a certified nurse aide (CNA) was educated that Resident #104 needed to wear the CAM boot for transfers and when out of bed. -Review of Resident #104's electronic medical record (EMR) did not reveal physician's orders for the resident to wear the CAM boot for transfers and when out of bed, or physician's orders for monitoring the resident's skin underneath the CAM boot.II. Staff interviewsThe regional clinical resource and the wound care nurse were interviewed together on 6/3/26 at 10:06 a.m. The wound care nurse said Resident #104 had a CAM boot on her right heel upon admission to the facility and the CAM boot came up to just below the resident's knee. The wound care nurse said the resident's heel was covered under the boot and her toes were exposed. The wound care nurse said the resident had surgery on her right ankle prior to her admission to the facility.The regional clinical resource said Resident #104 had surgery and a CAM boot was placed on the resident's right heel prior to her admission to the facility. The regional clinical resource said it did not look like the admitting nurse actually removed the CAM boot to assess the resident's heel upon her admission. She said a complete head-to-toe assessment of the resident should be completed upon admission to the facility.The regional clinical resource said the hospital discharging physician's order was for Resident #104 to have the CAM boot on for transfers when the resident was out of bed. The regional clinical resource said the resident was to have the boot removed at her follow up appointment on 4/23/26.The regional clinical resource said the therapy staff were getting Resident #104 up and out of bed and utilizing the CAM boot but the physician's order for the boot was not entered into the resident's EMR so it was not clear to all staff that the resident was to wear the boot. The regional clinical resource said a physician's order should have been placed upon admission for the boot because the resident was admitted with the boot.

Based on record review and interviews, the facility failed to provide pharmaceutical services to meet the needs of one (#64) of five residents out of 51 sample residents.Specifically, the facility failed to ensure Resident #64's anti-anxiety medication was ordered and delivered to the facility in a timely manner.Findings include: I. Facility policy and procedureThe Pharmacy Services policy, undated, was received from the nursing home administrator (NHA) on 6/4/26 at 1:04 p.m. It read in pertinent part, The facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice.II. Resident #64A. Resident status Resident #64, age less than 65, was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included Wernicke's encephalopathy (neurological condition caused by vitamin B1 deficiency), muscle weakness, anxiety disorder, major depressive disorder and attention deficit hyperactivity disorder (ADHD). The 4/21/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. She was independent with activities of daily living (ADL). B. Resident interview Resident #64 was interviewed on 5/27/26 at 2:25 p.m. Resident #64 said she missed some doses of her scheduled Wellbutrin (anti-anxiety medication) and started to feel withdrawal side effects. She said she felt increased anxiety and as if her insides were going to jump out. She said she let the director of nursing (DON) know about it. C. Record review A review of Resident #64's June 2026 CPO revealed the following physician's order: Wellbutrin XL Oral Tablet Extended Release 24 Hour 150 milligrams (mg), give 300 mg by mouth one time a day for ADHD, ordered 4/15/26. A review of Resident #64's May 2026 medication administration record (MAR) revealed the resident's Wellbutrin medication was not administered on 5/11/26, 5/19/26, 5/20/26, 5/21/26 and 5/31/26. The reason the medication was not administered on all five dates was documented as other/see nurse notes. A review of Resident #64's nursing progress notes revealed the following: On 5/11/26 at 10:50 a.m. a nursing note documented Resident #64's Wellbutrin medication was not on hand. On 5/19/26 at 10:39 a.m. a nursing note documented Resident #64's Wellbutrin medication was not on hand.On 5/20/26 at 2:33 p.m., a nursing note documented Resident #64's Wellbutrin medication was not available, the pharmacy was contacted and delivery was pending. On 5/21/26 at 9:54 a.m. a nursing note documented Resident #64's Wellbutrin medication was on order. On 5/31/26 at 10:10 a.m. a nursing note documented Resident #64's Wellbutrin medication was unavailable and on order. -The facility failed to provide Resident #64 with her prescribed medication and contact the physician when the medication was not available, which resulted in the resident missing five doses of medication. III. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 6/1/26 at 1:02 p.m. LPN #3 said each medication card had a darker blue slot with about 10 days of medication left and when the card reached that point, she was able to reorder the medication. She said it took one to two days for the pharmacy to deliver the medication once it was ordered. She said if the physician needed to send a new prescription for the medication, she would get in contact with the physician to do so. She said if a medication was unavailable to be administered, she would notify the physician and put the medication on hold, educate the resident, and call the pharmacy to see when the medication was expected to be delivered. She said she would write a progress note to document notifying the physician, pharmacy, resident and what actions were taken. Registered nurse (RN) #3 was interviewed on 6/2/26 at 9:50 a.m. RN #3 said when there was about a week of medication doses left on a medication card, she reordered the medication on the computer. She said if the pharmacy did not send the medication in one to two days after reordering, she would fax the medication label to the pharmacy and call the pharmacy. She said if the medication needed authorization, she would get in contact with the physician or the DON. She said if medication was unavailable to administer to the resident, she would check the emergency medication kit, notify the physician and write a nursing progress note. The DON, the NHA and the regional clinical resource were interviewed together on 6/2/26 at 3:00 p.m. The DON said the nurses passing medications should always reorder the medications when they are down to the last five days of medication. She said if they got down to the last three days, the nurses should call the pharmacy. The DON said if a medication was unavailable to be administered, the nurses should check the emergency supply of medications and if still unavailable, notify the physician and the pharmacy, notify the resident and the resident's representative, place the medication order on hold and write a nursing progress note to document everything. The DON said she was made aware of Resident #64's Wellbutrin unavailability and the facility was able to get it added to the facility's emergency medication supply system on 5/28/26 (during the survey). She said all nurses had access to the facility's emergency medication supply system -However, Resident #64's Wellbutrin was again documented as unavailable on 5/31/26 for administration (see record review above).

Based on record review, observations, and interviews, the facility failed to ensure residents unable to carry out activities of daily living (ADLs) received necessary services for one (#8) of five residents reviewed for ADLs out of 51 sample residents.Specifically, the facility failed to ensure Resident #8 received timely meal assistance.Findings include:I. Facility policy and procedureThe Assisted Nutrition and Hydration policy, revised 2025, was provided by the nursing home administrator (NHA) on 6/3/26 at 12:44 p.m. The policy read in pertinent part, The facility willprovide nutritional and hydration care and services to each resident, consistent with the resident's comprehensive assessment, recognize, evaluate, and address the needs of every resident, including but not limited to, the resident at risk or already experiencing impaired nutrition and hydration and provide a therapeutic diet, taking into account the resident's clinical condition and preferences. II. Resident #8A. Resident statusResident #8, age [AGE], was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included severe protein-calorie malnutrition, pressure ulcer of the sacral region, stage 4, congestive heart failure, dementia and generalized muscle weakness.The 4/30/26 minimum data set (MDS) assessment revealed Resident #8 was unable to complete the brief interview for mental status (BIMS). According to the staff assessment for mental status, the resident had short and long term memory problems and her cognitive skills for daily decision making were moderately impaired. The resident was dependent on staff assistance for most ADLs. She required setup or clean-up assistance for eating.B. Observations and resident interviewOn 6/2/26 at 8:15 a.m. Resident #8 was in her room eating breakfast by herself with a regular spoon and no staff assistance. The resident's breakfast consisted of eggs and what looked like hashbrowns. The resident's left hand was contracted and she could not open her fingers, which were curled closed.Resident #8 said she could eat by herself. On 6/2/26 at 11:40 a.m. Resident #8 was observed asleep in her room as the staff was delivering lunch room trays. Certified nurse aide (CNA) #5 delivered the residents' room tray. CNA #5 said hello to the resident, but did not ask the resident if she needed assistance with eating or offer to sit down to assist her with eating. After delivering the room tray, CNA #5 exited Resident #8's room.Resident #8 said she could not get the cover off her food plate and asked for assistance. CNA #5 was notified that the resident was having trouble and returned to the resident's room. CNA #5 uncovered Resident #8's plate and said she would help the resident eat in a moment, and then replaced the cover on the resident's plate again before exiting the room.-CNA #5 did not attempt to offer Resident #8 any bites of food prior to exiting the resident's room. At 12:11 p.m., 31 minutes after CNA #5 delivered Resident #8's room tray, the physical therapist (PT) entered the resident's room to speak with the resident. At 12:13 p.m. CNA #5 entered Resident #8's room and shut the door to the room.At 12:14 p.m. CNA #5 exited the resident's room again with Resident #8's roommate's lunch tray.At 12:22 p.m. the PT was observed doing arm exercises with Resident #8 and assisting the resident with eating.-However, Resident #8 did not receive meal assistance for over 30 minutes after her lunch tray was delivered to her room, despite the fact that documentation in the resident's electronic medical record (EMR) indicated the resident required assistance with eating (see record review below).C. Record reviewThe ADL care plan, initiated 11/21/24, revealed Resident #8 had an ADL self-care performance deficit related to dementia, encephalopathy, decreased mobility and increased weakness to the left side. Interventions included providing the resident with finger foods when she had difficulty using utensils and assisting the resident one-to-one with meals.The 5/1/26 registered dietitian (RD) progress note revealed Resident #8 required feeding assistance/encouragement at meals as needed (PRN).-However, observations revealed staff did not offer to assist the resident with eating (see observations above).III. Staff interviewsCNA #5 was interviewed on 6/2/26 at 9:44 a.m. CNA #5 said she assisted Resident #8 with her eating. She said the resident could sometimes eat her meal herself but she generally needed assistance. -However, CNA #5 did not provide or offer meal assistance to Resident #8 after delivering her lunch tray on 6/2/26 (see observation above).CNA #3 was interviewed on 6/2/26 at 3:17 p.m. CNA #3 said Resident #8 did not need staff assistance or queuing for meals and she was able to feed herself.The director of nursing (DON) was interviewed on 6/3/26 at 11:01 a.m. The DON said that occupational therapy normally informed the staff if a resident needed assistance with eating upon admission. The DON said it varied on how much feeding assistance Resident #8 required for meals. She said CNAs should be encouraging the resident to eat and offering her help frequently during meals.

Based on observations, record review and interviews, the facility failed to ensure residents with with limited range of motion received appropriate treatment and services to increase range of motion for one (#8) of one resident out of 51 sample residents.Specifically, the facility failed to provide passive range of motion services for Resident #8's left hand, which had a contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff and prevents normal movement of a joint or other body part).Findings include:I. Facility policy and procedureThe Prevention of Decline in Range of Motion policy, revised 2025, was provided by the nursing home administrator (NHA) on 6/3/26 at 12:44 p.m. The policy read in pertinent part, The facility will utilize a systematic approach for prevention of decline in range of motion, including assessment, appropriate care planning and preventative care. Licensed nurses will assess resident's range of motion (such as current extent of movement of his/her joints and the identification of limitations) on admission/readmission, quarterly, and upon a significant change. Residents who exhibit limitations in range of motion, initially and thereafter, will be referred to the therapy department for a focused assessment of range of motion. Nursing assistants will report any significant changes in range of motion, as noted during daily care activities, to the resident's nurse when any changes are noted. The assessment should include identified risks which could impact resident's range of motion including, but not limited to:-Immobilization;-Neurological conditions causing functional limitations;-Any condition where movement may result in pain, spasms or loss of movement; and,-Clinical conditions such as immobilized limbs or digits because of injury, fractures or surgical procedures including amputations. Based on the comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion.II. Resident #8A. Resident statusResident #8, age [AGE], was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included severe protein-calorie malnutrition, pressure ulcer of the sacral region, stage 4, congestive heart failure, dementia and generalized muscle weakness.The 4/30/26 minimum data set (MDS) assessment revealed Resident #8 was unable to complete the brief interview for mental status (BIMS). According to the staff assessment for mental status, the resident had short and long term memory problems and her cognitive skills for daily decision making were moderately impaired. The resident was dependent on staff assistance for most activities of daily living (ADL). The MDS assessment indicated the resident had impairment on one side of her upper extremities with no range of motion services. B. ObservationsOn 6/1/26 at 5:21 p.m. Resident #8 was observed to have a left hand contracture. She was unable to open her hand fully and she was unable to straighten her fingers. On 6/2/26 8:15 a.m., Resident #8 left hand was observed to be contracted and three of her fingers were curled closed. The resident was unable to open her hand fully. There was no hand splint in the resident's hand. C. Record reviewThe 12/26/24 occupational therapy and plan of treatment revealed no documentation to indicate Resident #8's left hand contracture was being addressed by therapy. The limited range of motion care plan, initiated 11/21/24, revealed Resident #8 had limited physical mobility related to dementia, encephalopathy, decreased mobility and weakness to the left side. Interventions included occupational therapy and physical therapy referrals as needed, monitoring/documenting/reporting as needed any signs or symptoms of immobility, such as contractures forming or worsening and thrombus formation and providing supportive care and assistance with mobility as needed.-However, the care plan did not indicate the resident was to receive passive range of motion assistance to prevent further contractures.The 4/23/26 nurse practitioner note revealed Resident #8 was transitioned to hospice for a comfort focus treatment plan and recommended the facility consider restorative care for passive range of motion (PROM) and palliative movement.The 5/1/26 nurse practitioner note recommended the facility consider restorative care for Resident #8 for PROM and palliative movement.-Review of Resident #8's Kardex (tool used to assist staff with providing consistent care of residents), as of 6/4/26, failed to reveal any documentation in regards to the resident's left hand contracture. -Review of the certified nurse aide (CNA) task section in Resident #8's electronic medical record (EMR) did not reveal any documentation related to providing range of motion to the resident's left hand. III. Staff interviews The director of rehabilitation was interviewed on 6/2/26 at 1:00 p.m. The director of rehabilitation said the facility did not have a restorative program. She said Resident #8 had not been on the therapy caseload since 2024.The director of nursing (DON) was interviewed on 6/3/26 at 11:01 a.m. The DON said if a resident had a contracture, the therapy department would be notified and a therapist would complete an evaluation to identify if a splint or range of motion program (ROM) was needed. She said Resident #8 was not receiving any range of motion services, however, physical therapy completed an evaluation on 6/2/26 for ROM exercises. The DON said the December 2024 occupational therapy notes did not indicate that therapy was assisting Resident #8 with her contracture.

Based on record review and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (#29) of three residents reviewed for accident hazards out of 51 sample residents.Specifically, the facility failed to ensure Resident #29, who was an elopement risk, was assessed timely and accurately for a wander guard (wearable tags/bracelets and door sensors that automatically alert staff or lock doors near a restricted exit).Findings include:I. Facility policy and procedureThe Elopements and Wandering Residents policy, dated 2025, was provided by the nursing home administrator (NHA) on 6/4/26 at 1:16 p.m. It read in pertinent part, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The facility is equipped with door locks/alarms to help avoid elopements. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly.II. Resident #29A. Resident statusResident #29, age greater than 65, was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included cognitive communication deficit, psychotic disorder with hallucinations due to known physiological conditions and major depressive disorder.The 3/25/26 minimum data set (MDS) assessment revealed the resident had both short and long term memory impairments and the resident's decision making skills were moderately impaired. The resident was independent with activities of daily living (ADL). The MDS assessment indicated that the resident had not exhibited wandering behavior, had no other behaviors, and that a wander/elopement alarm was not used.-However, staff interviews and record review (see below) revealed the resident had wandering behaviors and a wander guard was used.B. ObservationsOn 6/1/26 at 2:24 p.m. Resident #29 was observed in the hallway with a wander guard on his wrist. C. Record reviewResident #29's wandering care plan, revised 4/20/26, documented that due to wandering and exit seeking behavior and with approval of the resident's representative, the facility sought secure memory care placement for the resident's safety. Pertinent interventions, initiated 1/15/25 and revised 4/20/26 included that until potential discharge, Resident #29 continued to utilize a wander guard for safety.Resident #29's wandering/exit seeking care plan, revised 2/24/26, documented the resident presented with impaired cognitive function, confusion, impulsivity and poor safety awareness, as well as hallucinations, secondary to a diagnosis of dementia with psychotic features. Resident #29 had made statements that he was going to leave and was attempting to leave the building. The resident's photograph, description and face sheet had been placed in the facility's elopement binder and he also had a wander guard placed for safety.Pertinent interventions, revised 2/24/26, included to ensure that Resident #29 was safe by noting his location throughout the day; ensuring proper placement of the wander guard; and ensuring the wander guard was working appropriately, redirecting the resident from exits as needed and out of other residents' rooms as needed, and notifying the physician should wandering and/or exit seeking behaviors persist. The resident's photograph was placed in the elopement binder and the elopement binders were located at each nurses' station, the front desk and in the social services department.-However, a review of Resident #29's electronic medical record (EMR) revealed the resident did not have consent to have a wander guard placed until 3/14/26, a physician's order to ensure the wander guard was working properly was not placed until 5/27/26 (during the survey) and the resident was not evaluated for use of a wander guard until 5/30/26 (during the survey).A 3/14/26 nursing progress documented the facility contacted Resident #29's representative for consent of a wander guard. Education was provided and paperwork was read out loud to the resident's representative. The representative gave verbal consent to have Resident #29 on a wander guard and had no questions about the system.-However, Resident #29's care planned interventions, revised 2/24/26, documented to ensure proper placement of the resident's wander guard and to ensure the wander guard was working properly. There was no documentation that the resident had a wander guard or that it was working properly.A 3/15/26 fall risk assessment and elopement evaluation documented the resident had no falls in the last three months. The elopement evaluation documented the resident had not verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door. -However, a review of the Resident #29's progress notes documented the resident experienced a fall on 2/22/26. The resident's wandering/exit seeking care plan, revised 2/24/26 documented Resident #29 had made statements that he was going to leave and was now making attempts to leave the building.A review of Resident #29's May 2026 CPO documented a physician's order for a wander guard bracelet to be placed on the resident's left wrist (site selected by resident) for elopement risk and wandering behavior. The staff were to monitor the resident's skin under the bracelet for signs of skin breakdown and notify the physician if signs and symptoms of skin breakdown were present, ordered 5/27/26 (during the survey).-However the physician's order failed to include monitoring the placement and functionality of the wander guard bracelet.A 5/30/26 evaluation for restraint determination documented the evaluation was initiated and completed on 5/30/26 (during the survey). The evaluation revealed Resident #29 was assessed for a wander guard and documented that the wander guard ensured the resident did not wander out of the facility without staff, which put the resident at risk for harm. The evaluation additionally documented consent was completed, the care plan was updated and the order was received and entered from the provider.-However, Resident #29's representative had given consent for the wander guard to be placed on 3/14/26, over two months prior to the survey (see above) III. Staff interviewsThe NHA and the director of nursing (DON) were interviewed together on 6/1/26 at 2:37 p.m. The NHA said if a resident with a wander guard got close to the front door, and if the door was open, the door would alarm. The NHA said the alarms were very, very loud and you could hear each of the alarms down the hallways. The NHA said the facility had checked the wander guard system weekly and it was a scheduled task. The DON said the facility initially received consent from the resident's representative on 3/14/26 for the use of Resident #29's wander guard.The NHA said she thought it was possible the gap in the care plan (between the wander guard intervention being initiated and the placement of the wander guard) came from trying to get ahold of Resident #29's representative for consent. The NHA said it was social services staff member or nursing staff member who would call for consent for the wander guard.The NHA said Resident #29's wander guard order was entered into the resident's EMR on 5/27/26 and the facility had identified the order had not been entered when the wander guard bracelet had been applied during a recent audit. The NHA said the staff had started checking for the wander guard twice a day every shift and to monitor for skin breakdown. She said the facility had identified Resident #29 needed a wander guard regardless of the evaluation documenting he was at moderate risk for elopement.Certified nurse aide (CNA) #8 was interviewed on 6/1/26 at 2:06 p.m. CNA #8 said Resident #29 wandered all over the building all day long. CNA #8 said she thought the resident got the wander guard about six months ago.Licensed practical nurse (LPN) #5 was interviewed on 6/1/26 at 2:20 p.m. LPN #5 said Resident #29's wandering was frequent. LPN #5 said she thought the resident started on his wander guard in April 2026. LPN #5 said she thought the DON or the physician completed the resident assessments.CNA #9 was interviewed on 6/2/26 at 3:08 p.m. CNA #9 said it was fairly recently that Resident #29 got the wander guard bracelet but was not exactly sure when he got it. LPN #4 was interviewed on 6/2/26 at 4:58 p.m. LPN #4 said the staff did not have access to the wander guard tester and needed to ask the DON for it.

Based on observations, record review, and interviews, the facility failed to ensure respiratory care was provided in accordance with professional standards for one (#7) of two residents out of 51 sample residents. Specifically, the facility failed to ensure oxygen administered according to physician's orders for Resident #7.Findings include:I. Facility policy and procedureThe Oxygen Administration policy, revised 2026, was provided by the nursing home administrator (NHA) on 6/3/26 at 12:44 p.m. It read in pertinent part, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Oxygen is administered under orders of a physician, except in the case of an emergency. In such a case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control.II. Resident #7A. Resident statusResident #7, age greater than 65, was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD - a progressive, irreversible lung disease that restricts airflow, making it difficult to breathe), congestive heart failure and chronic respiratory failure.The 5/18/26 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. She was dependent on staff for most activities of daily living (ADL). She required substantial to maximal assistance for transfers.The assessment revealed the resident was receiving oxygen therapy.B. Resident observations and interviewsOn 6/2/26 4:31 PM., Resident #7 was lying in her bed with a nasal cannula in her nose. The resident's oxygen concentrator was set at 2.5 liters per minute (LPM).-However, according to the resident's care plan and physician's orders, the resident's oxygen flow rate was supposed to be 4 LPM (see record review below).Resident #7 said she had oxygen continuously. She said that at times, her oxygen was not on the correct LPM. She said that earlier in the day (on 6/2/26) she believed her oxygen was set too high as it had made her feel like electricity had been going through her body. She said her oxygen was normally set at three LPM.On 6/2/26 at 7:05 p.m. Registered nurse #2 (RN) observed that Resident #7's oxygen concentrator was set at 2.5 LPM. RN #2 said the resident's oxygen flow rate was not set according to the physician's order. Resident #2 asked the RN #2 what the physician's order was. RN #2 informed Resident #2 that the physician's order was for 4 LPM. The resident said she thought she was supposed to be on 3 LPM. RN #2 told the resident she would contact the physician to clarify what oxygen flow rate she should be receiving. C. Record reviewThe respiratory care plan for shortness of breath, initiated 3/4/26, revealed Resident #7 had shortness of breath related to COPD. Interventions included providing oxygen via nasal cannula at 4 LPM and monitoring/documenting/reporting breathing abnormalities to the physician.Review of Resident #7's June 2026 CPO revealed the following physician's orders:Apply oxygen via nasal cannula at 4 LPM every shift, ordered 5/27/26.-However, observations revealed the resident's oxygen was set to 2.5 LPM (see observations above). III. Staff interviewsRN #2 was interviewed on 6/2/26 at 7:03 p.m. RN #2 said Resident #7 was prescribed oxygen because of her COPD. She said according to the physician's order, the resident was supposed to be on 4 LPM. The director of nursing (DON) was interviewed on 6/3/26 at 11:01 a.m. The DON said she would generally expect residents' oxygen flow rates to be set to what the physician's order read. She said residents' oxygen flow rates could be 0.5 LPM more or less for special circumstances, but she said that should be documented in the resident's progress notes if it occurred.

Based on record review and interviews, the facility failed to ensure residents who required dialysis services received such services consistent with professional standards of practice for one resident (#1) reviewed for dialysis out of 51 sample residents. Specifically, the facility failed to:-Ensure thorough dialysis documentation was in place for Resident #1; and,-Consistently and thoroughly complete the dialysis communication forms between the facility and the dialysis center for Resident #1.Findings include:I. Facility policy and procedureThe Hemodialysis policy, dated 2025, was provided by the nursing home administrator (NHA) on 6/4/26 at 1:04 p.m. It read in pertinent part, The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The facility will coordinate and collaborate with the dialysis facility to assure that there is ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing home and dialysis staff. The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to:-Timely medication administration (initiated, held or discontinued) by the nursing home and/or dialysis facility;-Physician/treatment orders, laboratory values, and vital signs; and,-Nutritional/fluid management including documentation of weights, resident compliance with food/fluid restrictions or the provision of meals before, during and/or after dialysis and monitoring intake and output measurements as ordered.II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included acute kidney failure, dependence on renal dialysis (process to filter wastes from the body), and type 2 diabetes mellitus without complications.The 4/25/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. He was dependent on staff for toileting and eating. He required substantial to maximum assistance for oral hygiene.The MDS assessment indicated the resident received dialysis treatment. B. Record reviewReview of Resident #1's dialysis care plan, initiated 4/19/26, revealed the resident received dialysis related to anasarca (widespread swelling of the body caused by a buildup of fluid in the tissues). Interventions included encouraging the resident to go for the scheduled dialysis appointments, monitoring vital signs, notifying the medical director of significant abnormalities, and checking and changing the dressing daily at the access site. -However, the care plan did not include monitoring the resident's weights pre- and post-dialysis treatment. Review of Resident #1's May 2026 CPO revealed the following physician's orders related to dialysis:Obtain weight before dialysis every Monday, Wednesday, Friday and add in the electronic medical records (EMR) under weights, ordered 5/6/26.Obtain weight after dialysis in the evening every Monday, Wednesday, Friday and add in the EMR under weights, ordered 5/6/26.-However, the physician's orders were not entered into the resident's EMR until 5/6/26, even though the dialysis treatment started on 5/1/26 Resident #1's dialysis communication binder was provided by the assistant director of nursing (ADON) on 6/2/26 at 8:58 a.m. Review of Resident #1's dialysis communication forms in the binder revealed the following:-There were no dialysis communication forms for Resident #1's 5/4/26, 5/6/26, 5/8/26, 5/13/26, 5/15/26, 5/18/26 and 5/20/26 dialysis sessions. -The 5/1/26, 5/11/26, 5/13/26, 5/22/26 and 5/25/26 dialysis communication forms did not have the pre-dialysis section completed by facility staff.-The facility failed to complete the pre-dialysis section of the communication form for five dialysis sessions. Review of Resident #1's May 2026 treatment administration record (TAR) revealed pre- and post-dialysis weights were documented for Resident #1 on 5/8/26, 5/13/26, 5/15/26 and 5/20/26. -However, there was no documentation in the May 2026 TAR indicating pre- and post-dialysis weights were obtained for Resident #1 on 5/1/26, 5/4/26 and 5/6/26.III. Staff interviewsThe ADON was interviewed on 6/2/26 at 9:35 a.m. The ADON said staff were expected to obtain residents' vital signs and weights before the residents left for the dialysis center. She said staff should document the information in the dialysis communication form and send it to the dialysis center with the resident. The ADON said staff should obtain and document residents' weights and vital signs upon their return from the dialysis center. She said staff kept the dialysis communication forms in the binder. The ADON confirmed that a few of Resident #1's dialysis communication forms were not filled out properly. She said she was not aware of additional missing dialysis communication forms in the binder because she did not routinely work in the nursing unit.Licensed practical nurse (LPN) #4 was interviewed on 6/2/26 at 5:53 p.m. LPN #4 said staff should take the vital signs and weight before sending the residents out for dialysis. She said staff should document the information in the dialysis communication form and give it to the residents. LPN #4 said staff should check the vital signs and weights when the residents returned from the dialysis center. She said she never filled out a dialysis communication form for Resident #1 because she worked the night shift and never sent Resident #1 out for dialysis. LPN #4 said if a dialysis communication form was missing, she would contact the dialysis center and notify the director of nursing (DON). She said nurses should ensure dialysis communication forms were completed thoroughly before sending the residents out to the dialysis center.The DON was interviewed on 6/2/26 at 1:45 p.m. The DON said the nurses completed the dialysis communication forms and sent them with the residents to the dialysis center. She said the nurses reviewed the forms when the residents returned to the facility for any recommendations. The DON said she expected nurses to check Resident #1's vital signs and weights prior to sending the resident to the dialysis center and when the Resident #1 returned to the facility. She said the nurses should document weights pre- and post-dialysis in the EMR and the dialysis communication forms. The DON said Resident #1 was admitted on [DATE] and started his first dialysis session on 5/1/26. She said the dialysis center wanted the facility to call ahead to determine if Resident #1 needed a dialysis session or not. The DON said Resident #1 missed the dialysis session on 5/20/26 and he refused on 5/29/26. -The missing dialysis communication forms for Resident #2 were requested during the interview, however, the facility was unable to provide documentation of the forms at the time of the survey exit on 6/3/26.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to:-Ensure enhanced barrier precautions (EBP) were followed during high contact resident care areas for Resident #9, who had an indwelling urinary catheter and Resident #3, who had a tracheostomy (airway created through the neck); and, -Ensure Resident #83 and Resident #9's urinary catheter drainage bags and catheter tubing were not dragging on the ground.Findings include:I. Failure to ensure EBP were followed during high contact resident care areas for Resident #9 and Resident #3A. Facility policy and procedureThe EBP policy and procedure, no revision date, was received from the nursing home administrator (NHA) on 6/4/26 at 1:04 p.m. It documented in pertinent part, Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. An order for enhanced barrier precautions will be obtained for residents with any of the following: wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a multi-resistant drug organism (MDRO) or a resident with an infection or colonization with a center of disease control (CDC)-targeted MDRO when contact precautions do not otherwise apply. Personal protective equipment (PPE) for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. High-contact resident care activities include: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use and wound care.B. Observations During an interview with Resident #9 on 5/27/26 at 4:32 p.m., licensed practical nurse (LPN) #2 came into the resident's room to administer medication. After administering the medication. She donned (put on) clean gloves and drained the urine in Resident #9's catheter bag into a container. LPN #2 measured the urine and discarded it in the bathroom. -LPN #2 failed to don a gown prior to performing catheter care. During a medication administration observation on 6/1/26 at 11:30 a.m., LPN #2 was observed preparing medication to administer to Resident #3. LPN #2 gathered a nebulizer treatment and an insulin injection. LPN #2 went into Resident #3's room. LPN #2 donned clean gloves and administered the insulin. Respiratory therapist #1 came into the room to assist with setting up the nebulizer treatment. Respiratory therapist #1 donned sterile gloves and performed a suction treatment to Resident #3's tracheostomy before the nebulizer treatment. Respiratory therapist #1 then assisted LPN #2 with setting up the nebulizer treatment. LPN #2 administered the nebulizer treatment through Resident #3's tracheostomy oxygen tubing. -LPN #2 and respiratory therapist #1 failed to don a gown prior to administering treatments and suctioning the tracheostomy for Resident #3. II. Failure to ensure Resident #83 and Resident #9's urinary catheter bags and catheter tubing were not dragging on the groundA. Facility policy and procedureThe Infection Prevention and Control Program policy and procedure, no revision date, was received from the NHA on 6/4/26 at 1:04 p.m. It documented in pertinent part, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.B. Observations During an observation on 5/27/26 at 4:03 p.m., Resident #83 was lying in bed and her urinary catheter drainage bag was lying on the floor with the wheel of the bedside table on top of it. During an observation on 5/28/26 at 5:17 p.m., Resident #9 was wheeling himself around the hallways to the dining room and his urinary catheter tubing was dragging under the wheelchair on the ground. During an observation on 6/2/26 at 11:23 a.m., LPN #3 was notified that Resident #9 was sitting in his wheelchair moving around the hallways and his urinary catheter drainage bag was dragging on the ground. III. Staff interviewsRegistered nurse (RN) #3 was interviewed on 6/2/26 at 9:50 a.m. RN #3 said that a gown and gloves should be worn for any resident on EBP. RN #3 said this applied to any resident who had a wound, a Foley catheter, colostomy, tracheostomy or intravenous line. RN #3 said PPE should be worn by staff when they were completing any high contact care activity with residents on EBP. The pulmonary program coordinator was interviewed on 6/2/26 at 10:20 a.m. The pulmonary program coordinator said EBP should be used for any resident with an indwelling medical device. The pulmonary program coordinator said staff should be donning a gown and gloves any time a high contact care task was performed with a resident on EBP. The pulmonary program coordinator said this included suctioning a tracheostomy due to the potential for spread of infection. The infection preventionist was interviewed on 6/2/26 at 12:30 p.m. The infection preventionist said any resident with a wound or indwelling medical device should be placed on EBP. The infection preventionist said the PPE staff was required to wear included a gown and gloves any time a high contact care task was completed. The infection preventionist said the importance of utilizing EBP was to prevent the spread of infection and protect the staff and residents. The infection preventionist said catheter care and tracheostomy care required the use of EBP. The infection preventionist said that catheter tubing or the drainage bag should never be dragging on the ground because of the risk for infection. The director of nursing (DON), the NHA and the regional clinical resource were interviewed together on 6/2/26 at 3:00 p.m. The DON said a gown and gloves should be worn for residents on EBP for wounds and/or indwelling medical devices for high contact care areas. The DON said EBP should be used when emptying out a catheter and when administering breathing treatments and suctioning a tracheostomy. The DON said this was important for infection control measures. The DON said that urinary catheter drainage bags should be in a privacy bag and the bag and tubing should not be in contact with the ground.

Based on observations and interviews, the facility failed to post, in a form and manner accessible and understandable to residents, a list of names, addresses (mailing and email) and telephone numbers of all pertinent State Agencies and advocacy groups. Specifically, the facility failed to:-Ensure the required posting contained the correct phone number for the State Agency; and, -Ensure the required posting contained contact information for other pertinent state agencies and advocacy groups.Findings include:I. Facility policy and procedureThe Facility Required Postings policy and procedure, dated April 2025, was provided by the nursing home administrator (NHA) on 6/4/26 at 1:16 p.m. It revealed in pertinent part, The facility will post required postings in an area that is accessible to all staff and residents. Facility postings include the following: A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups to include but not limited to: State Survey Agency, State Licensure office, Adult Protective Services (where state law provides jurisdiction), office of the State of Long-Term Care Ombudsman, Protection and Advocacy Network, Home and Community Based Service Programs, Family and Medical Leave Act, Medicaid Fraud Control Unit, and applying for Medicare and Medicaid.II. Resident group interviewThe resident group interview was conducted on 6/1/26 at 10:49 a.m. with five residents (#31, #33, #55, #65 and #92) who routinely attended monthly resident council meetings and were deemed interviewable by the facility and assessment. The residents said they did not know how to file a complaint with the State Agency.Four of the residents said they only knew how to contact the ombudsman. III. ObservationsOn 6/1/26 at 11:22 a.m. there was a posting on how to file a complaint with the State Agency observed hanging on a bulletin board in a common area of the facility. The piece of paper contained the address, a phone number and an email address for the State Agency.-However, the phone number on the piece of paper was not the correct phone number for filing a complaint with the State Agency.-Additionally, the piece of paper failed to include a list of names for other pertinent state agencies and advocacy groups and their mailing addresses, email addresses and phone numbers.IV. Staff interviewsThe social services director (SSD) and the social services assistant were interviewed together on 6/2/26 at 2:11 p.m. The SSD reviewed the posting of the phone number and required posting. She confirmed the posting did not have the list of names, addresses (mailing and email) and telephone numbers of all pertinent state agencies and advocacy groups.

Based on record review and interviews, the facility failed to ensure residents, family members and legal representatives had full access to review the results of the facility's most recent survey findings that included the survey results, certifications, complaint investigations and plans of correction in effect for the preceding three years. Specifically, the facility failed to ensure residents, family members, and legal representatives had full access to review the facility's most recent survey findings for 2025, including recertifications, complaint investigations, and plans of correction.Findings include:I. Resident group interviewThe resident group interview was conducted on 6/1/26 at 10:49 a.m. with five residents (#31, #33, #55, #65 and #92) who routinely attended monthly resident council meetings and were deemed interviewable by facility and assessment. Three residents said they were not aware they could view the federal and state survey results. The residents said they were unaware that the results of the surveys were supposed to be posted for them to be able to access and read.II. Record reviewThe survey results binder was reviewed on 6/2/26 at 3:50 p.m. The last survey on file in the survey results binder was from 9/3/24.-The survey results binder did not contain any survey results from 2025 or any plans for corrections. -The folder did not hold the 2025 survey results from the complaint surveys which occurred on 1/22/25, 3/13/25, 6/26/25, 8/18/25 and 12/22/25. III. Staff interviewsThe nursing home administrator (NHA) was interviewed on 6/2/26 at 4:28 p.m. The NHA said she had the 2025 survey results on file; however, the documentation was in a different folder in her office and was unavailable to residents and family members.

III. Resident #1 A. Resident status Resident #1, age less than 65, was admitted on [DATE] and discharged home on [DATE]. According to the [DATE] CPO, diagnoses included multiple sclerosis (a disease that damages nerves and affects muscle control), muscle weakness and autistic disorder (developmental disorder). The [DATE] MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required substantial assistance with ADLs. The MDS assessment revealed the resident was going to stay at the facility for long term care. B. Resident #1's representative interview Resident #1's representative was interviewed on [DATE] at 10:30 a.m. The representative said Resident #1 discharged from the facility to home (on [DATE]). The representative said the facility did not set up any home health services for the resident when he was discharged home. She said there was no discharge planning and discussion of plans until a few days prior to discharge. The representative said while Resident #1 was at the facility, he spoke frequently about returning to his apartment, which he had. She said when he was living on his own, prior to living at the facility, he had a voucher for housing and he received home health services daily. She said for him to return to the community, a waiver for the Medicaid services needed to be completed. She said the facility failed to complete the waiver and did not start working on attempting to get the waiver completed until a few days prior to discharge. The representative said the resident disenrolled from hospice services that he was receiving at the facility so he could return to the community with the waiver. The representative said when Resident #1 was discharged to his apartment, the facility reassured them that there would be home health care starting the same day. She said when the home health services company contacted her, she was told the home health company would not be able to provide the services because the resident did not have a funding source. She said Resident #1 required two people a day to care for him, which included ADLs, meals and medications. She said she provided care to the resident for more than three days, giving care from the time he returned home until he was discharged again to another facility. C. Record review A review of the comprehensive care plan, initiated on [DATE], revealed there was not a care plan to address the resident's discharge goals and needs. The [DATE] social services evaluation revealed Resident #1 was unable to live independently due to physical limitations and it was anticipated that the resident was going to stay at the facility for long term care. The [DATE] progress note, documented by the NP, revealed Resident #1 had put a call out to the Physician Assisted Dying Program. The note documented that the resident was coordinating qualifications, criteria and initial evaluations through their services. The note documented the facility was coordinating with the DON so the resident understood he must discharge from the facility before proceeding with the program. The note also documented the staff needed to discuss logistics for how far along he needed to be in the program before discharge would be required. -However, review of Resident #1's EMR failed to reveal further documentation that the facility staff discussed the logistics of how far along he needed to be in the program. The [DATE] nursing progress note documented that the nurse, the NHA, the SSD and the hospice team completed a care conference with the resident and his friend regarding his discharge to his apartment. The [DATE] interdisciplinary team (IDT) note documented that Resident #1 frequently spoke about wanting to go home to live with his dogs. The meeting note revealed Resident #1 was dependent on staff for six out of six ADLs, required maximum two-person assistance or Hoyer lift transfers and was primarily bed-bound. The note revealed the resident wished to be discharged home. -The [DATE] IDT note did not include a plan addressing how extensive care needs would be met in the community or how services such as home and community-based services would be arranged. The [DATE] progress note documented nursing staff were informed Resident #1 would be discharged home that day and described the resident as alert and oriented, stable and refused to take his medications with him. It documented the nursing staff attempted to coordinate home health care and home and community-based services but confirmed the resident's waiver was inactive and the services could not be initiated on the day of discharge. It documented the resident and his representative still requested discharge and nursing staff and the NHA assisted the resident with packing, arranged final calls to coordinate services and ensured the resident left the facility with his belongings. The [DATE] discharge summary instructions revealed the facility had ongoing conversations with Resident #1 and the ombudsman about discharge to the community. -The [DATE] discharge summary did not include documentation of a complete plan or confirmation that needed supports were in place before discharge. The [DATE] IDT note revealed Resident #1 stopped hospice care in order to pursue discharge to the community with home health care. -The [DATE] IDT note did not include documentation of a completed plan addressing how necessary services, including home services would be arranged to meet the resident's high care needs after discharge. -A review of Resident #1's EMR did not reveal a documented plan for follow-up monitoring or contingency actions if planned services could not be started immediately. D. Staff interviews The SSD was interviewed on [DATE] at 11:36 a.m. The SSD said the facility's baseline care plan was completed within 24 hours of admission and care conferences occurred within 72 hours. She said discharge planning began on the first day of admission depending on whether the resident planned to remain long-term or return to the community. She said if the resident planned to return to the community then referrals were made for home health services and durable medical equipment. She said she called to confirm the receiving agencies could accommodate the resident's needs. She said confirmation was sometimes verbal and sometimes written. The SSD said that discharge planning was not always documented because staff became busy. The SSD was interviewed again on [DATE] at 2:04 p.m. The SSD said Resident #1 was admitted for long-term care on hospice services. The SSD said Resident #1 completed paperwork for the medical assistance in dying program in mid-[DATE] but stopped the process on [DATE] after the medical assistance in dying program notified him that he did not qualify. The SSD said a care conference was held on [DATE] with Resident #1, his representative, the SSD, the DON, the NHA and the hospice team to discuss discharge. The SSD said Resident #1 planned to return to his apartment with around the clock in-home care. The SSD said Resident #1 and his representative understood that he could not receive skilled home health and hospice services simultaneously. The SSD said hospice agreed to continue providing services, to order all needed durable medical equipment and medications for home use. The SSD said she spoke with Resident #1 and his representative on multiple occasions between [DATE] and [DATE] about discharge planning, safety concerns and the elderly blind and disabled waiver, which could not be activated until Resident #1 left the facility. The SSD said the uniform long-term care assessment was completed but the elderly blind and disabled waiver was not finalized. She said the case management agency was to meet Resident #1 at his apartment on [DATE]. The SSD said Resident #1 ultimately discharged on [DATE] but left the facility with no confirmed services in place, despite documentation indicating services would begin that day. The SSD said there was no formal discharge care plan documented for Resident #1, no documentation of IDT involvement at discharge, and no record showing Resident #1 or his representative was informed of the final discharge plan or offered the option to return if services were not in place. The SSD said the facility had identified this issue previously and did not implement a plan of correction due to scheduling conflicts but she said the facility would create a solid procedure moving forward. The DON was interviewed on [DATE] at 2:36 p.m. The DON said the IDT met daily to review pending discharges, needed services and medical equipment. She said social services sent referrals for services such as home health or medical equipment. She said once services were arranged, the resident picked a discharge date . She said nursing staff prepared the discharge summary, medication list and orders, reviewed these with the resident or representative and scanned signed copies into the record. The DON said the team tried to ensure home health services began within 24 hours after discharge. She said regarding Resident #1, the case management agency confirmed they would complete an assessment and start services on [DATE], but Medicaid was inactive and the waiver process could not be completed. The DON said Resident #1 insisted on discharging without services fully in place despite staff informing him of the risks. E. Facility follow-up On [DATE] at 9:52 a.m., the following documentation was received from the NHA: An email documented Resident #1 was seen for home health services on [DATE], [DATE] and [DATE]. He was then discharged to the hospital. -However, Resident #1 needed around the clock services to meet his needs (see record review above). Based on record review and interviews, the facility failed to ensure two (#5 and #1) of three residents were provided the care and services necessary to ensure a safe discharge from the facility to the community out of 13 sample residents. Resident #5 was initially admitted to the facility on [DATE] for long term care with diagnoses of complete C5-C7 (cervical vertebrae) quadriplegia (no movement of all four limbs), cervical fusion of spine, left ischium stage 4 pressure injury, unspecified convulsions, major depressive disorder, post-traumatic stress disorder (PTSD), and blood hypotension (low blood pressure). Resident #5 desired to discharge home with care and services. Resident #5 was dependent on staff for all activities of daily living (ADL). Upon discharge, the facility failed to provide the resident and his representative with information on taking his prescribed medications, which included two anti-seizure medications. Three days after discharge (on [DATE]), Resident #5 began having a seizure. Resident #5's representative said she initiated cardio-pulmonary resuscitation (CPR) and called emergency services (EMS). Resident #5 was transferred to the hospital. Additionally, the facility failed to ensure a thorough discharge plan was created and documented for Resident #1. Specifically, the facility failed to ensure Resident #5 and Resident #1 had a person-centered discharge plan that ensured the residents received the necessary care and services needed upon discharge from the facility. Findings include: I. Facility policy and procedure The Discharge Planning Process policy, revised 2025, was provided by the nursing home administrator (NHA) on [DATE] at 8:24 a.m. It read in pertinent part, Discharge planning is a process that generally begins on admission and involves identifying each resident's discharge goals and needs, developing and implementing interventions to address them, and continuously evaluating them throughout the resident's stay to ensure a successful discharge. The ongoing process of developing the discharge plan will include a regular re-evaluation of the resident to identify changes that require modification of the discharge plan, and updating of the discharge plan, as needed, to reflect the modifications. The facility will document any referrals to local contact agencies or other appropriate entities made for the purpose of the resident's interest in returning to the community. The facility will update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. The evaluation of the resident's discharge needs and discharge plan will be completely documented on a timely basis in the clinical record. II. Resident #5 A. Resident status Resident #5, age less than 65, was admitted on [DATE], readmitted on [DATE] and discharged home on [DATE]. According to [DATE] computerized physician orders (CPO), diagnoses included complete C5-C7 quadriplegia, cervical fusion of spine, left ischium stage 4 pressure injury, unspecified convulsions, major depressive disorder, post-traumatic stress disorder, and hypotension. The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required maximum assistance from two staff members using a Hoyer lift (mechanical lift) for repositioning and he was dependent on staff for all ADLs. The MDS assessment indicated there was an active discharge plan in place for the resident to return to the community. The MDS assessment indicated that there had been a referral made to the local contact agency. B. Resident #5's representative interview Resident #5's representative was interviewed on [DATE] at 1:30 p.m. The representative said Resident #5 had expressed a desire to come home since [DATE], but the facility had taken little action regarding it. She said the social services director (SSD) assured her that the resident would receive home services upon discharge, and these services would start on the day he came home. She said the facility had not completed the waiver services application, which was why there were no services. She said Resident #5 went home without a primary physician and they had to find one. Resident #5's representative said they received a bag of medication at discharge from the facility. She said they were not given a medication list or orders on when to take the medications. She said they were not provided any further discharge information. Resident #5's representative said that on [DATE], after Resident #5 discharged home, he had a seizure and stopped breathing. She said she performed CPR and called EMS. She said the resident was admitted to the hospital. She said this happened because they did not know the resident was supposed to take seizure medications. C. Record review The discharge care plan, dated [DATE], revealed Resident #5 desired to return to his home in the community. Pertinent interventions included encouraging the resident and caregiver to participate in discharge planning, meeting with the resident and caregiver to outline discharge goals and revising if needed with progression, providing discharge information and reconciling medications with the resident and caregiver prior to discharge. -The care plan had not been updated with the ongoing discharge process to outline the resident's needs at the time of discharge. The [DATE] social services progress note documented Resident #5 planned to discharge on Monday ([DATE]). The note documented the resident was denied by two home health agencies due to his advanced care needs. The [DATE] nurse practitioner (NP) discharge summary note documented the resident had multiple comorbidities requiring medication management that necessitated frequent clinical evaluations. The note documented that without regular monitoring and management, the resident was at moderate to high risk of symptom exacerbation and complications resulting in hospitalization or death. The note documented that the staff was unaware of any discharge plan. -However, Resident #5 discharged to the community on [DATE]. -Review of Resident #5's electronic medical record (EMR) did not reveal any further documentation regarding the resident's needs at time of discharge or the facility's attempt at setting up care and services for when Resident #5 discharged to the community. The [DATE] discharge summary instructions documented Resident #5 was discharged to home with family assistance. The special instructions were that the resident needed assistance in all areas of living 24 hours a day and seven days a week. The summary documented that home health was not ordered. The instructions revealed follow-up appointments and listed a physician's office (not a name) as the following physician. The discharge summary documented a verbal signature from the resident was received. -However, there was no phone number or address provided for the physician's office on the discharge summary instructions. -The discharge summary instructions did not indicate the resident needed wound care, what medications the resident was taking, catheter care plan, or instructions on what to do when seizures were present. The [DATE] hospital transcription report documented that Resident #5 was admitted to the emergency department (ED) for seizures. The note documented that day (/16/25), the resident said he had been out of his anti-seizure medications (carbamazepine and topiramate). The hospital staff gave this medication to him.The report documented the resident was recently discharged from a rehabilitation facility. The note documented Resident #5 said the facility staff did not tell him how or when to take his seizure medications when he was discharged from the facility. The resident said he was unsure if he had been taking the medications correctly. Review of Resident #5's [DATE] CPO revealed the following physician's orders: Carbamazepine (seizure medication) 200 milligrams (mg). Give two tablets by mouth three times a day, ordered [DATE]. Topiramate (medication used to treat seizure disorder) 25 mg. Give one tablet two times a day for convulsions treatment and prevention, ordered [DATE]. Eliquis (blood thinner) 5 mg. Give one tablet two times a day, ordered [DATE]. Wound care plan (suprapubic catheter, left lateral shin, and left ischium stage 4 pressure injury. Physical therapy. Magnetic resonance imaging (MRI ) of left ischium for suspected osteomyelitis. Psychiatric and psychological evaluations. D. Staff interviews The SSD and the social services director from another facility were interviewed together on [DATE] at 11:37 a.m. The SSD said the facility typically held a care conference when a resident decided they wanted to discharge from the facility. The SSD was interviewed a second time on [DATE] at 2:20 p.m. The SSD said after Resident #5 was admitted , he wanted to be transferred to a different city. The SSD said the facility sent referrals to other agencies and looked for wound care programs. The SSD said the resident was denied because of lack of services, the resident required advanced care or because the facility did not accept Medicaid. She said she confirmed the home health care would provide physical therapy, occupational therapy and nursing services to Resident #5 upon discharge. She said the home health agency could not visit daily to check his wounds. The SSD said due to the situation, Resident #5's representative received wound care training on [DATE]. The SSD said the facility arranged a physician along with the home health care services. The SSD said she did not receive confirmation that these services were in place prior to Resident #5 discharging. She said the resident's representative had an interest in becoming a certified nurse aide (CNA). The SSD said she did not do any follow up with the resident after he was discharged home. The SSD said the discharging nurse was responsible for reviewing the discharge summary and medications with the resident and his representative. The director of nursing (DON) and the assistant director of nursing (ADON) were interviewed together on [DATE] at 2:39 p.m. The DON said she reviewed Resident #5's EMR and confirmed there was no documentation in regards to his discharge. She said a discharge note should have been written by the discharging nurse. She said the note should document if medications were sent, prescriptions were sent and that the resident and representative were educated. She said a list of the medications and discharge summary instructions were to be sent with the resident and representative. She said there was no record that the forms were sent with Resident #5. The ADON said Resident #5's representative called the day after discharge as she had not received any discharge instructions or a list of medications. The ADON said she sent the list to the representative the next day, however, she did not document it and did not follow up with the representative. The DON confirmed Resident #5 had epilepsy and that he received medications to prevent seizures. She said she did not have any record of what medications were sent home with the resident. She said the social service department was responsible for setting up home health care services. E. Facility follow-up On [DATE] at 9:52 a.m., the following documentation was received from the NHA: A signed paper from the licensed nurse who completed the discharge with Resident #5. The signed paper, dated [DATE], documented the list of medications and instructions were reviewed with the resident. The medications, list of medications, facesheet and discharge summary were sent with the resident on [DATE]. -However, review of Resident #5's EMR did not reveal documentation indicating the nurse who discharged Resident #5 provided the resident or his representative with a list of medications or instructions on taking the medications (see record review above). A written statement, dated [DATE], documented the social services director from another facility was present during the discharge. The statement documented she observed Resident #5 and the resident's family member received the medication list, medications and the discharge summary. -However, review of Resident #5's EMR did not reveal documentation indicating the social services director from the other facility was present during the discharge, nor was there documentation to indicate that the resident received information regarding his medications at the time of discharge (see record review above).

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services and assistance for bathing for one (#6) of three residents reviewed for ADLs out of 13 sample residents. Specifically, the facility failed to provide Resident #6, who had cognitive impairments, incontinence care in a timely manner. Findings include: I. Facility policy and procedure The Incontinence policy and procedure, dated August 2024, was provided by the nursing home administrator (NHA) on 6/26/25 at 8:27 a.m. It revealed in pertinent part, Based on the resident's comprehensive assessment, all incontinent residents will receive appropriate treatment and services. II. Resident #6 A. Resident status Resident #6, age [AGE], admitted on [DATE]. According to the June 2025 computerized physician's orders (CPO), diagnoses included dementia, glaucoma (high eye pressure) and chronic kidney disease. The 6/10/25 minimum data set (MDS) assessment revealed the resident had memory impairment in making decisions regarding tasks of daily life, per the staff assessment for mental status. He required moderate assistance with oral care, personal hygiene, toileting, bathing, dressing and transferring. B. Observations During a continuous observation on 6/25/25, beginning at 2:01 p.m. and ending at 6:10 p.m., the following was observed: At 2:01 p.m. Resident #6 was napping in his wheelchair in the dining room. At 2:23 p.m. an unidentified certified nurse aide (CNA) attempted to wake Resident #6, but the resident continued to sleep. At 3:03 p.m. CNA #4 checked on Resident #6 by touching his head, but the resident did not wake up. At 3:34 p.m. an unidentified CNA tried to speak with Resident #6 and Resident #6 said he wanted to stay in his wheelchair in the dining room. At 4:11 p.m. CNA #1 assisted Resident #6 to his room. CNA #1 did not offer or provide incontinence care. At 4:35 p.m. CNA #1 and CNA #2 attempted to transfer Resident #6 from his wheelchair to his bed using a Hoyer lift. Resident #6 refused and said he wanted to remain in his wheelchair. Both CNA #1 and CNA #2 asked Resident #6 again if he wanted to be transferred to the bed to nap, but Resident #6 did not want to be transferred. CNA #1 said she would come back later. -The resident was not checked for incontinence or offered toileting assistance. At 5:01 p.m. CNA #1 checked on Resident #6 and asked if he needed anything, and Resident #6 said he did not need help. At 5:16 p.m. CNA #1 brought Resident #6's dinner tray and set it up for him while he remained in his wheelchair. At 6:33 p.m. after survey staff informed registered nurse (RN) #1, CNA #1 provided incontinence care for Resident #6. CNA #1 changed Resident #6's brief, which was observed to be soiled and saturated. -Resident #6 was not provided incontinence for over four and a half hours. C. Record review The ADL care plan, revised 3/1/25, documented Resident #6 had bowel and bladder incontinence related to poor sphincter control, minimal mobility and progression of dementia. Pertinent interventions included checking Resident #6 every two hours and assisting with toileting as needed, observing the pattern of incontinence and initiating a toileting schedule if indicated. According to the CNA task documentation for bladder incontinence, Resident #6 received incontinence care on 5/25/25 at 2:03 p.m. -However, a continuous observation of the resident conducted at that same time revealed the resident was in the dining room napping (see observations above). III. Staff interviews RN #1 was interviewed on 6/25/25 at 6:15 p.m. She said the staff were expected to offer and provide incontinence care for Resident #6 every two hours because he was incontinent of bladder and bowel. She said Resident #6 was also at risk for pressure injury if he was not changed every two hours. CNA #3 was interviewed on 6/26/25 at 12:30 p.m. CNA #3 said Resident #6 becomes combative when incontinence care was provided and fights the staff. CNA #3 said the staff used two people to change Resident #5 because he kicked and punched the staff. The director of nursing (DON) was interviewed on 6/26/25 at 2:36 p.m. The DON said all residents who were incontinent must be provided with incontinence care every two hours and staff should check if the resident was soiled. The DON said if a resident refused care, the staff should check again in 15 to 20 minutes and address refusals as best they could.

Based on observations, record review and interviews, the facility failed to provide an ongoing program to support residents in their choice activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two (#1 and #6) of three residents reviewed for activities programming out of 10 sample residents. Specifically the facility failed to: -Offer and provide personalized activity programs for Resident #1 and Resident #6 as documented in their care plans; -Ensure Resident #1 and Resident #6 were invited and encouraged to attend activities of their preference; and, -Ensure Resident #6 was meaningfully engaged during activities. Findings include: I. Resident #1 A. Resident status Resident #1, age less than 65, was admitted on [DATE] and discharged on 5/28/25 to the community. According to the May 2025 computerized physician orders (CPO), diagnoses included multiple sclerosis (a disease that damages nerves and affects muscle control), muscle weakness and autistic disorder. The 3/31/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment revealed it was very important for the resident to have books, newspapers, and magazines to read, be around animals such as pets, engage in favorite activities, go outside to get fresh air when the weather was good, participate in religious services or practices, and somewhat important to the resident to listen to music. B. Resident representative interview Resident #1's representative was interviewed on 6/25/25 at p.m. The representative said Resident #1 had complained about not having anything to do. She said the resident was not invited to the activities. The representative said Resident #1 always enjoyed going outside, however he was not assisted outside by the staff. C. Record review The activities care plan, initiated 3/24/25 and revised 6/5/25, identified that Resident #1 enjoyed writing books, listening to music, had published nine books and four recorded albums, enjoyed pet visits, being creative, computer time, and outside time when the weather was nice and he needed materials for in-room use as desired. He needed reminders and encouragement to attend group activities he may enjoy, and he had a strong spiritual faith which was important to him. Interventions included assisting and encouraging Resident #1 in meeting other peers who may share similar interests, inviting, assisting, and encouraging Resident #1 to attend group activities he may enjoy or be interested in, honor his wishes to decline activities as he chose, providing Resident #1 with a monthly activities calendar and providing Resident #1 with materials for in-room use as desired. The activity participation log, reviewed from 4/30/25 to 5/31/25, revealed Resident #1 had not received opportunities to spend time outside, have pet visits, or participate in spiritual faith activities. II. Resident #6 A. Resident status Resident #6, age [AGE], was admitted on [DATE]. According to the June 2025 CPO, diagnoses included dementia, glaucoma and chronic kidney disease. The 6/10/25 MDS assessment revealed the resident had memory impairment in making decisions regarding tasks of daily life, per the staff assessment for mental status. He required moderate assistance with activities of daily living (ADL). The 9/8/24 MDS assessment revealed, per staff assessment, the resident enjoyed listening to music and keeping up with the news. B. Resident representative interview Resident #6's representative was interviewed on 6/26/25 at 10:25 a.m. The representative said staff tended to leave Resident #6 in his room without much interaction or engagement. The representative said he lived out of state and visited Resident #6 once every few months. The representative said he often saw Resident #6 sitting in his wheelchair without much engagement or participation and said that in the past, Resident #6 had been much more engaged compared to now. The representative said Resident #6 enjoyed listening to music, listening to the news, and interacting with other residents and staff. C. Observations On 6/25/25 during a continuous observation, beginning at 2:01 p.m. and ending at 5:16 p.m., the following was observed: At 2:01 p.m. Resident #6 was napping in his wheelchair in the dining room where a karaoke activity was taking place. At 2:23 p.m. an unidentified certified nurse aide (CNA) attempted to wake Resident #6, but the resident continued to sleep. At 3:03 p.m. CNA #1 checked on Resident #6 by touching his head, but the resident did not wake up. At 3:34 p.m., once the karaoke activity was over, an unidentified staff member spoke to Resident #6, and Resident #6 said he wanted to stay in his wheelchair in the dining room. -The unidentified staff member did not offer the resident any meaningful engagement or purposeful activity. At 4:11 p.m. Resident #6 was taken to his room. A compact disc (CD) player was on the resident's nightstand; however, it was not playing any music and CNA #1 did not offer to turn it on for him. Resident #6's roommate's television was turned on with no other stimulation in the room for Resident #6. At 4:35 p.m. CNA #1 and CNA #2 attempted to transfer Resident #6 from his wheelchair to his bed using a Hoyer lift (mechanical lift) so he could nap, but Resident #6 refused and said he wanted to remain in his wheelchair. Both CNA #1 and #2 asked Resident #6 again if he wanted to be transferred to the bed to nap, but Resident #6 did not want to be transferred. CNA #1 said she would come back later. -The CNAs did not offer other engagement, social interaction, or activities to provide stimulation or meet his psychosocial needs. At 5:01 p.m. CNA #1 checked on Resident #6 and asked if he needed anything, and Resident #6 said he did not need help. -CNA #1 did not offer Resident #6 any meaningful interaction or opportunities for engagement. At 5:16 p.m. CNA #1 brought Resident #6's dinner tray to his room and set it up for him while he remained in his wheelchair. On 6/26/25 the following was observed: At 8:41 a.m. Resident #6 was in his room in his wheelchair listening to his roommate's television without any other stimulation. At 9:34 a.m., Resident #6 was lying in his bed sleeping, with no stimulation or interaction offered. There was no music playing in the resident's room. At 9:52 a.m., CNA #3 offered Resident #6 water, but she did not provide additional engagement or meaningful activity. At 10:00 a.m., an activity of news and coffee was taking place in the dining room; however, Resident #6 was not invited to the activity and remained in his room sleeping. At 11:14 a.m., Resident #6 was observed still in bed sleeping. There was no music playing in the resident's room. At 11:58 a.m., Resident #6 remained in bed sleeping. -Throughout the observations on 6/25/25 and 6/26/25, staff did not offer activities connected to Resident #6's known interests, such as keeping up with the news, listening to music, coffee time, hand massage, religious reading, or short stories. D. Record review The activities care plan, revised 12/6/24, identified that Resident #6 liked keeping up with the news. Resident #6's favorite activities included listening to music, including soul music, rock, Motown, and jazz and he loved music, day and night. Resident #6 had a CD player that he listened to regularly. Resident #6 declined invitations to attend group programs and preferred resting, keeping to himself, and coffee time. Resident #6 enjoyed hand massages, religious reading time, and short stories. Resident #6 was blind and required assistance due to vision deficiency. Pertinent interventions included cueing and reminders for activities. Staff would provide one-on-one visits with Resident #6 and offer social visits, music time, coffee time, and activities he might enjoy. Staff would remind Resident #6 when Bible study, music entertainers, resident socials, and religious services were offered and escort him to the activity if he wished to attend. III. Staff interviews The activities director (AD) was interviewed on 6/26/25 at 3:43 p.m. The AD said that upon admission, residents were asked about their activity preferences and were provided with an activity calendar to keep in their rooms. The AD said staff were expected to inform residents daily about planned activities and offer reminders. The AD said that staff often learned residents' preferences over time but said some residents, including Resident #6, may not always be offered invitations or reminders to join group activities. The AD said Resident #6 enjoyed listening to music and owned a CD player. She said the CNAs may need reminders to assist with playing music for him, despite this being part of his care plan. The AD said CNAs likely needed re-education to ensure residents were consistently invited to activities and received meaningful engagement according to their care plans and preferences.

Based on observations, record review and interviews, the facility failed to provide food and drinks that accommodated resident allergies, intolerances and preferences for one (#4) of four residents out of 13 sample residents. Specifically, the facility failed to ensure Resident #4 was provided a vegetarian diet per her preference. Findings include: I. Facility policy and procedure The Resident Food Preferences, revised July 2017, was received from the nursing home administrator (NHA) on 6/26/25 at 5:23 p.m. The policy read in pertinent part, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Nursing staff will document the resident's food and eating preference in the careplan. II. Resident #4 A. Resident status Resident #4, age [AGE], was initially admitted on [DATE] and readmitted on [DATE]. According to the June 2025 computerized physician orders (CPO) diagnoses included multiple sclerosis (disease that affects the nerves), dementia and shortness of breath. According to the 5/5/25 minimum data set (MDS) the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. The resident was independent in eating. B. Resident interview Resident #4 was interviewed on 6/25/25 at 12:15 p.m. Resident #4 said she was a vegetarian. She said at lunch today (6/25/25) she was served a pork chop. She said another resident told her that there was fish on the menu. She said she was not offered a vegetarian diet while residing at the facility. She said that her food choices were repetitive. Resident #4 was interviewed a second time on 6/25/25 at 5:04 p.m. Resident #4 said she received a grilled cheese sandwich, corn and refried beans for dinner tonight (6/25/25). She said she also received chocolate cake and she could not have chocolate cake because she had a colonoscopy procedure years ago and the doctor had told her to avoid it. C. Observations On 6/25/25 at 5:04 p.m. the resident had a piece of marble cake which had chocolate. D. Record review The June 2025 CPO revealed a physician's order indicating the resident was prescribed a vegetarian diet. The resident's meal ticket indicated the resident was prescribed a vegetarian diet. The care plan, revised on 5/5/25, identified the resident had a risk for inability to maintain nutrition due to hypertension (high blood pressure), falls, cerebral ischemia (stroke), dementia, epilepsy (seizure disorder) and vitamin D deficiency. Pertinent interventions included providing the resident's prescribed diet as ordered. -However, the care plan failed to identify that the resident preferred to eat a vegetarian diet and was unable to eat chocolate cake. The dietary manager provided a paper which was titled Resident #4's menu. The paper read -Soup: tomato and vegetable with crackers; -Rice; -Fish; -Poatoes: fried, baked mashed; and, -Chef Salad (no meat). III. Staff interviews The registered dietitian (RD) and the dietary manager (DM) were interviewed together on 6/26/25 at 1:39 p.m. The RD said the facility did have a menu extension for vegetarian diet, however, it was not utilized. The DM said she had met with the resident a year ago and reviewed her preferences and had developed the menu based on her preferences. She said the resident would tell the kitchen what she wanted to eat, but did not use a specific vegetarian spread sheet extension. The RD said she had learned a few weeks ago that Resident #4 did not want to have chocolate. She confirmed the marble cake on the menu had chocolate.

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 disease. Specifically, the facility failed to ensure: -A clean location was provided for wound care supplies; and, -Enhanced barrier precautions (EBP) and proper hand hygiene were followed for wound care activities. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC), Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDRO)'s, (4/2/24), retrieved on 4/23/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ target gown and glove use during high contact resident activities. EBP may be indicated (when contact precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO (multidrug resistant organism) colonization status and infection or colonization with an MDRO. Examples of high contact resident care activities requiring gown and glove use for EBP include: dressing, bathing/showering, transferring, providing hygiene changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheotomy/ventilator), wound care (any skin opening requiring a dressing). According to the CDC Clinical Safety, Hand Hygiene for Healthcare Worker (2/17/24), retrieved on 4/23/25 from https://www.cdc.gov/clean-hands/hcp/clinical-safety, Know when to clean your hands: immediately before touching a patient, before performing an aseptic task such as placing an indwelling device or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or patient's surroundings, after contact with blood, body fluids or contaminated surfaces and immediately after glove removal. II. Facility policy and procedures The Clean Dressing Change policy, revised 4/21/25, was provided by the nursing home administrator (NHA) on 4/21/25 at 5:05 p.m. It read in pertinent part, Set up clean field on the overbed table with needed supplies for wound cleaning and dressing application. If the table is soiled, wipe clean. Place a disposable cloth or linen saver on the overbed table. Establish area for soiled products to be placed. Wash hands and put on clean gloves. Place a barrier cloth or pad next to the resident, under the wound to protect the bed linen and other body sites. Loosen the tape and remove the existing dressing. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. Wash hands and put on gloves. Cleanse the wound as ordered, taking care not to contaminate other skin surfaces or other surfaces of the wound. Pat dry with gauze. Wash hands and put on clean gloves. Apply topical ointments or creams and dress the wound as ordered. Secure dressing. [NAME] with initials and date. Discard disposable items and gloves into appropriate trash receptacle and wash hands. The Enhanced Barrier Precautions policy, undated, was provided by the NHA on 4/21/25 at 5:05 p.m. The policy read in pertinent part, Enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions. High contact resident activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use and wound care. III. Observations During an observation of Resident #9's wound care on 4/21/25 at 10:45 a.m., the following was observed: Certified nurse aide (CNA) #2 and CNA #3 donned (put on) gloves and assisted licensed practical nurse (LPN) #2 with repositioning Resident #9 on his side to replace a wound dressing which had fallen off the sacrum (base of spine). -However, CNA #2 and CNA #3 failed to don a gown prior to high contact care for Resident #9. During the dressing change, CNA #2 left Resident #9's bedside, took the resident's roommate's water pitcher out of the room and filled it, assisted the roommate to drink water and then returned to Resident #9 during wound care. -However, CNA #2 did not change her gloves or use hand hygiene after she provided water to the roommate. LPN #2 cleaned Resident #9's wounds and applied a new wound dressing to the sacrum and left ischium (near hip joint), and the upper shin of the left leg. LPN #2 changed her gloves four times during wound care, after wounds were cleaned and prior to application of the new dressings. -However, LPN #2 did not use hand hygiene after she removed her gloves and before applying new gloves. During an observation of Resident #3's wound care on 4/21/25 at 12:55 p.m., the following was observed: LPN #3 placed dressing change supplies on Resident #3's bedside table. -However, LPN #3 did not clean the table and create an area on the table for the wound care supplies. The supplies were placed next to a peanut butter jar and cereal bowl on the table, amongst several other personal items of Resident #3. Resident #3's wound dressing had been removed prior to wound care, as it was soiled. LPN #3 donned a gown and gloves for Resident #3's left ischium wound care. She cleaned the wound and reapplied a dressing to the wound. -However, LPN #3 did not change her gloves or perform hand hygiene throughout Resident #3's wound care, specifically when she removed several soiled four by four inch gauzes which had been used to clean the wound. During an observation of Resident #8's wound care on 4/21/25 at 1:45 p.m., the following was observed: CNA #5 donned gloves and assisted the infection preventionist (IP) with repositioning Resident #8 onto her side. -However, CNA #5 failed to don a gown prior to high contact care for Resident #8. CNA #6 later entered the room to assist during the dressing change. CNA #6 donned gloves. -However, CNA #6 failed to don a gown prior to high contact care for Resident #8. IV. Staff interviews LPN #2 was interviewed on 4/21/25 at 12:23 p.m. LPN #2 said she changed her gloves each time after cleaning wounds and prior to applying clean dressings. LPN #2 said she changed her gloves four times during Resident #9's wound care and should have used hand hygiene when she changed her gloves each time. She said there was no hand sanitizer in the room. She said there was a sink in the room, but sometimes there were no paper towels to dry her hands. She said those were not sufficient reasons to not perform hand hygiene. LPN #2 said the use of hand hygiene would help to prevent infection. The director of nursing (DON) and the clinical resource (CR) were interviewed together on 4/21/25 at 5:16 p.m. The DON said the CNAs should have donned gowns when they repositioned residents with wounds and during wound care. The DON said a clean area for wound care supplies should be provided and the nurse should not have placed Resident #3's dressing supplies on the soiled bedside table mixed in with Resident #3's personal food items. The DON and the CR both said the nurses should have changed gloves and used hand hygiene each time they transitioned between dirty and clean, such as after cleaning the wounds. The treatment nurse (TN) was interviewed on 4/22/25 at 4:58 p.m. The TN said a gown should be worn for all wound care. The TN said she had provided education to the CNA staff which included the need to wear gowns during wound care. The TN said gloves should be changed and hand hygiene performed after touching soiled dressings and after cleaning wounds.

Based on record review and interviews, the facility failed to ensure one (#3) of three residents were free from abuse out of seven sample residents. Specifically, the facility failed to protect Resident #3 from physical abuse by Resident #2. Findings include: I. Facility policy and procedure The Abuse, Neglect, and Exploitation policy, revised 1/5/25, was provided by the director of nursing (DON) on 3/13/25. It read in pertinent part, The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. II. Facility investigations A. Incident of physical abuse by Resident #2 towards Resident #3 on 2/8/25 The facility's investigation documented an incident occurred on 2/8/25 between Resident #2 and Resident #3. Another resident reported to the staff that Resident #2 had pulled Resident #3's hair in the lunchroom. It was not determined the reason Resident #2 pulled Resident #3's hair. Resident #3 denied feeling unsafe and Resident #2 denied recollection of the event. Resident #2 was put on one-on-one supervision. Through the facility's investigation, they were unable to find any witnesses, as the reporting resident later stated she was not sure what she had seen. The facility unsubstantiated the abuse due to no injuries occurring and no intent to harm. The facility was unable to determine the reason the abuse occurred due to Resident #2 stating she had no recollection of her behavior or the event. B. Incident of physical abuse by Resident #2 towards Resident #3 on 2/19/25 The facility's investigation documented an incident occurred on 2/19/25 between Resident #2 and Resident #3. Resident #2 and Resident #3 were in the lunchroom in line to get coffee. Resident #3 reported to the staff that Resident #2 had cut in front of him in line and he asked her to move. Resident #2 then turned around and splashed her coffee in his direction and it hit him in the face. Resident #3 denied feeling unsafe and Resident #2 denied recollection of the event. Resident #2 was put on one-on-one supervision. Through the facility's investigation, they were unable to find any witnesses and Resident #2 could not recall the event. The facility unsubstantiated the abuse due to no injuries occurring and no intent to harm. The abuse occurred as a result of Resident #3 verbalizing displeasure to Resident #2's cutting in line and Resident #2's reaction to his verbalization of displeasure. III. Resident #3 (victim) A. Resident status Resident #3, age less than 65, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included anxiety, depression, traumatic brain injury and stroke. The 1/24/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of eight out of 15. He required staff supervision with bathing, bed mobility, dressing, eating, toileting and transfers. The resident used a wheelchair for ambulation. B. Resident interview Resident #3 was interviewed on 3/13/25 at 2:45 p.m. Resident #3 said he did not remember the incidents with Resident #2. C. Record review Resident #3's trauma care plan, initiated 2/24/25, revealed the resident had been involved in two resident-to-resident altercations with the same resident, where Resident #3 was the victim. Interventions included encouraging Resident #3 to either move away from that resident's (Resident #2) vicinity or to notify staff to redirect the resident away from the vicinity, providing the resident with validation when he was emotionally distressed, providing active listening and notifying social services and the resident's psychologist of emotional distress. The change of condition nursing note, dated 2/8/25, revealed Resident #3 was involved in a resident-to-resident incident. Neurological checks, skin checks and vital signs were all within normal range. The physician was notified of the incident. The change of condition nursing note, dated 2/19/25, revealed Resident #3 was involved in a resident-to-resident incident. Neurological checks, skin checks and vital signs were all within normal range. The physician was notified of the incident. The alert note, dated 2/19/25, revealed Resident #3 reported to staff there was no precepting reason for the incident. Resident #3 wanted to file a police report and denied injuries or feeling unsafe. IV. Resident #2 (assailant) A. Resident status Resident #2, age less than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included neoplasm of cerebellum (brain tumor), unspecified psychosis and a delusional disorder. The 1/20/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of two out of 15. She was independent in her bathing, eating, toileting, dressing and transferring. The resident used a wheelchair for ambulation. The MDS assessment indicated she had delusions and had physical and verbal aggressive behaviors directed towards others. B. Resident interview Resident #2 was interviewed on 3/12/25 at 2:09 p.m. Resident #2 said there was a horrible man in a white shirt (Resident #3) that ran his wheelchair over her foot because she was taking too long to fix her coffee in the dining room. Resident #2 said because of this, she splashed her cold cup of coffee in his face. Resident #2 said on another occasion, she pulled Resident 3's hair because she believed he wanted to rape and murder her. C. Record review Resident #2's behavior care plan, initiated 2/24/25, revealed the resident displayed fluctuations in cognition due to a mental illness and a brain tumor. She presented with episodes of delusional thinking and paranoia causing her to display verbal and physical aggression. She had been involved in multiple incidents. Interventions included one-on-one monitoring, providing psychological support, redirection and validating her feelings. Additional interventions included providing the resident space alone, music and conversations regarding her favorite topics (sports such as soccer) could be used as redirection. V. Staff interviews The regional clinical consultant (RCC) and the DON were interviewed together on 3/13/25 at 10:35 a.m. The DON said she had done one-on-one verbal training with the staff on person-centered approaches for Resident #2 but she did not document the training. The DON said Resident #2 had deteriorated due to her brain tumor and had refused to take medications or attend oncology appointments. The DON said during Resident #2's last hospital stay, a palliative assessment was recommended. The DON said she did not know the status of the palliative assessment. The DON said the current interventions for Resident #2 included a one-on-one staff member outside of her room and to explore options on how to implement a guardian for Resident #2 to assist with decision making. The DON said Resident #2 had behaviors of self-isolation, refusals of care and aggression. She said the resident had displayed physical and verbal aggression towards the nurses and the certified nurse aides (CNA), which included pushing, kicking, hitting and threats. The DON said Resident #2 suffered from delusions that consisted of the other residents wanting to rape and murder her. The DON said due to the inconsistency of Resident #2's cognition, creating an intervention to address the resident's behavior had been challenging. The DON said the facility implemented a one-on-one caregiver to sit outside of Resident #2's room from 2/8/25 to 2/11/25. She said after the second incident on 2/19/25, the one-on-one caregiver was restarted. The DON said Resident #2's behaviors of delusions and aggression should be monitored in the treatment administration record (TAR) or in the progress notes. She said the behavior monitoring should include non-pharmological interventions and effectiveness of interventions. The DON was unaware Resident #2 did not have an order for behavior monitoring. CNA #2 was interviewed on 3/13/25 at 12:01 p.m. CNA #2 said today (3/13/25) was her first shift as the one-on-one caregiver for Resident #2. She said she helped Resident #2 with her meals and monitored her behaviors when she left her room. CNA #2 said Resident #2 required a one-on-one caregiver because she had displayed physical aggression towards other residents. CNA #2 said she did not know if Resident #2 had altercations with staff. CNA #2 said the management did not tell her what the resident's triggers were. She said she knew she was supposed to de-escalate Resident #2, but she had not been trained on how to de-escalate Resident #2 specifically, only general training for all residents. CNA #1 was interviewed on 3/13/25 at 12:15 p.m. CNA #1 said she had only worked on Resident #2's hallway for four days and did not know her very well. She said she was given information on Resident #2's behaviors from the other CNAs, not from management. CNA #1 said she was was told by other CNAs that Resident #2 had behaviors of yelling out and wandering. CNA #1 said she did not know the resident's behavior triggers, diagnoses, or past incidents with staff and other residents. The social services assistant (SSA) and the social services director (SSD) were interviewed together on 3/13/25 at 1:15 p.m. The SSD said she worked at a sister facility and was working in the facility to assist the SSA until a permanent SSD was hired. The SSA said regarding Resident #2's behaviors, her role was to conduct investigations and provide psychosocial support to residents. Licensed practical nurse (LPN) #1 was interviewed on 3/13/25 at 2:30 p.m. LPN #1 said Resident #2 had behaviors of refusing care, refusing medications, and verbal and physical aggression towards staff and other residents. LPN #1 said the interventions the staff used with her were to leave her alone and give her space when she was agitated. LPN #1 said the nurses documented her behaviors on the TAR according to the behavior tracking order on the March 2025 CPO. LPN #1 said she was able to locate the behavior tracking order for Resident #2's verbally and physically aggressive behaviors and she initiated it on 3/12/25 (during the survey).

Based on observations, record review and interviews, the facility failed to ensure interventions were carried out or offered to prevent pressure injury from occurring for two (#8 and #9) of five residents reviewed for pressure injuries out of 15 sample residents. Resident #8, was admitted on [DATE] for long term care. The resident was admitted without a pressure injury to the right heel. The resident was at risk for developing pressure injuries. The facility failed to proactively implement treatment interventions to prevent the resident from developing a deep tissue pressure injury to her right heel on 11/1/23 that was staged as stage 3 on 11/28/23. No treatment orders or physician orders were in place to promote prevention and active healing of the pressure injury. The care plan was not updated with a focus, goals and interventions to specifically address the facility acquired pressure injury. Observations revealed the resident was not offered pressure relieving boot to her right heel. Additionally, Resident #9 was at high risk for pressure injuries when admitted to the facility on [DATE]. The facility failed to implement preventative measures despite the resident's known risk. The resident developed a facility acquired unstageable wound on 4/4/23, 15 days after her admission. The wound progressed to a stage 3 pressure injury on 6/16/23. Findings include: I. Professional reference The National Pressure Injury Advisory Panel, https://npiap.com/page/PressureInjuryStages accessed on 12/8/23 read in pertinent part: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Steps to prevent the emergence of pressure ulcers in individuals identified as being at high risk include scheduled repositioning to avoid individuals being in a position that places pressure on a vulnerable area for a long period of time. The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing: -Positioning that places pressure on the pressure ulcer should be avoided. -The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented. -The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications. -Signs of deterioration in the wound should be addressed immediately. -The assessment should include: location, category/stage, size, tissue type, color, periwound (skin around the wound) condition, wound edges, exudate, undermining/tunneling, order. II. Facility policy and procedure The Pressure Injury Prevention and Management policy, not dated, was provided by the nursing home administrator (NHA) on 12/6/23. It read in pertinent part: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries.The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: Redistribute pressure (such as repositioning, protecting and/or offloading heels); Minimize exposure to moisture and keep skin clean, especially of fecal contamination; Provide appropriate, pressure-redistributing, support surfaces; Provide non-irritating surfaces; and - Maintain or improve nutrition and hydration status, where feasible.Any changes to the facility's pressure injury prevention and management processes will be communicated to relevant staff in a timely manner. Interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications include: Changes in resident's degree of risk for developing a pressure injury. New onset or recurrent pressure injury development. Lack of progression towards healing. Resident non-compliance. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights. III. Resident #8 A. Resident status Resident #8, above the age of 65, was admitted on [DATE]. According to the December 2023 computerized physician orders (CPO), diagnoses included malignant neoplasm (cancer) of an unspecified part of an unspecified bronchus or lung, chronic respiratory failure, unspecified whether with hypoxia (inadequate oxygen delivery to the tissues either due to low blood supply or low oxygen content in the blood ) or hypercapnia (too much CO2 in the blood), secondary malignant neoplasm of retroperitoneum (an anatomical space located behind the abdominal or peritoneal cavity) and peritoneum (continuous transparent membrane which lines the abdominal cavity and covers the abdominal organs), extended spectrum beta lactamase resistance ( enzymes that confer resistance to most beta-lactam antibiotics, including penicillins, cephalosporins, and the monobactam aztreonam. Infections with ESBL-producing organisms have been associated with poor outcomes.), repeated falls, polyneuropathy (multiple peripheral nerves become damaged), unspecified protein calorie malnutrition, type II diabetes mellitus with hyperglycemia and essential primary hypertension. The 9/18/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She required extensive assistance with bed mobility, dressing and personal hygiene and limited assistance with toilet use. The resident did not have any pressure injuries or skin conditions coded on the assessment. B. Observations On 12/5/23 Resident #8 was observed continuously from 11:59 a.m. until 12:23 p.m. Resident #8 was sitting in her wheelchair without her heel pressure relief boot on. The pressure relief boot was on the resident's table covered with clothes. A dressing was on the resident's right heel. The resident's heel was resting directly on the wheelchair's foot pedal. A certified nurse aide (CNA) entered the resident's room, however, the heel pressure relief boot was not offered and foot elevation was not offered. The resident's mattress was a standard mattress and not an air mattress. On 12/6/23 Resident #8 was observed continuously from 10:35 a.m. until 11:15 a.m. Resident #8 was seated upright in her wheelchair without her heel pressure relief boot on. The pressure relief boot was on the resident's table covered with clothes in the same position as it was observed on 12/5/23. A dressing was observed on the resident's right heel. The resident's heel was resting directly on the wheelchair's foot pedal. A CNA and a registered nurse (RN) entered the resident's room, however, the heel pressure relief boot was not offered and foot elevation was not offered. The resident's mattress was a standard mattress and not an air mattress. C. Record review The 9/5/23 initial skin assessment documented the resident had no pressure injuries. The Braden scale completed on 9/5/23 documented the resident was at moderate risk for developing pressure ulcers. The wound to the right heel was identified on 11/1/23 on the weekly skin assessment. The comments revealed will monitor and float heel, wound Medical Doctor (MD) to evaluate. -There was no wound stage identified on the assessment. -However, the wound doctor did not assess the wound until a week later and those notes were not available. The first wound doctor note was on 11/16/23 (see below). The progress note dated 11/8/23 revealed interventions listed were to encourage offloading boots. -No orders were in place for offloading boots on the CPO. The weekly pressure ulcer report dated 11/14/23 was reviewed. It revealed the resident's deep tissue injury had dimensions of 5 centimeters (cm) by 4 cm by 0 cm. The treatment/evaluation of effectiveness listed was to continue to stress the importance of floating heel. The wound physician assessed Resident #8 on 11/16/23. The wound note dated 11/16/23 was reviewed, it revealed the resident developed a deep tissue pressure injury with dimensions of 5 cm by 4 cm by 0 cm. The treatment order was to paint with betadine daily and leave open to air. The progress note dated 11/17/23 revealed the intervention was to continue to float heels. The weekly pressure ulcer report dated 11/17/23 was reviewed. It revealed the resident's right heel deep tissue injury had dimensions of 5 cm by 4 cm by 0 cm. -The treatment/evaluation of effectiveness was not completed. The wound note dated 11/21/23 revealed the resident's deep tissue pressure injury dimensions were 3 cm by 3 cm by 0 cm. The treatment order was to use skin prep, xeroform and dry dressing change three times weekly. The weekly pressure ulcer report dated 11/21/23 revealed the resident's deep tissue pressure injury had dimensions of 3 cm by 3 cm by 0 cm. -The treatment/evaluation of effectiveness was not completed. The progress note dated 11/22/23 revealed the interventions were to continue treatment orders. The weekly pressure ulcer report dated 11/28/23 revealed the resident's deep tissue pressure injury to the right heel was classified as a stage 3 pressure injury with dimensions of 2.5 cm by 2.5 cm by 0.3 cm. -The treatment/evaluation of effectiveness was not completed. The progress note dated 12/1/23 revealed the intervention was to continue to float heels. A physician's order was initiated on 11/2/23 and discontinued on 11/28/23. The order read right heel wound orders: paint with betadine daily. A physician's order was identified for wound care to the right heel. The order was initiated on 11/29/23. The order read: Wound care orders for right heel: skin prep, silver alginate, foam and change three times per week one time a day for wound care. -No other physician orders were in place for the resident to be offloaded or to utilize the pressure relief boot. The care plan,revised on 11/17/23, identified the resident was at high risk for potential and or actual impairment to skin integrity related to fragile skin. Pertinent interventions included: pressure relieving device and positioning. -The care plan did not identify the specific pressure area and specific interventions to promote wound healing through wound care. D. Staff interviews CNA #1 was interviewed on 12/6/23 at 11:05 a.m. The CNA said she was aware of the resident's stage 3 pressure injury to the right heel. She said there was not anything certain to do for the resident's pressure injury that she would be involved in. She said the care plan only addressed repositioning in bed and to use a pressure relief device but she was not certain the resident had one to be used. She said the resident would benefit from offloading, an air mattress and pressure relief boots and said she did not offer to offload the resident and or offer any pressure relief devices. Licensed practical nurse (LPN) #1 was interviewed on 12/6/23 at 11:17 a.m. The LPN said the resident developed the pressure ulcer from not being mobile and from being in bed or the wheelchair most of the day as the resident required total assistance from staff. LPN #1 said in order to treat the pressure injury, the resident should be provided with an air mattress, repositioning every two hours, pressure relief boots when in bed or the wheelchair, offloading/elevation with a pillow andProstat (a protein supplement to promote wound healing). LPN #1 said any care staff member could offer the resident the pressure relief boots and they should be offered every time the resident was in bed or in her wheelchair. LPN #1 said she would review the physician's orders to determine what treatment to carry out. LPN #1 said there were no additional orders aside from wound care. LPN #1 said the resident was not offered the pressure relief boots because the resident did not have boots ordered and may not have a pressure relief boot in the room. LPN #1 identified the boot after prompting and she said the boot would be hard to find under a pile of clothes. LPN #1 said the resident was not offered repositioning by her or the staff present on 12/6/23 during continuous observation. LPN #1 said the resident did not have an air mattress. The assistant director of nursing (ADON) was interviewed on 12/6/23 at 12:40 p.m. She said Resident #8 acquired a stage 3 pressure injury at the facility. No treatment orders were obtained and or updated by the physician aside from the bandage to the heel. She said orders should be in place for boots and offloading. The ADON said the resident would benefit from an air mattress and Prostat for wound healing and said there were no orders currently in place. The ADON said the resident should be wearing the boot while in the wheelchair and in bed. The ADON said the resident's heels were not offloaded on 12/6/23 and the resident did not have an air mattress. The ADON said if appropriate interventions were in place the facility could have prevented the wound from developing. The ADON said the facility would obtain orders for the pressure relief boots, offloading, Prostat after consulting with the registered dietitian, obtain an air mattress and update the resident's care plan. 47064 IV. Resident #9 A. Resident status Resident #9, age 85, was admitted on [DATE]. According to the December 2023 CPO, diagnoses included Alzheimer's (disease affecting memory), dementia (disease affecting memory), chronic obstructive pulmonary disease (COPD) abnormal oxygen exchange), chronic respiratory failure (abnormal oxygen exchange) and major depressive disorder. The 11/8/23 MDS assessment revealed the resident was cognitively impaired with short and long term memory loss. She required maximal assistance with eating, dressing, toileting, transfers and toileting. It documented a stage 3 pressure injury over a bony prominence. B. Record review Review of the 3/22/23 comprehensive care plan, initiated on 9/26/23, revealed Resident #9 had potential/actual impairment to skin integrity related to limited mobility. The care plan documented the following interventions: floating heels while in bed, measure and document on wound progression weekly, physician notification if wound worsening, supplements per physician order, weekly skin checks per facility protocol and wound treatment orders to right heel per physician order. -The care plan interventions were all initiated five months after the right heel pressure injury was identified (see below). The discharge paperwork from the facility where Resident #9 previously resided prior to coming to the current facility documented the resident's skin was intact on 2/26/23. According to the admission assessment completed on 3/20/23, Resident #9's skin was observed to be intact on admission. A weekly skin assessment completed on 3/29/23 identified Resident #9's skin was intact. -Fifteen days post admission, a pressure injury was identified to the right heel during the weekly skin assessment (see below). The admission Braden scale (assessment tool to determine risk factors for pressure injury development) documented Resident #9 was at moderate risk for pressure injury development. The 3/27/23 admission MDS assessment indicated Resident #9 did not have any pressure injuries on admission but the resident was identified at risk for developing pressure injuries. The March 2023 CPO documented no orders for wound care to the right heel. The weekly skin assessment on 4/4/23 identified a pressure injury to the right heel. The April 2023 CPO revealed an order to start on 4/5/23 for wound care right heel apply betadine daily, leave open to air and off load heel. Review of the wound physician progress note dated 4/4/23 revealed the wound physician first evaluated Resident #9 who presented with a new unstageable wound to her right heel. An interdisciplinary team note dated 6/16/23 identified the wound progressed from unstageable to a stage 3 pressure injury. An evaluation summary progress note on 8/29/23 documented the right heel was a stage 4 pressure injury. An evaluation summary progress note on 9/19/23 documented the right heel wound as a stage 3 pressure injury. An evaluation summary progress note on 11/28/23 documented the right heel wound as a stage 3 pressure injury. C. Staff interviews The ADON was interviewed on 12/6/23 at 12:45 p.m. She said it was the responsibility of the nurse admitting the resident to complete a skin assessment. The ADON said if the admitting nurse was a LPNthey were to seek assistance from a registered nurse (RN) for staging a pressure wound. The ADON said skin assessments were to be completed on admission and then weekly by a licensed nurse. The ADON said if there was a skin issue identified, such asa pressure injury, the resident would see the wound physician at their next visit to the facility and the facility's wound physician made rounds weekly on Tuesdays. The ADON said the attending physician would then give wound care orders until the wound physician was able to see the resident. The ADON reviewed the following documents (identified above in record review) and said it was a facility acquired wound. The ADON said nursing completed weekly wound rounds with the wound physician. The NHAwas interviewed on 12/6/23 at 12:45 p.m. She said the MDS nurse was working remotely and did not see the resident personally when completing the MDS assessment and she would needed to do more research into Resident #9's wound situation to determine if the wound was facility acquired or if Resident #9 was admitted with the pressure injury. -However, the resident's skin assessments prior to developing the wound, 15 days after admission, indicated her skin was intact. V. Additional information The NHA provided a progress note on 12/6/23 at 1:45 p.m. The progress note, dated 8/15/23, documented the initial observation of the right heel wound was 3/20/23. -This progress note was dated five months after admission. The NHA provided a plan of correction dated 9/25/23 for accuracy of assessments identifying the director of nursing audited charts and corrected charts to ensure accuracy. The director of nursing (DON) was also responsible for educating staff on how to accurately complete assessments and ensure all data was correct. Documentation of staff that attended the education on 10/19/23 were six licensed nursing staff members including the DON. A seventh staff member completed the education on 10/23/23. -The staff education was not completed with all licensed nursing staff employed by the facility.

Based on interviews and record review the facility failed to ensure one (#1) of three sample residents were free from sexual abuse. The facility failed to protect Resident #1 who no longer wanted her prior consensual intimate relationship with Resident #2. On 3/22/23 (one day after Resident #1 returned from the hospital) Resident #2 came into Resident #1's room while she was sleeping and without her consent did a sexual act on her. Resident #1 said she was sleeping on 3/22/23 and the sexual act was non-consensual. After the 3/22/23 abuse, Resident #1 was moved to a different hallway in the facility to keep her away from Resident #2. On 4/6/23 Resident #2 came into her new room while she was sleeping and did a sexual act to her which again, which Resident #1 said also was non-consensual. The facility failed on both dates to protect Resident #1 from abuse by Resident #2. Resident #1 expressed she did not feel safe even after changing rooms until Resident #2 discharged from the facility on 4/13/23. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy 1/1/22, and revised 6/1/22 was provided by the nursing home administrator (NHA) on 4/18/23 at 3:08 p.m. It revealed in pertinent part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse. 'Willful' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 'Sexual Abuse' is non-consensual sexual contact of any type with a resident. Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship; The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect; Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: Responding immediately to protect the alleged victim and integrity of the investigation; Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; Increased supervision of the alleged victim and residents; Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; Protection from retaliation; Providing emotional support and counseling to the resident during and after the investigation, as needed. II. Resident status A. Resident #1 (victim) Resident #1, age 73, was admitted on [DATE] and readmitted on [DATE]. According to the April 2023 computerized physician orders (CPO), the diagnoses included emphysema (damage of lung tissue), chronic obstructive pulmonary disease (COPD), stage three chronic kidney disease, Parkinson's Disease, hypertension (high blood pressure), unspecified dementia, difficulty walking, and dysphagia (difficulty swallowing). The 3/23/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. She required extensive assistance with dressing, toilet use, and personal hygiene. She did not walk in her room or the corridors. She had adequate vision. B. Resident interview Resident #1 was interviewed on 4/18/23 at 4:05 p.m. She said she had been in a consensual romantic relationship with Resident #2. She said after her hospital stay in March 2023 she no longer wanted to be anything but friends with him. She said she certainly would never allow him to come into her room while she was sleeping and have sexual acts with her without her permission. She said she was sleeping on both occasions when Resident #2 came into her room and performed sexual acts on her. She said she had good vision but had a hard time keeping her eyes open. She said after the first time he took advantage of her the facility moved her onto another wing to live to keep her safe from Resident #2. She said she still talked to him in the hallways and dining room because they were once friends. She said in her new room he came in and did the same thing to her again. She said, I heard he doesn't live here anymore and that makes me feel safe. I didn't feel safe from him until he moved. C. Record review The sexual expression care plan was signed by Resident #1 on 2/1/23. Resident #1 signed a consent which read she wanted the facility to honor her wishes to have sexual relations. The target date on the facility form was only documented as ongoing. -This agreement was never re-evaluated or discussed with her again, including after both sexual abuse incidents on 3/22/23 and 4/6/23 (see social service director interview below). The form did not document any other review dates for her sexual expression. The progress note on 3/21/23 revealed, Resident #1 was readmitted to the facility from the hospital. The nursing progress note 3/22/23 at 2:39 p.m. revealed, the resident was unable to consent to sexual interactions. Her roommate went to a nurse to get help for Resident #1. The nurse witnessed Resident #2's pants down and (his) private areas were in Resident #1's mouth. Resident #2 was informed to put his pants up and leave the room. Resident #2 was told no sexual interaction could occur when the other person could not consent. Both residents remained separated. The comprehensive care plan updated 3/23/23 revealed in pertinent part, Focus: Psychosocial well-being: Resident #1 was at risk for emotional distress with a history of a sexual relationship with a resident of the opposite gender. She received unwanted sexual contact from another resident while she was sleeping and (was) unable to give consent. Resident #1 was previously agreeable to this sexual relationship but indicated she does not want it to continue. Resident #1 was able to discuss her feelings and concerns. Goal: Resident #1 will remain free from emotional distress with resident to resident altercation through the review date of 6/14/23. Interventions: Allow the resident time to answer questions and to verbalize feelings, perceptions, and fears as needed. Anticipate and meet the resident's needs. Ensure (the) resident feels safe in the facility. Frequent checks as needed when incidents occur. The social service progress note 3/24/23 revealed Resident #1 said she wanted to only meet with Resident #2 in the common areas such as the lobby and not in her room. Follow-up visits to be continued to ensure resident's safety. The social service progress note 3/27/23 revealed a BIMS test was conducted on Resident #1 and she scored a 14 out of 15, she was cognitively intact. The nursing progress note 4/6/23 at 2:39 a.m. revealed Resident #1 was unable to consent to sexual interactions. The nurse and a certified nurse aide (CNA) witnessed Resident #2 with his pants down and his private parts were in Resident #1's mouth while the resident was in her bed trying to sleep. Resident #2 was asked to leave the room and told sexual encounters cannot take place without consent. The social service progress note 4/6/23 at 2:09 p.m. revealed Resident #1 said, Resident #2's behavior was not acceptable and she did not want to see Resident #2 in her room again or in the common areas. III. Resident status A. Resident #2 (perpetrator) Resident #2, age under 65, was admitted on [DATE] and was discharged on [DATE]. According to the April 2023 CPO, the diagnoses included cerebral infarction (stroke), hypertension (high blood pressure), altered mental status, alcohol abuse, alcohol hepatitis (inflammation of liver) and homelessness. The 2/25/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. He required extensive assistance with dressing, and personal hygiene. He required limited assistance with bed mobility. He was independent in his room, and walking in his room and in the corridors. B. Record review The nursing progress note 3/22/23 at 2:30 p.m. revealed Resident #2 was found in the room of Resident #1 with his pants down and his private parts in her mouth. Resident #2 was reminded he was unable to have sexual interactions with an individual without their consent. The comprehensive care plan 3/23/23 revealed, Focus: Resident #2 has a potential behavior problem with sexually inappropriate activity. He has a history of exploring sexually consensual relationships with residents of the opposite gender, but he may attempt to engage in sexual activity when they are not able to give consent (when they are sleeping). He needs to have his care needs met daily without causing harm to himself or others. Goal: Resident #2 will have no evidence of behavior problems by review date. Interventions: Frequent checks as needed when incidents occur. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Divert attention, remove from(the) situation, and take to (an) alternate location as needed. Document behavior and potential causes. The comprehensive care plan was updated on 4/11/23 and revealed as an intervention, one-to-one as needed when incident(s) arise. The nursing progress note 4/6/23 at 2:21 a.m revealed Resident #2 was found in the room that Resident #1 had recently been moved into (see nursing home administrator below that Resident #1 was moved to another room to keep her safe from Resident #2). A nurse and a CNA witnessed Resident #2 with his pants down, and he extended his penis in Resident #1's mouth while she was sleeping. Resident #2 (was) reminded he was not allowed to have sexual encounters with others without their consent. -Resident #2 was placed on one-to-one care with a CNA until a discharge plan could be achieved. The social service progress note 4/6/23 revealed Resident #2 was told not to come into the resident's room, or near Resident #1 or the police would be called. The nursing progress note 4/10/23 revealed Resident #2 was found sitting in his wheelchair in a female's room. The note did not document who the female resident was. Fifteen minute checks were to go on for both residents. IV. Facility investigation The investigation summary of the 3/22/23 incident was provided by the NHA on 4/18/23 at 1:45 p.m. The summary revealed in pertinent part, On 3/22/23 it was reported to the administration that an alleged sexual abuse occurred where one of the other residents with whom resident has a history of sexual relationship on a consensual basis. On this day the alleged perpetrator was observed attempting to make sexual contact (with Resident #1). Resident #1 said, She was unaware of the alleged sexual abuse. Resident #1 stated she is not okay with that kind of behavior and does not want the alleged perpetrator in her room. Resident #2 said, Whosoever is saying that is lying. When Resident #2 was told that Resident #1 did not want him in her room he responded, Whatever. The investigation summary of the second incident on 4/6/23 was provided by the NHA on 4/18/23 at 3:35 p.m. (After it was revealed in a progress note that a second sexual abuse incident had occurred) It revealed in pertinent part, On this day the alleged perpetrator (Resident #2) was observed penetrating Resident #1's mouth while she was sleeping and hence, it was without her consent. V. Staff interviews The NHA was interviewed on 4/18/23 at 2:10 p.m. She said the CNAs were to do 15-20 minute checks on Resident #2 after the 3/22/23 incident. She said the facility CNAs did not observe him closely enough. She said Resident #1 was moved to a different hallway to protect her from Resident #2. The assistant director of nursing (ADON) was interviewed on 4/18/23 at 2:47 p.m. She said on 3/22/23 Resident #1's roommate came to alert her that Resident #2 was in the room and something sexual was going on. She said when she entered she could see Resident #2's private parts were on Resident #1's face. She said she told him to remove himself from the room. She said the facility moved Resident #1 to another room on a different hallway to keep her safe from Resident #2. She said Resident #2 was supposed to be watched by the CNAs but apparently he was not watched closely enough and on 4/6/23 he went into Resident #1's new room and did the same non-consensual sex act again. The social service director (SSD) was interviewed on 4/18/23 at 3:10 p.m. She said Resident #1 and Resident #2 had signed a sexual consent document back in February 2023. She said the facility had both Resident #1 and Resident #2 sign the paperwork called a consensual sexual expression care plan. She said as far as she knew Resident #2 was the only person Resident #1 had relations with. She said Resident #1 went to the hospital for pneumonia and respiratory failure in March 2023. She said when Resident #1 returned to the facility she noticed changes in her and did some cognitive tests. She said she never re-evaluated Resident #1 about her sexual consent paperwork. She said after both incidents, 3/22/23 and 4/6/23, she did not re-evaluate the sexual consent assessment with either Resident #1 or Resident #2. She said she interviewed Resident #1 after both incidents. She said Resident #1 told her she did not consent to either sexual incidents. She said Resident #1 was asleep both times Resident #2 was found in her room doing sexual acts. She said after the first incident Resident #2 said he did not care about what had happened. She said after she spoke to him after the second sexual incident he refused to speak or respond to her when she attempted to speak to him. She said he just shrugged his shoulders in front of her. The NHA was interviewed again on 4/18/23 at 3:40 p.m. She said there was no behavioral tracking done for either resident after the 3/22/23 or 4/6/23 incidents. She said after the first incident she put in a request for counseling for Resident #1 but had not heard back from the company yet and she would call the counseling company soon to see what had happened with her request. She said Resident #1 was moved to another hallway to keep her safe from Resident #2. She said after the 4/6/23 incident the CNAs were to do one-to-one observations 24 hours, seven days a week with Resident #2 until he could be discharged from the facility. She said on 4/6/23 he was found in Resident #1's new room and again had non-consensual sexual relations with her. She said apparently the 15-20 minute checks were not enough to stop him from doing this act again. She said the CNA was not watching him on 4/6/23 closely enough. She said Resident #2 was very quick when he walked. She said she did not know how Resident #2 got to Resident #1's room without being noticed on 4/6/23 except that he was not being watched closely enough. She did not know how Resident #2 knew where Resident #1's new room was except maybe Resident #1 talked to him in the halls and dining room area prior to 4/6/23 and told him. She said maybe Resident #2 noticed her coming out of the beauty salon which was close to her room and watched her go to her room. VI. Facility follow-up On 4/19/23 at 12:29 p.m. the NHA emailed follow-up staff interviews the facility had done after the 4/18/23 survey. During the recent interviews of the incidents almost a month later, the staff had variances in their story of where exactly Resident #2's private parts were during the incidents. During the follow-up interviews the facility staff verified Resident #2's pants were down and his private parts were exposed. On 4/19/23 at 12:29 p.m. the NHA also provided interdisciplinary care team (IDT) notes after the incidents which revealed in pertinent part, -On 3/23/23 Resident #1 only wanted to see Resident #2 in the hallways. Resident #1 was moved to another room to give her some space from Resident #2. Resident #2 was started on frequent safety checks. -On 4/6/23 after the incident occurred staff were educated on one-to-one supervision for Resident #2. Resident #2 remained with one-to-one care 24 hours, seven days a week until he was discharged to another facility.

Based on observations, interviews and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure the residents received the care and services they required as determined by resident assessments and individual plans of care. Specifically, the facility failed to consistently provide an adequate number of nursing staff to address the acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result of inadequate staffing, the facility failed to: -Provide care and services in a dignified, respectful manner and environment (cross-reference F550); -Provide necessary care and services to ensure residents' activities of daily living (ADL) needs were met (cross-reference F676); -Provide necessary care and services to prevent pressure injuries (cross-reference F686); -Provide necessary care and services to maintain residents' restorative care and prevent functional decline (cross-reference F688); and -Provide necessary care and services to residents to prevent accident hazards and accidents with injuries (cross-reference F689). These failures contributed to residents going without baths/showers and not feeling clean, residents experiencing accidents with injuries, residents developing pressure injuries, and residents going without restorative and range of motion services. Findings include: I. Resident census and conditions According to the 10/11/21 Resident Census and Conditions of Residents report, the resident census was 80. The following care needs were identified: -44 residents were in a chair most of the time; -Three residents had contractures; -62 residents needed assistance from one or two staff members for transfers and nine were dependent; -17 residents needed a mechanical lift (Hoyer or other lift) for transfers, -64 needed preventive skin care, -Two residents had pressure ulcers, -14 residents needed rehabilitative services, -24 residents were dependant for bathing, -47 residents needed one or two person assistance with bathing, -57 residents needed one or two person assistance with toilet use, and -12 residents were dependent for toilet use. II. Facility policy The Staffing policy, revised October 2017, provided by the interim nursing home administrator (INHA) on 10/14/21 at 12:50 p.m., read in pertinent part: The facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. III. Staffing expectations The INHA) was interviewed on 10/14/21 at 5:50 p.m. and provided the staff requirements for each unit in the facility based on the current census and resident needs. For all of the units in the facility, the licensed nurses worked 12 hour shifts from 6:00 a.m. to 6:00 p.m. The next shift worked 6:00 p.m. to 6:00 a.m. The certified nurse aides (CNAs) worked 12 hour shifts from 6:00 a.m. to 6:00 p.m. for day shift and 6:00 p.m. to 6:00 a.m. for the evening / night shift. Some CNAs worked eight hour shifts, 6:00 a.m. to 2:00 p.m for the day shift and 2:00 p.m. to 10:00 p.m. for the evening shift. Review of the daily staffing schedules revealed they were confusing and difficult to follow. The numbers of nursing staff who worked on each unit or called off for their shifts were not well documented. Comparison/determination of staffing expectations versus staff who reported for duty was impossible to decipher. IV. Resident #71 observation/interview On 10/12/21 at 9:10 a.m., Resident #71's call light was on. The resident was lying in bed. She said she turned her call light on about five minutes ago. She said she was waiting on staff to get her out of bed. She said she needed two person assistance. She said one of the CNAs came into her room and said she was going to get help to get her up. She said it happened frequently, they were always short staffed and she has to wait for a long time. At 9:42 a.m. (32 minutes later), CNA #4 came to answer the resident's call light. She said they were helping another resident who needed two person assistance. She said they did not have enough staff. V. Effects of working schedule on facility residents A. Cross-reference F550 The facility failed to provide dignified, respectful care to Resident #68, who was observed on two occasions struggling to eat his meals while suffering violent tremors. Although the resident called for help repeatedly, he did not receive timely assistance, causing him distress and psychosocial harm. B. Cross-reference F676 The facility failed to provide assistance with ADLs to ensure the highest practicable quality of life and care, for Residents #51, #58, #63, #64 and #77. The facility failed to provide regular showers to Residents #51, #58, #63, #64 and #77 who needed assistance with ADLs; and failed to provide nail care for Residents #51 and #58. Residents said during interviews that they requested baths and nail care and did not receive the assistance they needed. Residents #51, #58 and #63 said they could smell themselves, because it had been so long since they bathed. Resident #64 said she did not want to put on clean clothes because she felt dirty. Resident #77 said she wore a cap because she did not want anyone to see her stringy, greasy hair. C. Cross-reference F686 The facility failed to turn and reposition Resident #29 at least every two hours to prevent the development of a pressure injury, accurately assess the resident's skin and identify the pressure injury once it developed, and implement timely treatment interventions to treat the pressure injury after it was first identified. The facility failures contributed to the resident developing an unstageable pressure injury to the coccyx. The resident said during interview that staff did not reposition her, and staff stated during interview that they were too busy to turn/reposition residents as frequently as needed to prevent skin breakdown. D. Cross-reference F688 The facility failed to ensure Resident #56 was provided the goods and services necessary to maintain her physical well-being with restorative care. Interviews regarding restorative care revealed the following. Certified nurse aide (CNA) #3 was interviewed on 10/12/21 at 2:00 p.m. She said the facility was short staffed and all the residents' care cannot be completed. She said the schedule changed every day. She said the schedule had five and six CNAs listed but she said the staff listed had not worked. She said there were no restorative aides because they work on the floor now. Restorative certified nurse aide (RCNA) was interviewed on 10/13/21 at 8:30 a.m. She said there were about 20 residents who were on the restorative program. She said she was pulled to the floor to work often so the residents did not receive restorative care on those days. She said Resident #56 was on a restorative program for range of motion and to apply a splint to her hand. She said she had not worked with her in over three weeks. CNA #6 was interviewed on 10/13/21 at 4:10 p.m. She said Resident #56 was supposed to wear the splint daily and the restorative aides had not worked with the resident. She said the staff was short and the restorative aide had to work on the floor to help out. Record review for Resident #56 also revealed documentation for restorative care showed nothing after 9/16/21. The RCNA said it had been a struggle at the facility to keep staff. E. Cross-reference F689 The facility failed to ensure Resident #56's safety with transfers via Hoyer lift, with which the resident was injured twice Interviews regarding hoyer lifts and falls revealed the following. CNA #2 was interviewed on 10/13/21 at 4:00 p.m. He said there was not enough staff to help with hoyer lift transfers. He said residents had to stay in bed when they cannot find another staff person to help with the transfer. CNA #6 was interviewed on 10/13/21 at 4:10 p.m. She said the facility did not have enough staff to help with the care of residents. She said she assisted with hoyer transfers with two people but she said some CNA moved residents without getting help. VI. Individual resident and staff interviews regarding staffing Additional resident and staff interviews confirmed the facility failed to have an adequate number of staff to meet the residents' needs. Interviews with residents who, per facility assessment were cognitively intact and interviewable, and with staff, revealed the following. Resident #57 was interviewed on 10/13/21 at 4:40 p.m. He said he had to have a Hoyer lift for transfers in and out of bed. He said he had to stay in bed often because there was not enough staff to help with the transfers. He said when a transfer occurred with one CNA it worried him that he would fall. Resident #59 was interviewed on 10/13/21 at 4:45 p.m. He said he used a Hoyer lift for transfers and he had to wait long periods of time for staff members to find help. He said they always used two people with the lift. Agency certified nurse aide (ACNA) #1 was interviewed on 10/13/21 at 9:00 a.m. She said the facility was short staffed and she had a hard time getting help to transfer residents with Hoyer lifts. The staffing coordinator (SC) was interviewed on 10/13/21 at 4:05 p.m. She said she scheduled nursing staff based on the day's census. She said there were 10 to 12 residents assigned to one CNA. She said the facility was aware they were short staffed and they were using agency and temporary staff, and many current staff were working overtime. She said they offered sign on bonuses with full time employment. She said they pulled as many staff as they could from restorative and non-nursing duties to help with answering lights, bathing, passing food trays, and providing help with resident care. The director of nursing (DON) was interviewed on 10/14/21 at 5:50 p.m. She said the facility was short staffed and they pulled the restorative aide to work on the floor a few times a week. She said they tried to juggle the needs of the residents to help maximize the cares. The INHA was interviewed on 10/14/21 at 5:50 p.m. She said they were trying to hire staff. They were in between staff coordinators so they all worked together to make up the daily schedule. Some CNAs worked 16 hours to help with the overlap of cares. She said they had ads out and they were recruiting daily. They were pulling friends and family members to help recruit and calling prior employees. She said they had new contracts with agencies and they had increased wages.

Based on observations, interviews and record review, the facility failed to ensure care was provided for one (#68) of one resident out of 37 sample residents in a manner and in an environment that maintained or enhanced the resident's dignity and respect, in full recognition of his or her individuality. The facility failed to provide timely assistance and adaptive utensils for Resident #68, who was experiencing violent tremors while attempting to eat his meals. Staff failed to respond appropriately and in a timely manner to assist the resident in a dignified manner, causing the resident distress and psychosocial harm. Cross-reference F725 failure to provide sufficient nursing staffing, and F810 failure to provide adaptive eating utensils. Findings include: I. Resident #68 status Resident #68, age 78, was admitted on [DATE] and readmitted on [DATE]. According to the September 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/20/21 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of nine out of 15. He required extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. Eating assistance needs were not assessed. He required a mechanically altered diet (food that was altered to make it easy to chew and swallow). II. Observations Resident #68 was observed on 10/11/21 at 11:50 a.m. eating lunch in the dining room. He had two sandwiches on a plate, no silverware, and two cups of fluid. He tried to eat the sandwich but he was experiencing continued, uncontrolled jerking movements to his extremities. The bread from the sandwich flung around the table because the resident could not control his jerking movements/tremors. He was sliding down in his wheelchair while trying to eat his lunch. Two staff members noticed he had a hard time holding his sandwich and he was sliding down in the wheelchair. The resident said please help me up and the staff members assisted him to sit up better in the chair. The sandwich was taken out of his hand and he was assisted out of the dining room. On 10/13/21 at 5:48 p.m. Resident #68 was in his room in his bed. The bed was elevated to about a 45 degree angle. He had a room tray in front of him with a plate of spaghetti with marinara sauce on the tray. He did not have any silverware, regular or adaptive, and did not have a plate guard on his plate. His dessert cup was on the ground on top of a fall mat with the contents spilled out on the mat. He called out help me, someone get me some silverware please, a fork, a spoon. He repeated this several times. He said Please, please, please, give me a fork and a spoon please. He continued to use his left hand to stir the spaghetti while repeating please, please and he ate the plate of spaghetti with his hands. The resident swayed continuously on his bed back and forth with his shoulders from the right to the left. His head shook continuously in yes/no motions. His hands, hair and shirt were red from the marinara sauce. His face from below his eyes to his neck were splashed with marinara sauce. His blanket and sheets had marinara sauce on them. -At 5:58 p.m. an unidentified staff member entered Resident #68's room and said, I heard you fell , why did you fall? Why did you fall out of your chair? She left the room at 6:01 p.m. She did not provide silverware, clean him from the spaghetti on his clothes or go get staff members to provide care. -At 6:07 p.m. the surveyor notified the director of nursing (DON) concerning the situation and asked for her assistance. The DON and surveyor entered the resident's room. The DON said the resident should not have been given food without silverware, and he needed special weighted silverware to help him eat because of having [CONDITION(S)]. She said staff should have noticed immediately that he could not eat his meal without silverware. She said the staff member who came in and asked him about his fall also should have helped him. The DON said she would clean the spaghetti off of his clothes, pick up the dessert off the floor, clean his hands, feed him, and make sure the situation never happened again. The DON said she would identify the staff member who did not provide the resident with care a few minutes before. III. Record review The 10/11/21 care plan interventions and tasks revealed the following: -Assist the resident while eating meals, i.e. nursing, CNA -Adaptive devices as recommended by therapy or physician. Monitor for safe use. Monitor/document to ensure appropriate use of safety/assistive devices. -Provide adaptive equipment for dining at meals and snacks: plate guard, weighted utensils, 2-handled cup with straw. (Cross-reference F810.) The nursing progress note written by the interim nursing home administrator on (INHA) on 10/13/21 at 8:10 p.m. revealed: The resident was assessed for needs for adaptive equipment or preferences during dining. Resident was asked if he would be comfortable eating in the dining room and he said he preferred to eat in his room. He agreed to the nurse's suggestion to eat in a private restorative dining area. Occupational therapy to evaluate the resident's needs and positioning in the dining area. IV. Resident interview Resident #68 was interviewed on 10/14/21 at 8:40 a.m. He said he was having a very good morning. He said breakfast was delicious. He said he did not remember eating spaghetti the previous evening. V. Staff interviews The interim nursing home administrator (INHA) was interviewed on 10/14/21 at 10:30 a.m. She said the facility had begun an investigation into what happened last night with Resident #68. She said he agreed last night to eat in the restorative dining room and he did well eating there that morning. She said the resident also agreed to move to a room closer to the nurse's station so that he could get more assistance. She said the facility would use the situation that happened last night as a learning tool to teach staff about multitasking and how it can be a distraction to resident cares. She said last night the DON came to her and they took care of the situation with the resident immediately. She said the resident was not treated with dignity and the staff needed to treat everyone with dignity and respect.

Based on record review and interviews, the facility failed to ensure five (#4, #16, #47, #51 and #52) of six residents reviewed out of 37 sample residents were free from abuse. Specifically, the facility failed to: -Protect Resident #4 from physical abuse by a staff member; -Protect Residents #4 and #47 from physical abuse by Resident #16; and, -Protect Residents #52 and #51 from physical abuse. Findings include: I. Facility policy The Abuse Prevention policy, not dated, was provided by the director of nurses (DON) on 10/14/21 at 10:30 a.m. read in pertinent part; Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse by anyone, including but not limited to staff (including agency or contract vendors), residents, volunteers, consultants, family members, legal guardians, friends or other individuals. This policy was based on Federal regulations and Colorado Occurrence Reporting Guidelines section of The Elder Justice Act. II. Incident of Resident #4 abuse from staff member on 10/2/21 A. Facility investigative report The facility investigative report, dated 10/2//21, provided by the interim nursing home administrator (INHA) on 10/12/21 at 10:30 a.m., read in pertinent part; Upon notification of the alleged incident of abuse between Resident #4 and the registered nurse (RN) #4, immediate action was taken by the center to ensure thorough investigation was upheld. The security camera footage was reviewed and revealed at approximately 7:00 p.m. RN #4 was observed on surveillance to be walking down the hallway sector with the supervised smoking material for authorized smoke break. Resident #4 observed self ambulating down the hallway at approximately 7:04 p.m. and walked outside into the smoking area. The footage was unable to articulate or visually see anything outside the courtyard in the smoking area and it was dark. At 7:09 p.m. Resident #4 was seen back in the building and sat in his walker. His demeanor showed him to be yelling and pointing to the RN. Other residents who were alert and oriented witnessed the allegation of abuse between the resident and the RN. RN requested the smoking material for safety measures from Resident #4, however the resident refused. RN #4 seized the smoking materials making contact with the resident shirt in an attempt to grab the smoking material from the resident. Due to the inappropriate encounter with the resident, RN was removed from the schedule. Among the interviews conducted, 50% of the resident population interviewed who are alert and oriented reported to see Resident #4 on the ground with the RN attempting to take a smoking item away from him. The other 50% did not see the incident. In totality of what the evidence revealed through thorough investigation, staff interviews, resident interviews, surveillance footage and observation, the allegation of Resident #4 being pinned by RN, the facility was unable to be efficiently substantiated. A police report was filed, family notified and the physician The investigation further revealed: Resident #4 was interviewed by the facility on 10/4/21 and he said in pertinent part; He was outside during smoke break when RN asked him for his lighter. Resident then replied RN grabbed him and pulled him off of his wheelchair causing him to fall on his butt and left him there face down. Another resident interviewed said in pertinent part, Resident #4 and RN started yelling at each other and RN grabbed the resident and pulled him out of his wheelchair. Resident tried to swat him away and the resident fell from his chair. RN did assist him up to the wheelchair after a few minutes. Two other residents witnessed RN #4 to pull Resident #4 out of his wheelchair onto the ground. B. Resident status Resident #4, age 75, was admitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/18/21 minimum data set (MDS) assessment revealed the resident had a cognitive deficit with a brief interview for mental status (BIMS) of 12 out of 15. He required supervision of one person for bed mobility, transfers, toilet use and dressing, and limited assistance for personal hygiene. He had verbal behaviors. C. Resident interview Resident #4 was interviewed on 10/13/21 at 1:30 p.m. He said RN #4 tried to take the cigarette lighter from him and they got into a physical altercation which caused him to fall out of his wheelchair. He said the RN tackled him on the ground, went through his pockets and took the lighter from him. D. Record review The health status note dated 10/3/21 at 9:00 a.m. read in pertinent part; Late entry, no behavioral problems noted. The health status note dated 10/3/21 at 5:53 p.m. which showed a line crossed through it (struck out as incorrect documentation), read in pertinent part, Resident notified the nurse he was abused by one of the staff members yesterday evening and there were also other residents who witnessed the incident. Resident told the nurse he was sitting in his walker smoking in the smoking area and the staff member came and pushed him and he rolled to the ground. The staff member started checking his pockets if he was hiding cigarettes in his pocket. Resident stated he was abused by the staff member and he wanted to report the incident. Incident was reported to the abuse coordinator, the director of nurses (DON), the doctor and family member. A skin assessment was done, no injury noted at that time, will continue to be monitored. Social service notes dated 10/4/21 at 9:03 a.m. read in pertinent part, Late entry: Social services checked in with resident regarding residents well being. Resident reported he was doing well but wanted to meet with social services more, as he feels this helped him. The behavior care plan, dated 6/23/2020, read in pertinent part: Resident #4 experienced issues with mood and behavior exhibited by impatience, verbal aggression, yelling, physical aggression, intimidating others, and acting in a way that is physically threatening towards others related to his disorder. Interventions include when conflict arises, remove residents to a calm safe environment and allow him to vent and share feelings.Increase communication between resident/family/caregivers about care and living environment: Explain all procedures and treatments, medications, all changes, rules and options. Frequent visits with one on one social worker for behavior and coping. Assist, encourage and support to set realistic goals. Allow him time to answer questions and to verbalize feelings, perceptions and fears as needed. III. Altercation with Resident #16 toward Residents #4 and #47 A. Facility investigative report The facility investigative report dated 10/9//21, provided by the INHA on 10/12/21 at 10:30 a.m., read in pertinent part: It was reported that a male resident (#16) utilizing his wheelchair to locomote was wheeling past another male resident (#4) and a verbal exchange took place as both residents were attempting to navigate in the opposite direction around a bed that was located in the hallway. Per witnesses of both staff and other residents the alleged victim (#4) began yelling at the assailant (#16) who in turn escalated and grabbed the broom off the housekeeping cart to hit the resident (#4) in the shin. Upon hearing the exchange between the residents, Resident #47 attempted to intervene, grabbing the broom while seated in his wheelchair and the alleged victim made contact with him on his left lower extremity. Staff intervened and immediately separated the residents and began assessing for any injury. The investigation further revealed Resident #47 was interviewed on 10/9/21, and stated: He saw Resident #16 hitting Resident #4 and he quickly got involved to stop the hitting and Resident #16 hit him with the broomstick to his left lower extremity. Resident #16 was interviewed by the facility on 10/9/21, and refused to talk to them. Resident #4 was interviewed by the facility on 10/9/21, and stated Resident #16 hit him with a broomstick in the knee as he was trying to pass him in the hallway. Four other staff and residents were interviewed and witnessed Resident #16 hit Residents #4 and #47. B. Resident #4 interview See resident status above. Resident #4 was interviewed on 10/14/21 at 11:30 a.m. He said Resident #16 hit him with a broomstick after he told the resident to speak English. He said he was a crazy man and he hit him in the leg. He said his leg was tender to touch but otherwise it was ok. He said the resident went to the hospital so he was no longer there. B. Resident #47 1. Resident status Resident # 47, under the age of 65, was admitted on [DATE]. According to the October 2021 CPO, pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 9/3/21 minimum data set (MDS) assessment revealed the resident had a cognitive deficit with a brief interview for mental status (BIMS) of 15 out of 15. He required extensive assistance of two people for bed mobility, transfers and toilet use. He required supervision for dressing and personal hygiene. He had no behaviors. 2. Resident interview Resident #47 was interviewed on 10/14/21 at 11:40 a.m. He said he saw Resident #16 hitting Resident #4 with a broomstick so he tried to take the broomstick away from the resident and in the process of doing so he was hit in the leg. He had no pain and said his leg was fine. C. Resident #16 1. Resident status Resident #16, age 81, was admitted on [DATE] and discharged to hospital on 10/9/21 on an M1 hold (deemed to be in imminent danger of harming himself or others). According to the October 2021 CPO, pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 8/11/21 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) of three out of 15. He required limited assistance from one person for dressing. He had supervision with bed mobility, transfers, toileting, dressing and personal hygiene. He had no behaviors. 2. Record review for Resident #16 The health status note dated 10/9/21 at 1:24 p.m. for Resident #16 read in pertinent part, The nurse was called by the housekeeper to the hallway and said resident was seen hitting others, upon arrival she saw resident (#16) holding a broom stick and swinging at another resident (#4) hitting him in the lower extremity. The health status note dated 10/9/21 at 3:43 p.m. read in pertinent part, Resident #16 was sent to the hospital as ordered by the doctor for further evaluation. The risk management follow up for the incident on 10/9/21 for Resident #16 read in pertinent part: Type of incident: behavior, the root cause: resident to resident altercation. Treatment required, the resident was sent to the hospital. New interventions, the residents were immediately separated from each other, an incident was reported to the state and an investigation started. The physical altercation care plan for Resident #16 dated 9/8/21 read in pertinent part: Resident was involved in a physical altercation with another resident. The resident will not harm another resident or staff. Interventions put in place documented the physician was aware, medication was started and family were aware. State health department was aware, the police department was aware and social services will visit with the resident. One on one observation and staff will redirect the resident as needed based on presenting behavior. The social service care plan dated 8/14/21 read in pertinent part that Resident #16 had exhibited socially inappropriate behavior: instigating, name calling, and taunting. The resident will stop inappropriate behavior within five minutes of staff intervention. If behavior occurs, do not scold or embarrass residents, simply redirect residents, offer snacks to distract residents from behavior. Allow resident time to process the new environment, ensure safety and dignity and then monitor from a distance if necessary. Redirect residents to an activity in the facility. Notify social service and nursing if behaviors worsen. Notify the doctor if necessary. Psychiatric services if needed to evaluate and treat. D. Staff interview Licensed practical nurse (LPN) #2 was interviewed on 10/14/21 at 12:10 p.m. She said she was the nurse working the day of the incident between Residents #16, #4 and #47. She said she took the broomstick away from the resident gently, reported the incident to the director of nursing (DON), did the skin assessments and documentation to make sure the residents were safe. She said Resident #16 was sent to the hospital later that day and had not returned. IV. Administrative interview The INHA was interviewed on 10/14/21 at 5:55 p.m. She said regarding the incident between Resident #4 and RN #4, there were a lot of complaints about the nurse toward residents. She said they did a full investigation for the incident and since then the facility had fired the RN. She was not specific on the date, but said RN #4 had not returned to work since the day of the incident. She said the incident was unsubstantiated at first because the video footage did not have sufficient evidence but after the investigation they determined it was substantiated. She said they were in the process of reporting RN #4 to the department of regulatory agencies (DORA). The incident between Resident #16, #4 and #47 was investigated and substantiated. She said Resident #16 had been sent out to the hospital after the incident and had not returned as of survey exit day 10/14/21. V. Altercation between Resident #51 and Resident #52 A. Facility investigation The facility investigation provided by the INHA was reviewed. It documented Residents #52 and #51 got into an argument over the television (TV) and ended up striking each other. The residents were immediately separated and monitored to prevent reccurrence. Both residents were coached on de-escalation and coping skills. Residents were currently safe and there has been no recurrence. The investigation further documented that Residents #51 and #52 were interviewed. Resident #51 reported that he hit Resident #52 in his face. It documented Resident #52 reported that Resident #51 hit him and then he hit Resident #51 back in his eye. Review of the nurse progress notes dated 9/20/21 (the day the incident was reported) revealed there was no documentation of the incident between Residents #51 and #52. Further review of the medical records for Residents #51 and #52 revealed there was no evidence that both residents were assessed for injury and pain. The interdisciplinary team (IDT) note for Resident #51 dated 9/21/21 documented an incident that was brought to staff attention on 9/20/21 and was investigated immediately. It documented Resident #51 was involved in a physical altercation with his roommate (Resident #52). The residents were separated immediately. Residents were immediately moved to separate rooms. It further documented that the police were notified and residents would remain separated. Staff would continue to monitor both residents for any behaviors. The IDT note for Resident #52 dated 9/21/21 documented an incident that was brought to staff attention on 9/20/21 and was investigated immediately. It documented per the resident's interview that Residents #51 and #52 were having a disagreement and it was reported that Resident #52 struck Resident #51 with a closed fist. It documented residents were separated immediately. B. Resident #51 Resident #51, age 65, was initially admitted [DATE] and was readmitted 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 moderately cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. He had no behaviors and rejection of care. He required limited assistance with bed mobility and supervision with transfers. The comprehensive care plan, initiated on 9/20/21 and revised on 9/21/21, identified the resident reported that he was hit by a fell ow resident. Interventions included: resident remains safe, physician made aware, no new orders, resident now resides in a room of his own and social service department will provide support and stress management as resident allows. Resident #51 was interviewed on 10/14/21 at 1:30 p.m. He was sitting in his room. He said he got into an argument with his roommate (Resident #52) about flushing the toilet. He said Resident #52 held his wheelchair and punched him in his face so he hit him back on his jaw. He said the staff separated them and he was in his own room now. He said he was not afraid of Resident #52. He said he was not assessed by the nurse. C. Resident #52 Resident #52, under age of 65, was admitted on [DATE]. According to the October 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/9/21 MDS assessment revealed the resident had moderately cognitive impairments with a BIMS score of 12 out of 15. He had no behaviors or rejection of care. He was independent with bed mobility and supervision with transfers. The care plan, initiated on 9/20/21 and revised on 9/21/21, identified it was reported by a fell ow resident that the resident had struck out at him making contact. Interventions included another room was offered to the resident, physician made aware, nursing assessment revealed no injuries. Resident #52 was interviewed on 10/13/21 at 10:45 a.m. He said he got into an argument with his roommate (Resident #51) and they both hit each other. He said he was moved to a different room. He said he was not afraid of Resident #51. D. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 10/12/21 at 1:39 p.m. She said she had worked at the facility for many years. She said Resident #51 sometimes got aggressive with other residents and sometimes would hit. She said she did not witness the altercation with his roommate (Resident #52) but heard he was involved in a physical altercation and both residents had been separated. The NHA was interviewed on 10/14/21 at 5:15 p.m. She said she had worked at the facility for two weeks. She said both residents were interviewed and they said they hit each other. She said Resident #52 was not accurate in reporting. She said after a reported altercation, the nurse should assess the residents for injury and pain. She acknowledged that there were no documented assessments for both residents regarding the incidents. She said education would be provided to the nurses on assessing residents after an altercation.

Based on record review and interviews, the facility failed to keep residents as free from accident hazards as possible for one (#56) of five residents reviewed for accidents out of 37 sample residents. Resident #56 required a mechanical lift for transfers and two staff for transfers. On 8/10/21 she was transferred by staff with the mechanical lift and caused an injury above the resident's eyebrow. The facility did not conduct an investigation and did not provide additional training to the staff on mechanical lift transfers to prevent further injury. Due to the facility failures, the resident was lowered to ground after she was improperly transferred with the mechanical lift on 8/24/21. Findings include: I. Facility policy The Fall and Accident Prevention policy, revised on 7/27/2020, provided by the interim nursing home administrator (INHA) on 10/14/21 at 12:50 p.m., read in pertinent part: It is the policy of the facility to prevent injuries, falls, accidents and incidents and eliminate preventable occurrences, practices, or systems, which negatively impact residents and or residents care and environmental hazards whenever possible. All facility staff will be provided with ongoing education on safe practices. The director of staff development will conduct the training. The facility will establish routine monitoring systems to assess, correct, and modify safety risk factors. II. Resident #56 status Resident #56, age 89, was admitted on [DATE]. According to the October 2021 computerized physician orders (CPO), pertinent diagnoses included [CONDITION(S)], hypertension and dementia. The 9/10/21 minimum data set (MDS) assessment revealed the resident was cognitively impaired and unable to perform a brief interview for mental status (BIMS) score. She required extensive care with two people for transfers, bed mobility, toileting, hygiene and dressing. She required extensive assistance from one person for eating. She used a Hoyer (mechanical) lift for transfers. III. Record review The activities of daily living care plan revised 12/29/16, for Resident #56, read in pertinent part Resident #56 required assistance with activities of daily living and mobility related to cognitive deficits and left handed contracture. She had the total assistance of two people with transfers and a hoyer lift. The fall care plan, revised on 12/1/2020 for Resident #56, read in pertinent part: Resident #56 will be free of any major injury related to falls through the next review date. She had anti-tippers on her wheelchair for safety. If a resident falls, observe for signs and symptoms of bleeding due to aspirin use. Use a lipped mattress and observe for decline in function and notify the nurse; refer to physical therapy and occupational restorative nursing as indicated. The health status note, dated 8/10/21 at 9:20 a.m. for Resident #56, read in pertinent part: The night certified nurse aide (CNA) reported to the nurse that while transferring (Resident #56) that morning from bed to wheelchair using the hoyer lift, it accidentally hit the resident on the right eyebrow. The eyebrow was assessed and the injured skin area measured 0.8 centimeters (cm) by 1.5 cm, it was not open and it was slightly bruised. The nurse will monitor and a message was left for the doctor and the family. A pain evaluation was completed on 8/10/21 for Resident #56 and revealed no pain. -There was no interdisciplinary team follow-up after the 8/10/21 incident or investigation completed (cross-reference F610 for investigation). The health status note, dated 8/24/21 at 6:38 a.m. for Resident #56, read in pertinent part: Resident #56 had a witnessed fall that morning from the hoyer lift sling and was supported by a staff member to the ground. The resident was non communicative and no physical injury occurred. The resident was assisted back to the wheelchair. Vital signs were normal and no apparent injury was noted. The family and doctor were notified. A fall risk assessment tool was completed on 8/25/21 for Resident #56. It indicated the resident was confused, there were no unsafe environmental factors and a mechanical lift was used. The risk note, dated 8/30/21 at 6:02 a.m. for Resident #56 which was a late entry for the 8/25/21 incident, read in pertinent part: Interdisciplinary team reviewed an investigation of an incident that occurred at the bedside on 8/24/21. According to staff (Resident #56) was lowered to the floor by staff while utilizing the hoyer lift. This was a witnessed fall with no injuries. Therapy will assess the need for training with line staff with regards to using the hoyer lift. Risk management follow up notes, dated 9/1/21 at 12:42 p.m. for Resident #56, read in pertinent part: Date of incident was 8/24/21. Type of incident was an assisted fall. Root cause read therapy will assess (Resident #56) for proper use of transfers. Treatment required was to have therapy assess the appropriateness of transfers. -Evidence of staff training on transfers was requested on 10/14/21 and no training was provided by the facility. The facility failed to educate staff on the use of the Hoyer lift after the injury on 8/10/21, and a fall involving a Hoyer lift transfer that occurred on 8/24/21 for Resident #56. IV. Staff interviews Certified nurse aide (CNA) #6 was interviewed on 10/14/21 at 10:30 a.m. She said she assisted Resident #56 to the floor after the resident slid from the Hoyer lift sling. She said CNA #8 did not put the sling on correctly prior to the transfer from bed to wheelchair. She said the resident had no injury and the nurse was notified. She said vitals were taken and the resident was assisted back to the wheelchair. She said she had no additional training on how to use the Hoyer lift. She said the Hoyer lift required two staff to use it and because they were short handed, it was used with one person at times (cross-reference F725 sufficient staffing). CNA #8 was interviewed on 10/14/21 at 1:30 p.m. She said she refused to answer any questions regarding the incident with Resident #56. CNA #2 was interviewed on 10/14/21 at 1:35 p.m. He said he used the Hoyer lift with residents but often he had a hard time finding help to transfer someone with the lift, so the residents ended up staying in bed (cross-reference F725). He said there were two staff people when he used the lift but he had seen some staff members transferring residents alone. Registered nurse (RN) #3 was interviewed on 10/14/21 at 10:00 a.m. He said when a resident had a fall an assessment was completed, the doctor was called and the family. He did recall Resident #56 had a fall on 8/24/21. He said he followed the facility policy. He had no additional training on Hoyer lifts. He said he helped the CNAs a lot with transfers because the facility was short staffed (cross-reference F725). The director of nurses (DON) was interviewed on 10/14/21 at 5:50 p.m. She said a fall assessment, a pain assessment and a risk management form was completed for any resident who had a fall or injury. She said the RN assessed the resident for any injury and performed first aid if needed. She said the doctor was notified and the family. She said she was informed of the fall in the 24 hour book and then discussion happened in the interdisciplinary team meeting for follow up. The care plan was updated with interventions and education given to the key personnel involved in the incident. She was unaware of the 8/10/21 and the 8/24/21 incident with Resident #56. She said unless the staff wrote the fall in the 24 hour report book or told someone in management, she was unaware. She said she started today (during survey) to train the nursing staff on Hoyer lifts. V. Facility follow-up The staff inservice sign in sheet on Hoyer lift transfers with no date (that was initiated during survey), was provided by the INHA on 10/14/21 at 11:45 a.m. It listed 11 staff signatures but did not indicate their disciplines.

Based on record review and interviews, the facility failed to ensure two (#68 and #182) out of 37 sample residents were free of significant medication errors. The facility failed to: -Notify the physician and follow up timely when [MEDICATION(S)] Solution medication (for tremors related to [CONDITION(S)]) was not available and not given for Resident #68; and -Notify the physician and follow up timely when [MEDICATION(S)] ([MEDICATION(S)]) medication was not available and not given for Resident #182. These failures contributed to Resident #68 experiencing violent tremors and Resident #182 experiencing severe (7/10 on a scale of zero to 10) pain. Cross reference F550 dignity/respect, and F755 pharmacy services. Findings include: I. Facility policy The Administering Medications policy, revised December 2012, provided by the interim nursing home administrator (INHA) on 10/14/21 at 10:50 a.m., read in pertinent part: Medication shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. The individual administering the medications must check the label to verify the right resident, right medication, right dosage, right time and right route before administering the medication. When a resident uses an as needed medication the attending physician and interdisciplinary team with support from the pharmacist, shall evaluate the situation, examine the individual as needed, determine if there was a clinical reason for the as needed medication and consider whether a standing dose was clinically indicated. II. Professional reference According to Perry, Potter & Ostendorf, Clinical Nursing Skills & Techniques, 8th ed. 2016, pp 480-489: To prevent medication errors follow the six rights of medication administration consistently every time you administer medications. Many medication errors are linked in some way to an inconsistency in adhering to the six rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation -Medication errors often harm patients because of inappropriate medication use. Errors include inaccurate prescribing; administering the wrong medication, by the wrong route, and in the wrong time interval; and administering extra doses or failing to administer a medication . -When an error occurs, the patient's safety and well-being become the top priority . III. Resident #68 A. Resident status Resident #68, age 78, was admitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/20/21 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of nine out of 15. He required extensive assistance with two people for transfers, bed mobility, toileting, dressing and hygiene. He was not assessed for eating. He had no behaviors and he had no rejection of cares. B. Observations Resident #68 was observed on 10/11/21 at 11:50 a.m. eating lunch in the dining room. He had two sandwiches on a plate, no silverware and two cups of fluid. He tried to eat the sandwich but had continued, uncontrolled jerking movements to his extremities. The bread from the sandwich flung around the table because the resident could not control his jerking movements/tremors. He was sliding down in his wheelchair while trying to eat his lunch. Two staff members noticed he had a hard time holding his sandwich and he was sliding down in the wheelchair. The resident said please help me up and the staff members assisted him to sit up better in the chair. The sandwich was taken out of his hand and he was assisted out of the dining room. On 10/13/21 at 5:48 p.m. Resident #68 was in his room in his bed. He was attempting to eat his spaghetti and his hands and his arms shook uncontrollably. He called out help me, someone get me some silverware please, a fork, a spoon. He repeated this several times. He said, Please, please, please, give me a fork and a spoon please. He continued to use his left hand to stir the spaghetti while repeating please, please and he ate the plate of spaghetti with his hands only. (Cross-reference F550 dignity and F810 adaptive utensils.) The resident swayed continuously back and forth, flailing his arms and shoulders from the right to the left. C. Record review The [CONDITION(S)] care plan, dated 3/19/18 for Resident #68, read in pertinent part: Monitor, document and report to the medical director as needed any signs and symptoms of [CONDITION(S)] complications. Poor balance, constipation, poor coordination, [CONDITION(S)], dysphagia, tremors, gait disturbance, incontinence, muscle cramps or rigidity, decline in range of motion, skin breakdown, mood changes, and decline in cognitive function. The psychosocial well-being care plan revised on 10/11/21 read in pertinent part: (Resident #68) will verbalize feelings related to emotional state related to his disease process. Administer medications per physician order. See medication record. Monitor for effectiveness and side effects. The October 2021 CPOs for Resident #68 revealed the following orders: -[MEDICATION(S)] Solution 10 milligrams per milliliters (mg/ml), inject 0.2ml subcutaneously every six hours as needed for severe tremors related to [CONDITION(S)] four times daily. Check blood pressure before and after administration, hold if blood pressure less than 120/80, recheck 30 minutes after administration. The order start date was 10/23/18. The August 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The September and October 2021 MARs revealed Resident #68 had no doses of [MEDICATION(S)] administered. The health status note dated 10/12/21 (during the survey) at 8:33 a.m. for Resident #68 read in pertinent part: The nurse contacted the pharmacy to refill the medication [MEDICATION(S)] injection. The pharmacy person stated the medication was a specialty med (medication) and can only be refilled by a specialty pharmacy. The nurse called the provider to get an updated prescription, and the provider told the nurse another pharmacy will refill the medication and send it to the facility when it was approved. Record review revealed no other doctor contacts for medication refills for Resident #68 and no follow up. The medication was not administered or available on 10/12/21 when needed. There was no documentation in nurses notes since the medication was last administered regarding tremors, assessment and/or monitoring. D. Staff interviews Certified nurse aide (CNA) #6 was interviewed on 10/14/21 at 10:30 a.m. She said Resident #68 needed a lot of assistance when he flailed his arms and body around. She said the flailing happened often. Licensed practical nurse (LPN) #1 was interviewed on 10/13/21 at 9:30 a.m. She said she wanted to give Resident #68 the medication [MEDICATION(S)] for his tremors but there was no medication available to administer. Registered nurse (RN) #1 was interviewed on 10/13/21 at 1:30 p.m. She said Resident #68 had a lot of tremors. She said the physician was aware of them. The director of nurses (DON) was interviewed on 10/14/21 at 5:50 p.m. She said she was not aware of the Resident #68's tremors and the medication. She said when medication was not available the nurse called the pharmacy and the physician for follow up. III. Resident #182 A. Resident status Resident #182, under age 60, was readmitted on [DATE]. According to the October 2021 CPO, pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/18/21 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. He required extensive assistance with two people for bed mobility, transfers, toileting, hygiene and dressing. He had supervision of one for meals. He had no behaviors and no refusals of care. He took scheduled and as needed pain medications. B. Resident interview/observation Resident #182 was observed and interviewed on 10/12/21 at 11:30 a.m. He sat in a recliner chair in his room and was eating cookies, talking to his family. He said he did not have any pain. He said when he missed his medication ([MEDICATION(S)]) he had a hard time sleeping and he felt more restless when he did not get the medication. C. Record review Review of Resident #182's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] (HCl) tablet, give sublingually two milligrams (mg) or one film three times a day for chronic pain. Order date was 8/19/21. The August 2021 MAR pain record for Resident #182, revealed on a 0-10 scale with 10 being the worst pain, he had a pain levels of: -zero, 10 times out of 24 assessments, -one, two times out of 24 assessments, -three, two times out of 24 assessments, -four, two times out of 24 assessments, and; -seven, three times out of 24 assessments. The August 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There were 19 check marks that were documented see nurse notes. The health status note dated 8/12/21 at 2:52 p.m. read in pertinent part: (Resident #182's) medications were verified by the physician. New medication order for tylenol as needed and a discontinued order for [MEDICATION(S)] were updated. All other orders remained the same. An electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . -At 12:55 p.m. waiting for delivery, and -At 4:35 p.m. still waiting in the pharmacy. The pain assessment on 8/13/21 revealed Resident #182 had no pain, and did not receive any scheduled pain medication or as needed medication EMAR notes dated 8/14/21 at 10:05 a.m. read in pertinent part: [MEDICATION(S)] tablet sublingual two mg, waiting for pharmacy delivery. -At 2:16 p.m. waiting for the pharmacy to deliver, and -At 6:27 p.m. waiting for the pharmacy to deliver. EMAR notes dated 8/15/21 at 9:49 a.m. read in pertinent part: [MEDICATION(S)] tablet sublingual two mg, waiting for pharmacy to deliver. -At 11:15 a.m. waiting for pharmacy to deliver, and -At 4:51 p.m. waiting for the pharmacy to deliver. EMAR notes dated 8/16/21 at 9:15 a.m. read in pertinent part: [MEDICATION(S)] tablet sublingual two mg, waiting for pharmacy to deliver. -At 11:43 a.m. waiting pharmacy to deliver, and -At 4:10 p.m. waiting for the pharmacy to deliver. EMAR notes dated 8/17/21 at 8:42 a.m. read in pertinent part: [MEDICATION(S)] tablet sublingual two mg, unable to fill due to only prescribed by an additional specialist. -At 1:45 p.m. the medication was on hold due to additional specialist may need to prescribe, -At 6:23 p.m. the doctor changed the medication order. EMAR notes dated 8/18/21 at 8:29 a.m. read in pertinent part: [MEDICATION(S)] tablet sublingual two mg, doctor to change medication order. -At 12:45 p.m. see nurses note, and -At 4:25 p.m. the pharmacy was called and said they were still waiting for the signed prescription from the medical director. The EMAR note dated 8/19/21 at 8:43 a.m. read in pertinent part: [MEDICATION(S)] tablet sublingual two mg, message left at the doctor's office for possible medication replacement. The September 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There were three check marks that were documented see nurse notes. The September 2021 MAR pain record for Resident #182, revealed he had a pain level of: -zero, eight times out of 20 assessments, -five, one time out of 20 assessments, -six, five times out of 20 assessments, and; -seven, seven times out of 20 assessments. EMAR note dated 9/12/12 at 4:51 p.m. read in pertinent part: Buprenoorphine tablet sublingual one mg, not given. EMAR note dated 9/13/12 at 4:00 p.m. read in pertinent part: Buprenoorphine tablet sublingual one mg, not given. The health status note dated 9/16/21 at 9:03 a.m. read in pertinent part; Resident went to the follow up appointment on Thursday 9/16/21 for the medication [MEDICATION(S)]. The health status note dated 9/16/21 at 11:40 a.m. read in pertinent part: Resident went to the follow up appointment for [MEDICATION(S)] and the resident told them he had severe chest pain and needed to go to the hospital. He was sent to the hospital from his appointment. The pain care plan for Resident #182 revised on 10/12/21 (during the survey) read in pertinent part: Resident is at risk for pain. The resident will voice a level of comfort through the review date. Give pain medications as ordered and monitor for effectiveness. Monitor for side effects of pain medications, update medical director as needed. Monitor pain every shift. Resident #182 was in and out of the hospital during October 2021. He was admitted to the hospital on 9/16/21 (see above note) and returned to the facility on [DATE], returned to the hospital on 10/12/21 and returned to the facility on [DATE]. He received [MEDICATION(S)] per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility failed to give [MEDICATION(S)] medications as ordered during August and September 2021. III. Staff interviews The pharmacist was interviewed on 10/14/21 at 3:15 p.m she said all medication orders were faxed to the pharmacy and filled the same day. The pharmacy had up to three deliveries a day so no resident would be without their medications. She said the medication [MEDICATION(S)] Solution was used for uncontrolled body movements or tremors related to [CONDITION(S)]. Resident #68 had the medication ordered and the pharmacy was able to deliver the medication shortly after it was called in for a refill anytime it was needed. She said the medication benefited the resident if it was used correctly for his quality of life. The director of nurses (DON) was interviewed on 10/14/21 at 5:50 p.m. She said medications were to be given as ordered. When a resident refused medication, a nurse note was written and the doctor was notified each time. She said she gave some education on medication administration a few days ago on resident refusals and missed doses. When the medication was not available the nurse called the pharmacy to follow up on the medication and called the physician if needed for any changes. She was aware of the medication Buprenoorphine for Resident #182 not being available and said a plan was put in place to reeducate the admissions department about special medications. She said the facility had put provisions in place for Resident #182 with the clinic specializing in the medication [MEDICATION(S)]. She said appointments were made in advance for the resident to make sure he had the medication refilled. Regarding Resident #68, the DON said she was unaware of his tremors and medication unavailability (see above). The physician was interviewed on 10/14/21 at 3:00 p.m. She said the medication [MEDICATION(S)] for Resident #68 was prescribed by the neurologist. She said when the tremors or shaking started for Resident #68 the medication was supposed to help alleviate them. She said the Buprenoorphine medication was a specialty medication and she could not sign for it. She started Resident #182 on [MEDICATION(S)] to help with his pain levels until the medication [MEDICATION(S)] was available. The resident had been in and out of hospitals and the facility was told he had to come back to the facility. The facility realized they could not meet the residents needs with filling the medication for his pain. She said the resident had the medication prescribed to help with the withdrawal of a drug and since he had been in and out of the hospital he was no longer in withdrawal. She said the resident would be seen in the outpatient clinic for behavioral issues and to take him off the [MEDICATION(S)] medication. Every time he went to the outpatient clinic he complained of chest pain so the clinic sent him back to the hospital. She said his chest pain was not related to not having the medication but from anxiety from wanting the real drug instead of a synthetic one. -However, there was no care plan or progress notes in Resident #182's medical record regarding these behavioral symptoms, withdrawal issues and treatment, or evidence of a plan to discontinue the resident's [MEDICATION(S)] medication.

Based on observations, record review, and staff interviews, the facility failed to ensure one (#29) of three out of 37 sample residents received the care and services necessary to prevent the development of pressure injuries and to promote healing of pressure injuries. The facility failed to turn and reposition Resident #29 at least every two hours to prevent the development of a pressure injury, accurately assess the resident's skin and identify the pressure injury once it developed, and implement timely treatment interventions to treat the pressure injury after it was first identified. The facility failures contributed to the resident developing an unstageable pressure injury to the coccyx. Findings include: I. Professional reference According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .), Cambridge Media: Osborne Park, Western Australia; 2014, from http://www.npuap.org (10/18/21): Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [CONDITION(S)] of intact skin. Intact skin with a localized area of non-blanchable [CONDITION(S)], which may appear differently in darkly pigmented skin. Presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], abrasions). Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). The National Pressure Ulcer Advisory Panel (NPUAP), Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing: -Positioning that places pressure on the pressure ulcer should be avoided. -The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented. -The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications. -Signs of deterioration in the wound should be addressed immediately. -The assessment should include: location, category/stage, size, tissue type, color, peri-wound (skin around the wound) condition, wound edges, exudate, undermining/tunneling, order. II. Resident status Resident #29, age 86, was admitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/20/21 minimum data set (MDS) assessment revealed the resident's cognition was not assessed. According to the admission progress note dated 8/14/21, the resident was alert and oriented to person, place and situation. The MDS documented she required extensive assistance from staff to perform bed mobility and transfers. The resident did not have any pressure injuries at the time of assessment but was at risk of developing pressure injuries. III. Observations and interview The resident was observed on 10/12/21 from 10:15 a.m. to 12:30 p.m. She was lying on her back in her bed. She was on a pressure relieving mattress, not an alternating air mattress. Multiple staff were observed to walk the hall and did not offer to turn or reposition the resident. During an interview with the resident at 12:35 p.m., she said no staff came to turn her. IV. Wound care observation The resident's wound was observed on 10/13/21 at 10:35 a.m. during wound care. There was no dressing on the wound. The nurse said the hospice certified nurse aide (CNA) visited with the resident and gave her a bed bath. She said she believed that was when the dressing fell off. The wound was red in color with some slough. There was no odor or drainage. There were no signs of infection. The nurse cleaned the wound and applied the dressing. The nurse said the wound was unstageable. V. Record review The comprehensive care plan, initiated on 10/11/21 (14 days after wound was identified) and revised on 10/13/21 (during survey), identified the resident had a pressure ulcer to her coccyx and it was unstageable. Interventions included to administer treatments as ordered and monitor for effectiveness, follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, initiated on 10/13/21 (during survey) and revised on 10/13/21, identified the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Intervention included: if the resident refused care, talk to the resident about her concerns and go back at a time agreed on, inform hospice if the resident continues to refuse and respect the resident's wishes. -The care plan failed to include that the resident was at risk for skin breakdown, and appropriate interventions to prevent skin breakdown, such as turning and repositioning every two hours. -There was no evidence that the resident refused to be repositioned. The admission skin assessment, dated 8/14/21 documented, bilateral lower extremities dry skin and discoloration. It documented the resident's skin was intact. A Braden Scale for Predicting Pressure Ulcer Risk assessment was completed on 8/14/21. The resident's score was 18, mild risk for developing pressure injuries. The assessment identified a potential problem: Rarely eats a complete meal and generally eats only about half of food offered. Protein intake includes only three servings of meat or dairy products per day. Occasionally will take a dietary supplement. Weekly skin assessments dated 9/2/21, 9/4/21, 9/11/21, 9/18/21, 9/25/21 and 10/2/21 revealed no skin issues. A shower sheet dated 9/28/21 was reviewed. It was identified by the director of nursing (DON) that the resident had an open area on her coccyx and [CONDITION(S)] to bilateral feet. -There were no descriptions and measurements of the wound. -There was no evidence the physician was notified, treatment orders requested/implemented, or the care plan updated (see above). A timeline of the wound was provided by the regional nurse consultant/infection preventionist (RNC/IP) on 10/13/21 at 11:00 a.m. It documented the following: -9/15/21 - the physician noted on a visit that the resident's skin was fragile and at high risk for skin breakdown. Resident is on a pressure relieving mattress (the care plan was not updated). -9/20/21 - the hospice nurse noted upon her visit that the resident's skin was intact. -9/25/21 - the facility registered nurse (RN) noted on a skin assessment that the resident's skin was intact. -9/28/21 - during a full facility skin sweep, the director of nursing (DON) noted an open area to the resident's coccyx. The physician was made aware and the hospice nurse in the facility was made aware. -10/5/21 -Wound doctor noted that the ulcer was healing. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound tracker form dated 9/30/21 documented the resident had an unstageable pressure injury to her coccyx and it measured 4.5 x 6 centimeters (cm) x utd (undetermined depth). The wound tracker form dated 10/5/21 was reviewed. It documented the resident had an unstageable pressure injury to her coccyx and it measured 2 x 4.5 cm x utd. It revealed the wound was healing. Review of point of care documentation (where CNAs document) from 8/14/21 to 10/14/21 revealed there was no task/intervention for the CNA to reposition or turn the resident. VI. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 10/12/21 at 2:00 p.m. She said the resident was in hospice and was unable to reposition herself. She said she believed the resident developed the wound because she laid on her back most of the time. She said sometimes she would be so busy and did not have time to reposition the resident. (Cross-reference F725, sufficient nursing staffing.) The director of nursing (DON) and the regional nurse consultant/infection preventionist (RNC/IP) were interviewed on 10/14/21 at 2:45 p.m. The DON said she had been in her position for two weeks. She said according to the weekly skin assessments, the resident had no skin issues. She said the staff should be turning and repositioning the residents who were unable to turn themselves, to prevent skin breakdown. She said she did a house wide sweep to assess all residents' skin to identify any skin breakdown. She said on 9/28/21 during the skin assessments, she identified an open area on Resident #29's coccyx. She said she notified the doctor but did not assess and measure the open area. She said she did not measure the wound because she did not want to measure inaccurately. She said she was not sure how the wound developed but she believed probably because of poor nutrition intake and immobility. The RNC/IP said when a wound was first identified, it should be assessed and measured. She said the nurse should notify the physician to obtain orders for treatments. She said not treating the wound in a timely manner could cause the wound to get worse. She said the DON should have measured the wound and ensured treatment orders were in place. The RNC/IP said the resident was seen by the wound doctor and the wound was healing. VII. Facility follow-up The interim nursing home administrator (INHA) provided a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . It documented in pertinent part, The resident developed an unavoidable skin breakdown on her buttocks that may never heal due to poor nutritional status, immobility, poor hydration, and terminal cancer. She is on a pressure relieving mattress and a wound care team is in place. -However, findings revealed the resident's pressure injury was not unavoidable or impossible to heal. According to the 10/5/21 wound tracker form, the wound had decreased in size and showed signs of improvements. It documented that the wound doctor noted that the wound was improving.

Based on observations, record review, and interviews, the facility failed to provide care and services to prevent the development and worsening of pressure injuries for two (#1 and #3) residents reviewed out of six sample residents. The facility failed to assess and monitor Resident #3's skin integrity on a routine basis and implement a care plan for skin integrity with interventions to prevent the development of pressure injuries even though the resident was a high risk. Facility staff had identified a break in Resident #3's skin integrity on 5/16/21 on the resident's knees but did not document an assessment of the area until 5/26/21 and did not implement any interventions to prevent further breakdown from occurring. Without preventative measures being put into place, the left and right knee wounds, which were avoidable, developed into unstageable pressure injuries by 6/10/21, approximately four week later. Furthermore, the facility also failed to identify the development of a pressure wound in a timely manner and implement effective interventions to prevent further progression of the wound for Resident #1. Findings include: I. Facility policy and procedure The Prevention of Pressure Ulcers/Injuries policy and procedure, last revised July 2017, provided by the nursing home administrator (NHA) on 7/28/21 at 4:02 p.m., revealed in pertinent part, Skin and Risk Assessment - Assess the resident for existing pressure ulcer/injury risk factors quarterly and upon any changes in condition. Conduct a comprehensive skin assessment upon admission and weekly. Inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living (ADLs). Prevention - Keep the skin clean and free of exposure to urine and fecal matter. Monitor the resident for weight loss and intake of food and fluids. Include nutritional supplements in the resident's diet to increase calories and protein. Choose a frequency for repositioning based on the residents mobility, the support surface in use, skin condition and tolerance, and the resident's stated preferences. At least every two hours or as needed, turn residents who require assistance in a position of comfort. Teach residents who can change positions independently the importance of repositioning. Provide support devices and assistance as needed. Remind and encourage residents to change positions. Support Surfaces and Pressure Redistribution - Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight and overall risk factors. II. Resident #3 A. Resident status Resident #3, age less than 65, was admitted [DATE]. According to the July 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/21/21 minimum data set (MDS) assessment revealed the resident had severely impaired cognitive function. The resident required extensive to total assistance of one to two people for all activities of daily living (ADLs). The resident was at risk for pressure ulcer development and had two unstageable pressure ulcers during the assessment period. B. Record review The 2/23/21 Braden Scale for predicting pressure ulcer risk revealed the resident was high risk with a score of 11. It indicated the following clinical suggestions: -Provide routine skin care; -Turn and reposition at least every two hours while in bed; -Evaluate/provide routine skin care as needed (PRN); -Evaluate oral care; -Feed resident meals; -Encourage small, frequent position changes; -Encourage meals; and, -Obtain order for physical therapy (PT)/occupational therapy (OT) consultation. Review of the record on 7/16/21 revealed the resident did not have a skin integrity care plan in place prior to 6/21/21, see below. A 5/16/21 shower sheet revealed the nurse was notified of skin tears between both of the resident's legs on her knees. Review of the record on 7/16/21 revealed no further documentation of the skin impairment to the resident's knees until 5/26/21, see below. The 5/25/21 weekly skin check revealed the resident had no skin conditions or changes, ulcers or injuries. It indicated the resident had no open areas or bruising. Review of the record revealed that prior to the 5/25/21 weekly skin check, the resident had not had a skin check done since 5/4/21. The resident's skin was checked three out of four weeks in January 2021, two out of four weeks in February 2021, one week out of five in March 2021 and two out of four weeks in April 2021. A 5/26/21 skin/wound note revealed the resident had abrasions to bilateral lower extremities from friction, one on the right inner thigh and two on the left inner thigh. It indicated wound care was provided and a pillow was placed between the resident's thighs to avoid friction. A 5/27/21 weekly skin alteration (non-pressure) evaluation revealed the resident had three abrasions to her lower extremities, the left inner distal knee measured 2.1 centimeters (cm) by 1.2 cm by 0.1 cm, the left inner posterior knee measured 2.2 cm by 0.9 cm by 0.1 cm and the right knee measured 1.5 cm by 2.7 cm by 0.1 cm. It indicated the wounds were evaluated by the wound physician that day and treatment was to apply Santyl (an ointment used to remove dead tissue) and cover with a dry dressing daily. The 5/27/21 wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] -Wound #4, the left distal inner knee was an abrasion with an area of 2.52 square (sq) cm and a volume of 0.251 cubic cm. The wound bed had 70% slough (dead tissue) and 30% granulation (healing inner tissue) with a small amount of serosanguinous (fluid) drainage. -Wound #5, left proximal inner knee is an abrasion with an area of 1.98 sq cm and a volume of 0.198 cubic cm with 10% epithelialization (healing outer tissue), 80% slough and 10 % granulation with a small amount of serosanguinous drainage. -Wound #6, the right knee was an abrasion with an area of 1.05 sq cm and a volume of 0.405 cubic cm. The wound bed had 40% epithelialization, 10% slough and 50% granulation with a small amount of serosanguinous drainage. -All three wounds were surgically debrided to remove subcutaneous (the deepest layer of skin) along with devitalized tissue: slough, with the use of a curette. -Wound care for all three wounds included: cleanse with normal saline, apply Santyl and cover with a dry dressing daily and as needed (PRN). -Wounds #1 to #3 had previously been treated by the wound care physician and healed in May 2020 and November 2020, which showed the resident had the ability to heal and she was at high risk for developing pressure injuries. A 5/29/21 shower sheet revealed the resident had deep tissue injuries (DTI) to the inside of both knees. The 6/3/21 wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] -Wound #4, the left distal inner knee was deteriorating with an area of 3.57 sq cm and a volume of 0.357 cubic cm with 20% epithelization and 80 % granulation and a small amount of serosanguinous drainage. -Wound #5, the left proximal inner knee was deteriorating with an area of 4.4 sq cm and a volume of 0.44 cubic cm with 30% epithelialization, 70% granulation and a small amount of serosanguinous drainage. -Wound #6, the right knee was deteriorating with an area of 4.2 sq cm and a volume of 0.42 cubic cm with 40% epithelialization and 60% granulation with a small amount of serosanguinous drainage. -Wound care for all three wounds included: cleanse with normal saline, apply honey-gel and cover with a dry dressing daily and PRN. -The wheelchair cushion was evaluated. The 6/10/21 wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] -The left inner proximal knee and right knee wounds were reclassified as unstageable pressure injuries. -Wound #4 to the left distal inner knee continued to be classified as an abrasion was improving with an area of 1.32 sq cm and a volume of 0.132 cubic cm with 20% slough and 90% granulation and a small amount of serosanguinous drainage. -Wound #5 to the left proximal inner knee, now classified as an unstageable pressure injury, was deteriorating with an area of 4.2 sq cm and no measurable depth with 80% eschar, 10% slough and 10% granulation and a small amount of serosanguinous drainage. -Wound #6 to the right knee, now classified as an unstageable pressure injury, was deteriorating with an area of 5.7 sq cm and a volume of 0.57 cubic cm, with 20% slough, 80% granulation and a small amount of serosanguinous drainage. -All three wounds were surgically debrided to remove subcutaneous along with devitalized tissue: slough, with the use of a curette. -Wound care for the left distal inner knee included: cleanse with normal saline, apply honey and cover with a dry dressing daily and PRN. Wound care for the wounds to the left proximal inner knee and the right knee included: cleanse with normal saline, apply Santyl and cover with a dry dressing daily PRN. -Recommendations included: please place a pillow between legs to avoid pressure injury from contractures. According to the June 2021 CPO, an order was received on 6/10/21 to place a pillow between the resident's legs/knees every shift. The 6/17/21 wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] -Wound #4 to the left distal inner knee, continued to be classified as an abrasion, had no changes noted in the wound progression with an area of 1.5 sq cm and a volume of 0.15 cubic cm with 70% epithelization and 30% granulation and a small amount of serosanguinous drainage. -Wound #5 to the left proximal inner knee, classified as an unstageable pressure injury, had no change in wound progression with an area of 4.0 sq cm and no measurable depth with 30% eschar, 40% slough and 30% granulation and a small amount of serosanguinous drainage. -Wound #6 to the right knee, classified as an unstageable pressure injury, was improving with an area of 3.4 sq cm and a volume of 0.34 cubic cm, with 100% granulation and a small amount of serosanguinous drainage. -The wound to the left proximal inner knee, #5, was surgically debrided to remove subcutaneous along with devitalized tissue: slough, with the use of a curette. -Wound care for the left distal inner knee and right knee included: cleanse with normal saline, apply honey and cover with a dry dressing daily and PRN. Wound care for the wound to the left proximal inner knee included: cleanse with normal saline, apply Santyl and cover with a dry dressing daily PRN. According to the June 2021 CPO, the order for the pillow between the knees was discontinued and a new order was entered to place a knee separator between her knees every shift. The care plan, initiated 6/21/21, revealed the resident was at risk for pressure injuries/skin breakdown related to bowel and bladder incontinence, impaired mobility and contractures to the lower extremities with actual pressure to left knee and right knee. Interventions included: -Assist with positioning; -Wound team to follow; -Place knee separator between her knees; and, -Pressure reducing cushion to chair. Review of the record revealed the resident continued to be seen by the wound physician weekly and the resident's wounds were healed or improving with latest measurements on 7/15/21 being: -Wound #4 -healed -Wound #5 to the left proximal inner knee, classified as an unstageable pressure injury, was improving with an area of 2.47 sq cm and no measurable depth with 10% slough and 90% granulation. -Wound #6 to the right knee, classified as an unstageable pressure injury, was improving with an area of 0.25 sq cm and no measurable depth, with 100% epithelialization. -The most current wound measurements show improvement or healing which showed these wounds were avoidable and had the ability to heal. The proper interventions were not implemented and followed consistently when the skin impairment was first identified on 5/16/21 in order to prevent the wounds from becoming unstageable on 6/10/21. III. Resident #1 A. Resident status Resident #1, age less than 65, was admitted on [DATE] and discharged on [DATE]. According to the June 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/8/21 minimum data set (MDS) assessment revealed the resident had severely impaired cognitive function. The resident required extensive to total assistance of one to two people for all activities of daily living (ADL). The resident was at risk for pressure ulcer development but did not have any pressure ulcers at the time of the assessment. B. Record review The 3/1/21 Braden Scale for predicting pressure sore risk revealed the resident was moderate risk with a score of 13. According to the form, a score of 15-18 was at risk, 13-14 moderate risk, 10-12 high risk and 9 or below very high risk. It indicated no clinical suggestions were made. The care plan, last revised 12/11/2020, revealed the resident had a potential/actual impairment to his skin integrity and is at risk for pressure areas and skin breakdown related to bowel and bladder incontinence and impaired mobility. Interventions included: -Apply protective barrier cream to peri-area after each incontinence and/or with morning and evening cares; -Avoid friction and shearing. Use turn sheet for repositioning; -Avoid scratching and keep hand and body parts from excessive moisture. Keep fingernails short; -Daily skin inspection during care. Notify the licensed nurse of skin integrity impairments; -Document education, verbalization of understanding and continued non-compliant choices; -Encourage good nutrition and hydration in order to promote healthier skin; -Encourage and assist as needed to turn and reposition when in bed; -Pressure relieving cushion to wheelchair and pressure relieving mattress to bed; -Provide loose fitting, easy to remove clothing; -Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Keep skin clean and dry. Use lotion on dry skin; -Monitor for signs and symptoms of infections, do wound rounds; and, -Weekly licensed nurse skin assessment to include review/check of footwear. The 6/10/21 weekly skin check revealed the resident had no skin conditions, changes, ulcers or injuries. It indicated the resident had scratches to his bilateral arms, legs and chest and creams and antihistamines were being applied. According to a 6/16/21 skin/wound note written at 5:58 a.m., the resident had moisture associated skin disorder (MASD) on his buttocks. It indicated the wound was cleansed and covered with a foam dressing. A 6/16/21 skin/wound note written at 1:13 p.m. revealed the wound to the resident's buttocks had a skin flap and an open area on the coccyx with bleeding that was cleansed and a dressing applied. It indicated the resident was having increased weakness and was unable to assist with repositioning in bed. The note indicated the physician was notified and was to come into the facility to assess the resident. A 6/16/21 skin/wound note written at 3:37 p.m. revealed the resident was assessed by the physician and the physician had the resident sent to the emergency room for further evaluation. The 6/16/21 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . It indicated the resident was transferred to the emergency room for evaluation. A clarification of this progress note was made on 7/14/21 to include: I just glanced at this wound and did not measure it or checked thoroughly for wound depth because the patient was in acute distress and it was apparent he needed transfer to the emergency room as soon as possible (ASAP). The 6/16/21 emergency room progress note revealed the resident had a stage 2 pressure ulcer to his coccyx with no tunneling noted. It indicated the surrounding tissue was sloughing and had notable [CONDITION(S)] (redness). IV. Staff interviews Registered nurse (RN) #1 was interviewed on 7/16/21 at 10:25 a.m. He said he had been the wound nurse since August 2020 but he was not wound certified. He said weekly skin assessments should be done by the floor nurse and documented in the electronic medical record (EMR) weekly. He said he monitored all wounds in the building weekly along with the wound physician. RN #1 said anytime a new skin issue was identified, a risk management (incident report) was completed. He said he reviewed these daily and then went and assessed the wound himself. He said interventions to prevent breakdown included: frequent positioning, incontinent care and an up/down schedule. He said interventions he would put into place if a resident had a wound included: following wound care ordered by the physician, adding supplements for nutrition, continuing with frequent positioning and an up/down schedule. He said he would also involve therapy if needed to evaluate the resident's wheelchair and cushion. RN #1 said Resident #3's wounds started out as abrasions and because of her contractures, the wound developed into pressure areas. He said he thought the staff were using a separator in between the resident's knees to prevent them from rubbing together. He said the separator was started sometime at the end of June 2021. He said the wounds were improving. RN #1 said Resident #1 was a young guy that had a stroke and was primarily bed bound but he did not consider him at high risk for skin breakdown. He said the resident was sent out to the emergency room before he had an opportunity to assess the wound but he was told it was a stage 2 on his bottom. RN #1 said it was the MDS coordinator's responsibility to update the resident's care plan. Certified nurse aide (CNA) #1 was interviewed on 7/16/21 at 11:08 a.m. She said she tried to always observe the resident's skin when she was changing them but especially when she was bathing them. She said if she noticed any new skin issues she would call the nurse right away to assess the area. She said she tried to make sure her residents were kept clean and changed frequently and to off load areas using blankets or pillows. She said they tried to keep padding in between Resident #3's knees at all times since she had sores on both of them. The director of nursing (DON) was interviewed on 7/16/21 at 3:22 p.m. He said the nurses should be doing weekly skin assessments or more often if they were at high risk and the CNAs should be monitoring the resident's skin daily with care. He said the primary care physicians usually deferred all wound care to the wound physician and all wounds were reviewed by the wound physician weekly. He said they tried to make sure preventative measures and the proper documentation were in place but he was having to do re-education with the nurses on this. He said he felt like the staff had implemented interventions immediately for Resident #3 but did not document it. The DON said he interviewed the nurse that sent Resident #1 out to the hospital. She told him the resident had a small wound on his coccyx. He said he also interviewed the physician about the wound. He said the physician told him the wound had feces on it so he was just guessing the staging of the wound but did not really see it. He said the physician was more concerned about the resident being in distress. Licensed practical nurse (LPN) #1 was interviewed on 7/16/21 at 4:10 p.m. She said skin assessments were done weekly by the RN because LPNs were not allowed to assess but could inform the RN of any skin breakdown. She said all wounds in the facility were assessed by the wound nurse and physician weekly. She said interventions to prevent breakdown included: repositioning every two hours, change when needed, keep clean, and make sure the bed is made properly with no wrinkles. She said if a resident already had a wound, intervention to prevent further decline included: repositioning, monitoring the wound and providing wound care as ordered, keep the resident clean and dry and off-load the area of concern. She said it was the RN's responsibility to update the care plan.

Based on record review, resident and staff interview, the facility failed to ensure four incidents of abuse involving four residents (#29, #73, #82, and #20) were thoroughly investigated and residents remained free from abuse. Cross reference to: -F609 Reporting of Alleged Violations because the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin were reported to the state agency in a timely manner. -F657 failure to develop and maintain a person centered comprehensive care plan. -F741 failure to ensure that all staff had received the required inservice training related to handling aggressive behaviors. -F835 failure to ensure facility was administered in a manner that enabled it to use its resources effectively and efficiently. Specifically, the facility failed to: -Thoroughly investigate resident-to-resident verbal altercations involving residents #20 and #73. -Identify interventions and approaches to minimize and prevent recurrence of resident-to-resident altercations. -Follow-up with reported concerns related to resident behaviors. Resident #29 had expressed to facility staff feelings of being fearful of resident #82. An effective system of follow-up on such concerns could not be identified. -Follow-up on Resident #82's documented behaviors. The resident continued to exhibit behaviors that were distressing to other residents. -Have an effective system to ensure staff understood the verbalizations, actions and situations that necessitated abuse reporting and investigation. Findings include: I. Immediate Jeopardy [NAME] Findings Triggering Immediate Jeopardy 1. Resident #73 Interviews and record review conducted on 6/20/19 demonstrated Resident #73 was involved in two verbal altercations in the activities room from 5/12/19 through 6/20/19 with one resident (#20). (See incidents #1, and #2 below for descriptions of each resident-to-resident verbal altercation.) Resident #20, who was involved in incident #1 and #2, stated staff did not protect her from resident #73 and she contacted the police. 2. Resident #82 Interviews and record review of progress notes conducted on 6/20/19 demonstrated Resident #82 was wandering throughout the facility and entering resident rooms from 5/30/19 through 6/20/19and residents were fearful. An interview with Resident #29 revealed she felt harassed by and fearful of resident #82 because of resident #82's aggressive behavior and wandering (see below). 3. Incidents Review of incident #1, 5/12/19 (see below) revealed it was not thoroughly investigated and the investigation was not completed timely. Review of incident #2, 6/20/19 (see below) was witnessed by activity volunteers. The volunteers did report the incident to social services director (SSD) for investigation, however the other residents, and staff in the activity incidents were not interviewed during the investigation. Review of incident #3, 6/20/19 (see below) was reported to certified nurse aide (CNA) #1. The CNA did not report the incident to the nursing home administrator (NHA) for investigation and follow-up. Record review and interviews (see below) demonstrated Resident #82 had documented behaviors from 3/4/19 through 6/20/19 that were unaddressed with new interventions to protect Resident #82 from retaliation by others resulting from his known behaviors. On 6/20/19 (see incident #3 below) Resident #29 reported she was fearful of Resident #82 going into her bedroom and wandering, which resulted in reporting feeling fearful of resident #82. Additionally, the facility failed to protect others from resident #82's aggression. Review of incident #3, reported to the facility on [DATE], and reported to the Colorado Department of Public Health and Environment (CDPHE) on 6/24/19, showed Resident #82 was involved in a potential abuse/physical altercation with Resident #29 on 5/30/19. On 5/30/19 Resident #29 reported to CNA#1 that Resident #82 was coming in her room and she was fearful. CNA#1 reportedly told Resident #29 that resident #82 was harmless and did not report the incident to anyone. CNA #1 failed to report the resident ' s concern to facility staff; therefore the facility failed to investigate resident #29 ' s allegation. The facility's failure to keep facility residents safe created a situation of immediate jeopardy (IJ) with the potential for serious harm. B. Imposition of Immediate Jeopardy Based on staff and resident interviews (see below), which revealed inconsistent staff training on residents with dementia, abuse, and aggression, and no indication by staff they had been specifically trained on Resident #73 and 82 ' s behaviors, the clinical nurse consultant (CNC) was notified on 6/20/19 at 8:48 p.m., that the facility's failure to develop a specific plan for supervision of Resident #73 and #82, no plan to train staff on recognizing resident #73 and #82's behavioral triggers and aggression, and no specific approaches on how to safely and effectively intervene to protect fearful Residents #20 ,#29, and others from Resident #73 and #82's aggression, created a situation of immediate jeopardy with the potential for serious harm. C. Facility Response and Removal of Immediate Jeopardy On 6/21/19 at 8:00 a.m., the district director of clinical services (DDCS) submitted the following removal plan (draft four): Request for Removal of Immediacy of Immediate Jeopardy F600 immediate Jeopardy (MONTH) 21, 2019. IMMEDIATE PLAN AND STEPS TAKEN F600 and F689: Corrective Action Resident # 9 (#82) was placed on every fifteen-minute checks starting at 8:00 p.m. At 9:00 p.m. resident # 9 was put on one to one supervision which was provided by licensed practical nurse(LPN), who was trained by the director of nursing (DON) to include: management of aggressive behaviors, de-escalation techniques, abuse and neglect reporting. The resident continued to escalate throughout the night and became more agitated with the one to one monitoring. On 6/21/19 at 6:00 a.m. resident was placed on an Ml hold by police officer and transported to hospital. CNC will be available on site over this coming weekend and the week of 6/24/ 2019. Nursing home administrator (NHA) will take over in the facility as the NHA for (Lowry Hills Care and Rehabilitation). Effective 7/1/19. An internal investigation was started on 6/20/19 related to comments made by another resident, who reported that they were afraid and did not feel safe at times. Further investigation is pending at this time to identify additional residents that may have concerns about abuse, neglect or feeling safe in their environment. All residents throughout the facility will be interviewed. All residents who are non-verbal will be assessed through observational assessment. Employee education will include: management of aggressive behaviors, de-escalation techniques, abuse and neglect reporting and monitoring of residents with behaviors to include 15-minute checks up to one on one monitoring as of 6/21/2019. Education was provided by the clinical resource nurse to the assistant director of nursing (ADON), DON and social services director(SSD). Education is being provided to staff by the ADON, DON- along with a Spanish speaking employee and will continue over the weekend and will be provided for each shift until all employed have been educated on the correct steps for reporting abuse, neglect or residents' concerns. Employees will not be able to start their shift without the abuse and neglect training. Employee education will be completed by Monday (MONTH) 24, 2019. The DON or a designee will be available over the weekend to provide training. All staff members (on vacation or leave) who were unable to attend the mandatory training will be receiving written education before returning to employment. Failure to complete the written education will result in being taken off the schedule until completed. Staff must complete the training to retain employment. Follow up education will be provided on an individual basis if procedures are not followed. Re-education by S[NAME], DON, ADON or designee on management of aggressive behaviors, de-escalation techniques, abuse and neglect reporting and monitoring of residents will be provided. Training/Education Continuing education will be provided for all employees. The first in-service for all staff will be provided on (MONTH) 25, 2019 by Doctor of Philosophy (PHD). PHD will be presenting information on how to deal with agitated residents and de-escalati on tactics. Power points will be reviewed by the S[NAME] or designee. Systematic Changes Identifying residents that may have behavior concerns will be completed by using a behavior evaluation screening tool. The tool will address behaviors that may occur at different times of the day, i.e. verbal aggression, repetitive/obsessive behavior or hallucinations/delusions. A full copy of the seven (7) page evaluation tool is available in PCC. Behavior evaluation will be conducted on all current residents. Any residents with a behavior, an intervention will be put into place which will be appropriate for the behavior up to and including one on one monitoring. The medical provider and family/ responsible parties will be notified. Eight current residents which have been identified by the 672 will have an evaluation conducted by end of day 6/21/2019. The remainder of the Residents in the facility will be completed by Monday (MONTH) 24,2019 end of day. Education and training identification for aggressive behavior and timely notification will be implemented on 6/21/2019. All current staff will be educated on reporting abuse and neglect and will be compliant by (MONTH) 24,2019. New hires will be educated in the NEO class. The facility will start Angel care rounds the week of 6/24/2019. Angel Care rounds is a way in which the facility management team round on specific residents weekly to help ensure their needs are being met related to care needs, housekeeping, abuse/neglect. Identifying residents that may have concerns Residents that have been identified with behavior concerns and start to escalate such as screaming , hitting staff or other residents, verbal abuse to staff or residents an investigation will be conducted at that time to see if there are patient concerns surround abuse, neglect and safety, Residents with concerns will be addressed immediately. The education plan will be implemented at that time if needed. Plan for Resident Return Resident # 9 (#82) will be treated with respect and dignity as with all other resident s and will be placed in a single room for privacy. Resident will be monitored for medication refusal. Additional snacks that he enjoys, or drinks will be available to assist in decreasing his agitation. If at any time resident starts to exhibit increased aggression towards staff or other residents an investigation will be conducted. Regular checks every 15 minutes can be conducted or one to one observation if needed. At 4:00 p.m., on 6/21/19 the CNC was notified that the draft of the final removal plan signed by the CNC had been accepted and the IJ had been removed at 4:40 p.m. on 6/21/19. The findings include: II. Facility Policy In pertinent part, the facility's abuse and neglect prohibition policy, revised (MONTH) (YEAR), included: -Each resident had the right to be free from abuse. - The facility administrator is the Abuse Prevention Coordinator. - Abuse meant the willful (intention to perform the action) infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. - Physical abuse includes hitting, kicking, pinching and slapping. - Verbal abuse included oral, written or gestured language that was disparaging or derogatory, regardless of their ability to comprehend or disability. - Sexual abuse was non-consensual sexual contact of any kind, including sexual harassment, coercion, or sexual assault. - The facility would address all concerns in accordance with 'truly listening to our customers' policy. Residents, families, and staff would be able to report incidents and concerns without fear of retribution. - Facility supervisors would immediately investigate and correct reported or identified situations in which abuse, neglect, injuries of unknown origin, or misappropriation of resident property was at risk for occurring. - Residents identified as exhibiting abusive behavior would be reviewed by the physician and treatment modified as appropriate. - The facility would protect residents from harm during the investigation. - The facility would make referrals to the appropriate state agencies as necessary. - The facility would timely conduct an investigation of any alleged abuse. - The facility would report all allegations and substantiated occurrences of abuse to the administrator, state survey agency, and law enforcement officials and adult protective services in accordance with Federal and state law. III. Facility failure Record review and staff and resident interviews revealed the facility was aware of Resident #73 and #82 verbal and physical behaviors against others. The facility had interventions such as distraction, medication management and redirection; however, their behaviors were escalating with no positive response to the interventions. The facility did not ensure the residents were safe from the escalating behaviors. IV. Resident #73 [NAME] Resident status Resident #73, age 72, was admitted on [DATE] and discharged [DATE]. According to the June, 2019 computerized physician orders [REDACTED]. The 6/6/19 minimum data set (MDS) assessment, revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. Resident was frequently incontinent for bladder and occasionally for bowel. There was no documented behavior for the resident. The resident required extensive assistance for transfers, bed mobility, toileting, personal hygiene and dressing. He required limited assistance for eating. B. Record review The inaccurate care plan, initiated 5/10/19 and revised 5/10/19, identified Resident had mood problems related to [MEDICAL CONDITION] (the resident did not have a [DIAGNOSES REDACTED]. Interventions included behavioral health consults as needed, educate resident regarding expectations of treatment, concerns with side effects and potential adverse effects, evaluation, maintenance. Monitor/record mood to determine if problems seem to be related to external causes, i.e. medications, treatments, concern over diagnosis. Monitor/record/report to medical doctor as needed to risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self. 1. Facility resident abuse investigation reports a. Incident #1 The 5/12/19 investigation report revealed Resident #73 began to act out and started calling staff derogatory names . Resident #73 then struck Resident #20, and kicked another resident. Resident #20 was interviewed. Resident #73 was not interviewed. All of the residents in activities, at the time of the incident, were not interviewed. Facility investigation follow-up The investigation initial report read Resident #73 began to act out and started calling staff derogatory names. Resident #73 then struck Resident #20, and kicked another resident. The police department took Resident #73 to the hospital for evaluation. Interventions implemented by the facility included medication changes and a referral for psychological and psychiatric services. Documentation did not highlight behavioral training to staff or resident redirection. b. Incident #2 (6/20/19) The 6/20/19 investigation report documented Resident #73 exhibited physical abuse towards another resident. Report further revealed police were called because of Resident #73 hitting Resident #20 in the face and pushing the resident. Resident #20 was interviewed. Resident #73 was not interviewed. All of the residents in activities were not interviewed. Facility investigation follow-up The police were contacted by Resident #20 and upon arrival at the facility the police issued an M1 psychiatric hold for Resident #73 and he was sent to the hospital. The facility did not do an ongoing assessment of resident #82 which included environment, staffing levels, training opportunities for stress management for dealing with difficult residents, and screening prospective residents in order to deem them a good fit for the facility and provide appropriate care and services. The facility did not implement a plan to ensure resident ' s needs and preference were managed. The resident was diagnosed to receive antipsychotic medication. The facility failed to create a plan to make sure residents needs for medication was addressed and given. V. Resident #82 [NAME] Resident status Resident #82, under the age 65, was admitted on [DATE] and discharged on [DATE]. According to the June, 2019 CPO, [DIAGNOSES REDACTED]. The 6/6/19 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of three out of 15. The resident had behavior delusions (misconceptions or beliefs that are firmly held, contrary to reality) and behavior symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) were present one to three days a week. The resident also exhibited other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). The resident refused all activities of daily living frequently and was independent with bowel and bladder. B. Record review The care plan, initiated 3/4/19 and revised 6/18/19, identified resident review Pre-admission screening and resident review (PASRR) due to [MEDICAL CONDITION] unspecified, [MEDICAL CONDITION] with hallucinations due to known physiological condition, patient noncompliance with other medical treatment and regimen diagnoses. Interventions included monitor for changes in mood/behavior during adjustment period. Orient resident to new surroundings room, unit, social areas, dining room, outdoor living. The resident did not have any behavior care plans included in his medical record. 1. Facility resident abuse investigation report form The 6/20/19 facility resident abuse investigation form revealed staff investigated Resident #82 wandering into Resident #29 ' s room possibly three weeks prior. Resident #29 was interviewed and said she was not afraid of Resident #82. The resident was started on 15 minute checks and one on one supervision was started on 6/20/19 at 8:00 p.m. Nursing progress notes Nursing progress note dated 3/4/19 at 5:01 p.m. read , Resident arrived from hospital, isolated in room throughout the afternoon, refused all cares by curling up in a ball. He did not want to be touched on multiple occasions with different staff will continue to monitor. The note did not mentioned contact to the physician. Nursing progress note dated 3/5/19 at 9:19 a.m. read, Resident was admitted yesterday and had difficulty adjusting. He isolated in room and refused all nursing care and assessments. The note did not mentioned contact to the physician. Nursing progress note dated 3/6/19 at 6:28 p.m. read , Resident continues to refuse care, did not eat and stayed in bed all day. The note did not mentioned contact to the physician. Nursing progress note dated 3/12/19 at 8:01 p.m. read ,Resident refusing all cares, showers, meal trays, and medications. The note did not mention contact to the physician. Nursing progress note dated 3/23/19 at 7:30 a.m. read , Resident remain alert, confused, and restless, went to bed at about 9:00 p.m. and stayed in bed. Nursing progress note dated 3/24/19 at 6:38 p.m. read , Resident refusing all cares, showers, meal trays, and medications. The note did not mention contact to the physician. Progress notes dated 3/25/19, 3/26/19, 3/27/19, 4/1/19, 4/2/19, 4/13/19, 4/17/19, 4/20/19, 4/21/19, 4/24/19, 4/26/19, 4/27/19, 5/9/19, and 5/14/19, read , Resident continued to refuse all cares and medications. The notes did not mention contact with the physician. Nursing progress note dated 4/18/19 at 6:20 p.m. revealed the resident was in a loud verbal argument with his roommate. The document read in pertinent part No visible injury noted on resident, he denied skin assessment, nor vital checks, he also denied being physically attacked, social services and medical doctor notified. Left message for resident ' s brother. Nursing Progress note dated 4/18/19 at 6:58 p.m. revealed resident to resident altercation. The document stated in pertinent part Resident ' s roommate standing over him and said I punched him in the head. Licensed practical nurse told resident to talk with administrator after dinner, no visible sign of injury noted on resident, vitals checked, skin assessment done, social services, medical doctor, and Resident ' s brother notified. There was no investigation for this incident. Nursing progress note dated 4/18/19 at 7:24 p.m. revealed in pertinent part, Resident has challenges with behavior, does not make appropriate decisions, he will go into other residents ' rooms without permission, touch their stuff, run in the hallways, several times a day. Staff and other residents will try to redirect him with no success. Behavior notes Behavior note dated 5/20/19 at 5:11 p.m. read , Resident was out of control, pushed staff, and punched in the face. Two residents witnessed incident and were very upset. Shift supervisor called police and staff refused to press charges because of resident ' s mental status. the note did not mention notification of physician, social services or making sure residents that witnessed incident were okay and felt safe. Behavior note dated 5/28/19 at 12:57 p.m. read , Resident has been walking down the hall half naked. He was told by staff to wear something but refused. He has been abusive to his roommate, has banged room door on nursing staff, refusing to let nurses take care of his roommate. Nurse stated it is so scary to to provide care to him. note did not mention notification of physician, social services or making sure residents that witnessed incident were okay and felt safe. Behavior note dated 6/16/19 at 4:42 p.m. read , Resident ' s behaviors are out of control, sometimes the resident is in hallway half naked. Behavior note dated 6/19/19 at 10:40 a.m. read , Resident is walking around the facility without a shirt and very loose pants and yelling at staff members. Resident attempted to steal social services director food. the note does not mention physician contacted or incident completed. Behavior note dated 6/19/19 at 9:43 p.m. read , Resident continues to yell at staff and has become increasingly violent toward staff and other residents. the note did not mention notification of physician, social services or making sure residents that witnessed incident were okay and felt safe. Health status note Health note dated 5/27/19 at 6:04 p.m. read , Resident aggressive today following very closely behind certified nursing assistants(CNA), took supplies from md cart, took glucometer machine, pushed a resident ' s wheelchair down the hall and slammed into wall. Resident refused all medications and cares. No notifications to physician or incident reports filled out. Health note on 6/21/19 at 6:28 a.m. read , Resident picked up a metal pill crusher and attempted to hit nurse. Resident attempted to pin nurse on one on one to chair and said, I just want to hold you. Resident refused all medications and cares. No notifications to physician or incident reports filled out. C. Facility follow-up 1. Staff inservice for abuse training The inservice documentation on abuse training, fifteen-minute checks, a full house sweep, interviews of all residents about others entering their rooms uninvited, and action to take if residents felt uncomfortable by other residents. was received on 7/2/19 and indicated all staff were trained. 2. Fifteen minute check observation record Fifteen minute checks were initiated for Resident #82 on 6/20/19 and continued to one on one at 8:00 p.m. until 6/21/19 when he was sent to the hospital and placed on a M1 hold (Mental Health Hold) due to behaviors that included throwing a pill crusher and punching a CN[NAME] VIII. Resident interview Resident #29 was interviewed on 6/20/19 at 12:15 p.m. The resident stated Resident #82 had come wandering in her room and she had to tell him to get out She stated the resident walked down the hallway with no shirt on. Resident #29 also stated that she tries to go to bed very late to avoid the resident. She stated that she would often go to the television room to avoid resident and on one occasion thet resident came and sat on the couch very close to her when no one was in the area. She said she was fearful of the resident and was concerned Resident #82 would eventually hit her. Resident #29 was interviewed on 6/20/19 at 1:10 p.m. She said that Resident #82 always walked around the facility without a shirt or shoes and was allowed to wander into your room. She said she felt like she was in danger because she never knew how he would react. She said he had attempted to go into her room and staff would just yell at him and tell him to get out of there. Resident #29 was interviewed again on 6/20/19 at 2:33 p.m. She said that Resident #82 ran would go behind the nurses ' station and get into the refrigerator. Resident #20 was interviewed on 6/20/19 at approximately 5:45 p.m. She said that Resident #73 had punched her in the face and hit her with a bingo card earlier in the day. She said she had called the police because she was not going to put up with it any longer. She said she had been hit in the arm right after he had admitted to the facility but they had not called the police. She said she was not afraid of him. She said Resident #82 was not hygienic because he does not wear shoes, socks or a shirt and touches everything, including food in the refrigerator. She said he is wiry and took a swing at me. She said he could cause damage and a CNA was a witness to this and told the nurse. She said staff can not control him so she would avoid him. She said I ' m a little bit afraid of him, he ' s very unpredictable. Resident #51 was interviewed on 6/25/19 at 5:15 p.m. He said that Resident #82 was very disruptive to everyone and staff did not know how to handle his behavior. He said Staff didn ' t seem to know how to stop him. Staff would either ignore him or hand him some food to distract him. IX. Staff interviews CNA #1 was interviewed on 6/20/19 at 4:04 p.m. She said Resident #82 typically refused everything but did mind his own business. She said the resident would typically be up all night and sleep all day. She said Resident #29 told her on 6/19/19 that she was fearful of Resident #82 when Resident #82 was headed out to the common area to watch television. She said she told Resident #29 to not worry about it and go sit with the resident. She said that when Resident #29 talked to her later she said she told her he (Resident #83) was not that bad. Licensed practical nurse (LPN) #3 was interviewed on 6/20/19 at 7:00 p.m. She said that Resident #82 usually slept during the day and then would be up at night. She said the resident frequently refused his medications and preferred to take tablets rather than capsules. She said he had trouble with other residents and would invade their space and get too close. She said staff would usually tell him to get away and sometimes he would get away and other times he would laugh. She said that she knew some of the other residents were afraid of Resident #82. She said Resident #20 had told her earlier in the day that she was afraid of him and did not like him. She said that Resident #73 was erratic and would try to intimidate other residents and staff. She said the way the facility managed his behavior was to redirect him and if it did not work they would tell other staff. She said she had not received any training since she had begun working in the facility several years ago. Licensed practical nurse (LPN) #1 and LPN #2 were interviewed on 6/20/19 at 7:00 p.m. LPN #1 said that she had been working when resident #82 was admitted and said she did not think that the facility was the best place for him. She said the resident had told her that he no longer ate meat and was asking for snacks constantly. She said the resident ' s behavior was very sporadic and he was up all over the place. She said she would try to redirect him but he did not listen. She said he frequently refused his medication; she said he would occasionally take some of them and would throw the rest away. She said he was ordered 600 mg of [MEDICATION NAME] and [MEDICATION NAME] daily but rarely took it. She said the resident had not showered or changed his clothes since his admission. She said she was not afraid of the resident but had never received any training related to behavior management since she started working at the facility. LPN#1 said his behaviors ' had become more erratic since he admitted and they had gotten worse because he refused his medications. She said when he was first in the building, she might have said she was afraid of him but said now she talked to him and would check on him frequently. She said he would sometimes sleep for two days and then be up and all over the nurses ' station. LPN#7 was interviewed on 7/2/19 at 5:15 p.m. She said she worked all over the facility for several years. She said she worked with Resident #82. She said he would wander into other residents' rooms, take stuff , punch staff, and steal things off the medication cart. She said resident would not wear socks or a shirt in the facility and had trouble keeping his pants up. She said she was not afraid of the resident but knew many of the residents were. She said she had not received any training on behaviors and dementia for the residents. The Social services director(SSD) and the regional financial consultant (RFC) were interviewed on 6/20/19 at 7:20 p.m. The SSD said she was involved in the admission process and recalled when Resident #82 was admitted there was concern about his wandering but the nursing staff said they believed they could meet his needs The RFC said that the resident was safe here but not thriving. The SSD said that the resident was difficult to manage and they would redirect him. He walked around a lot and refused cares. She said he had a roommate but they had an altercation and the roommate was moved. She said that other residents did not say they were afraid of him but did say they did not like to see him with his shirt off. She said the resident refused all mental health services. She said their interventions included redirection and offering him food. The SSD and the RFC both said he was frequently hungry and food usually helped with his behaviors. The SSD said the resident ' s PASSAR II was reviewed when he admitted to the facility. She said the recommendations included revealed the (TRUNCATED)

Based on interviews and record review the facility failed to ensure resident's environment was as free from accident hazards as possible and residents received adequate supervision and assistance to prevent accidents. Specifically, the facility failed to: -Ensure Resident #387 had adequate supervision to prevent two suicide attempts while at the facility. -Ensure the gate from the courtyard to the street was opearable. -Ensure that three residents (#2, #63, and #64) who had an air mattress was plugged into an outlet that received power from the generator after the power failed. Cross reference to: -F657 - failure to update the care plan because the facility failed to ensure Resident #25 and #37 ' s care plan were revised timely and updated to reflect the resident ' s pressure injury (PI) to his coccyx and buttocks; Resident #387 ' s care plan was updated to reflect a recent suicide attempt and intervientions related to the suicide attempt; and Resident #73 ' s care plan reflected current diagnosis. -F838 - failure to ensure the facility assessment was accurate and comprehensive to include the necessary care and services to meet the needs of the current resident population on a day to day and emergent basis. -F677 - failure to ensure Resident #2 was provided timely incontinent care after multiple requests. Findings include: I. Suicide Ideations A. Facility policy and procedure The facility Suicide Threats Policy and Procedure, revised (MONTH) 2010, was provided by the social services director (SSD) on 7/2/19 at 11:27 a.m., revealed in pertinent part: Resident suicide threats shall be taken seriously and addressed appropriately. The facility Wandering, Unsafe Resident Policy and Procedure, revised (MONTH) 2014, was provided by the SSD on 7/2/19 at 11:27 a.m., revealed in pertinent part: The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. B. Resident #387 ' s status Resident #387, under the age of 65, admitted on [DATE] and discharged on [DATE]. According to the (MONTH) 2019 computerized physician's orders [REDACTED]. The 2/21/19 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15 on the BIMS. She had little interest or pleasure in things during the review period. She had hallucinations and delusions but did not reject care or wander. She was independent with all activities of daily living but bathing where she needed supervision. 1. Record review a. Progress notes The 4/1/19 progress note documented the resident came to the nurse at 7:00 p.m. and reported her son was going to take her out. The nurse went into the resident's room at 10:30 p.m. and did not see the resident. The nurse observed the resident had signed herself out of facility and documented she was going out with her son; however her son did not come to the facility. At 11:30 p.m. the resident's son called the facility, told the nurse the resident was at a nearby grocery store, alone, and needed to come back to the facility. The resident's son denied taking her out of the facility or promising to take her out. A nurse from the facility picked up the resident and brought her back to the facility. The resident stated I went to the gas station and bought gasoline, went somewhere, took off my clothes and started lighting the match to burn myself, but I was so cold and the match will not light, Then I put on my clothes and went up to store to call my son to come pick me up. Resident complained of burning sensation under her breast due to gasoline she applied on herself. Nurse completed head to toe skin check, Redness noted under both breast. No other skin issues but complained of chills and burning sensation. Five boxes of matches were found in resident's bag. Nurse called 911 and sent resident to hospital for further evaluation. The 4/18/19 progress note documented the resident returned to the facility. The 4/18/19 admission progress note documented the resident arrived at the facility from the hospital at 2:00 p.m. and was placed on 15 minute checks and had a wander guard. The resident was not noted to be in any distress upon admission. The 4/25/19 social services progress noted, documented by the social services director documented the resident came to the SSD and said she had been receiving messages from her bible stating she has no friends and that everyone at the facility is mad at her. The resident reported she had no thoughts of harming herself and no thoughts of leaving the facility but did feel as if she had done something bad and was concerned that others in the facility are talking about her and pointing at her. She reported being paranoid and having racing thoughts. The SSD assured the resident and spoke to the director of nursing (DON), the nurse practitioner (NP) and the psychologist. The resident continued to be on frequent monitoring and said if she continued to have troubling thoughts she would call a family member and tell staff. The DON advised nursing staff to keep the resident on frequent checks and for staff to call the DON and physician if the resident experienced hallucinations. The 4/28/19 behavior note, written at 8:58 p.m. documented the nurse went to check on the resident at 6:46 p.m. The resident was lying on her bed and was awake and calm with no sign of the resident being worried about something (the note did not indicate the resident was asked how she was doing). At 8:24 p.m., a CNA called for the nurse and when the nurse came into the room the resident was lying on her bathroom floor with blood on her chest. The nurse completed an assessment and observed the resident had a self-inflicted wound, the size of a nickel, which was bleeding. The CNA reported she had done a routine 15-minute check on the resident and she was in the bathroom when she went back to the room [ROOM NUMBER] minutes later the resident remained in the bathroom and she decided to go into the bathroom since the resident was taking so long. When she discovered the resident, she had a knife; the physician was notified and gave order for he resident to go to the hospital. The 4/28/19 progress note, written at 9:23 p.m. documented that the resident was holding a butter knife that was soiled with blood. 2. PASARR Level II Notice of Determination for MI (mental illness) a. (MONTH) 14, (YEAR) The Preadmission Screening and Resident Review (PASARR) Level II, authorization date 11/14/18, documented the resident was at risk for self-harm such as drinking Drano (drain clog remover) and lighting herself on fire. The explanation of identified risks included: There must be no access to janitorial or other chemicals; outing outside the facility need to be supervised at least by family and (resident name) cannot have her own lighter or matches. This clinician feels that a care plan is needed so the staff have a plan in place to protect (resident name) from herself. The interventions above are recommended. Resident has had eight attempts at self-harm, five within the past year. She still feels that her voices are from God and she is still having voices, though she is adamant that she will never burn herself again, due to the severe pain from which she is suffering. The nursing home does need to indicate how they will prevent access to chemicals and lighters/matches for the resident. b. (MONTH) 15, 2019 The PASARR Level II, authorization date 4/15/19, documented the resident was at risk for suicidal/self-injury, risk gradual dose reduction and elopement risk. The explanation of identified risks, in pertinent part, included: Suicidal/Self-Injury/Elopement Risk: most recently, she (resident #387) cut her wander guard off and went out and bought lighter fluid in an attempt to light herself on fire in a local park. Resident may need placement in a secured facility, at a minimum, she needs placement in a facility with a wander guard in place and this needs to be checked regularly throughout each day. The facility needs to have a detailed plan regarding how they will prevent the most recent issues that brought about psychiatric hospitalization in place at the time of the resident's readmission. Resident tried to harm herself with a comb to her neck and scratched herself as a result while at the hospital. Sharp items (including scissors) need to be out of resident's possession and outings out of the facility need to be supervised by family. 3. Psychologist notes The 1/2/19 diagnostic assessment, completed by the psychologist, revealed the resident admitted to the facility from a psychiatric hospital after lighting herself on fire in response to auditory hallucinations. This attempt was the fifth suicide attempt within the last year and her eighth within her lifetime. During the assessment, the psychiatrist concluded that the resident met the criteria for paranoid [MEDICAL CONDITION]. The 3/20/19 psychological services progress note documented the resident's anxiety; unusual thought content and suspiciousness were moderately severe. The resident was receptive to interventions and worked to identify and process the discrepancy between knowledge of the Bible and her delusional beliefs. She showed increased insight and ability to manage triggers to unsafe behavior. No suicidality present at this time. The facility did not provide any psychologist notes for the week of 3/24/19, prior to her second suicide attempt while at the facility. The 4/25/19 psychological services progress note documented the resident's anxiety; unusual thought content and suspiciousness were moderately severe. The resident was receptive to provider and denied any current command hallucinations or thoughts of harming herself. Delusions were present and she remains paranoid. Remaining in facility and telling staff if she becomes unsafe discussed. 4. Computerized physician's orders [REDACTED].>The (MONTH) 2019 CPO documented staff should check placement of wander guard one time per day for safety. The order start date was 11/27/18. 5. Care plan The care plan initiated 12/3/18 documented the resident had the potential for [MEDICAL CONDITION] related to history of suicide attempt. The goal was for the resident to express and demonstrate freedom from suicidal ideation through the review date. The care plan had not been updated or reviewed since 12/3/18. Interventions included: -Administer medications as ordered and monitored for effectiveness and side effects. -Assess the seriousness of the resident's desire to die and ask her about a plan. -Consult with the attending physician as needed for medications or mental health services, encourage the resident to discuss feelings of frustration, hopelessness, anxiety, anger, fear, etc., evaluate level of suicide risk, and express hope in low key manner. -Make nursing observation rounds at irregular intervals especially at times that were predictably busy for staff (change of shift, early morning, etc.), monitor for expressions of suicidal expressions, and opportunities for self-harm (e.g., keep doors, windows and access to stairways secured, monitor cleaning, chemical, and repair supplies). -Refer to alternate support systems as appropriate mental health services. -Remove Resident's access from potentially harmful substances or items that may be used as a weapon belts, scarves, razor blades, shoelaces, scissors, plastic bags, etc. as needed and routinely check environment for hazards to ensure the environment was safe. The care plan initiated 11/28/18 and revised on 12/3/18 revealed the resident was an elopement risk. The goal was for the resident to have her wandering behavior addressed by walking or redirection. The care plan had not been updated or reviewed since 12/3/18. Interventions included: -Engage in diversional activity. -Complete Elopement Risk Assessment upon admission, quarterly and with significant change in status. -Determine lifestyles that may trigger episodes of elopement. -Distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books. -Identify pattern of wandering to determine if purposeful, aimless, or escapist. -Wander guard and check placement every shift. 6. Unsafe Wandering Risk Evaluation The 11/20/18 Unsafe Wandering Risk Evaluation documented the resident was at risk for wandering and elopement due to her [DIAGNOSES REDACTED]. The summary revealed that frequent monitoring of the resident would occur. It did not specify the frequency of the monitoring. There was no other Unsafe Wandering Risk Evaluations in the resident's medical record. 7. Documentation for 15-minute checks Facility staff was unable to provide documentation indicating that 15-minute checks were completed upon readmission on 4/18/19 until discharge date , which was indicated as part of the preventative interventions according to the SSD interview below. 8. Staff interviews Certified nurse aide (CNA) #6 was interviewed on 7/2/19 at 11:40 a.m. She said she thought watching someone every 15 minutes was a good way to observe a resident but said she thought it should be more when a resident expressed [MEDICAL CONDITION] (SI). She said she thought the resident was showing signs about wanting to kill herself because she had acted in similar ways right before the first attempt (4/1/19). She said before the second attempt the resident was writing poetry, asking about God and wanting to give her things away. The CNA said that was what she had done before, on 4/1/19. She said she had told a nurse on the day of the second attempt (4/28/19) about these behaviors and how they were similar to past behaviors, but they just continued the 15-minute checks and had not increased any monitoring. The social service director (SSD), social services assistant (SSA), and the nursing home administrator (NHA) were interviewed on 7/2/19 at 10:00 a.m. The SSD said nurses complete the wander guard and elopement assessment and was not sure why only one had been completed. She said we would discuss both in care conferences but not every time. The SSD said that the previous director of nursing (DON) always placed anyone who had SI on 15 minute checks. She said the new DON had said anyone with SI would be placed on one-to-one supervision. She said she agreed with the one to one supervision because she thought only checking every 15 minutes was too long in between checks and anything could happen. She said that the previous administrator had told her that she could never conduct a room search to honor the resident ' s privacy, therefore they never completed one with Resident #387. She said the resident's son never wanted her to go out alone and knew the resident was not able to go out on her own. She said that was the reason she had a wander guard but when she got the gasoline she had cut the wander guard off before going out. The DON was interviewed on 7/2 at 12:56 p.m. She said in the future any resident who admitted with SI would be on a one-to-one observation until the facility staff call provider and determine what to do next. She said if a resident required a wanderguard and was unsafe or had cognitive issues then the staff wanted to make sure the residents did not get out of the facility. She said, We call and get an order from the doctor, obtain family consent, and explain the justification to the resident. She said she thought the elopement risk assessments were completed weekly and thought the nurses initiated them. Licensed practical nurse (LPN) #7 was interviewed on 7/2/19 at 4:45 p.m. She said she thought Resident #387 should not have been at the facility because she required too much care. She said when she was working she would also talk to Resident #387 and had a verbal contract with her regarding any symptoms of SI. II. Air mattresses A.Observations and staff interviews On 6/25/19 at 12:08 p.m. the power went off in the facility and the emergency generators were initiated. In the #300 hall there were two individuals who had air mattresses and were observed laying on their deflated air mattress in rooms #612 and #308. At 12:10 p.m. in room [ROOM NUMBER] the air mattress cord was observed plugged into a multi-outlet plug which was plugged into the wall. At 12:13 p.m., in room [ROOM NUMBER], the air mattress cord was observed plugged into a power strip.This was observed and confirmed by CNA #5. Neither of the air mattresses were plugged into the power outlet in the wall or into an emergency outlet that held power by the generator. At 1:45 p.m., the clinical nurse coordinator (CNC) said she was unaware that the air mattresses were plugged into a power strip and a multi-outlet plug and agreed she would plug the air mattresses into a generator powered outlet. At 2:00 p.m., extension cords were observed from the rooms with the air mattresses, taped to the floor and plugged into generator powered outlets at the nurses ' station and in the hallways. This was a tripping hazard and staff were in the hall redirecting the residents. The cords remained in the hallway until the power came back on at 3:00 p.m. III. Courtyard gate A. Observations -At 10:30 a.m. to 11:30 a.m. on 6/27/19. The emergency electric exit gate for hall 400, 500, and 600 was observed held together by two metal strips and two iron nails in the center across gate handles exiting outward. The courtyard was an area outside a building that was framed and enclosed by a wooden fence. There were chairs for residents. -At 12:00 on 6/27/19 emergency electric gate for hall 400, 500, and 600 was observed secure with no metal strips placed on it.The courtyard was an area outside of the building that was framed and enclosed by a wooden fence. There were chairs for residents to smoke cigarettes but in the enclosed fence. B. Staff interviews The activities director (AD) was interviewed on 6/27/19 at 10:00 a.m. He was asked about the metal strips being on the electrical exit gate. He said they were there for approximately two weeks. He said he had no idea how they would exit the gate with it being secured with metal strips. The maintenance assistant (MA) was interviewed on 6/27/19 at 10:35 a.m. He said he put the metal strips covering the electrical exit gate on 6/26/19 after the facility had a power outage the previous day and secured the gate. He said he knew that he had secured the exit gate for over twenty-four hours. He said he did not know what he, other staff or residents would do if there was an emergency and residents needed to get out of the gate.

Based on observation, record review and interview, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed - To use resources effectively and efficiently to protect residents from abuse. - To ensure the facility nursing home administrator (NHA) information was reported and changed in the Centers for Medicare and Medicaid Services (CMS) timely. - To ensure the new NHA was made aware of the lack of behavioral training for staff and interventions. - To ensure the NHA had adequate information to successfully manage the facility. - To ensure the NHA actively participated in daily decision making to manage the facility. Cross-reference F600: failed to protect and investigate after Resident #29 reported to certified nurse aide (CNA) #1 that she was fearful of Resident #82. Cross-reference F600: failed to protect Resident #20 from Resident #73 and Resident #20 contacted the police in an effort to protect herself. Cross-reference F600: failed to follow-up on Resident #82's documented behaviors; the resident continued to exhibit behaviors that were distressing to other residents. Cross reference F689: facility failed to ensure residents environment remained as free of accident hazards as possible. Cross-reference F741: failed to ensure all staff had received the required in-service training related to handle dementia/ aggressive behaviors. Findings include: Record review The state agency computer system revealed the former NHA (FNHA) remained the NHA until 6/20/19, although facility documentation revealed that the current NHA started on 6/3/19. The facility provided print off of dual certification notification for 6/20/19 showing facility changes were not complete until notification during survey on 6/20/19. The temporary permit for emergency situations documented the NHA received his temporary license for administrator, effective 6/3/19. The emergency situation form, documented the FNHA was terminated on 5/30/19. The appointing authority/chief executive officer did not sign the documentation for the switching of administrators. Facility record review revealed the facility was aware that there was not a licensed administrator assigned to the building from 5/31/19 to 6/3/19. Staff interviews The clinical nurse consultant (CNC) was interviewed on 6/20/19 at 2:05 p.m. The CNC said the facility tried to complete the change over for the NHA but had not hit the buttons in the system to complete the process. She said she and the regional financial consultant (RFC) were monitoring the building and were here frequently. She said she was a licensed NHA in another state but not in Colorado and the RFC was not an NHA. The RFC said they frequently speak to the NHA on the phone and inform him of what was happening in the facility The RFC said she did not document any of these conversations regarding time or content. The NHA was interviewed via telephone on 6/21/19 at 10:13 a.m. He said he recently obtained his NHA emergency license and became the facility NHA on 6/3/19. He said he had never been in the facility but talked to staff daily over the phone. He said he would talk to the RFC, CNC, assistant director of nursing (ADON), director of nursing (DON) and the social services director (SSD) depending on the situation. The RFC said that the NHA also received the department managers email which all department managers received. He declined from answering whether his not being in the facility placed the facility at a disadvantage. He said he believed his oversight was adequate and he had received good communication from everyone in the facility. He said he did not attend the morning meeting on a regular basis and said he thought he had attended two of the meetings via the phone.

Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards for four (#62, #69, #35 and #54) residents reviewed of 43 sample residents. Specifically, the facility failed to: -Hold Resident #62's blood thinner prior to dental appointment causing a delay in treatment, continued pain and the potential for the infection to become worse; -Obtain and document abdominal girth measurements for Resident #69; -Monitor and report significant weight fluctuations for Resident #69; -Obtain, monitor and report blood sugar results out of the physician's prescribed parameters for Resident #35; and -Monitor, report and document blood sugar levels outside physician-ordered parameters for Resident #54. Findings include: I. The facility's failure to follow the dentist's orders to hold Resident #62's anticoagulant medication resulted in Resident #62's continued increase in pain for an additional 48 hours. A. Facility policy and procedure The Dental services policy, revised on 10/31/07, was provided by the admissions coordinator (AC) on 7/11/18 at 7:50 a.m. The policy revealed, in pertinent part, Residents are assisted with obtaining routine dental services and 24-hour emergency dental services. Emergency dental services: services needed to treat an episode of acute pain in teeth, gums, or palate; broken or otherwise damaged teeth, or any other problem of the oral cavity by a dentist that required immediate attention. B. Resident #62 status Resident #62, age 48, was admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. According to the 7/4/18 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance from two people for bed mobility, transfers, dressing, toileting and personal hygiene. The assessment failed to reveal the resident had mouth or facial pain, discomfort and/or difficulty in chewing. The resident's oral pain had an onset date of 6/27/18 which was seven days prior to the completion of the 7/4/18 MDS assessment. (Cross-reference F641) C. Observations and interviews on 7/11/18 The dentist was observed on 7/11/18 at 2:10 p.m. speaking with a nurse at the nurses' station. The nurse informed the dentist the facility did not have a physician's orders [REDACTED]. The dentist told the nurse she was unable to perform the dental extractions for Resident #62 because the medication was not held. The dentist was interviewed on 7/11/18 at 2:17 p.m. She said she saw the resident on 6/27/18 due to reported tooth pain and ordered antibiotics to treat the resident's tooth infection. She said the resident had decay located near the pulp on multiple teeth which required tooth extractions. She said she informed the unit manager the resident's anticoagulant medication needed to be held for 48 hours before she returned to the facility to perform multiple tooth extractions.The dentist said she also informed the social worker of the need to hold the anticoagulant medication. She said the scheduler for the dental company notified the director of nursing (DON) of her return date with an attached physician's orders [REDACTED]. The dentist said nursing staff at the facility informed her, on the day of the scheduled procedure, the anticoagulant medication was not held as ordered. She said she could not perform the tooth extractions until the medication was held for 48 hours to prevent the resident from having increased bleeding from the procedure. She said the resident was being treated for [REDACTED]. She confirmed the resident's mouth pain was not being managed by the use of pain medication she normally took for her chronic pain. She said the only way to manage the resident's mouth pain was to extract the teeth and clear up the infection. She said the resident would remain in pain for a minimum of 48 hours until she was able to return to complete the scheduled procedure because the anticoagulant medication was not held as ordered. Registered nurse (RN) #2 was interviewed on 7/11/18 at 2:30 p.m. He said he was the unit manager. He said the dentist had directed him on 6/27/18 to hold the anticoagulant medication so the multiple tooth extractions for Resident #62 could be completed on 7/11/18. He said he did not write the order because he did not know if the dentist confirmed his planned returned date to the facility. He said he had not been informed by the DON of the dentists return date, to be able to write the order to hold the anticoagulant medication. He confirmed he was aware the dentist wanted the anticoagulant medication held prior to the tooth extractions but did not follow up with the DON or social services to obtain the dentist's return date. D. Resident interview The resident was interviewed on 7/11/18 at 3:06 p.m. She said the nurse had just informed her prior to this interview the dentist was in to conduct multiple tooth extractions, but, because a medication was not held, the dentist could not perform the extractions. She said she had constant pain in her mouth, especially when she ate. She said the mouth pain was what caused her to have headaches. She said her pain level was an 8 to 9 out of 10. During the interview, the resident began to cry and stated, why would they do this to me? They know how much pain I am in right now. Resident was observed grabbing the left side of her face near the jaw region. E. Record review 1. Dental services The (MONTH) (YEAR) physician progress notes [REDACTED]. -Xarelto (an anticoagulant medication) 20 milligram (MG) tablet - give one tablet by mouth one time a day for [MEDICAL CONDITIONS] - ordered on [DATE]. The 6/27/18 dental progress note revealed the resident was seen due to significant pain on her upper left side of the mouth. It documented the following recommendations: -tooth #9 was covered over by gum tissue and recommended surgical extraction, -tooth #10 was fractured to the gum line, percussion, palpation sensitive and recommended extraction, and -tooth #11 was fractured significantly to the pulp and recommended extraction. The notes directed staff to hold the resident's blood thinners for 48 hours prior to the extractions. The 6/28/18 email from the dental services scheduler to the DON revealed the resident was seen by the dentist on 6/27/18. Attached was the following order: -stop blood thinners 48 hours prior to dental appointment for tooth extractions. It documented the dentist would be at the facility on 7/11/18 at 1:00 p.m. to perform the tooth extractions. A review of the entire resident's medical record did not reveal a physician's orders [REDACTED]. 2. Chronic pain a. (MONTH) (YEAR) The 6/19/18 pain evaluation revealed the resident had chronic pain and received scheduled and as needed pain medication. The evaluation did not identify the resident's accepted level of pain. b. (MONTH) (YEAR) The (MONTH) (YEAR) CPO revealed the following medications for the resident's chronic pain: -[MEDICATION NAME] tablet - give 650 MG by mouth every six hours as needed for pain - ordered on [DATE]; -Asper-Flex cream 10% -apply topically as needed for pain - ordered on [DATE], -[MEDICATION NAME] HCI capsule 10 MG - give one capsule by mouth every six hours as needed for abdominal pain - ordered on [DATE]; -[MEDICATION NAME] Capsule 200 MG - give one capsule by mouth three times a day for pain - ordered on [DATE]; -[MEDICATION NAME] HCI tablet 20 MG - give one tablet by mouth every six hours as needed (PRN) for chronic pain - ordered on [DATE], discontinued on 7/4/18; -[MEDICATION NAME] HCI tablet 20 MG - give two tablets by mouth every six hours as needed for chronic pain - ordered on [DATE]. The (MONTH) (YEAR) medication administration record (MAR) revealed the resident received PRN pain medication on the following dates and times: -7/1/18 at 4:55 a.m. 11:53 am. , and 5:58 p.m. (pain level 8/10). -7/2/18 at 8:56 a.m. , 3:52 p.m. (pain level 8/10), and 10:46 p.m. (pain level 5/10). -7/3/18 at 1:17 p.m. (pain level 8/10) and 8:43 p.m. (pain level 5/10). -7/4/18 at 6:53 a.m. (pain level 7/10) and 7:51 p.m. (pain level 9/10) -[MEDICATION NAME] was increased to two tablets. -7/5/18 at 12:03 p.m. (pain level 6/10), 3:50 p.m. (pain level 7/10), and 9:53 p.m. (pain level 8/10). -7/6/18 at 3:56 a.m. , 9:58 a.m.), 5:13 p.m. , and 11:16 p.m. (pain level 8/10). -7/7/18 at 8:04 a.m. , 1:53 p.m. (pain level 8/10), and 10:04 p.m. (pain level 7/10. -7/8/18 at 4:58 a.m. (pain level 8/10), and at 11:01 a.m., and 5:32 p.m. (pain level 6/10). -7/9/18 at 5:46 a.m. (pain level 6/10), and at 11:42 a.m., and 5:47 p.m. (pain level 8/10). -7/10/18 at 7:10 a.m. (pain level 9/10) and 5:12 p.m. (pain level 8/10). -7/11/18 at 9:00 a.m. (pain level 8/10) and 3:00 p.m. (pain level 9/10). F. Additional staff interviews The DON and nursing home administrator (NHA) were interviewed on 7/11/18 at 3:27 p.m. The DON said she received an email from the dental services scheduler on 7/2/18 informing her the dentist would be at the facility on 7/11/18 to perform tooth extractions for Resident #62. She said the email was sent with an attached physician's orders [REDACTED].#62's anticoagulant medication. She said she did not look at the attachment on the email as she did not see it the first time she read the email. She noticed the attachment with the orders from the dentist during the interview.She said she was aware the dentist would be doing tooth extractions on 7/11/18. She said she did not inform the nursing staff to hold the anticoagulant medication as directed by the dentist. During the interview, the DON contacted Resident #62's PCP. He agreed to hold the anticoagulant medication for the dental procedure. He said he had spoken with the resident on 7/4/18 regarding her mouth pain. He confirmed the resident had been in significant mouth pain at a minimum from that date. He said he increased the [MEDICATION NAME] medication from one tablet to two tablets in an attempt to assist with the mouth pain until the resident could have her teeth extracted. II. Failure to obtain and document abdominal girth measurements, and monitor and report significant weight fluctuations A. Resident #69 status Resident #69, age under 60, was admitted [DATE] and readmitted on [DATE]. According to the (MONTH) (YEAR) CPO, [DIAGNOSES REDACTED]. The 6/16/18 MDS assessment indicated the resident had no cognitive impairment with a BIMS score of 15 out of 15. B. Record review The care plan, last revised 6/21/18, indicated the resident was at risk for nutritional decline and dehydration related to liver [MEDICAL CONDITION] with ascites (the accumulation of fluid in the abdomen). Interventions included: -Monitor and document vital signs as ordered per protocol. Notify the physician of significant abnormalities; -Monitor, document and report to the physician any signs and symptoms of complications including ascites; -Obtain weight as per protocol; and -Notify the dietician, the physician and the family of significant weight changes. According to the (MONTH) (YEAR) CPO, orders included: -Weigh three times a week on Sunday, Tuesday and Thursday related to weight gain/ascites; and -Measure abdominal girth at umbilicus twice a week on Sunday and Wednesday for ascites, received on 6/28/18. According to the 5/8/18 re-admission clinical evaluation, not completed until 5/15/18, the resident's most recent weight was 170 lbs. This weight was obtained on 5/12/18. The abdominal evaluation indicated the resident's abdomen was normal; slightly rounded, bowel sounds were present in all four quadrants. According to a 5/9/18 and a 5/10/18 health status note, the resident's abdomen was soft and distended per baseline due to ascites. This was the first mention in the record of the resident having ascites. According to a 5/23/18 health status note, the resident went to the hospital for a paracentesis (removal of fluid from the abdominal cavity) and 4,500 milliliters of fluid was removed. According to the (MONTH) and (MONTH) (YEAR) MARs, the order to measure the abdominal girth was documented as being done, however no measurements were actually recorded. Review of the record revealed no baseline abdominal girth measurement was obtained. According to the (MONTH) (YEAR) treatment administration record (TAR), the resident had multiple weight fluctuations with a gradual total weight gain of 10.6 lbs for the month. There was no documentation the physician was notified. The following weight changes were documented on the TAR: 6/5-6/7/18 (2 days) = 6.3 lb loss 6/12-6/14/18 (2 days) = 4.6 lb gain 6/19-6/21/18 (2 days) = 4.4 lb gain 6/26-6/28/18 (2 days) = 7.4 lb gain 6/17-6/24/18 (8 days) = 8.4 lb gain 6/17-6/28/18 (11 days) = 15.8 lb gain There was no documentation of reweights being done to verify accuracy and there was no documentation the physician was notified of the weight gain. According to the (MONTH) (YEAR) TAR, the resident had a recorded weight loss of 30.8 lbs in 2 days (from 7/1-7/3/18) then a gain of 21.4 lbs in 2 days (from 7/3-7/5/18). This fluctuation was most likely due to a documentation error, however no reweigh was documented as being done and the resident still had a loss of 9.4 lbs from 7/1-7/5/18, then a gain of 7 lbs from 7/5-7/8/18 that was not reported to the physician. C. Interviews Registered nurse (RN) #3 was interviewed on 7/11/18 at 11:49 a.m. She said abdominal girth measurements should be documented on the TAR or in a progress note. She said they obtained these measurements along with assessing the resident's weights to determine if the resident was retaining fluid and needed to be scheduled to have a paracentesis. She said a weight change of 3 lbs in 24 hours or 5 lbs in a week should be reported to the physician and it should be documented in a progress note. Licensed practical nurse (LPN) #2 was interviewed on 7/11/18 at 2:04 p.m. She said abdominal girth measurements and weights were needed to assess whether the resident was retaining fluid and these needed to be documented on the TAR. The assistant director of nursing (ADON) was interviewed on 7/11/18 at 4:50 p.m. He said obtaining abdominal girth measurements and frequent weights for a resident with ascites was important to determine how much fluid they were retaining. He said the physician should be notified of any significant changes and it should be documented in a progress note. The director of nursing (DON) was interviewed on 7/11/18 at 6:24 p.m. She said a baseline abdominal girth measurement should have been obtained and documented in a progress note then the following measurements should have been documented on the TAR. She said the physician should have been notified with any significant weight changes, which was different for each resident. III. Failure to obtain and report blood sugar results out of the physician's prescribed parameters A. Facility policy and procedure The Blood Sugar Monitoring policy and procedure, last revised 10/31/10, was received from the medical records director (MRD) on 7/11/18 at 5:40 p.m., which included: If the patient's blood sugar results are over 300 mg/dl (or registers hi/high) or less than 70 mg/dl (or registers low/lo), retest to validate results. If blood sugar remains over 300 mg/dl (or physician established blood sugar parameters) or less than 70 mg/dl, notify the physician and follow the physician's orders [REDACTED]. B. Resident #35 status Resident #35, age under 60, was admitted on [DATE]. According to the (MONTH) (YEAR) CPO, [DIAGNOSES REDACTED]. The 5/17/18 minimum data set (MDS) assessment indicated the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. It indicated the resident was diabetic and received insulin injections. C. Record review According to the (MONTH) (YEAR) CPO, the resident had the following orders: -Check finger stick blood sugar (FSBS) before meals and at bedtime. Call the physician if the results were less than 70 or greater than 350. According to the (MONTH) (YEAR) medication administration record (MAR), the resident's blood sugar on 6/12/18 at 4:30 p.m. was 370. There was no documentation the results were reported to the physician as per the physician's orders [REDACTED]. According to the (MONTH) (YEAR) MAR, the resident's blood sugar was out of parameters on the following dates and times with no documentation the physician was notified: -On 7/1/18 at 11:30 a.m. the blood sugar was 365; -On 7/4/18 at 11:30 a.m. the blood sugar was 388; and -On 7/7/18 at 7:00 a.m. the blood sugar was 368. The care plan, last revised 2/21/18, indicated the resident had diabetes mellitus. Interventions included: -Diabetic medication as ordered by the physician. Monitor and document for side effects and effectiveness; and -Obtain blood sugar as ordered by the physician. D. Interviews Registered nurse (RN) #3 was interviewed on 7/11/18 at 11:49 a.m. She said all the diabetics in the facility had parameters for when to report the results to the physician that was individualized for each resident. If a results was out of parameter, the physician would be notified and it would be documented in a progress note. Licensed practical nurse (LPN) #2 was interviewed on 7/11/18 at 2:04 p.m. She said if a resident's blood sugar was out of parameter the physician was notified and it was documented on the MAR and in a progress note. The assistant director of nursing (ADON) was interviewed on 7/11/18 at 4:50 p.m. He said most of the diabetics in the facility had specific blood sugar parameters set by the physician for when to report a result out of parameter but the facility also had parameters for when to report a blood sugar result. He said the results were documented on the MAR and under the vital signs tab in the computer. He said if notification to the physician was made, it would be documented in a progress note. The director of nursing (DON) was interviewed on 7/11/18 at 6:24 p.m. She said she was disappointed to hear about the blood sugars not being reported because she was having her unit managers audit the blood sugars monthly and provide on the spot education with the nurse regarding the importance of notifying the physician as per the order. This education was requested and not provided. She said the physician should be notified any time a blood sugar was out of parameter and this should be documented in a progress note along with any orders received. IV. Failure to consistently monitor, report and document blood sugar levels outside physician-ordered parameters A. Resident #54 status Resident #54, under age 60, was admitted on [DATE] and re-admitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The MDS assessment dated [DATE] documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He had an active [DIAGNOSES REDACTED]. B. Resident observations and interview On 7/9/18 at 9:30 a.m., Resident #54 was observed in the hallway outside of his room having a conversation with a nurse. He said he did not want to take his insulin that morning because he could tell his blood sugar (BS) level was fine and he did not want to cause it to go lower. He was alert and calm, and his gait was steady. On 7/9/18 at 11:37 a.m., Resident #54 was sitting on his bed in his room. He said he was a type II diabetic and could not eat anything at that time because he had a gastrostomy tube for tube feedings. He said he took insulin daily but did not know how much. He said there had been times recently when his BS level had dropped and he would refuse to take his insulin. He said, I don't like the feeling when it drops like that. He said he knew when he should and should not take his insulin based on how he was feeling, and said he could tell when he did and did not need the insulin. C. Record review The resident's care plan, initiated 6/14/18, identified a focus on diabetes mellitus. Staff were to administer medication as ordered by the physician, monitor and document for side effects and effectiveness, and check fasting serum blood sugars as ordered. 2. Lack of documentation in insulin administration: The CPO for (MONTH) (YEAR) documented the following orders: -Check BS before each tube feeding. Call the doctor if less than 70 mg/dl (milligrams/deciliter) or greater than 250 mg/dl three times a day, started 3/27/18 -Humalog insulin (rapid acting) five units subcutaneously (SQ) once a day. Hold if BS is less than 120 mg/dl and notify MD is BS is less than 70 or greater than 250, started 11/29/17 -[MEDICATION NAME](rapid acting) five units SQ once a day, started 5/4/18 -[MEDICATION NAME](long acting) five units SQ once a day at bedtime, started 11/27/18 3. The medication administration record (MAR) for (MONTH) through 7/11/18 documented the following: -BS 59 on 7/3/18 at 5:30 p.m. No documentation physician was notified. -No documentation a BS was checked at 12:30 p.m. on 7/8/18. -No documentation a BS was checked at 12:30 p.m. on 7/7/18. -BS 66 on 7/10/18 at 9:30 a.m. No documentation physician was notified. -BS 62 on 6/27/18 at 5:30 p.m. No documentation physician was notified. -BS 69 on 6/26/18 at 5:30 p.m. No documentation physician was notified. -No documentation a BS was checked at 12:30 p.m. on 6/23/18. -No documentation a BS was checked at 12:30 p.m. on 6/21/18. -No documentation a BS was checked at 5:30 p.m. on 6/17/18. -No documentation a BS was checked at 5:30 p.m. on 6/9/18. -No documentation a BS was checked at 12:30 p.m. on 6/4/18. -No documentation a BS was checked at 12:30 p.m. on 6/1/18. -BS 127 on 5/31/18 at 5:30 p.m. No documentation that the Humalog was administered. -No documentation a BS was checked at 5:30 p.m. on 5/18/18. D. Staff interviews Registered nurse (RN) #3 was interviewed on 7/11/18 at 6:06 p.m., and she confirmed she routinely worked with Resident #54. She said the nurses had parameters for when to notify a physician if a BS was above or below a certain number. She said if insulin were held for some reason, she would write a progress note that indicated the reason why and said, If you hold it, you have to document it in the progress note and give the reason. She explained the progress notes had space provided which specifically addressed the BS. She said Resident #54 did not refuse to have his BS checked and his levels were usually normal. She said he would occasionally come to her and tell her when he could feel his BS was low. The DON was interviewed on 7/11/18 at 7:20 p.m. She confirmed if a resident's BS fell outside the range indicated on the order, the physician needed to be notified and it should be documented in the progress notes. She said the facility had a process for documenting that, and explained a link could be added to the MAR by the nurse who could then document out of range or reached out to physician. She said the nurses should be utilizing that feature and stated, We audit that. She explained if she found blanks on the MAR, she would go back to the nurse and ask them to complete it.

Based on record review, observations and interviews, the facility failed to provide the necessary care and services to attain the highest practicable physical, mental, and psychosocial well-being for one out of 41 sample residents (#35). Specifically, 1. The facility failed to ensure resident #35's pain was adequately assessed and managed and the resident reported elevated pain levels on 11/21 and 11/25/13. 2. The facility failed to adequately monitor fluid intake for sample resident #35 as ordered. The findings include: A. Resident #35, age 67, was admitted to the facility on [DATE] and readmitted [DATE]. According to her computerized physician orders [REDACTED]. Her most recent minimum data set (MDS), dated [DATE], indicated the resident was cognitively intact and scored a 15/15 on her brief interview for mental status (BIMS). She exhibited slight mood problems and no behaviors. The resident was totally dependent on staff for all mobility. The MDS indicated that resident was frequently in pain and rated her pain at an 8/10. There were no reported behaviors. 1. PAIN Pain Policy The facility's pain policy stated in pertinent part that: -The center's practice was to assist each resident with pain or that has a potential for pain to maintain or achieve the highest practicable level of well being and functioning through pain management. -Residents would be screened for pain upon admission/readmission, quarterly, with any new complaints, or with significant status change resulting in pain thereafter. -Resident's complaining of pain are assessed with [REDACTED]. -A care plan is developed and implemented, using pharmacologic and/or non-pharmacologic interventions to manage the pain and/or try to prevent the pain consistent with the resident's goals. -The pain assessment, interventions and evaluation of effectiveness are documented in a clear and concise manner. The resident's pain care plan, dated 1/20/12 and last updated on 10/21/13, stated that resident was at risk for pain due to impaired mobility. She was usually able to verbalize pain, but not always her acceptable pain level. Resident's [DIAGNOSES REDACTED]. Her care plan stated she had chronic abdominal pain related to diverticulitis, possible history of ischemic [MEDICAL CONDITION] and constipation with refusal of stool softeners. -The goal listed was for the resident's pain not to impact her sleep or meal intake patterns in the next 90 days. -Approaches included: --Evaluate pain every shift and PRN. --Evaluate for non-verbal signs of pain if unable to verbalize. --Provide diversional activities of preference and offer non-pharmacological interventions, such as heat, cold, repositioning, rest, etc. --Encourage to verbalize pain and to request pain medication as needed to promote pain management. --Monitor effectiveness of pain management regimen. Contact MD if pain relief not adequate or changes in pain management regimen is needed. --Observe meal intake and sleep patterns for changes and notify nurse. --Encourage resident to take stool softeners. --Administer medications as ordered. There had been no updates or revisions since 10/21/13. A. Resident's computerized physician orders [REDACTED]. -[MEDICATION NAME] (nonopioid [MEDICATION NAME] used for mild to moderate pain) 500 mg (milligrams) -two tablets by mouth (PO) three times daily (TID) as needed (PRN) started 9/27/13 for pain. -A telephone order was written on 11/1/13 for [MEDICATION NAME] ([MEDICATION NAME] used to treat moderate to severe pain or chronic pain) 50 mg PO every 6 hours PRN for pain. -Staff was directed to assess pain every shift using a verbal scale of 0-10. There were no parameters to indicate or direct nursing staff when to administer [MEDICATION NAME] versus [MEDICATION NAME] recently added on 11/1/13. There was no hourly parameter established on how often the Tylenol could be administered except for TID. A resident's nursing evaluation, dated 11/15/13, indicated the resident had pain in the past five days all day long and rated the pain at an 8/10. The resident indicated her acceptable level of pain was a 2/10. There was no further information regarding resident's pain on this document. Another resident pain assessment, dated 11/15/13, indicated that resident had had pain in the back and buttock all day long described as an internal sharp ache which was worse in the morning. She verbally rated her pain an 8/10 and stated her acceptable level of pain was a 2/10. The pain assessment also indicated she received Tylenol 500 mg three times a day PRN and that massage relieved her pain. There was no indication if the pain was managed with Tylenol and the addition of [MEDICATION NAME] had not been listed as part of the pain management plan. B. Observations and Interviews with the resident about pain: 11/18/13 On 11/18/13 at 4:35 p.m., the resident reported that she had pain in her stomach. Resident had recently returned from [MEDICAL TREATMENT] and also reported nausea. She stated that the nurse had not been in to see her yet. She was observed to be holding her stomach and rocking back and forth. Review of the nursing notes revealed that there was no nursing assessment on 11/18/13. Review of the Medication administration record (MAR) for 11/18/13 revealed the resident received [MEDICATION NAME] (for nausea) 5 mg at 5:00 p.m. and Tylenol 1000 mg at 11:30 p.m. for a pain level of 8/10, there was no indication of a post medication assessment of pain. The resident did not receive anything for pain in the morning or afternoon, according to the MAR. The every shift pain assessment on the MAR did not indicate that resident had any pain on 11/18/13 or 11/19/13, with 0/10 documented for all shifts for both days. 11/21/13 On 11/21/13 at 10:55 a.m., the resident was observed in her wheelchair by the nurses' station rocking forward and back. She was breathing heavily. She stated that her stomach was hurting really badly. She stated that she told her nurse and her nurse said that there was nothing she could do for her. She stated she had had her medications that morning. She stated she had had a piece of candy and that the nurse said that that was not good for her. She said that her stomach hurts every day and she rated the pain at an 8/10, she said that she would like her pain to be at a 0/10. She stated that her pain medications were effective for a little while, but did not last long enough until her next dose. Review of the nursing notes on 11/21/13 revealed that the nurse documented that the resident complained of abdominal pain. This note did not reference a pain rating but did reference the nurse speaking to resident about her diet and stated that all her scheduled medications were taken. As stated above, the resident was complaining of pain at a level 8/10 at 10:55 a.m. There was no indication the nurse performed any further assessments, offered non-pharmalogical interventions or sought physician guidance to address the resident's pain. The resident's MAR on 11/21/13 indicated that she received Tylenol 1000 mg at 5:30 p.m. The documentation of giving this medication offered no pre medication rating, listed the location of the pain as abdominal, and documented that the post medication rating was 0/10. According to the MAR, the resident did not receive anything for pain in the morning or afternoon. Even though the resident reported she got something for pain that morning. The MAR pain per shift assessment for 11/21/13 was 6/10 on the night shift, a 0/10 on the day shift, and a 4/10 on the evening shift. 11/24/13 Nursing notes from 11/24/13 revealed the resident had been complaining of abdominal pain that day. The note indicated that resident was rocking back and forth and holding her side. The nurse wrote that she asked resident what she had eaten when out on pass with her family. The note did not indicate that any medications or non-pharmacological interventions were attempted to relieve her pain. The resident's MAR indicated the resident did not receive any medication for pain on 11/24/13. 11/25/13 On 11/25/13 at 8:57 a.m., the resident was observed to be rocking back and forth holding her stomach in bed. She stated that she had pain in her stomach that morning and said that she had received Tylenol and other medicine, but she did not know how long it had been. An emesis basin was observed on her bedside table with small amount of emesis in it. She stated her pain level was at an 8/10 and the nurse knew she was feeling sick. She stated that the nurse had been in, but the resident did not know if she had really checked on her. She said that the nurse did not ask about her pain again. The resident stated that the Tylenol helped sometimes but she did not know she had an order for [REDACTED]. She stated that she could not recall any nurse asking her about the effectiveness of her pain medications. The resident's nurse was alerted immediately about the resident's pain. Review of the nursing notes on 11/25/13 revealed that the nurse called the resident's husband to inquire about what the resident ate when she was at home over the weekend. There was no further assessment of the resident's pain to address relief. The resident's MAR indicated the resident received Tylenol 1000 mg on 11/25/13 at 5:30 a.m. and 9:00 a.m. The documentation for giving these doses of Tylenol indicated that at 5:30 a.m. the resident complained of abdominal pain. There was no indication of a pre medication pain assessment/rating and a post medication rating was documented as 2/10. The documentation for the 9:00 a.m., dose indicated that resident rated her pain at a 7/10 pre-medication, but there was no post medication rating/assessment as patient was out to [MEDICAL TREATMENT]. The resident's per shift pain assessments for 11/24/13 indicated that resident rated her pain a 2/10 on night shift, a 0/10 on day shift, and 0/10 on evening shift. The resident's pain assessments for 11/25/13 revealed 7/10 on night shift, 0/10 on day shift and 0/10 on evening shift. There was no indication the resident's physician had been contacted regarding resident's increase in pain frequency. On 11/25/13 at 9:04 a.m., a licensed practical nurse (LPN) was interviewed. The LPN stated that she was aware that resident was having emesis and writhing stomach pain. She stated she would have to go talk to her again and she suspected that resident ate something that exacerbated her diverticulitis the previous weekend when she was home with her family. C. Pain Monitoring Review of the nursing notes, medication administration records (MAR), and pain shift assessments for November (11/1/13 through 11/25/13) revealed the pain levels fluctuated from 2/10 to 7/10; the highest level being 8/10 (indicated only on the resident interview portion of the nursing pain assessment). Nurses assessed for pain every shift on the MAR. The resident's PRN dose of [MEDICATION NAME] was given 15 times in November 11/4, 11/5, 11/6, 11/8, 11/11, 11/16, 11/17, 11/18 (twice), 11/20 (twice), 11/21, 11/22 and 11/25 (twice). Staff documented the resident had pain either general or abdominal. They inconsistently assessed pain prior or post the administration of medications. There were no post medication assessments for pain on 11/5, 11/6, 11/11, 11/16, 11/18, 11/20 x 2, 11/22 or 11/25 9:00 a.m. dose. On 11/17/13, the nurse administered one dose of [MEDICATION NAME] for abdominal pain. The resident's pain level was 7/10 prior and 1/10 afterwards. D. Failures There was no identification of the resident's acceptable level of pain indicated on the resident's care plan. On 11/15/13, staff identified massage might be effective in pain relief. There was no documentation that this was offered nor was it added to the resident's care plan. With the addition of [MEDICATION NAME] to the pain regime, there was no clarification to nursing staff on when to administer Tylenol versus [MEDICATION NAME]. On 11/21/13 and 11/25/13, when the resident reported continued pain, the nurse did not attempt non-pharmaceutical approaches or contact the physician for guidance. There was no pain monitoring flow sheet with resident's MAR (another tool utilized by the facility to track prn pain medications and assessments for effectiveness). E. Interviews On 11/25/13 at 9:17 a.m., the same LPN stated that if a resident was able to verbalize pain, nurses asked residents to rate their pain with every medication pass or in passing. If the resident was non-verbal they monitor for guarding, mood changes, grimacing or acting out of the norm. She stated that the facility used a 0-10 pain scale. She said that every resident had a pain monitoring flow sheet kept in the MAR. She said the sheet gives them clues of what to look for. She said the pain monitoring flow sheet would only be taken out of the MAR at the end of the month (LPN was observed to be flipping through the MAR and could not find a pain flow sheet that had pain or prn medications documented on it). She stated that residents were assessed for pain at least once a shift, sometimes more. She stated that resident #35 had pain in cycles as she was good after coming home from the hospital until a couple days prior to the interview (she was hospitalized from [MEDICAL TREATMENT] for sedation a few days prior). She said that the resident's stomach had been acting up since the previous weekend. She stated resident frequently had heartburn and that she took medications for GERD. She stated that resident was on [MEDICAL TREATMENT] which increased her nausea. She said that the resident's pain had to be from something she ate at home over the weekend. The LPN stated that resident had a history of [REDACTED]. The nurse did not indicate what was effective to relieve the resident's pain or when [MEDICATION NAME] versus Tylenol would be administered. On 11/25/13 at 9:28 a.m., the director of nursing (DON) was interviewed. She stated that if a resident had an order for [REDACTED]. She said that if a medication was not a prn order, then the documentation would be written on the back of the MAR. The DON could not find any pain flow sheets in the MAR in her office to use as an example. She said that the nurse on the floor should do a pain rating every shift for every resident and document the rating on the MAR. She stated that when a pain medication was given, the nurse should document on the MAR and the flow sheet that they gave the medication and then they should go back 30-40 minutes later to assess the effectiveness of the medication. The effectiveness should then be documented on the pain flow sheet. She stated that every resident should have a pain flow sheet. -At 9:36 a.m., the DON stated that resident #35 went through bouts of pain and that she got abdominal pain from her slowing bowel status (the records did indicate nursing staff was evaluating and assessing bowel sounds for the resident). She went on to state that resident's husband took her home quite a bit and she was out of the facility frequently. (There was no documentation on her MAR that she had been out of the facility frequently in the month of November). -At 9:48 a.m., the DON confirmed that there was no pain flow sheet for resident #35 and then she said that every resident should have one. 2. Lack of monitoring fluid intake as ordered by the physician: Record Review: Review of the 11/13 CPO revealed the following order: "Fluid restrictions = 1200ml/24 hours; 860 ml (milliliters) = dietary, 340 ml = nursing." Review of a medical nutrition assessment dated [DATE] documented in part the resident was on a 1200 ml (milliliter) fluid restriction. Review of a physician progress notes [REDACTED]. Review of the November Medication Administration records revealed nursing was to track fluid intakes every shift. Review of a [MEDICAL TREATMENT] care plan due to "resident requires [MEDICAL TREATMENT] related to [MEDICAL CONDITION]," initiated 1/20/12 and last updated 6/26/13, documented the estimated goal date of 1/18/14. Some of the approaches listed were [MEDICAL TREATMENT] three times per week, pre/post [MEDICAL TREATMENT] vitals and weights and fluid restriction as ordered. -On 11/20/13 at 5:58 p.m., resident in room with meal tray observed. There was a large sized plastic cup (240ml; 8 ounce), with a red beverage in it and half-way full. -On 11/21/13 at 12:20 p.m., the resident had her lunch tray with one beverage; an 8 ounce plastic cup of red juice. There was also an 8 ounce bottle of soda observed on her nightstand and half way full. Review of food intake records for 9/13, 10/13, 11/13 revealed several missing entries for fluids during meal intake: -September; 9/4, 9/11, 9/12, 9/13, 9/18, and 9/30; -October; 10/3, 10/4, 10/8, 10/9, 10/10, 10/11, 10/12, 10/13, 10/21, 10/22, 10/23, 10/24, and 10/25; -November; 11/12, 11/13, 11/14, 11/19, and 11/22. Review of medication administration records (MARS) for the past three months revealed in 9/13 there were seven consecutive days (9/24 through 9/30) where fluid monitoring was not occurring and no documentation explaining why the entries were blank. Review of the 10/13 MAR revealed the order for fluid monitoring was missing altogether. Review of the 11/13 MAR revealed from 11/1 through 11/18 nurses were initialing across all shifts, however; the fluid intake for these days was missing to ensure the resident was receiving the correct amount per physicians orders. Further review of the 9/13 food intake record revealed the words "hosp" for hospital was written in on 9/24, 9/25, and 9/26; reflecting inconsistent monitoring. There was no documentation to show they were reviewing and totaling fluid intakes daily. Interviews: On 11/20/13 at approximately 6:00 p.m., the resident was interviewed. The resident stated she knew she was on a fluid restriction, but did not know how much she was allowed and that was why she did not have a water pitcher in her room. On 11/26/13 at approximately 3:00 p.m., an evening certified nursing assistant (CNA) familiar with caring for the resident, stated she was aware the resident was on a fluid restriction, but was not aware how much the resident was allowed to have. She stated she usually just gave the resident a small cup of ice for the entire shift. The CNA also stated that sometimes the resident would get something to drink on her own such as a soda. On 11/26/13 at 4:10 p.m., the registered dietician (RD) was interviewed. The RD stated the resident was not very compliant with the restrictions and when she goes home for days at a time there was no way to monitor her fluids. The RD acknowledged she has educated the resident several times about this, but had not spoken to the husband about limiting her fluids when she goes home. The RD stated it was her expectation that staff were following the order for restriction of fluids and should be monitoring and documenting daily. The RD confirmed the fluid restriction order was on the resident's meal ticket so it was up to the nurses and CNA'S to give the allotted fluids.

Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible; and that two of 28 sample residents (#25, #120) received adequate supervision and assistance devices to prevent accidents. Specifically: -The facility failed to implement fall interventions to prevent a fall for resident #120. Resident #120, who was observed several times without her safety alarms, fell and sustained head injuries that required sutures/staples. -The facility failed to ensure medications were not left at the bedside of resident #25. The findings include: I. Falls A. Facility Policy Review of the facility fall policy revealed it documented, in pertinent part, "The center provides an environment that is free from accident hazards over which the center has control and provides supervision and assistive devices to each patient to prevent avoidable accidents. This includes systems and process designed to: identify hazards and risks; evaluate and analyze hazards and risks; implement interventions to reduce hazards and risks; and monitor for effectiveness and modify approaches when necessary." B. Resident Failures 1. Resident #120, [AGE] years old, was admitted to the facility on [DATE]. According to the 9/11 computerized physician orders (CPO), the resident had [DIAGNOSES REDACTED]. The resident was admitted to hospice care on 9/14/11. 2. Resident Status - Known Fall Risk According to the most recent minimum data set (MDS) 3.0 dated 8/03/11, the resident had both short and long-term memory loss. The BIMS (brief interview for mental status) could not be completed with the resident being coded with a score of "99." The resident required extensive assistance for most activities of daily living. It could not be determined on the MDS if the resident had a fall history prior to admission. However, review of an admission nursing assessment dated [DATE], documented the resident had a history of [REDACTED]. The assessment tool scored the resident at a "40," indicating medium risk for falls. 3. Facility Response to Risks Review of an admission nursing note dated 7/27/11, documented: "...placed bed in low position with bed alarm for safety..." Review of the 9/11 CPO documented the following orders: "Resident to have W/C (wheelchair) alarm for safety Q (every) shift." And, "Resident to have bed alarm for safety Q (every) shift." Start date 7/27/11. Review of a fall care plan, created on 8/05/11 and last reviewed on 9/23/11, documented the following problem: "(name of resident) has risk for falls/injury d/t (due to) impaired cognition and mobility, incontinence, poor balance, possible impaired vision..." -Goal: "(name of resident) risk for falls/injury will be decreased with approaches used next 90 days." -Approaches: "keep call light in reach and remind (resident) to use it to request assist, bed and w/c alarms in place to alert staff when (resident) attempts self-transfer without assist, review falls as they occur for root cause, interventions to be placed as appropriate..." Review of a hospice comprehensive nursing assessment dated [DATE], documented in the safety section that the resident was a fall risk and she needed monitoring. However, the places to check if the resident had a body alarm, low bed or fall mat in place were left unchecked. Review of the 9/11 TAR (treatment administration record) documented the resident had a W/C (wheelchair) and bed alarm for safety and it was to be checked on each shift (10-6, 6-2, 2-10). The documentation revealed signatures through all shifts from 9/01 through the day shift on 9/29/11. 4. Fall 9/28/11 Review of a nurse note entry dated 9/28/11 at 10:50 a.m. documented the resident had fallen on the floor and gashed her forehead. The note documented the resident's injury as a 3.1 cm (centimeter) gash to her left brow area and a 3.5 cm (centimeter) gash to the top parietal area. The hospice nurse was notified and directed the resident to be sent out to the hospital for evaluation and treatment. A nurse note entry dated 9/28/11 at 5:30 p.m. revealed the resident had returned to the facility that evening. The note read, "...noted with sutures to left facial area (7 sutures) and staples (15) to scalp area, peri-orbital bruise to left eye...kept safe and comfortable in bed with call light within reach, kept in low bed w/floor mat on the side for safety..." - There was no mention of any alarms in place as ordered. Review of a fall investigation for the above fall, dated 9/28/11, documented the resident had a fall with significant injury from the bed. The report further documented the resident was found on the floor in her room and she had fallen out of bed. The event was documented as unwitnessed. The report further documented the resident hit her left forehead above the eyebrow on her nightstand. First aid was administered and the resident was sent out to the hospital. -The report summary documented: "floor mat bedside, bed low, will look in to providing lipped mattress, night stand removed from bedside." -There was a section of the report that read, "factors related to event." Selections available included: "circumstances unknown, environmental factors, refused prescribed treatment, resident assisting resident, visitor assisting resident, while ambulating, while giving care, while reaching, while repositioning, while transferring, while providing self-care." None of the available selections were marked. -There was no documentation either in the nurses' notes or the investigation report indicating what area of the room the resident was found, in what position she was found, if her call light was on or in reach, or if any alarms were sounding at the time. There was no documentation whether an interview was attempted with the resident regarding the events surrounding the fall. 5. Failure to implement planned safety measures a. Before the fall 9/28/11 Observations: On 9/26/11 at 11:50 a.m. the resident was observed in the main dining room sitting in her wheelchair. The resident did not have an alarm on her wheelchair as ordered and care planned. On 9/27/11 at approximately 10:00 a.m. the resident was observed in her room in bed resting. There was no bed alarm observed anywhere on her bed as ordered and care planned. Interviews: On 10/3/11 at 12:55 p.m. the hospice nurse visiting the resident was interviewed. The hospice nurse stated that since she had been coming in to visit the resident the past two weeks, she had never seen any alarms on the resident's bed or wheelchair. During this interview, there was a private caregiver present and assisting the resident to eat her lunch. The caregiver was asked if the resident had any alarms. The caregiver stated that since she had been coming to see the resident (daily for the past month) to assist her with eating lunch, she had never seen any alarms. b. After the fall 9/28/11 Observation: On 10/03/11 at 11:00 a.m. the resident was observed in her room lying in bed sleeping. There was a fall mat on the floor. There was no bed alarm observed on her bed as ordered and care planned. Interviews: On 10/3/11 at 1:05 p.m. the district nurse (DN) with the unit manager (UM), wound nurse (WN) and staff development coordinator (SDC) present were informed of the above findings and the fall investigation was reviewed. The DN acknowledged she did not know the specifics of how the resident was found after her fall; she said there were no witnesses, so no one else was interviewed. The DN stated she could have the nurse who found the resident talk with the surveyor. The DN noted the information given to her of the findings and stated "I get your point." At the conclusion of the survey on 10/03/11, no further follow up was provided regarding the resident's fall. II. Environment A. Facility Policy Review of the facility policy for self-administration of medications documented in pertinent part, the following rationale: "Patients who desire to self-administer medication are permitted to do so if the center's interdisciplinary team has determined that the practice would be safe for the patient and other patients of the center..." Procedure: #2, if the patient indicates no desire to self-administer medications, document this in the appropriate place in the patient's medical record; #3, if the patient desires to self-administer medications, assess the patient's cognitive, physical and visual ability to carry out this responsibility, during the care planning process. Assessment to self-administer medications includes, but is not limited to: patients are not allowed to self-administer medications without determining competency. B. Facility failure 1. Resident #25, [AGE] years old, was admitted to the facility on [DATE]. According to the 9/11 CPO, the resident had [DIAGNOSES REDACTED]. According to the most recent MDS 3.0 dated 8/04/11, the resident had little cognitive impairment scoring a "14" on the BIMS. The resident had physical and verbal behaviors directed towards others during the assessment period. 2. Observations On 9/28/11 at 3:15 p.m. upon entering the resident's room during medication pass with the medication nurse assigned to the resident, a plastic medicine cup with one white tablet inside of it was observed on top of the resident's bedside table. After exiting the room, the nurse was informed of the above observation and asked to re-enter the resident's room and retrieve the item. After doing so, the nurse identified the medication as a pain reliever (Tramadol). The nurse stated the resident was not capable of taking her own medications. Review of the medication administration record (MAR) for the resident revealed the resident last had the medication at 2:30 a.m. on 9/28/11. The medication was a PRN (as needed) medication. 3. Record review Review of the 9/11 CPO documented the following order: "Tramadol HCL 50 mg, 1 tab PO (by mouth) every 6 hours PRN (as needed). Dx: Pain." Start date 3/03/10. No physician order for [REDACTED]. Review of the resident's clinical record revealed the resident did not desire to self-administer medication as assessed on a patient nursing evaluation. There was no assessment for self-administration of medication found. 4. Interviews On 9/29/11 at 9:12 a.m. the DN was informed of the above findings. The DN stated she had heard about the findings and confirmed the resident was not capable of self-administering her own medications.

Based on record review and staff interviews, the facility failed to ensure that the resident environment remained as free of accident hazards as possible for one of three sample residents (#1). Specifically, facility staff failed to transfer the resident with the assistance of two staff, as the resident was assessed and care planned to need. Several hours after the transfer, the resident complained of pain and was subsequently assessed with [REDACTED]. Findings include: 1. Resident #1 (closed record), age 53, was initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged to the hospital on [DATE], and did not return to the facility. According to his most recent Minimum Data Set (MDS), a quarterly assessment completed on 7/12/10, the resident was totally dependent on staff for assistance with his activities of daily living (ADLs) and he required the assistance of two staff members with bed mobility, transfers, personal hygiene and bathing. Resident #1 could not ambulate and had a history of [REDACTED]. 2. Record review - resident status Review of the care plan (dated 2/29/09) revealed the following: -"Problem: Self care deficit dressing, grooming, bathing, transfers and hygiene. -Goal: Res needs will be met for the next 90 days. -Approach: ...11/7/09 - 2 person transfer (pivot) ..." Review of the Nursing Assessment (full) completed on 6/14/10 when the resident was readmitted read, in pertinent part: " ...Functional Status: Transfers: 2 or more person assist ..." The assessment was completed by a facility Registered Nurse (RN). A Fall Risk Assessment, also completed when the resident was readmitted read, in pertinent part: -He had intermittent confusion -He had 1-2 falls in the previous 3 months -He was chair bound -He was unable to walk -He took 3-4 medications that could impact physical stability -He had 3 or more predisposing conditions that affected his fall risk -He had a total fall risk score of 18; a score of 10 or higher indicated the resident was a high risk for falls. A Bed Safety Evaluation, also completed when the resident was readmitted read, in pertinent part: -" ...Does the resident have an alteration in safety awareness due to cognitive decline? Yes -Does the resident have a history of falls? Yes -Has the resident demonstrated poor mobility or difficulty moving to a sitting position on the side of the bed? Yes -Does the resident have difficulty with balance or poor trunk control? Yes ..." Record review of the ADL Flowsheet for August 2010, showed the resident was documented as being a 4/3 for transfers. The "4" indicated the resident was totally dependent and required full staff performance of activity. The "3" indicated he was a two + persons physical assist. The coding indicated resident #1 required at least two people for all transfers. Resident #1 was documented as being a 4/3 since his readmission. 3. Record Review - injury, associated with fracture and pain a. Review of nurses' notes revealed the following documentation: -8/12/10 - 7:00 a.m. "This writer was notified by nurse on shift (referred to change of shift report received from the nurse going off duty) that resident has a swollen knee. Upon examination resident has a swollen, warm knee and abrasion under the patella (knee cap). Resident grimaced when knee is touch (SIC). MD notified and gave order for STAT (immediate) x-ray of right knee. (Name of portable x-ray provider) notified." -8/12/10 - 11:30 a.m. "VS (vital signs) 98.8, 96, 20 142/88. Called and x-ray result comminuted fracture (fracture of a bone with more than one break) of right femur (thigh bone). Received order to send resident to (name of hospital) for eval (evaluation) and treatment. Left a message for resident's mother, POA (power of attorney), to call (facility). (Name of ambulance company) here to transfer resident to hospital. -8/12/10 Late Entry 10:00 a.m. "During a.m. care R (right) knee noted swollen and abrasion 1X4 cm below knee. Supervisor RN (Registered Nurse) notified. Pt. (patient) evaluated by RN. NP (Nurse Practitioner) ___ (name) / (name of physician) notified with new order for STAT x-ray. PRN pain meds (medication) given with + effect. B/P 134/82, P 86, R 22, temp 98.2, Pt. in bed, refused food, good fluid intake, awake, alert. Cooperative with x-ray. No distress noted at this time ..." b. Review of the August 2010 Medication Administration Record (MAR) revealed the resident had a pre-existing physician's orders [REDACTED]. Two tabs p.o. (by mouth) or via GT (gastrostomy tube) every 6 hours prn (as needed) for pain." The resident had not received pain medication in 6/10, 7/10 or 8/10, until 8/12/10, when he sustained the right knee/leg injury (see below). c. X-ray Report A copy of the final x-ray report was reviewed. It read, in pertinent part: " ...Exam reason: pain and swelling in right knee, no reason given for the pain or swelling ...Impression: Comminuted distal femur fracture ...new major diagnosis..." The report was noted to have been reviewed by a radiologist on 8/12/10 at 10:13 a.m. 4. Record review - facility investigation of injury The facility investigation was documented on a facility form titled, "Alleged Abuse, Neglect and Exploitation Worksheet." It read, in pertinent part: -"Type of Allegation: Injury of Unknown Origin...What allegedly occurred? Resident (#1) was found with a swollen, warm right knee with an abrasion below right patella (kneecap) ... -Injuries? Yes, below right knee, 3 cm X 2 cm ... -Description of Incidence Witnessed: No scratches noted to right lower extremity on Tues. 8/10/10. Noted resident's right paralyzed leg has a tendency to slide off right calf rest (on wheelchair) on right side. May have sustained scratches that way while self-propelling (his wheelchair) ... -Summary report of findings: Res. did have fracture discovered upon x-ray. Discussed incident with staff via interviews. There was no indication of injury or complaint of pain until approximately 0500 (5:00 a.m.). Medical director reviewed as well. Dr. (name of Medical Director) did say that medications and non-weight bearing status may contribute to loss of bone mass & density may have fractured during transfer ... -Conclusions: The root cause of the fracture may not be known. It is possible that it may have happened during the pivot- transfer with CNA (certified nurse aide). CNA counseled regarding following of care plan. Bone density/mass may have been lost secondary to medication use and non-weight bearing status R/T (related to) to CVA (cerebral vascular accident/stroke) for a long period of time. Abuse is not suspected." 5. Staff Interviews a. Director of Nursing (DON) The DON was interviewed on 10/6/10 at approximately 12:30 p.m. She was asked about the fractured femur sustained by resident #1 and the investigation that was completed. She stated she had interviewed a couple of residents and one family member and the facility social worker (SW). She stated that all of these people offered no complaints regarding care provided. However, she was unable to provide any documentation of these interviews. She stated that the facility investigation of the resident's injury yielded evidence that a CNA had incorrectly transferred resident #1 on 8/11/10, the night before the fracture was diagnosed . She stated that he had been employed by the facility for just under a year, and otherwise was a "good employee." She stated that due to his accent he sometimes came across as speaking in what was perceived as a "clipped manner." She stated that the employee had been counseled, in writing, as a result of the investigation into the cause of the injury to resident #1 and that there had been a "definite improvement." She stated that he told her he "thought he could do it" (transfer the resident by himself) and that was why he did a one person transfer on 8/11/10. The DON was asked how a CNA would know what type of care and/or assistance any resident would require. She stated that information was shared each day at change of shift and that each resident had an ADL (activities of daily living) flowsheet on which the CNAs were to document the level of assistance provided to a resident. (Review of the ADL Flowsheet for August 2010 showed the resident was documented as being a 4/3 for transfers. See above.) b. CNA On 10/6/10 at approximately 4:15 p.m. the CNA who transferred the resident by himself on 8/11/10, was interviewed in the presence of the DON. He stated he had been a CNA for about eight years and had worked at the facility for less than a year. When asked what had happened in regard to resident #1, he gave the following description of events: -On the evening of 8/11/10 at approximately 6:30 - 7:00 p.m., he transferred resident #1 from his wheelchair to his bed. He stated he did the transfer alone. When asked if he was aware the resident required the assistance of two staff members, he at first stated he did not know that. He then stated that he did it to "help out a co-worker who was busy." He also stated, "I thought I could do it by myself." -He stated that later that night, at about 9:00 p.m., he was making rounds and resident #1 told him he was in pain and stated the pain was in his right thigh area. The CNA stated he informed the charge nurse (a Licensed Practical Nurse/LPN) that resident #1 complained of pain in his thigh. He stated he did not tell the LPN he had transferred resident #1 alone earlier that evening. He stated that the LPN stated later that the resident had an abrasion under the right knee and that he (LPN) would give him a pain pill. c. LPN On 10/6/10 at approximately 4:30 p.m., the LPN on duty the evening of 8/11/10 was interviewed. He stated the CNA had reported that resident #1 complained of pain. He stated that the CNA did not specifically state where the pain was. The LPN then stated that he met with the resident and asked him if he was having pain and that resident #1 stated he had pain in his "bottom." The LPN pointed to his crotch area. When asked for clarification, the LPN stated that the resident pointed between his legs when asked to locate his pain. The LPN stated that he repositioned the resident who then offered no further complaints. The LPN stated that he did not offer the resident any pain medication. The LPN also stated that the CNA had worked with resident #1 before and should have been familiar with the requirement that he be transferred by two persons. He confirmed that the CNA had worked in the resident's unit numerous times. 6. Facility documentation On 10/6/10 the DON provided a written statement/summary. She stated it was a summary of the counseling given to the CNA. Review of the statement revealed it read: -"Following the investigation of injury sustained by (resident #1), the staff member was counseled regarding use of 2 persons (for transfers) as well as use of a gait belt. Education has been provided previously in CNA meetings and huddles. (The CNA) was informed that the expected level of performance was that a CNA "will transfer resident with the use of a gait belt as well as according to the resident's care plan." The correction action plan was that the staff member "would follow the resident's care plan for transfers and use of a gait belt. Failure to do so will result in further disciplinary action up to and including suspension and/or termination." The counseling was done with the staff member on 8/20/2010 and was signed by both the staff member and this writer." It was signed by the DON. Although the DON stated in interviews above that the CNA had been counseled and that staff go over transfers, care plans, and gait belt usage on an on-going basis, the facility presented no documentation to show that it had identified other residents having the potential to be affected by the same deficient practice or evidence of any systematic changes to ensure the deficient practice did not recur.