Every finding on record at Mantey Heights Rehabilitation & Care Center

Based on record review and interviews, the facility failed to ensure was kept free from physical abuse for one (#4) of five residents reviewed for abuse out of six sample residents.Specifically, the facility failed to protect Resident #4 from physical abuse by Resident #5.Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation and Misappropriation Prevention policy, revised April 2021, was provided by the director of nursing (DON) on 7/20/26 at 4:10 p.m. The policy revealed, The residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the residents symptoms. The resident abuse neglect and exploitation prevention program consists of a facility wide commitment and resource allocation to support the following objectives. Protect the resident from abuse, neglect, exploitation, or misappreciation of property by anyone including but not necessarily limited to facility staff and or other residents. Develop and implement policies and protocols to prevent identity abuse. Ensure adequate staffing and oversight. Conduct employee background checks. Establish and maintain the culture of compassion and care for all residents and particularly those with behavioral, cognitive or emotional problems. II. Incident of physical abuse by Resident #5 towards Resident #4 on 6/20/26 A. Facility investigationThe 6/22/26 facility investigation, documented at 2:40 p.m., revealed Resident #4 and Resident #5 had a physical altercation on 6/20/26. A verbal altercation started when Resident #4 accused Resident #5 of taking a radio. Resident #5 became upset with the allegation and Resident #5 pushed Resident #4 in the chest. Both residents lost their balance and fell to the ground. The altercation was witnessed by another resident (Resident #9) who notified staff of the incident. The residents were immediately separated and assessed for any injuries. No injuries were reported. Both residents were placed on every 15-minute safety checks (staff to monitor the whereabouts of each resident) and to keep them separated from each other. The abuse investigation was started. The residents' representatives, providers and the ombudsman were notified. Both residents were interviewed by the DON on 6/22/26 and both residents reported they were verbally and physically abusive to one another. The resident who witnessed the altercation between Resident #4 and Resident #5 was interviewed by the DON on 6/22/26 and the resident confirmed the interaction started with a verbal exchange, which led to physical contact between the two residents.The next day after the altercation (on 6/21/26), Resident #4 was sent to the hospital for an evaluation for rib and chest pain. All diagnostics were negative for fractures and the resident returned to the facility the same day. The final diagnosis from the hospital was a chest contusion. The physical abuse investigation concluded the abuse between Resident #4 and Resident #5 did happen, based on the residents' reports and the witness statement. The facility substantiated the abuse.B. Resident #4 (victim)1. Resident statusResident #4, age greater than 65, was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses dementia of unspecified severity with agitation, chronic obstructive pulmonary disease (COPD) and diabetes. According to the 5/19/26 minimum data set (MDS) assessment, the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of six out of 15. The resident was independent with activities of daily living (ADL) for ambulating, eating and dressing, and hygiene. The assessment indicated the resident had behavioral symptoms directed towards others, (threatening, screaming and curing) which occurred one to three days a week during the assessment look-back period. 2. Record reviewThe nurse note, dated 6/20/26 at 10:58 p.m., documented a certified nurse aide (CNA) communicated to the nurse that Resident #9 had witnessed a physical aggression incident between Resident #4 and Resident #5 and reported this to the CNA. Resident #4 and Resident #5 were assessed and Resident #4 complained of back pain.The nurse note, dated 6/21/26 at 7:21 a.m., documented Resident #4 continued to request more pain medications related to his back pain, which he rated as a 10 out of 10 on a pain scale of 1-10. The resident was offered an ice pack but refused, and demanded more pain medications. The nurse note, dated 6/21/2026 at 4:12 p.m., documented Resident #4 had altered mental status related to uncontrolled pain. It was recommended to transfer the resident to the hospital for an evaluation. The provider note, dated 6/21/26 at 5:21 p.m., documented Resident #4 was in a resident-to-resident altercation and staff reported the resident had had a change in mentation since the altercation. Resident #4 was now unable to walk straight, was leaning to the left side and reported an increase in pain. Resident #4 declined to have an Xray at the facility and requested to go to the hospital for an evaluation. The nurse note, dated 6/21/26 at 6:35p.m., documented Resident #4 was transferred to the hospital for complaints of pain. The nurse note, dated 6/21/26 at 7:49 p.m., documented Resident #4 returned from the hospital with a diagnosis of a chest wall contusion (bruising). The interdisciplinary at risk note, dated 6/22/26 at 9:32 a.m., documented Resident #4 was engaged in a verbal altercation with Resident #5, which resulted in Resident #4 being punched in the chest by Resident #5. The root cause was from Resident #4 making an accusation and engaging in antagonistic behaviors toward Resident #5. Current interventions for Resident #4 were to analyzing key times, places, triggers and what de-escalated the resident's behaviors, offering for the resident to fold linens when experiencing anxiety, monitoring and documenting circumstances surrounding verbal abusive behaviors to determine the cause and removing the cause when possible, offering snacks and fluids when visibly distressed, validating the resident's feelings when agitated and intervening when agitation escalated and guiding the resident away from the source of distress and discharge planning for the most appropriate placement to meet the resident's psychosocial and cognitive needs. Resident #4's behavior care plan, revised 3/25/26, revealed Resident #4 often threatened to leave the community when he was told he was out of cigarettes or money. When he had anxiety and agitation, he often paced the community hallways. There were days the resident could become verbally agitated towards others. Interventions included immediately separating residents if they engaged in unreciprocated physical behavior, offering for the resident to assist with folding linens when he was experiencing anxiety, monitoring for and reporting to management immediately any episodes of the resident engaging in unreciprocated physical affection, monitoring and documenting the circumstances surrounding the resident's verbally abusive behavior, attempting to determine the pattern or cause of behaviors, and where possible, altering or removing the cause, offering snacks and fluids when the resident was visibly distressed, specifically sweet treats and decaffeinated coffee, when the resident became agitated, intervening before the agitation escalated and guiding the resident away from the source of distress, and engaging calmly in conversation, if the resident's response was aggressive, staff was to walk calmly away and approach later. C. Resident #5 (assailant)1. Resident statusResident #5, age less than 65, was admitted on [DATE]. According to the July 2026 CPO, diagnoses included dementia of unspecified severity without behavioral disturbances, schizophrenia with psychotic disturbances and COPD.According to the 4/10/26 MDS assessment, the resident was moderately cognitively impaired with a BIMS score of 12 out of 15. The resident was independent with ADLs. The assessment indicated the resident had no behaviors.2. Resident interviewResident #5 was interviewed on 7/20/26 at 1:35 p.m. Resident #5 said Resident #4 accused him of taking his things. Resident #5 said he did not like when people accused him of taking things. He said he got mad and pushed Resident #4 and then Resident #4 pushed him and both of them fell to the ground. He said he always tried to stay away from Resident #4 but on that day (6/20/26), Resident #4 was too close to him. He said he was not mad anymore and he felt safe around Resident #4. 3. Record reviewThe nurse note, dated 6/20/26 at 3:53 p.m., documented Resident #5 had an altercation with Resident #4 where Resident #5 punched Resident #4 in the chest. An assessment was completed and no injuries were noted. Staff were monitoring both residents with 15-minute checks. The provider note, dated 6/21/26 at 3:55 p.m., documented Resident #4 and Resident #5 were involved in a physical altercation, which was witnessed by Resident #9. Resident #5 pushed and shoved Resident #4 in the chest and both residents fell backwards. Staff reported the residents' had been separated and placed on every 15-minute safety checks. The interdisciplinary at risk note, dated 6/22/26 at 9:30 a.m., documented Resident #5 was engaged in a verbal altercation with Resident #4, which resulted in Resident #4 being punched in the chest by Resident #5. The root cause was Resident #5 became agitated after Resident #4 engaged in accusatory statements. Current interventions for Resident #5 were to assess the residents' understanding of the situation and allow time for the resident to express his feelings, analyzing key times, places, triggers and what de-escalated the behaviors and documenting and assessing the resident's coping skills and support system with a plan for success. Resident #5's behavior care plan, dated 6/23/26, revealed Resident #5 had safety concerns due to physical aggression. The resident had a history of becoming physically aggressive toward others when feeling antagonized. Resident #5's triggers were feeling tense and threatened. Interventions included continuing to support the resident in identifying coping strategies when he felt tense, overwhelmed or threatened, supporting the resident by providing reminders and assistance to schedule and attend follow-up behavioral health appointments as needed, analyzing key times, places, circumstances, triggers, and what de-escalated behavior and documenting, assessing resident's coping skills and support system, assessing the resident's understanding of the situation, allowing time for the resident to express himself and his feelings towards the situation and planning for success. III. Staff interviewsCNA #1 was interviewed on 7/20/26 at 1:15 p.m. CNA #1 said there was an altercation between Resident #4 and Resident #5 on 6/20/26. She said she was working that day and was told about the incident. She said Resident #4 was always in other residents' space, accusing residents of taking his things. She said according to Resident #9, both Resident #4 and Resident #5 were verbally aggressive toward each other and a physical fight broke out. She said since the altercation, the two residents had stayed away from each other and staff monitored to keep them separated. CNA #1 said the residents lived in separate hallways. She said Resident #5 was not aggressive unless someone provoked him. She said Resident #4 had behaviors with aggression toward staff and other residents. CNA #2 was interviewed on 7/20/26 at 1:20 p.m. CNA #2 said both Resident #4 and Resident #5 were independent and walked around the hallways during the day. She said she worked the day of the incident (6/20/26) and was informed that both residents were verbally aggressive toward each other, with Resident #4 accusing Resident #5 of taking his things. She said Resident #5 pushed Resident #4 and they both fell over. She said staff separated the residents and had to complete 15-minute checks on the residents to make sure they stayed away from each other. She said Resident #5 lived on a different hallway from Resident #4 and he did not have any behaviors. She said Resident #4 had behaviors of yelling and screaming at other residents and staff. Registered nurse (RN) #1 was interviewed on 7/20/26 at 1:25 p.m. RN #1 said she knew about the altercation between Resident #4 and Resident #5 and the goal was to keep the residents separated for safety. She said the residents lived in different hallways and staff checked on them often. She said there had been no other incidents between the residents since that day (6/20/26). She said Resident #4 was supervised while outside on the patio and he had a wander guard to alert staff when he went outside. Licensed practical nurse (LPN) #1 was interviewed on 7/20/26 at 1:40 p.m. LPN #1 said she heard about the altercation between Resident #4 and Resident #5 (on 6/20/26). She said the facility was trying to find another facility for Resident #4 because he had shown aggression with staff and residents. She said the facility kept the two residents separated.The social services director (SSD) was interviewed on 7/20/26 at 2:10 p.m. The SSD said she assisted with safety plans for residents with aggressive behaviors to keep all residents safe from harm. She said when a physical altercation or verbal altercation occurred, the residents were separated and placed on 15-minute checks. She said the interdisciplinary team (IDT) met regularly to discuss the residents' plan of success goals (person-centered care plans). She said both Resident #4 and Resident #5 had a safety plan. The DON was interviewed on 7/20/26 at 3:30 p.m. The DON said the process when there was a resident-to-resident altercation was to first separate the residents for safety. She said 15-minute checks were implemented. She said she reported any allegations of abuse to the reporting portal website and started an investigation. The DON said she completed the investigation for the physical abuse between Resident #4 and Resident #5. She said physical abuse did occur between the two residents. She said Resident #5 was moved to a different room on a different hallway to minimize the risk of another altercation between the two residents. She said both Resident #4 and Resident #5 were supervised during smoking times and Resident #4 had had one-on-one supervision with him since 7/1/26 for his and other residents' safety. The DON said the facility had sent referrals out to other facilities for Resident #4 for alternate placement, as he continued to falsely accuse residents and staff of taking his things. The DON said she identified the need for further education with residents who were cognitively impaired with dementia so she started a plan of correction back in May 2026. She said part of the plan was to educate the staff on redirecting residents who wandered into other residents' rooms and disrupted other residents' space. She said the education included what to say or not to say to the residents who were agitated and how to monitor for any triggers that may aggravate the residents. She said her goal was to keep all the residents and staff safe.

Based on record review and interviews, the facility failed to timely report an allegation of abuse involving three (#2, #1 and #5) of five residents reviewed for abuse out of five sample residents.Specifically, the facility failed to throughly investigate and timely report two allegations of sexual abuse by Resident #1 toward Resident #2 and Resident #5. Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, revised September 2022, was provided by the nursing home administrator (NHA) on 2/17/26 at 5:59 p.m. It read in pertinent part, All reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If abuse, neglect, exploitation, or misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and two other officials according to state law. The administrator or other individuals making the allegation immediately reports his or her suspicion to the following person or agencies: The state licensing/certification agencies responsible for surveying/licensings of facility; the local/state ombudsman; the residents' representative; aAdult Protective services; law enforcement officials; and, facility medical director. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions are needed for the protection of residents.According to the policy, the facility should report within two hours of the allegation involving abuse or result in serious bodily injury or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.II. Incident between Resident #1 and Resident #2A. Facility investigation A 10/13/25 sexual abuse investigation was provided by the NHA on 2/17/26 at 4:05 p.m. The investigation provided was an incident reported submitted to the State Agency on 10/16/25. According to the incident report, the incident that prompted the allegation of sexual abuse occured on 10/13/25 at 2:30 a.m. The facility was first made aware of the allegation on 10/14/26 at 8:30 a.m. and the initial report to the State Agency was on 10/16/25 at 4:59 p.m. -The occurrence report identified the report was submitted late by the facility. B. Resident #2 (alleged victim)1. Resident statusResident #2, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included progressive multiple sclerosis, generalized muscle weakness, major depressive order recurrent, in full remission, post-traumatic stress disorder, generalized anxiety and tobacco use.The 2/4/26 minimum data set (MDS) assessment identified Resident #2 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out 15. The MDS assessment indicated Resident #2 used a wheelchair for mobility and was independent with most of her activities of daily living (ADLs). According to the MDS assessment, the resident had delusional behavioral symptoms.2. Resident interview and observationsResident #2 was interviewed on 2/17/26 at 1:45 p.m. Resident #2 said one of the residents at the facility kissed her. She said Resident #1 had come into her room, closed her room door and kissed her on the mouth while she was asleep in her bed two or three months ago. She said prior to Resident #2 kissing her on the mouth, he would occasionally kiss her on the forehead. Resident #2 said she was fearful of Resident #1 when he kissed her on the mouth and was angry, but said it was a couple of months ago and she was no longer fearful of him because he had not done anything recently to her. She said staff were aware of her concern and she felt that she could handle the situation if anything happened again.3. Record review-Review of Resident #2's progress notes on 10/13/25 did not document the 10/13/25 allegation between Resident #1 and Resident #2.C. Resident #1 (alleged assailant)1. Resident statusResident #1, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included mild cognitive disorder due to known physiological condition without behavioral disturbance, post-traumatic stress disorder, chronic, major depressive disorder, single episode, unspecified dementia and specified severity without behavioral disturbance psychotic disturbance or mood disturbance, anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, and tobacco use.The 2/7/26 MDS assessment identified Resident #1 was cognitively intact with a BIMS score of 13 out 15. The MDS assessment indicated Resident #1 did not use a mobility device and was independent with most of his ADLs. The MDS assessment did not indicate he had inattention, disoriented thinking or behaviors directed towards himself or others. According to the MDS assessment, Resident #1 had wandering behaviors. B. Record review-Review of Resident #1's progress notes on 10/13/25 or 10/14/25 did not document the allegation between Resident #1 and Resident #2.III. Incident between Resident #1 and Resident #5Record review and interviews during the survey (see below) identified a 12/22/25 allegation of sexual abuse involving Resident #1 and Resident #5 was not reported to the State Agency.Cross reference F610: failure to thoroughly investigate an allegation of abuse.A. Resident #51. Resident statusResident #5, age greater than 65, was admitted on [DATE] and discharged on 1/12/26. According to the January 2026 computerized physician orders (CPO), diagnoses included heart failure, unspecified mood disorder, anxiety disorder and nicotine dependence. The 12/12/25 MDS assessment identified Resident #5 was cognitively intact with a BIMS score of 13 out 15. The MDS assessment indicated Resident #5 independent with mobility and most of her ADLs. The MDS assessment did not indicate behaviors directed towards herself or others.2. Record reviewThe 12/22/25 behavior note documented Resident #5 said that Resident #1 leaned down to kiss her but she moved her head and the kiss landed on her cheek rather than her lips. According to the note, Resident #1 said the kiss made her feel very uncomfortable and she did not view Resident #5 as a romantic interest. The note identified that Resident #5 felt Resident #1 had become increasingly more invasive over time. The note documented Resident #5 said a few weeks ago (from the time the note was written), Resident #5 was engaging in a phone conversation with a family member when was interrupted by Resident #1 who was outside listening in on the conversation. The note documented Resident #5 felt unsure of what to do about behavior from Resident #1. The note documented Resident #5 was reassured by the nurse that staff would be able to assist her in uncomfortable situations with Resident #1.The 1/3/26 nursing note identified Resident #5 came up to the nurses' station on 1/3/26 at 3:45 a.m. and said that she felt unsafe with Resident #1. According to the note, the resident reported Resident #1 tried to kiss her the other day on the porch in the smoking area and came into her room. The note documented the assistant director of nursing (ADON) was informed of the incident. B. Resident #11. Record reviewThe 12/22/25 behavior note for Resident #1 documented a certified nurse side (CNA) reported seeing Resident #1 kiss a female resident (Resident #5) on the outside smoking porch. According to the note, the registered nurse (RN) attempted to speak to Resident #1 regarding the incident. Resident #1 became defensive and stated that he did not know any information about the incident and denied anything happened. According to the note, Resident #1 became angry and refused to continue the conversation with the RN.IV. Staff interviewsThe NHA was interviewed on 2/17/26 at 4:05 p.m. The NHA said Resident #1 had two incidents of potential sexual inappropriateness with two different residents (Resident #2 and Resident #5). The NHA said Resident #2 claimed that she was unwillingly kissed by Resident #1 on 10/13/25 while she was asleep in her bed. The NHA said he reported the incident to the State Agency because the resident's allegation was related to sexual abuse from another resident. The NHA said the second incident was related to Resident #5, who had since been discharged from the facility. He said he was told Resident #1 traded cigarettes with Resident #5 for a kiss. He said the incident was not reported to the State Agency because he was under the understanding that the kiss was mutually agreed upon. The director of nursing (DON) and the ADON were interviewed together on 2/17/26 at 4:25 p.m. The ADON said it was reported to her that Resident #1 kissed Resident #5's cheek when they were outside. She said the kiss made Resident #5 feel uncomfortable. The ADON said Resident #5 alleged Resident #1 would stand outside of her door and listen to her phone conversations. The ADON said she reported the allegations to the interdisciplinary team (IDT) after it was reported to her. The DON said said she did not believe she was at the facility when it was reported that Resident #1 kissed Resident #5. The ADON said after an allegation was reported, the facility would investigate the allegation. She said the facility would investigate anything out of the ordinary. The ADON said a report of a resident not feeling comfortable when kissed by another resident would rise to the level of an investigation. The DON said anything that met the criteria of potential abuse should have been reported to the State Agency. She said the incident involving Resident #5 and Resident #1 would be reportable. The DON said the incident should have been reported and then investigated. The NHA was interviewed again on 2/17/26 at 4:47 p.m. The NHA said when there was a reportable allegation, the facility would generally interview staff and residents to determine if other residents had similar experiences of potential abuse or an awareness of potential abuse. The NHA said he reported Resident #2's 10/13/25 allegation to the State Agency but it was reported late, on 10/16/25. He said he thought allegations of potential abuse needed to be reported within 48 hours. He said he had since learned that allegations should be reported within 24 hours to the State Agency. The DON was interviewed again on 2/17/26 at 5:50 p.m. The DON said she was currently in the process of educating staff on abuse allegations and how to take appropriate actions. VI. Facility follow up A 2/18/26 email sent by the DON identified the facility conducted leadership training on 2/18/26 related to reporting of alleged violations.

Based on observations, record review and interviews, the facility failed to timely investigate an allegation of abuse involving three (#2, #1 and #5) of five residents reviewed for abuse out of five sample residents.Specifically, the facility failed to throughly investigate allegations of sexual abuse by Resident #1 towards Resident #2 and Resident #5. Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, revised September 2022, was provided by the nursing home administrator (NHA) on 2/17/26 at 5:59 p.m. It read in pertinent part, All reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If abuse, neglect, exploitation, or misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and two other officials according to state law. The administrator or other individuals making the allegation immediately reports his or her suspicion to the following person or agencies: The state licensing/certification agencies responsible for surveying/licensings of facility; the local/state ombudsman; the residents' representative; aAdult Protective services; law enforcement officials; and, facility medical director. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions are needed for the protection of residents.According to the policy, the facility should report within two hours of the allegation involving abuse or result in serious bodily injury or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.The abuse policy identified how the facility should investigate allegations. The policy documented in pertinent part, All allegations are thoroughly investigated. The administrator initiates investigations. Investigations may be assigned to an individual trained in reviewing, investigating and reporting such allegations. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. The administrator is responsible for keeping the resident and his/her representative informed of the process of the investigation. According to the policy, person conducting the investigation would as a minimum would review the documentation as evidence; review the residents' medical record determine the residents' physical and cognitive status at the time of the incident and since the incident; observe the alleged victim, included in his or her interactions with staff and other residents; interview the persons reporting the incident; interview any witnesses to the incident; interviews the resident or the residents representative; interviews the resident's attending physician as needed determine the residence condition; interview staff members who have had contact with the resident during the period of the alleged incident; interview the resident's roommate, family members, and visitors; review all events leading up to the alleged incident; and document the investigation completely and thoroughly. II. Incident between Resident #1 and Resident #2A. Facility investigation A 10/13/25 sexual abuse investigation was provided by the NHA on 2/17/26 at 4:05 p.m. The investigation provided was an incident reported submitted to the State Agency on 10/16/25. According to the incident report, the incident that prompted the allegation of sexual abuse occured on 10/13/25 at 2:30 a.m. The facility was first made aware of the allegation on 10/14/26 at 8:30 a.m. and the initial report to the State Agency was on 10/16/25 at 4:59 p.m. The occurrence report identified the report was submitted late by the facility. The investigation report identified Resident #2 said she was kissed unwillingly by Resident #1. Resident #1 and Resident #2 were separated and observations of both residents were increased. The investigation documented Resident #2 said Resident #1 entered her room in the early morning hours on 10/13/25 and kissed her while she slept in her bed. Resident #2 said she woke up to Resident #1 leaning over her and kissing her. Both residents were interviewed. The investigation documented Resident #1 had dementia, was not oriented to time and place, and could not remember the incident. The investigation documented Resident #2 could not describe the details of the incident or the precise time of the event, when she was investigated. -The investigation did not identify when Resident #1 and Resident #2 were interviewed.The investigation indicated the staff were interviewed along with residents who were in the proximity to the Resident #2's room. The investigation indicated there were no witnesses and the residents felt safe and cared for. The investigation documented Resident #1's change in care plan as result of the occurrence was to redirect Resident #1 away from Resident #2 when she requested Resident #1 to push her in her wheelchair to her room. The investigation documented there were no changes to Resident #2's care plan. According to the investigation, staff were asked to redirect Resident #1 and Resident #2 away from each other to prevent a recurrence. The investigation identified the allegation of sexual abuse was unsubstantiated.-Review of the investigation did not identify the events leading up to the allegation. The investigation did not identify where Resident #1 was or what he was doing prior to the alleged time of 2:30 a.m. or when he was last seen by staff. -The investigation did not identify where staff was or what they were doing at the alleged time of the incident. -The investigation identified that staff and residents were interviewed but it did not include who and when the staff and residents were interviewed. The investigation did not include documented interviews by staff and residents. B. Resident #2 (alleged victim)1. Resident statusResident #2, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included progressive multiple sclerosis, generalized muscle weakness, major depressive order recurrent, in full remission, post-traumatic stress disorder, generalized anxiety and tobacco use.The 2/4/26 minimum data set (MDS) assessment identified Resident #2 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out 15. The MDS assessment indicated Resident #2 used a wheelchair for mobility and was independent with most of her activities of daily living (ADLs). According to the MDS assessment, the resident had delusional behavioral symptoms.2. Resident interview and observationsResident #2 was interviewed on 2/17/26 at 1:45 p.m. Resident #2 said one of the residents at the facility kissed her. She said Resident #1 had come into her room, closed her room door and kissed her on the mouth while she was asleep in her bed two or three months ago. She said prior to Resident #2 kissing her on the mouth, he would occasionally kiss her on the forehead. Resident #2 said she was fearful of Resident #1 when he kissed her on the mouth and was angry but said it was a couple of months ago and she was no longer fearful of him because he had not done anything recently to her. She said staff were aware of her concern and she felt that she could handle the situation if anything happens again.Resident #2 said Resident #1 would also go to her window from the outside and look into her room. Resident #2 said she had to yell at the top of her lungs for staff when he would come to her window. She said she wanted to have her privacy and if he did it again she would call the police. She said the staff had talked about getting her a screen over the window that let light in and she could see out but Resident #1 could not see into her room. She said she had not heard anything more about it and she was still waiting for it. She said he had not looked into her window for a couple months but felt it was because it had been cold outside. Resident #2 said Resident #1 could see her window from the smoking area and he would tell her that he noticed her lights were on in her room. She said she kept her window blinds down so he could not look into her room. She said she did not like the blinds down because she liked to look outside, but she did not feel safe enough to keep them open. Resident #2 said it was hard to know how to deal with Resident #1. She said he had dementia and would forget that he should not look into her window or go into her room. She said she smoked independently in the smoking area on the back porch and Resident #1 was always there. She said he had not done anything inappropriately to her when they were smoking outside. Resident #2 said she was not the only female resident that he had interest in. She said he would try to come on to/flirt with Resident #5 before she was discharged from the facility (see record review and interviews below). During the 2/17/26 interview with Resident #2, Resident #1 was observed at 2:07 p.m. to leave the back porch of the smokers' area. He crossed over the lawn, towards the window of Resident #2 while she was in her room and entered the facility by use of a side door near Resident #2's room. Resident #1 did not enter Resident #2's room. At 2:25 p.m. Resident #2 self propelled herself in her wheelchair out to the porch of the smokers' area. At 2:29 p.m. Resident #1 opened the outside door to the smokers' area, saw Resident #2 and called her sweetheart as he proceeded out the door.At 2:37 p.m. Resident #1 and Resident #2 entered back into the facility. Resident #1 pushed Resident #2 down two of the hallways and past a nurses' station. When the residents arrived on her hall, Resident #2 told Resident #1 that she could go the rest of the way to her room. Resident #2 propelled herself down her hallway and into her room. Resident #1 turned around and left the area. -The 2/17/26 observation did not identify staff intervened or encouraged Resident #1 not to push Resident #2's wheelchair. The staff was not observed to offer to push Resident #2 in her wheelchair instead of Resident #1.Resident #2 was interviewed again on 2/17/26 at 2:43 p.m. Resident #2 said Resident #1 was talking to her outside when they both were smoking and he was appropriate to her. She said he would forget that he was not supposed to push her wheelchair and he had helped her get to her hallway. She said she made sure he did not take her all the way to her room but it was really convenient for her when he helped her down the other long two halls. 3. Record reviewThe behavior care plan, revised 2/6/26, documented Resident #2 had a history of making allegations about other residents regarding peers standing over her bed, watching her sleep and accused staff of allowing the situation to happen. The care plan indicated Resident #2 had a history of flirtation prior to admitting to the facility and had a history of having caregivers terminated because they made her mad. Interventions included checking in with Resident #2 to ensure she was feeling safe and remind her that staff were available to help (7/30/25), providing a positive attitude when conversing with the resident (5/8/25). According to the care plan, the resident enjoyed when her power of attorney (POA) visited because the POA provided her with new books and personal entertainment items (10/15/25). -Review of the care plan, did not include interventions to help ensure Resident #2's privacy in her room or how to assist her if a resident entered her room unwelcomed or while she was sleeping. The 7/29/25 social service progress note documented Resident #1 gave Resident #2 a letter asking if she liked him in a romantic way. According to the progress note, Resident #2 felt that Resident #1's interest in her was unwanted and she was not interested in him and did not want him to come to her room or her door anymore. The note documented staff would redirect Resident #1 when he attempted to visit Resident #2 and implement 15-minute checks. Review of Resident #2's progress notes on 10/13/25 did not document the 10/13/25 allegation between Resident #1 and Resident #2.C. Resident #1 (alleged assailant)1. Resident statusResident #1, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included mild cognitive disorder due to known physiological condition without behavioral disturbance, post-traumatic stress disorder, chronic, major depressive disorder, single episode, unspecified dementia and specified severity without behavioral disturbance psychotic disturbance or mood disturbance, anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, and tobacco use.The 2/7/26 MDS assessment identified Resident #1 was cognitively intact with a BIMS score of 13 out 15. The MDS assessment indicated Resident #1 did not use a mobility device and was independent with most of his ADLs. The MDS assessment did not indicate he had inattention, disoriented thinking or behaviors directed towards himself or others. According to the MDS assessment, Resident #1 had wandering behaviors. B. Record reviewThe behavior care plan, revised 10/21/25, identified Resident #1 threatened to leave the facility when he was told he was out of money, cigarettes or able to roll cigarettes at the moment and had a history of misinterpreting female kindness for wanting a relationship. According to the care plan, Resident #1 would often push his friend/another resident in a wheelchair. Interventions included directing the staff to validate Resident #1's feelings (6/12/25), gently remind resident that the cigarettes in his case were all the cigarettes he had until a staff member could sit with him to roll more cigarettes and ensure the resident had a full case of cigarettes daily (6/12/25), and reminding him of boundaries of his peers in a gentle tone (7/30/25). According to the care plan, initiated 10/15/25, Resident #1 declined counseling services but would continue to encourage counseling services due to signs and symptoms of depression. The 10/21/25 intervention directed staff to remind Resident #1 that it was not safe for him or any resident to push other residents in their wheelchairs.-However observations on 2/17/26 did not identify that the staff reminded or intervened when Resident #1 pushed Resident #2 in her wheelchair from the smokers' area to her hallway (see observations above). Review of Resident #1's progress notes on 10/13/25 or 10/14/25 did not document the allegation between Resident #1 and Resident #2.III. Incident between Resident #1 and Resident #5Record review and interviews identified an investigation was not available or located and provided when requested regarding a potential sexual abuse allegation on 12/22/25. Cross reference: F609 failure to report to the State Agency.A. Resident #51. Resident statusResident #5, age greater than 65, was admitted on [DATE] and discharged on 1/12/26. According to the January 2026 computerized physician orders (CPO), diagnoses included heart failure, unspecified mood disorder, anxiety disorder and nicotine dependence. The 12/12/25 MDS assessment identified Resident #5 was cognitively intact with a BIMS score of 13 out 15. The MDS assessment indicated Resident #5 independent with mobility and most of her ADLs. The MDS assessment did not indicate behaviors directed towards herself or others.2. Record reviewThe leisure care plan, initiated 1/3/26, identified Resident #5 was independent with her leisure activities. According to the care plan, Resident #5 preferred to watch television in her room and use her phone. Review of Resident #5's comprehensive care plan did not identify she was at risk for abuse or had interventions to prevent unwanted sexual advances from other residents. The care plan did not include interventions to ensure the resident felt safe and comfortable in the facility. The 12/22/25 behavior note documented Resident #5 said that Resident #1 leaned down to kiss her but she moved her head and the kiss landed on her cheek rather than her lips. According to the note, Resident #1 said the kiss made her feel very uncomfortable and she did not view Resident #5 as a romantic interest. The note identified that Resident #5 felt Resident #1 had become increasingly more invasive over time. The note documented Resident #5 said a few weeks ago (from the time the note was written), Resident #5 was engaging in a phone conversation with a family member when she was interrupted by Resident #1 who was outside listening in on the conversation. The note documented Resident #5 felt unsure of what to do about behavior from Resident #1. The note documented Resident #5 was reassured by the nurse that staff would be able to assist her in uncomfortable situations with Resident #1.The 1/3/26 nursing note identified Resident #5 came up to the nurses' station on 1/3/26 at 3:45 a.m. and said that she felt unsafe with Resident #1. According to the note, the resident reported Resident #1 tried to kiss her the other day on the porch in the smoking area and came into her room. The note documented the assistant director of nursing (ADON) was informed of the incident. B. Resident #11. Record reviewReview of Resident #1's comprehensive care plan did not identify new interventions were put in place after Resident #1 was observed kissing Resident #5. The 12/22/25 behavior note for Resident #1 documented a certified nurse side (CNA) reported seeing Resident #1 kiss a female resident (Resident #5) on the outside smoking porch. According to the note, the registered nurse (RN) attempted to speak to Resident #1 regarding the incident. Resident #1 became defensive and stated that he did not know any information about the incident and denied anything happened. According to the note, Resident #1 became angry and refused to continue the conversation with the RN.IV. Additional resident interview and observation Resident #4 was interviewed on 2/17/26 at 3:14 a.m. Resident #4 said Resident #1 came into her room all the time. She said he did not knock but would just walk into her room and ask her for soda pop and cigarettes. She said the stop sign banner should have been across her doorway to help prevent Resident #1 from entering her room but the staff never put it back up. Observation outside of Resident #4's doorway revealed there was a stop sign banner attached to the wall by velcro on the right side of the resident's door. The banner was bunched up on top of the hand railing and not across the doorway of the resident's room to deter other residents from coming into her room. Resident #4 said Resident #1 had not done anything inappropriate to her, but she was angry that Resident #4 would come into her room without her permission. V. Staff interviewsCNA #1 was interviewed on 2/22/26 at 2:27 p.m. CNA #1 said Resident #1 could get a little too familiar with other residents. She said he would enter female residents' rooms and they would get upset and she had heard he kissed other female residents. RN #1 was interviewed on 2/17/26 at 3:25 p.m. RN #1 said Resident #1 could get too friendly with other residents and get in their personal space. She said Resident #1 spent a lot of time around Resident #2 and would go near her room. She said staff would redirect him away from Resident #2. RN #1 said the last time she was aware that Resident #2 was not comfortable about Resident #1 being around her was a couple of months ago. She said she saw the two residents outside talking together on 2/16/26 but there did not seem to be any concerns.RN #1 said Resident #1 had an incident with another female resident. RN #1 said Resident #1 kissed Resident #5 on 12/22/25. She said both residents smoked outside and Resident #1 would talk to Resident #5 and joke with her. She said on 12/22/25 Resident #1 and Resident #5 were talking and he leaned over her to kiss her on the mouth and she quickly turned and he kissed her cheek. RN #1 said after that incident, the staff tried to redirect him away from her. RN #1 said she reported the incident to management.CNA #2 was interviewed on 2/17/26 at 2:50 p.m. CNA #2 said was not aware of or been told about any behaviors or anything to watch for with Resident #1 but she would try to redirect a resident's behavior if she saw a concern. She said she did not know of any behavior specific interventions around other residents or any specific residents. The NHA was interviewed on 2/17/26 at 4:05 p.m. The NHA said Resident #1 had two incidents of potential sexual inappropriateness with two different residents (Resident #2 and Resident #5). The NHA said Resident #2 claimed that she was unwillingly kissed by Resident #1 on 10/13/25 while she was asleep in her bed. The NHA said he reported the incident to the State Agency because the resident's allegation was related to sexual abuse from another resident. The NHA said he felt the allegation needed to be investigated to determine if the allegation was valid. He said there was not enough evidence to support the allegation and it was unsubstantiated. The NHA said there were no witnesses that could confirm Resident #2's allegation and Resident #1 did not remember the incident and denied the allegation. The NHA said the second incident was related to Resident #5, who had since been discharged from the facility. He said he was told Resident #1 traded cigarettes with Resident #5 for a kiss. The NHA said the incident was investigated and was soft filed. He said a soft file was when there was an incident that did not rise to the occasion to report it to the State Agency but was investigated. The director of nursing (DON) and the ADON were interviewed together on 2/17/26 at 4:25 p.m. The ADON said it was reported to her that Resident #1 kissed Resident #5's cheek when they were outside. She said the kiss made Resident #5 feel uncomfortable. The ADON said Resident #5 alleged Resident #1 would stand outside of her door and listen to her phone conversations. The ADON said she reported the allegations to the interdisciplinary team (IDT) after it was reported to her. The DON said said she did not believe she was at the facility when it was reported that Resident #1 kissed Resident #5. The DON said if she was present at the facility at the time of the allegation and was made aware of it, the first measures she would have taken would have been to ensure Resident #5's safety. The DON said when there was an allegation of potential sexual inappropriateness she would usually implement 15-minute checks as a standard procedure and update both residents' care plans. The DON reviewed Resident #5's care plan and said there were no care plan interventions put in place after it was reported that she was kissed by Resident #1 and she felt uncomfortable. The ADON said after an allegation was reported, the facility would investigate the allegation. She said the facility would investigate anything out of the ordinary. The ADON said a report of a resident not feeling comfortable when kissed by another resident would rise to the level of an investigation. The DON said Resident #1 had had other incidents in the past with other female residents. She said in the Fall of 2025, Resident #2 reported a similar allegation about Resident #1. The DON said Resident #1's care plan identified that Resident #1's goal was to understand boundaries with peers and provide him reminders but there were no new care plan interventions created after Resident #2 and Resident#5's allegations to ensure resident and staff safety. She said there should have been new interventions put in place and she would update his care plan. The NHA was interviewed again on 2/17/26 at 4:47 p.m. The NHA said when there was a reportable allegation, the facility would generally interview staff and residents to determine if other residents had similar experiences of potential abuse or an awareness of potential abuse. He said the facility would ask the residents basic abuse questions. The NHA said the facility would normally document the interviews as part of the investigation. He said the investigation would help them determine if the residents felt safe and identify if there were other incidents that were not reported to administration. He said the facility wanted to make sure residents in the facility felt cared for. The NHA said a thorough investigation would help the facility get to the bottom of the allegation and help uncover any potential problems. The NHA said the facility did not have documented evidence to show that other staff and residents were interviewed or more to their investigation other than what was reported to the State Agency. He said he did not know who was interviewed after Resident #2's 10/13/25 allegation. The NHA said he reported Resident #2's 10/13/25 allegation to the State Agency but it was reported late, on 10/16/25. He said he thought allegations of potential abuse needed to be reported within 48 hours. He said he had since learned that allegations should be reported within 24 hours to the State Agency. The NHA said he could not find an investigation related to Resident #1 kissing Resident #5 on 12/22/25. He said he did not feel at the time it was reportable and needed an investigation. He said if Resident #5 said she was uncomfortable about the kiss then it should have been reported and investigated and potential sexual harassment. The NHA said the 1/3/26 progress note that documented she was kissed the other day should have been looked into more to determine if Resident #5 was referring to the 12/22/25 incident or if the 1/3/26 allegation referencing another incident was when she was kissed by Resident #1. The NHA said with both allegations he would want to have documentation to show the incidents were reported and thoroughly investigated. The investigation process would assist in creating interventions to help prevent potential occurrences. He said to lower the risk, there should have been care planned interventions. The 2/17/26 observations of Resident #1 pushing Resident #2 in her wheelchair were reviewed with the NHA. The NHA said staff should have known of the intervention to not have Resident #1 push Resident #2 in her wheelchair and help redirect the resident. He said the staff needed more training to make sure they followed the care plan interventions in place. The DON was interviewed again on 2/17/26 at 5:50 p.m. The DON said she was currently in the process of educating staff on abuse allegations and how to take appropriate actions. VI. Facility follow up A 2/18/26 email sent by the DON identified actions taken in response to the above concerns. The facility created an internal plan for correction on dementia care; conducted leadership training on reporting of alleged violations; updated Resident #1's care plan, and were going to review Resident #1's preferences with him. The email indicated the facility would continue to focus on care planning efforts, which included triggers and dementia appropriate interventions.

Based on record review, and interview, the facility failed to provide choices for preference of bathing schedule for two (#4 and #1) of six residents reviewed for self-determination out of 10 sample residents. Specifically, the facility failed to ensure Residents #1 and Resident #4, who were dependent on staff for care, received regular bathing in accordance with preferences and plan of care. Findings include: I. Facility policy and procedure The Resident Self Determination policy, revised August 2022, was provided by the director of nursing (DON) on 6/11/25 at 6:05 p.m. The policy read in part, Our facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life. Each resident is allowed to choose activities, schedule health care and healthcare providers, that are consistent with his or her interests, values, assessments and care plans including daily routine, such as sleeping and waking, eating, exercise, bathing schedules and personal care needs such as bathing methods and grooming styles and dress. The Activities of Daily Living (ADL), Supporting policy, revised 2018, was provided by the DON on 6/11/25 at 6:05 p.m. The policy read in part, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming and oral care). If residents with cognitive impairments or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having other staff members speak with the resident may be appropriate. Intervention to improve or minimize a residents functional abilities will be in accordance with the residents assessed needs, preferences, stated goals and recognized standards of practice. The resident's response to interventions will be monitored, evaluated and revised as appropriate. II. Resident #4 A. Resident status Resident #4, age greater than 65, was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), the diagnoses included basal skin carcinoma of the skin, vascular dementia, hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side (limited movement on the left side due to a stroke), cerebral infarction (stroke), weakness and cognitive communication deficit. The 4/14/24 minimum data set (MDS) assessment identified Resident #4 was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The assessment documented Resident #4 was dependent on staff for most of her ADLs to include bathing. The MDS assessment indicated Resident #4 had rejections of care behaviors. B. Resident interview Resident #4 was interviewed with her representative on 6/10/25 at 2:02 p.m. Resident #4 said she preferred to shower twice a week on Monday and Thursday or Friday. She said she did not always get her showers and she was not allowed to refuse her showers. Resident #4's representative said Resident #4 was lucky if she got a shower once a week. She said the facility told her that was told Resident #4 would often refuse her showers. She said she had asked staff to call her if Resident #4 refused the shower, but she had not received any calls from the facility regarding bathing refusals. C. Record review Resident #4's ADL care plan, initiated 11/20/24, identified Resident #4 had limitations in her ability to perform her ADLs related to her impaired mobility due to her cerebrovascular accident (CVA) with left sided hemiparesis. According to the care plan, Resident #4 preferred showers twice a week during the day shift and required extensive assistance of one to two staff with bathing. -The ADL care plan did not identify Resident #4 refused bathing opportunities or interventions on her to address her refusals. Resident #1's bathing record from 4/15/25 to 6/11/25 was provided by the DON on 6/11/25 at 2:09 p.m. The April 2025 bathing record indicated Resident #4 received one shower (4/25/25) in April 2025 and refused one shower (4/18/25) between 4/15/25 and 4/29/25. The April 2025 bathing record identified Resident #4 receive three showers/bed baths out of 16 opportunities for bathing. The May 2025 bathing record documented the resident refused a shower on 5/16/25. The May 2025 bathing record identified Resident #4 receive six out of 31 opportunities for bathing. The May 2025 and June 2025 bathing records between 5/20/25 and 6/2/25, did not indicate Resident #4 received or refused another bathing opportunity until 6/2/25. A review of Resident #4's progress note, dates documented on 5/25/25, documented Resident #4 refused her last shower day. -The 5/25/25 progress note did not document when the resident refused her shower or why she refused her shower. The 5/29/25 behavior note documented Resident #4 requested a shower and was out on the shower list for 5/29/25. -The note did not identify that she received a shower on 5/29/25. III. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE] and discharged on 2/1/25. According to the February 2025 CPO, the diagnoses included cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting unspecified side (limited movement on one side of the body due to a stroke), weakness, dysphagia following other cerebral vascular disease (difficulty swallowing), other lack of coordination, unsteadiness on feet, cognitive communication deficit and aphasia following cerebral infarction (difficulty talking). The 2/28/25 MDS assessment revealed the resident had some difficulty in new situations that impacted independent decision making. According to the staff assessment mental status the resident did not have memory impairment. Resident #1 required partial to moderate staff assistance with most of her ADLs to include bathing. The MDS assessment indicated Resident #1 did not have rejections of care. B. Resident representative interview Resident #1's representative was interviewed on 6/11/25 at 11:15 a.m. via phone. The representative said Resident #1 had a shower everyday when she was at home. He said Resident #1 wanted a shower at least every other day while she was at the facility. He said Resident #1 did not receive showers every other day. He said she did not receive more than one shower a week while at the facility. He said her hair was dirty and she had an odor. Resident #1's representative said he sometimes had to take her home on the weekends to bathe her while she was at the facility. He said when he complained about the lack of bathing to the facility staff, he was told that people over the age of 60 did not like bathing everyday. C. Record review Review of Resident #1's care plan did not identify Resident #1 had an ADL specific care plan. Review of the comprehensive care plan did not reveal the resident required staff assistance with her ADL's. The care plan did not identify Resident #1 wanted to be bathed every other day. The care plan did not identify that the resident refused opportunities to bathe. The 11/21/24 admission data collection assessment identified Resident #1 wanted a shower every other day in the mornings. Resident #1's bathing record from 1/1/25 to 1/1/25 was provided by the DON on 6/11/25 at 2:09 p.m. The bathing record identified Resident #1 needed partial to total physical assistance from staff for her bathing. In January 2025 she received a shower on 1/2/25, 1/16/25, 1/20/25, 1/22/25, 1/27/25 and 1/30/25. The January 2025 EMR indicated Resident #1 receive six out of 31 opportunities for bathing. IV. Staff education Staff education for bathing documentation and the procedure to address bathing refusals was provided by the assistant director of nursing (ADON) on 6/11/25 at 5:05 p.m. The staff education was attended by 21 staff members on 6/4/25 and five staff members on 6/11/25 (during the survey). The education identified certified nurse aides (CNA) must report when residents refuse showers to the nurses. The nurses needed to determine the root cause of the resident's refusal if possible and offer interventions to help ensure the shower was completed. According to the provided education, if a resident continued to refuse a bathing opportunity, the nurse must notify the resident's representative and the resident's physician. The nurses needed to document the refusal in a progress note. The education indicated the refusal of a shower/bath must be documented in the resident's care plan. V. Staff interviews CNA #1 was interviewed on 6/11/25 at 4:13 p.m. CNA #1 said if a resident received a shower/bath or if they refused it should be documented in the bathing record. She said the staff should make three attempts to offer the shower and let the nurse know. She said staff should also document why the resident refused. The DON was interviewed on 6/11/25 at 4:40 p.m. The DON said residents received bathing opportunities twice a week unless they identified they preferred more or less showers/baths in a week. She said residents were asked their bathing preferences on admissions and throughout their staff at the facility. She said some of the residents wanted a shower daily and other residents wanted only a shower weekly. She said the facility tried to follow the residents' preferences for showering. The DON said if a resident refused a shower, staff should offer the shower three times that day and document the residents refusal. She said the nurse should encourage the resident to shower and determine why the resident continued to refuse the shower. The DON said the nurse should contact the POA in efforts to encourage the resident to shower and notify the resident's physician. The DON said in May 2025, she noticed holes in residents' bathing documentation and felt staff needed increased education to ensure showers were documented and offered according to the residents'shower schedule and their preferences. She said she did verbal education with staff in May 2025 and the ADON formalized the education in June 2025. The DON said she wanted to make sure staff identified the root cause of the refusals so interventions could be put in place. The DON said Resident #4 frequently refused her showers but there was limited documentation identifying her refusals and her care plan did not identify interventions to address the refusals. The DON said documentation indicated Resident #4 was not offered bathing opportunities for over a week at time. She said she did not know if the resident was offered to bathe but refused and the staff did not document it appropriately . The DON said Resident #1 was scheduled to receive showers on Mondays and Thursdays. She said the resident's shower schedule did not identify the resident preferred to be showered every other day. The DON said the resident's EMR indicated she was not offered bathing opportunities for long periods at a time. She said she did not know why the resident was not offered showers routinely and as preferred. The DON said Resident #1's shower preference might have changed while she was at the facility but nothing was shown in the record to identify she wanted less showers or frequently refused showers. The DON said she would continue to provide staff education.

Based on record review and interviews, the facility failed to ensure a copy of medical records were provided timely for two (#2 and #1) of three residents out of 10 sample residents. Specifically, the facility failed to ensure medical records were provided timely upon request to the representatives of Resident #2 and Resident #1. Findings include: I. Facility policy and procedure The Release of Information policy, revised November 2009, was provided by the director of nursing (DON) on 6/11/25 at 6:05 p.m. The policy read in pertinent part, The resident may initiate a request to release such information contained in his or her records and charts to anyone he or she wishes. Such requests will be honored only upon the receipt of a written, signed, and dated request from the resident or representative. A resident may obtain photocopies of his or her records by providing the facility with at least a 48 hour advance notice of such request. II. Residents' representative interviews Resident #2's representative was interviewed on 6/10/25 at 4:13 p.m. The representative said she requested Resident #2 medical records at the end 2024 and it took a week for the facility to provide them to her. She said she felt the medical records should have been provided to her within a couple days. She said she called the former social service director (SSD) a couple times to remind the facility of the request before she received them. Resident #1's representative was interviewed on 6/11/25 at 11:15 a.m. The representative said Resident #1 was at the facility from November 2024 through January 2025 and discharged on 2/1/25. Resident #1's representative said he requested the resident's medical record from the facility in spring 2025 for social security requirements. Resident #1's representative said he did not receive the medical records for over a week after he requested them. II. Record review The authorization for release of protected health information (PHI) forms for Resident #2 and Resident #1 were provided by the former medical records director (FMRD) on 6/11/25 at 4:17 p.m. The PHI authorization release for Resident #2 identified the request for the resident's record was on 9/10/24. The form did not identify when the representative received the records. Review of the provided forms did not identify another PHI authorization release request at the end of 2024 as identified by Resident #2's representative. The PHI authorization release form for Resident #1 identified a request for the resident's record on 4/2/25. The form did not identify when the representative received the records or when the records were sent to the representative. III. Staff interviews The FMRD was interviewed on 6/11/25 at approximately 3:30 p.m. The FMRD said when a resident or their representative requested medical records, they needed to submit an authorization for release of the medical records. The FMRD said the facility had 30 days to gather the records and send them to the requester. The FMRD was interviewed again on 6/11/25 at 4:17 p.m. The FMRD said Resident #1's medical records were requested by her representative on 4/2/25. She said the representative said he needed the medical records right away. The FMRD said she prioritized the request for Resident #1's medical records by providing them to Resident #1's representative within two weeks of the request. The FMRD said Resident #2's representative requested Resident #2's medical records on 9/10/24. She said she remembered she provided the representative the medical records on the day of the request. She said she did not find any other request for medical records for Resident #2. The DON was interviewed on 6/11/25 at 6:05 p.m. The DON said she would make sure the FMRD was aware of the facility's expectation of providing residents and/or the residents in 48 hours of the request.

Based on record review and interviews, the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for two (#4 and #1) of three residents out of 10 sample residents. Specifically, the facility failed to: -Provide timely restorative services, as was care planned and recommended, for Resident #4; and, -Offer and provide a restorative service program for Resident #1 to help maintain the resident's function after the resident was discharged from therapy services. Findings include: I. Facility policy and procedure The Functional Impairment policy, revised September 2012, was provided by the director of nursing (DON) on 6/11/25 at 6:05 p.m. The policy read in pertinent part, Upon admission to the facility, at any time a significant change of condition occurs, and periodically during the resident's stay, the physician and staff will assess the resident's physical condition and functional status. A physician, nurse or therapist may initiate screening for the potential to benefit from rehabilitation services such as physical and occupational therapy. Following the screening, the therapist will document whether the resident may benefit from a more detailed rehabilitation evaluation from unskilled therapy, as for example restorative nursing services that can be provided by caregivers or exercises with which family members can assist. In conjunction with the physician and staff, therapists will propose a rehabilitation or restorative care plan that provides an appropriate intensity, frequency and duration of interventions to help achieve anticipated goals and expected outcome efficiently using available resources. II. Resident #4 A. Resident status Resident #4, age greater than 65, was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included basal skin carcinoma of the skin, vascular dementia, hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side (limited movement on the left side due to a stroke), cerebral infarction (stroke), weakness and cognitive communication deficit. The 4/14/24 minimum data set (MDS) assessment identified Resident #4 was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The assessment documented Resident #4 was dependent on staff for most of her activities of daily living (ADL). B. Resident and resident's representative interview Resident #4 was interviewed along with her representative on 6/10/25 at 2:02 p.m. Resident #4 said she recently fell out of bed. Resident #4's representative said Resident #4 had not been evaluated by therapy and she had not received restorative services even though she requested Resident #4 to be screened for services in May 2025. She said she was told by the facility that there were no restorative services available at the time, but the facility was working on hiring someone. C. Record review The restorative program care plan, initiated 1/9/23 and revised 6/11/25 (during the survey), directed staff to provide active range of motion (AROM) for Resident #4 to the right side of her body and passive (PROM) to the left side of her body. Interventions included staff providing and encouraging the resident with AROM exercises and AROM ADL self-care activities as tolerated (initiated 10/16/24) and a restorative nurse aide (RNA) was to encourage and assist Resident #4 with (PROM) to her upper and lower extremities as tolerated (initiated 10/10/24 and revised 6/11/25, during the survey). The fall and behavior care plan, revised 6/10/25, documented Resident #4 had a history of falling/removing herself from her bed. The resident's most recent fall (6/1/25) resulted in skin tear. According to the care plan, Resident #4 stated she climbed out of bed because staff was not paying enough attention to her. The intervention, initiated 6/3/25, directed staff to offer the resident a restorative program. The 6/3/25 interdisciplinary team (IDT) note documented the IDT reviewed Resident #4's 6/1/25 fall and recommended a physical therapy (PT) and occupational therapy (OT) evaluation for a restorative program for Resident #4. Review of Resident #4's May 2025 and June 2025 progress notes did not reveal documentation to indicate Resident #4 was on a restorative services program. III. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE] and discharged home on 2/1/25. According to the February 2025 CPO, diagnoses included cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting unspecified side (limited movement on one side of the body due to a stroke), weakness, dysphagia following other cerebral vascular disease (difficulty swallowing), other lack of coordination, unsteadiness on feet, cognitive communication deficit and aphasia following cerebral infarction (difficulty talking). The 2/28/25 MDS assessment revealed the resident had some difficulty in new situations that impacted independent decision making. According to the staff assessment for mental status, the resident did not have memory impairment. Resident #1 required partial to moderate staff assistance with most of her ADLs. B. Resident's representative interview Resident #1's representative was interviewed on 6/11/25 at 11:15 a.m. via phone. The representative said Resident #1 had a decline in function before she was discharged on 2/1/25. The resident's representative said he was having to pay out-of-pocket for her PT/OT and speech therapy services. He said Resident #1 was not offered restorative services and he was not informed that restorative nursing was an option for Resident #1 to help maintain function with range of motion through the nursing program. He said he was only informed of services he would have to pay out-of-pocket for. C. Record review The fall care plan, initiated 12/8/24, directed staff to encourage Resident #1 to participate in activities that promoted exercise, physical activity for strengthening and improved mobility. The 1/11/25 physical therapy encounter note documented Resident #1 was discharged from PT due to a financial choice and slow progress. The 1/24/25 OT discharge summary identified Resident #1 was discharged from therapy related to an existing co-pay and the resident/responsible party declined treatment. -The OT discharge summary did not identify if a restorative program through the nursing department was recommended or available for Resident #1. IV. Staff interviews The DON and the assistant director of nursing (ADON) were interviewed together on 6/11/25 at 3:29 p.m. The DON said the facility had not had a restorative program for several months that could offer residents passive and active range of motion. She said the only restorative programming that the facility was able to offer for residents was meal assistance. She said the facility had just hired a restorative nurse aide and would now be able to start a complete restorative program. She said the facility's restorative program was currently being set up and they would soon be able to offer restorative services again. The ADON said after Resident #4 fell on 6/1/25, the IDT recommended OT to evaluate the resident for the restorative services program. She said there was some miscommunication between the IDT and OT. The ADON said OT did not evaluate Resident #4 when requested on 6/3/25 after the resident fell. The ADON said the resident would be immediately evaluated by OT and the facility would follow up with Resident #4 and her representative. The ADON was interviewed again on 6/11/25 at 4:28 p.m. The ADON said OT had just evaluated Resident #4 (on 6/11/25) and felt OT was not appropriate and recommended a restorative services program for the resident. The DON was interviewed again on 6/11/25 at 6:35 p.m. The DON said residents would usually be offered restorative services through the nursing department after discharging from OT and PT to help continue their functional goals and progress achieved with therapy. She said Resident #1 was not offered restorative services after she completed therapy in January 2025 because the facility did not have a restorative program at that time. V. Facility follow-up The 6/11/25 OT evaluation and plan of treatment documented Resident #4 was not appropriate for OT at the time of the 6/11/25 OT evaluation. According to the evaluation, Resident #4 would benefit from a restorative services program five to seven days a week for four weeks with active and passive range of motion. The 6/11/25 restorative services program note documented Resident #4's representative was contacted on 6/11/25 and informed that Resident #4 would be added to the facility's restorative program for active and passive range of motion.

Based on record review and interviews, the facility failed to thoroughly investigate allegations of abuse for two (#7 and #8) of seven residents out of 13 sample residents. Specifically, the facility failed to complete a thorough investigation after: -An allegation of physical abuse towards Resident #7 by Resident #3; and, -An allegation of sexual abuse towards Resident #8 by Resident #3. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation-Investigating and Reporting policy, revised September 2022, was provided by the director of nursing (DON) on 4/2/25 at 3:34 p.m. The policy read in pertinent part, All reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by the facility management. Findings of all investigations are documented and reported. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions are needed (if any) for the protection of residents. Allegations are thoroughly investigated. The administrator initiates investigations. The individual conducting the investigation at minimum: reviews the documentation and evidence; reviews the resident's medical record determine the resident's physical and cognitive status at the time of the incident and since the incident; observes the alleged victim, including his or her interactions with staff and other residents; interviews the person reporting the incident; interviews any witnesses to the incident; interviews the resident (as medically appropriate) or the resident's representative; interviews the resident's attending physician as needed to determine the resident's conditions; interviews staff members (on all shifts) who have contact with the resident during the period of the alleged incident; interviews the resident's roommate, family members, and visitors. According to the policy, the individual conducting the investigation should review all events leading up to the alleged incident and document the investigation completely and thoroughly. The policy documented witness statements should be obtained in writing, signed and dated and a follow-up investigation should occur within five business days of the incident. The follow-up investigation report should include as much information as possible at the time of the submission of the report. The report should have sufficient information to describe the results of the investigation; what corrective actions were taken if the allegation was verified; and, the notification of the outcome of the investigation to the resident/representative. II. Incident of physical abuse of Resident #7 by Resident #3 A. Facility investigation The 3/10/25 incident report was provided by the DON on 4/2/25 at 5:05 p.m. The incident report revealed Resident #7 reported to a nurse and a certified nurse aide (CNA) that Resident #3 pinched his leg on 3/10/25 at 8:30 p.m. According to the report, another CNA witnessed the altercation. The incident report identified the CNA was pushing Resident #3 (in her wheelchair) to her room when Resident #3 leaned out from the wheelchair and pinched Resident #7. Resident #7 said ouch in response to the pinching. The incident report documented there were no injuries at the time of the incident or post incident. The nurse manager contacted the nurse practitioner, the on call nurse manager and the residents' representatives. -Review of the provided facility investigation did not include other staff or other residents' interviews after the 3/10/25 incident. -Additionally, the facility failed to investigate if other residents had been involved in altercations with Resident #3 and/or if they felt safe in the facility and free from abuse. Cross reference: F600 failure to protect Resident #7 from physical abuse. B. Resident #7 (victim) 1. Resident status Resident #7, age greater than 65, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included unspecified disorder of psychological development, lack of coordination, difficulty in walking, unqualified vision loss in the left eye, cerebral palsy, cerebellar ataxia (movement disorder, reduced mobility, dependence on a wheelchair, weakness and contracture of the right and left lower leg muscles. The 2/4/25 minimum data set (MDS) assessment documented Resident #7 had severe cognitive impairments with a brief interview of mental status (BIMS) score of seven out 15. The resident presented with inattention and disorganized thinking. The MDS assessment indicated Resident #7 did not exhibit verbal, physical or other behavioral symptoms directed towards others. He had upper extremity impairment to one side and lower extremity impairment to both sides. He used a manual wheelchair for mobility. 2. Record review The 3/10/25 alert note documented Resident #7 reported that another resident (Resident #3) pinched his leg. The note indicated the resident's left thigh was assessed and there was no redness, bruising or open areas identified. According to the note, Resident #7 said his leg no longer hurt but it did at the time of the incident. The 3/17/25 IDT (interdisciplinary team) note documented the IDT met and reviewed the physical aggression incident involving Resident #7. The note identified Resident #7 often sat in his wheelchair in his room doorway or in the hall near his room. He had some difficulty communicating with other residents which may have led to intermittent tension. Resident #7 was reminded to ask staff for help when needed and to keep the halls clear when possible. The note indicated the resident often blocked the hallway with his wheelchair while visiting with others. The IDT note indicated his care plan was updated. C. Resident #3 (assailant) 1. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the April 2025 CPO, diagnoses included unspecified dementia, and specified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The 2/27/25 MDS assessment documented Resident #3 had severe cognitive impairments with a BIMS score of two out 15. The resident presented with inattention and disorganized thinking. According to the MDS assessment, she did not have an upper extremity impairment and was able to propel her manual wheelchair for short and long distances. The MDS assessment indicated Resident #3 had physical and verbal behavioral symptoms directed at others. The MDS assessment identified her behaviors impacted others and put them at risk for physical injury. 2. Record review The behavior care plan, initiated 3/17/25, revealed Resident #3 may become physically and/or verbally aggressive towards staff and others due to poor impulse control, dementia and history of harm to others. The care plan identified Resident #3 could be physically aggressive towards others, usually due to sundowning (increased confusion later in day and or evening). According to the care plan, staff should attempt to redirect the behavior. The 3/10/25 alert note for Resident #3 documented there was a witnessed physical altercation between Resident #3 and Resident #7 on 3/10/25. According to the note, the CNA asked the resident to apologize after Resident #3 pinched Resident #7 on the leg. Resident #3 apologized and then Resident #3 was assisted to her room. The 3/20/25 interdisciplinary note (IDT) note documented Resident #3 lacked impulse control, experienced cognitive decline related to disease process and required frequent redirection during episodes of verbal and physical aggression. D. Additional resident interview Resident #11 was interviewed on 4/1/25 at 11:12 a.m. She said there was a resident who yelled all the time in the dining room. She said recently the resident entered her room and started yelling at her. Resident #11 identified the resident as Resident #3. Resident #11 said staff were aware that Resident #3 was yelling at her in her room. III. Allegation of sexual abuse between Resident #8 and Resident #3 on 3/16/25 A. Facility investigation A request was made for the facility's investigation after an allegation of sexual abuse was documented in Resident #3 progress notes on 3/16/25 (see record review below). -The facility was unable to provide documentation indicating the sexual abuse allegation documented in Resident #3's electronic medical record (EMR) was investigated. B. Resident #8 (victim) 1. Resident status Resident #8, age greater than 65, was admitted on [DATE]. According to the April 2025 CPO, diagnoses included Parkinson's disease without dyskinesia, anxiety disorder, major depressive disorder, abnormalities of the gate and mobility, weakness and unsteadiness on his feet. The 2/12/25 MDS assessment documented Resident #8 was cognitively intact with a BIMS score of 13 out of 15. He required partial to moderate staff assistance with transfers from surface to surface and bed mobility. He used a manual wheelchair for mobility. Resident #8 did not exhibit behaviors directed at others. 2. Resident #8 interview Resident #8 was interviewed on 4/2/25 at 1:58 p.m. Resident #8 said Resident #3 was sitting next to him in an activity on 3/16/25 when she put her hand under his shirt. Resident #8 said Resident #3 put her hand in the sleeve of his t-shirt and proceeded to move her hand down his shirt and up against his side by his ribs. Resident #8 said Resident #3 started to move her fingers in a tapping fashion. He said he told her to stop but she continued even after he told her to stop. He said Resident #3 continued to touch him in this manner for a couple minutes until the staff came over and stopped it. Resident #8 said the incident made him very uncomfortable. He said he felt Resident #3 was inappropriate towards him. He said he did not want to be around her and it would be uncomfortable if he was near her again. Resident #8 said Resident #3 came into his room last night (4/1/25) and was sitting by his bathroom until the staff removed her. He said he was very wary of doing anything because she had touched him before. He said he had also seen that she had very aggressive behaviors and hit and pounded on things with her fists. 3. Record review The trauma care plan, initiated 5/6/24, identified Resident #8 was at risk for side effects of trauma. The 5/22/24 intervention directed staff to draw connections among the resident's history of trauma and subsequent consequences. -Review of Resident #8's progress notes did not identify documentation of the 3/16/25 incident or facility follow-up with Resident #8 after the incident. C. Resident #3 (assailant) 1. Record review The depression care plan intervention for Resident #3, initiated 1/28/25, directed staff to track her sexually inappropriate behaviors. The psycho-social care plan, revised 1/20/25, identified Resident #3 was semi-dependent on staff for meeting her emotional, intellectual, physical, spiritual and social needs. According to the care plan, Resident #3 could be very sexually inappropriate. The 1/31/25 care plan invention directed staff to draw boundaries, redirect her hands, offer her a task to help and redirect her to a conversation so she could have safe interactions with others. The review of Resident #3's progress notes identified the resident had multiple incidents of sexually inappropriate behaviors, including touching staff inappropriately, between 1/29/25 and 3/15/25. The 3/16/25 behavior note documented Resident #3 was observed touching another resident inappropriately. According to the note, the other resident (Resident #8) reported that Resident #3 stroked his arm and side. When Resident #8 asked her to stop, she responded with you know you like it. The note indicated Resident #3 was then redirected with an activity. -However, the facility did not investigate Resident #3's sexually inappropriate behavior towards Resident #8 on 3/16/25. D. Other resident interviews Resident #12 and Resident #13 were interviewed together on 4/1/25 at 11:25 a.m. Resident #12 said there was a resident that was always yelling. Resident #12 said resident would pinch other residents. Both Resident #12 and Resident #13 denied being touched by Resident #3 but said they had seen it happen to other people. They said the other resident inappropriately touched staff and other residents. IV. Staff interviews Registered nurse (RN) #2 was interviewed on 4/1/25 at 4:40 p.m. RN #2 said Resident #3 had a history of inappropriate sexual behaviors but it was usually directed at staff. She said she was not aware of incidents involving other residents. She said Resident #3 was difficult to redirect after her inappropriate sexual behaviors because Resident #3 did not think her behavior was wrong. RN #2 said Resident #3's representative said she had inappropriate sexual behaviors since she was diagnosed with dementia. CNA #3 was interviewed on 4/2/25 at 9:30 a.m. CNA #3 said Resident #3 was pretty calm and was easier to redirect and more cognizant in the mornings. She said her behaviors usually increased after 2:00 p.m. and she was harder to redirect. She said Resident #3 had physical and sexual behaviors. CNA #3 said Resident #3 had sexual behaviors directed toward staff and residents. She said she had not seen the sexual behavior towards residents herself but had been told it was a behavior. She said Resident #3 did not target one particular resident. She said when Resident #3 had inappropriate behaviors, staff would separate them and would try to redirect Resident #3 to an activity. The nursing home administrator (NHA) was interviewed on 4/2/25 at 10:25 a.m. The NHA said abuse prevention started with making sure staff was appropriately trained to help prevent abuse occurrences. He said all potential abuse allegations should be investigated and reported. The NHA was interviewed again on 4/2/25 at 12:02 p.m. The NHA said the 3/16/25 incident between Resident #3 and Resident #8 was investigated by the nurse manager (NM). The NHA said the incident did not rise to the level of abuse because Resident #8 said Resident #3 just touched his arm. -However, Resident #8 said Resident #3 put her hand under Resident #8's shirt (see Resident #8's interview above). The NM was interviewed on 4/2/25 at 12:20 p.m. The NM said she was the nurse manager a few days a week. She said if an incident occurred on her weekend shift, she would make sure the floor nurse documented the incident in a note and would look at the risk management process. The NM said on 3/16/25 the floor nurse, licensed practical nurse (LPN) #3 reported to her that another staff member told LPN #3 they either witnessed or heard that Resident #3 touched Resident #8 and Resident #3 was told to stop. The NM said LPN #3 spoke to Resident #8 after the incident. She said LPN #3 told her Resident #8 said Resident #3 was touching his arm, he told her to stop and Resident #3 asked him if he liked it. The NM said her role related to the investigation was to talk to LPN #3, direct her to write a progress note and report the incident to the DON. The NM said she completed no documentation and was not involved in any other part of the investigation. The NM said she did not usually do anymore in an investigation other than just oversight of the situation when she was the nurse manager on duty. She said the DON or the NHA did the full investigation. The social services designee (SSD) was interviewed on 4/2/25 at 10:30 a.m. The SSD said she had not been part of any investigations but was aware of Resident #3's inappropriate sexual behaviors toward staff. She said she was not aware of any incidents involving residents. She said Resident #3 tended to reach out and grab staff inappropriately. The SSD said she had displayed as many sexual behaviors in the past month since she was admitted to hospice services. She said the staff had been instructed to hold her hand when she tried to reach for them. She said she felt Resident #3 just needed a human touch. She said Resident #3's family decided they were going to move her closer to other family members to help with her behaviors, but the family and the facility had had difficulty finding another facility because of Resident #3's behaviors. The DON was interviewed on 4/2/25 at 12:51 p.m. She said allegations of abuse should be reported to the nurse, nurse leadership, including the DON, and the NHA should be alerted. She said the facility talked with staff and to find out what happened. The DON said if the incident was an abuse allegation, it should be reported to the State Agency within 24 hours. She said a reportable sexual abuse allegation would be reported if it was determined that there was a inappropriate touch to a resident and if the resident who was touch did not consent. The DON said non-consentual touch could be considered sexual abuse. She said if a resident touched another resident and indicated it was not welcomed by words, such as no or do not touch me, it could be considered sexual abuse. The DON said she did not have the investigation for the 3/16/25 investigation involving Resident #3 and Resident #8 but the NHA might have it. She said the NM spoke to LPN #3, Resident #3 and Resident #8 after the incident. The DON said a risk management report should have been completed after the 3/16/25 incident but she could not find one. The DON said, based on what Resident #8 reported the NM, she felt that the 3/16/25 incident was not an allegation of sexual abuse because there was not a concern of sexual contact. She said she could assume that was why a risk management report was not done. The DON said when there was a allegation of sexual abuse, the staff would review the resident's chart to look for similar behaviors. She said Resident #3 had a history of sexual behaviors towards staff. The DON said the physician was aware of the behaviors. She said the behaviors were tracked and reviewed in IDT and the medication review meeting. Physician (PHY) #1 was interviewed on 4/2/25 at 2:55 p.m. PHY #1 said she was the physician for Resident #3. She said during her rounds at the facility, she was told Resident #3 was inappropriate with another resident (Resident #8). She said the incident was reported to her one to two days after the incident occurred. She said she was not told what happened so she reviewed the chart and learned Resident #3 touched a male resident's arm and chest in his room and staff had to remove her. PHY #1 said she was told Resident #3 pinched the leg of another resident. She said anytime there was a new behavior, she and the facility would assess the behavior and the facility would update the care plan. PHY #1 said she would make recommendations. She said it was determined to continue Resident #3 with her current medications because hypersexual behavior was a normal behavior and could be expected with Alzheimer's dementia. The DON was interviewed again on 4/2/25 at 3:47 p.m. The DON said she reviewed the available documentation and the facility did not have an investigation for the 3/16/25 incident between Resident #3 and Resident #8. The NHA was interviewed again on 4/2/25 at 4:25 p.m. The NHA said after Resident #3 pinched Resident #7, the facility did a risk management review and felt the incident did not rise to the level of abuse. He said the pinching did occur but there was no potential for harm. The NHA said Resident #7 said ouch when he was pinched. He said the resident may have said ouch out of a response to the pinching but it might not have indicated he was in pain. The NHA said an investigation was not documented for the 3/16/25 incident between Resident #3 and Resident #8. The NHA said he would write out an investigation today (4/2/25). The NHA said the facility needed to continue to train the staff on abuse. He said the facility would work on notifying PHY #1 after an incident. The NHA said the facility needed to do a better job with investigating alleged abuse. The DON was interviewed a third time on 4/2/25 at 5:08 p.m. The DON said Resident #3 pinched Resident #8 on the leg and he said ouch. She said the incident was a resident-to-resident altercation. She said the IDT reviewed the incident and determined the pinching was intentional. The DON said after the 3/10/25 incident, the facility implemented increased rounding and safety checks on Resident #3. She said the checks were not formal or documented. She said prior to the 3/10/25 resident-to-resident altercation, staff were not concerned about Resident #3's behaviors as a safety risk to other residents. The DON said since 3/10/25, Resident #3's behaviors had continued to progress. She said the staff were now more aware and observant. The DON said Resident #3 did not have any new care plan interventions for sexual behaviors towards residents after the 3/16/25 incident because she and the NM did not think the incident was sexually inappropriate. The DON said now that she had dug more into the situation, she now felt the incident was a concern. She said that was why it was important to do a thorough investigation.

Based on record review and interviews, the facility failed to report all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property for three (#7, #8 and #3) of seven residents out of 13 sample residents. Specifically, the facility failed to: -Report an allegation of physical abuse towards Resident #7 by Resident #3 to the State Agency; -Report an allegation of sexual abuse towards Resident #8 by Resident #3 to the State Agency; and, -Report an allegation of sexual abuse towards Resident #3 by Resident #9 to the State Agency. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation-Investigating and Reporting policy, revised September 2022, was provided by the director of nursing (DON) on 4/2/25 at 3:34 p.m. The policy read in pertinent part, All reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by the facility management. Findings of all investigations are documented and reported. II. Incident of physical abuse of Resident #7 by Resident #3 A. Facility investigation The 3/10/25 incident report was provided by the DON on 4/2/25 at 5:05 p.m. The incident report revealed Resident #7 reported to a nurse and a certified nurse aide (CNA) that Resident #3 pinched his leg on 3/10/25 at 8:30 p.m. According to the report, another CNA witnessed the altercation. The incident report identified the CNA was pushing Resident #3 (in her wheelchair) to her room when Resident #3 leaned out from the wheelchair and pinched Resident #7. Resident #7 said ouch in response to the pinching. The incident report documented there were no injuries at the time of the incident or post-incident. The nurse manager contacted the nurse practitioner, the on call nurse manager and the residents' representatives. -The facility did not report the incident of physical abuse to the State Agency until 4/2/25 (during the survey), 22 days after the incident occurred. C. Resident #7 (victim) 1. Resident status Resident #7, age greater than 65, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included unspecified disorder of psychological development, lack of coordination, difficulty in walking, unqualified vision loss in the left eye, cerebral palsy, cerebellar ataxia (movement disorder, reduced mobility, dependence on a wheelchair, weakness and contracture of the right and left lower leg muscles. The 2/4/25 minimum data set (MDS) assessment documented Resident #7 had severe cognitive impairments with a brief interview of mental status (BIMS) score of seven out 15. The resident presented with inattention and disorganized thinking. The MDS assessment indicated Resident #7 did not exhibit verbal, physical or other behavioral symptoms directed towards others. He had upper extremity impairment to one side and lower extremity impairment to both sides. He used a manual wheelchair for mobility. 2. Record review The 3/10/25 alert note documented Resident #7 reported that another resident (Resident #3) pinched his leg. The note indicated the resident's left thigh was assessed and there was no redness, bruising or open areas identified. According to the note, Resident #7 said his leg no longer hurt but it did at the time of the incident. The 3/17/25 IDT (interdisciplinary team) note documented the IDT met and reviewed the physical aggression received by Resident #7. D. Resident #3 (assailant) 1. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the April 2025 CPO, diagnoses included unspecified dementia, and specified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The 2/27/25 MDS assessment documented Resident #3 had severe cognitive impairments with a BIMS score of two out 15. According to the MDS assessment, she did not have an upper extremity impairment and was able to propel her manual wheelchair for short and long distances. The MDS assessment indicated Resident #3 had physical and verbal behavioral symptoms directed at others. The MDS assessment identified her behaviors impacted others and them at risk for physical injury. 3. Record review The 3/10/25 alert note documented a witnessed physical altercation occurred between Resident #3 and Resident #7. According to the note, the CNA asked the resident to apologize after Resident #3 pinched Resident #7 on the leg. Resident #3 apologized and then Resident #3 was assisted to her room. The 3/20/25 interdisciplinary note (IDT) note documented Resident #3 lacked impulse control, experienced cognitive decline related to disease process and required frequent redirection during episodes of verbal and physical aggression. III. Allegation of sexual abuse by Resident #3 towards Resident #8 on 3/16/25 -The facility did not report the allegation of sexual abuse by Resident #3 towards Resident #8 to the State Agency until 4/2/25 (during the survey), which was 16 days after the incident occurred. A. Resident #8 (victim) 1. Resident status Resident #8, age greater than 65, was admitted on [DATE]. According to the April 2025 CPO, diagnoses included Parkinson's disease without dyskinesia, without mention of fluctuations, anxiety disorder, major depressive disorder, recurrent, mild, abnormalities of the gate and mobility, weakness, and unsteadiness on his feet. The 2/12/25 MDS assessment documented Resident #8 was cognitively intact with a BIMS score of 13 out 15. The resident did not exhibit inattention and disorganized thinking. He required partial to moderate staff assistance with transfers from surface to surface and bed mobility. He used a manual wheelchair for mobility, According to the MDS assessment, he did not have an upper extremity impairment and was able to propel her manual wheelchair for short and long distances. Resident #8 did not exhibit behaviors directed at others. 2. Resident #8 interview Resident #8 was interviewed on 4/2/25 at 1:58 p.m. Resident #8 said Resident #3 was sitting next to him in an activity on 3/16/25 when she put her hand under his shirt. Resident #8 said Resident #3 put her hand in the sleeve of his t-shirt and proceeded to move her hand down his shirt and up against his side by his ribs. Resident #8 said Resident #3 started to move her fingers in a tapping fashion. He said he told her to stop but she continued, even after he told her to stop. He said Resident #3 continued to touch him in this manner for a couple minutes until the staff came over and stopped it. Resident #8 said the incident made him very uncomfortable. He said he felt Resident #3 was inappropriate towards him. He said he did not want to be around her and it would be uncomfortable if he was near her again. Resident #8 said Resident #3 came into his room last night (4/1/25) and was sitting by his bathroom while he was in bed until staff removed her. He said he was very wary of doing anything because she had touched him before. He said he had also seen that she had very aggressive behaviors and hit and pounded on things with her fists. 3. Record review The review of Resident #8's progress notes did not identify the 3/16/25 allegation of sexual abuse or facility follow-up with Resident #8 after the incident. B. Resident #3 (assailant) 1. Record review The 3/16/25 behavior note documented Resident #3 was observed touching another resident (Resident #8) inappropriately. According to the note, the other resident (Resident #8) reported that Resident #3 stroked his arm and side. When Resident #8 asked her to stop, she responded with you know you like it. The note indicated Resident #3 was then redirected with an activity. IV. Allegation of sexual abuse by Resident #9 towards Resident #3 on 3/31/25 A. Facility investigation The 3/31/25 incident report was provided by the DON on 4/2/25 at 5:08 p.m. The incident report identified Resident #9 was sexually inappropriate with another resident (Resident #3). Resident #9 hit the registered nurse (RN) in the face and cursed at her when she attempted to separate both residents. According to the incident report, Resident #9 was taken to his room and told his behaviors were highly inappropriate. The incident report documented the residents were not injured. The report identified the physician was notified on 3/31/25. -The facility did not report the alleged sexual abuse to the State Agency until 4/2/25 (during the survey, which was over 24 hours after Resident #9 was sexually inappropriate towards Resident #3. C. Resident #3 1. Record review The 3/31/25 note documented RN #2 responded to a reported event. The note documented another resident (Resident #9) exposed his genitals to Resident #3. The note indicated the RN immediately removed the other resident (Resident #9) from the situation. According to the note, neither resident could say exactly what had happened and Resident #3 could not identify who she was speaking with at the time of the incident. The note identified Resident #3's representative and the hospice staff were alerted to the situation. D. Resident #9 (assailant) 1. Resident status Resident #9, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the April 2025 CPO, diagnoses included personal history of traumatic brain injury (TBI), bipolar disorder, lack of coordination and the dependence on a wheelchair. The 2/28/25 MDS assessment documented Resident #9 was cognitively intact with a BIMS score of 13 out 15. The MDS assessment indicated Resident #9 had fluctuating difficulty focusing his attention. He had lower extremity impairment to both sides. The resident did not have upper extremity impairment. He used a manual wheelchair and required substantial to maximum staff assistance for mobility. According the MDS assessment Resident #9 did not exhibit behaviors directed at others or rejections of care. 2. Record review The 3/31/25 eInteract situation, background, assessment, response (SBAR) summary for providers note documented Resident #9 had a change of condition related to physical aggression/verbal aggression. -The note did not identify Resident #9's sexually inappropriate behavior of exposing himself to Resident #3. The 4/1/25 IDT note identified the IDT met to review Resident #9's physical aggression According to the note, Resident #9 had a history of sexually inappropriate behaviors and verbal and physical aggression. The intervention was for the nursing home administrator (NHA) to speak with Resident #9 and his representative related to his behaviors and update the resident's plan of care to ensure safety of staff and residents. V. Staff interviews RN #2 was interviewed on 4/1/25 at 4:40 p.m. RN #2 said on 3/31/25 Resident #9 exposed his genitals to Resident #3. She said a dietary aide reported the incident to her and several other staff members also saw it happen. RN #2 said when she separated the two residents, Resident #9 attempted to hit her. She said she was not aware of other incidents of sexual behavior involving Resident #9. RN #2 said she reported the incident to the nurse supervisor and to the DON. The NHA was interviewed on 4/2/25 at 10:25 a.m. The NHA said abuse prevention started with making sure staff was appropriately trained to help prevent abuse occurrences. He said all potential abuse allegations should be investigated and reported to the State Agency. He said if there was injury involved in the allegation, the facility should report the allegation/incident within two hours of the occurrence. The NHA was interviewed again on 4/2/25 at 12:02 p.m. The NHA said the 3/16/25 incident between Resident #3 and Resident #8 was investigated by the nurse manager (NM). The NHA said the incident did not rise to the level of abuse because Resident #8 said Resident #3 just touched his arm. The NM was interviewed on 4/2/25 at 12:20 p.m. The NM said she was the nurse manager a few days a week. She said if an incident occurred on the weekend of her shift, the floor nurse would write up the incident in a progress note. The NM said she would make sure the incident was documented in a note and would look at the risk management process. The NM said on 3/16/25 the floor nurse, licensed practical nurse (LPN) #3, reported to her that another staff member told LPN #3 that they either witnessed or heard that Resident #3 touched Resident #8 and Resident #3 was told to stop. The NM said LPN #3 spoke to Resident #8 after the incident. She said LPN #3 told her Resident #8 said Resident #3 was touching his arm, he told her to stop and Resident #3 asked him if he liked it. CNA #4 was interviewed on 4/2/25 at 10:42 a.m. CNA #4 said Resident #9 recently was showing his genitals out in the open to Resident #3. The DON was interviewed on 4/2/25 at 12:51 p.m. The DON said allegations of abuse should be reported to the nurse, nurse leadership, including the DON, and the NHA should be alerted. She said the facility would talk with staff and find out what happened. The DON said if the incident was an abuse allegation, it should be reported to the State Agency within 24 hours. She said a reportable sexual abuse allegation would be reported if it was determined that there was inappropriate touching to a resident and if the resident who was touched did not consent. The DON said non-consentual touch could be considered sexual abuse. She said if a resident touched another resident and indicated it was not welcomed by words, such as no or don' t touch me, it could be considered sexual abuse. The DON said Resident #9 was exposing himself to Resident #3 on 3/31/25. She said the nurse assisted him to his room. She said Resident #9 had a history of sexual behaviors. She said she did not know if an investigation was started. She said she did not know if the incident was reported. The NHA was interviewed a third time on 4/2/25 at 1:25 p.m. The NHA said Resident #9 exposed himself on 3/31/25. He said Resident #9 did not expose himself to other residents. He said it was reported to him that Resident #9 exposed himself to RN #2. He said if the incident involved another resident, it needed to be reported to the State Agency. The NHA reviewed the 3/31/25 progress note identifying Resident #9 exposed himself to Resident #3 (see record review above). The NHA said he would see if an investigation was started. The NHA was interviewed a fourth time on 4/2/25 at 4:25 p.m. The NHA said after Resident #3 pinched Resident #7, the facility did a risk management review and felt the incident did not rise to the level of abuse. He said the pinching did occur but there was no potential for harm. The NHA said Resident #7 said ouch when he was pinched. He said the resident may have said ouch out of a response to the pinching but it might not have indicated he was in pain. He said the incident was not reported but he would report it today (4/2/25). The NHA said the facility needed to continue to train the staff on abuse. The NHA said the facility needed to do a better job with investigating alleged abuse.

Based on record review and interviews, the facility failed to ensure that residents were free of unnecessary psychotropic medications for one (#1) of three residents reviewed for unnecessary medications out of 13 sample residents. Specifically, the facility failed to: -Document behaviors that justified the rationale for Resident #1's physician's order for the use of as needed (PRN) Lorazepam (an antianxiety medication) after 14 days; and, -Ensure the physician was notified of Resident #1's frequent refusals of scheduled Lorazepam and reassessed Resident #1 for the need to continue the medication. Findings include: I. Facility policy and procedure The Antipsychotic Medication Use facility policy and procedure, revised July 2022 was provided by the director of nursing (DON) on 4/2/25 at 6:08 p.m. It read in pertinent part, Residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the health care practitioner has evaluated the resident for the appropriateness of that medication. The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications. The physician shall respond appropriately by clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risk or suspected or confirmed adverse consequences. II. Resident #1 A. Resident status Resident #1, age greater than 65 was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included Alzheimer's dementia with mood disturbance, abnormal gait and mobility and weakness. The 2/22/25 minimum data set (MDS) assessment revealed that the resident had significant cognitive impairment with a brief interview for mental status score (BIMS) score of zero out of 15. The resident was dependent on staff for bathing, dressing and grooming and required substantial assistance with personal hygiene and toileting. The MDS assessment documented the resident had no physical behavior symptoms, including biting, kicking, hitting or pinching. The MDS assessment indicated the resident consistently had an altered level of consciousness and disorganized speech and thought. B. Record review Review of Resident #1's April 2025 CPO revealed the following physician's orders: Lorazepam oral liquid 0.5 milligrams (mg) by mouth every six hours as needed for anxiety or agitation, ordered 1/15/25 with an end date of 4/15/25. Lorazepam 0.5 mg by mouth scheduled at bedtime, ordered 1/15/25. Review of a quarterly psychoactive medication evaluation, dated 2/6/25, documented to continue Resident #1's Lorazepam was ordered for aggression toward staff and refusal of care. -However, there was no documentation in the resident's EMR regarding aggressive behaviors to justify the continued use of the medication (see progress notes below). The monthly medication review document, dated 2/21/25, documented that the consulting pharmacist (CP) sent a recommendation to the prescribing physician to reassess the use of the PRN Lorazapam. The prescribing physician's response, dated 3/2/25, documented the physician disagreed with the recommendation and referred to the physician's face-to-face assessment of the resident on 1/15/25. -However, there was no documentation to indicate the physician had reassessed Resident #1 face-to-face to provide a rationale for the justification of the continued use of the medication since ordering the initial PRN Lorazepam on 1/15/25. Progress notes dated 1/26/25 and 1/27/25 documented Resident #1 was observed to have night time restlessness and confusion, but offered no verbal or non-verbal signs or symptoms of pain or other unmet needs. When asked, the resident was unable to express any unmet needs. Because the resident thought the call light was a microphone and was unable to use the call light, she was checked on frequently throughout the night. The resident was monitored frequently throughout the night and the notes failed to document any other behavioral concerns. A nursing note, dated 2/1/25, documented Resident #1 had episodes of sleeping all day and staying awake all night. The note did not document the resident was exhibiting aggression toward any person or refusing care. A medication administration order, dated 2/4/25, documented receipt of a new physician's order for Lorazepam 0.5 mg scheduled at bedtime for restlessness. -However, the first dose of Lorazepam was not administered until 2/6/25, because the medication was unavailable. -Additionally, there was no documentation in the nursing progress notes to indicate the resident was having aggressive behaviors toward others from 1/15/25 through 2/6/25. Review of Resident #1's March 2025 medication administration record (MAR) documented Resident #1 refused 17 out of 31 scheduled doses of Lorazepam and received one PRN dose of Lorazepam. -However, there was no documentation to indicate that the physician was notified of the resident's frequent refusals of Lorazepam or that the resident was reassessed by the physician for the continued need of the scheduled and/or PRN Lorazepam. -Additionally, there was no documentation of any nonpharmacological interventions attempted for aggressive behaviors or restlessness. III. Staff interviews The director of nursing (DON) was interviewed on 4/2/25 at 1:50 p.m. The DON said the facility recently changed pharmacy services. She said all PRN orders for Lorazepam should be reviewed every 14 days. The DON said the new consulting pharmacy held monthly reviews for gradual dose reductions (GDR) and appropriate physician's orders. The DON said if any concerns were found regarding physician's orders, the pharmacy contacted the facility's medical director. The CP was interviewed on 4/2/25 at 2:52 p.m. The CP said she oversaw all medications indicated for GDR each month and the pharmacy staff sent a recommendation to the prescribing physician on 2/21/25 regarding Resident #1's PRN Lorazepam. The CP said she was aware that PRN Lorazepam orders need to be reviewed or discontinued every 14 days. The CP said Resident #1's physician replied to her recommendation about the PRN Lorazepam on 3/2/25. She said the reply documented by the physician indicated that the physician disagreed with the recommendation based on the face-to-face visit conducted with the resident on 1/15/25. The CP said she was not sure how the 1/15/25 face-to-face physician's visit would be sufficient to rationalize extended use of Resident #1's PRN Lorazepam since it was before the order for Lorazepam was started on 1/16/25. The CP said she did not send another recommendation to Resident #1's physician in March 2025 since the physician had already replied earlier in the month and disagreed with the recommendation.

Based on observations, record review and interviews, the facility failed to consistently provide catheter care, treatment and services to minimize the risk of urinary tract infections for one (#2) of three residents reviewed for catheter care out of 13 sample residents. Specifically, the facility failed to: -Ensure staff provided appropriate catheter care for Resident #2, who had a history of recurring urinary tract infections (UTI); and, -Ensure Resident #2's baseline care plan included catheter care for his indwelling Foley catheter. Findings include: I. Facility policy and procedure The Catheter Care policy, revised August 2022, was provided by the director of nursing (DON) on 4/2/25 at 5:40 p.m. It read in pertinent part, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Use a clean washcloth with warm water and soap (or bathing wipe) to cleanse and rinse the catheter from the insertion site to approximately four inches outward. Ensure that the catheter remains secured with a securement device to reduce friction and movement at the insertion site. II. Resident #2 A. Resident status Resident #2, age less than 65, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included stroke affecting the right dominant side, neuromuscular dysfunction of the bladder, sepsis and type 2 diabetes. The 2/25/25 minimum data set (MDS) assessment revealed that the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) score of nine out of 15. He was dependent with toileting, bathing, dressing, and personal hygiene. He required assistance with setup to eat and complete oral hygiene. B. Observation On 4/1/25 at 11:34 a.m. Resident #2's incontinence care was observed. Certified nurse aides (CNA) #1 and CNA #2 entered the resident's room to provide care. CNA #2 assisted the resident onto his side while CNA #1 cleaned the resident following an episode of bowel incontinence. -During the incontinence care, CNA #1 did not clean the resident's indwelling catheter or the catheter's insertion site, despite the fact that Resident #2 had been incontinent of bowel. C. Resident and resident representative interviews Resident #2 was interviewed on 4/1/25 at 10:02 a.m. Resident #2 said staff cleaned his catheter sometimes, but he said staff did not clean his catheter daily. Resident #2's representative was interviewed on 4/1/25 at 2:46 p.m. The resident's representative said she attended a care conference with the facility and the hospice agency on 3/18/25. She said they discussed the provision of hygiene assistance because she was concerned that the facility was not providing Resident #2 sufficient hygiene assistance and she was concerned that he had another UTI due to lack of consistent catheter care. The representative said Resident #2 had occasionally refused care, so she was not sure how they ensured proper catheter care was being completed for the resident. D. Record review The history and physical exam, completed 2/20/25, indicated the clinical justification for Resident #2's indwelling catheter was for neurogenic bladder dysfunction after suffering a stroke and failed voiding trials in the hospital prior to his admission to the facility. The exam indicated the resident had an indwelling catheter on admission to the facility that had clear yellow urine without discharge. The physician recommended continued management of the indwelling catheter in the admission assessment. -However, Resident #2's baseline care plan failed to document a care plan focus to address the care of the resident's indwelling catheter within 48 hours after the resident's admission to the facility. Review of Resident #2's comprehensive care plan, initiated 3/2/25, revealed the resident had an impaired urinary elimination pattern due to a neurogenic bladder diagnosis. Interventions included providing indwelling catheter care each shift and as needed and securing the catheter with a securement device without pulling on the catheter. -However, the facility did not provide catheter care as needed appropriately after bowel incontinence (see observation above). -Additionally, per the hospice registered nurse's (HRN) 3/9/25, nursing note, the securement device for the catheter was placed incorrectly (see note below). -Review of Resident #2's March 2025 treatment administration record (TAR) did not document a physician's order for catheter care until 3/2/25, 12 days after the resident's admission to the facility. -Additionally, there was no documentation that nursing staff were assessing the catheter's patency (flow) or performing indwelling catheter care prior to 3/2/25. The progress note, dated 3/9/25 at 7:18 a.m. documented an observation of purulent drainage thick, cloudy drainage) from Resident #2's indwelling catheter. The HRN note, dated 3/9/25, documented an observation of redness, swelling, and discharge around the resident's catheter insertion site. The note documented a concern that Resident #2's catheter was pulled to the side due to inappropriate placement of the securement device that held the catheter in place in line with the resident's anatomy (body). The HRN cleaned the area and readjusted the placement of the catheter tubing and securement device, so that it was not pulling on Resident #2's genitals at the insertion site. The facility progress note, dated 3/10/25, documented the HRN changed the indwelling catheter because the catheter was clogged. The HRN's progress note, dated 3/10/25, documented an observation of blood-tinged and foul smelling urine from Resident #2's indwelling catheter. The HRN requested the facility complete a urinalysis (UA) to assess for a possible infection. The UA results, dated 3/11/25, documented that Resident #2's urine tested positive for bacteria, indicating the resident had acquired a UTI. -The facility obtained new physician's orders for antibiotics to treat a UTI on 3/12/25. The March 2025 CPO documented the resident was prescribed Ciprofloxacin 250 milligrams (mg) twice a day, starting 3/12/25 with an end date of 3/15/25. III. Staff interviews Licensed practical nNurse (LPN) #1 was interviewed on 4/1/25 at 11:11 a.m. LPN #1 said the nurse on the unit was assigned to do daily catheter care. He said the CNAs should also clean the catheter if it was leaking or the resident was incontinent. CNA #1 was interviewed on 4/1/25 at 12:02 p.m. CNA #1 said the CNAs provided incontinence care and that the nurse provided Foley catheter care. She said she thought the nurses provided catheter care once a shift but she was not sure. She said she would ask the nurse for help if she found the catheter was leaking or looked infected. Registered nurse (RN) #1 was interviewed on 4/1/25 at 12:58 p.m. RN #1 said the CNAs were supposed to provide catheter care when they changed the resident or provided incontinence care, but said he also provided catheter care whenever a catheter appeared soiled. He said the CNAs did not always tell him if they did the catheter care and that there was no place for them to chart if they did or did not provide the care. The HRN was interviewed on 4/2/25 at 9:12 a.m. The HRN said she went to the facility on [DATE] to assess Resident #2 after the facility reported the resident's catheter had purulent drainage and foul smelling urine. The HRN said she observed that the resident's skin around the urethra was red, irritated and had discharge. She said she changed the catheter at that time and implemented new orders with the facility to keep the catheter flowing and test for a UTI. The HRN said she reminded the facility staff to provide catheter care following each episode of fecal incontinence and to bathe Resident #2 per the bathing agreement between hospice and facility staff. The DON was interviewed on 4/2/25 at 1:50 p.m. The DON said she attended a care conference for Resident #2 on 3/18/25. She said she remembered they discussed Resident #2 refusing care and how to reapproach him for care. She said they also discussed ways to communicate more effectively with hospice as to who was providing what type of care and on what day the care was to be provided. The DON was interviewed a second time on 4/2/25 at 5:15 p.m. The DON said she expected her staff to provide catheter care when completing incontinence care for bowel movements in order to reduce the risk for infection.

Based on record review and interviews, the facility failed to ensure one (#7) of five residents reviewed were free from abuse out of 13 sample residents. Specifically, the facility failed to ensure Resident #7 was free from physical abuse by Resident #3. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation-Investigating and Reporting policy, revised September 2022, was provided by the director of nursing (DON) on 4/2/25 at 3:34 p.m. The policy read in pertinent part, All reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by the facility management. Findings of all investigations are documented and reported. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of Resident property or injury of unknown source, the administrator is responsible for determining what actions are needed (if any) for the protection of residents. II. Incident of physical abuse of Resident #7 by Resident #3 A. Incident of physical abuse on 3/10/25 The 3/10/25 incident report was provided by the DON on 4/2/25 at 5:05 p.m. The incident report revealed Resident #7 reported to a nurse and a certified nurse aide (CNA) that Resident #3 pinched his leg on 3/10/25 at 8:30 p.m. According to the report, another CNA witnessed the altercation. The incident report identified the CNA was pushing Resident #3 (in her wheelchair) to her room when Resident #3 leaned out from the wheelchair and pinched Resident #7. Resident #7 said ouch in response to the pinching. The incident report documented there were no injuries at the time of the incident or post incident. The nurse manager contacted the nurse practitioner, the on call nurse manager and the residents' representatives. B. Resident #7 (victim) 1. Resident status Resident #7, age greater than 65, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included unspecified disorder of psychological development, lack of coordination, difficulty in walking, unqualified vision loss in the left eye, cerebral palsy, cerebellar ataxia (movement disorder, reduced mobility, dependence on a wheelchair, weakness and contracture of the right and left lower leg muscles. The 2/4/25 minimum data set (MDS) assessment documented Resident #7 had severe cognitive impairments with a brief interview of mental status (BIMS) score of seven out 15. The resident presented with inattention and disorganized thinking. The MDS assessment indicated Resident #7 did not exhibit verbal, physical or other behavioral symptoms directed towards others. He had upper extremity impairment to one side and lower extremity impairment to both sides. He used a manual wheelchair for mobility. 2. Record review The at-risk care plan, revised 4/12/22, identified Resident #7 was an at-risk adult due to a developmental delay. The care plan goal was to keep Resident #7 free from abuse. The interventions, revised 7/12/24, directed staff to observe Resident #7's interactions with others closely for safety, to provide emotional support and the opportunity for him to express himself and to thoroughly investigate allegations of abuse per policy and regulation. The 1/31/25 physical aggression care plan identified Resident #7 was a prior victim of physical aggression from another resident. According to the care plan, Resident #7 would remain safe and free from physical aggression from others. The 1/31/25 intervention directed staff to immediately separate Resident #7 and the other resident during incidents of physical aggression. The 3/17/25 intervention directed staff to monitor Resident #7's psychosocial well-being related to the physical aggression he received. The 3/10/25 alert note documented Resident #7 reported that another resident pinched his leg. The note indicated the resident's left thigh was assessed and there was no redness, bruising or open areas identified. According to the note, Resident #7 said his leg no longer hurt but it did at the time of the incident. The 3/17/25 IDT (interdisciplinary team) note documented the IDT met and reviewed the physical aggression received by Resident #7. The note identified Resident #7 often sat in his wheelchair in his room doorway or in the hall near his room. He has some difficulty communicating with other residents which may have led to intermittent tension. Resident #7 was reminded to ask staff for help when needed and to keep the halls clear when possible. The note read the resident often blocked the hallway with his chair while visiting with others. The IDT indicated his care plan was updated. C. Resident #3 (assailant) 1. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the April 2025 CPO, diagnoses included unspecified dementia, and unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The 2/27/25 minimum data set (MDS) assessment documented Resident #3 had severe cognitive impairments with a BIMS score of two out 15. The resident presented with inattention and disorganized thinking. According to the MDS assessment, she did not have an upper extremity impairment and was able to propel her manual wheelchair for short and long distances. The MDS assessment indicated Resident #3 had physical and verbal behavioral symptoms directed at others. The MDS assessment identified her behaviors impacted others and put them at risk for physical injury. 2. Observations On 4/2/25 at 3:42 p.m. Resident #3 pounded on the side of the housekeeper's cart. A CNA asked her what she needed and moved her away from the cart. At 4:21 p.m. Resident #3 was sitting at the nurse's station when a male resident walked up to the nurse's station. Resident #3 proceeded to loudly yell at the male resident to shut his mouth and started to hit the wall in front of the nurse's station until the male resident walked away. An unidentified staff member at the nurse's station and licensed practical nurse (LPN) #2, who was in the hallway, observed the interaction but did not intervene. 3. Record review The adjustment care plan, initiated 2/4/25, indicated Resident #3 had difficulty transitioning to the facility. The interventions were to contact her family when she became upset or exhibited verbal/physical aggression and speak to her in a calm tone. The anti-psychotic medication care plan, initiated 2/21/25, identified Resident #3 was administered Seroquel (antipsychotic) for her dementia related to agitation and aggression. The care plan interventions directed staff to complete behavior tracking for the resident's increased aggression and elopement tendencies. The behavior care plan, initiated 3/17/25, revealed Resident #3 may become physically and/or verbally aggressive towards staff and others due to poor impulse control, dementia and history of harm to others. The behavioral care plan interventions directed staff to provide Resident #3 with physical and verbal cues to alleviate anxiety, give her positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage her to seek out a staff member when agitated and, give the resident as many choices as possible about care and activities. The care plan identified Resident #3 could be physically aggressive towards others, usually due to sundowning (increased confusion later in day and or evening). According to the care plan, staff should attempt to redirect the behavior. Review of the March 2025 CPO revealed a physician's order that directed staff to monitor Resident #3's behavior every shift for behaviors of hitting herself or increased agitation, ordered 1/29/25. Review of the January 2025 (1/1/25 to 1/31/25), the February 2025 (2/1/25 to 2/28/25) and the March 2025 (3/1/25 to 3/31/25) treatment administration records (TAR) for Resident #3 documented she hit herself and/or had agitation, on at least one shift, 22 times between 1/29/25 and 3/9/25. Review of progress notes between January 2025 and March 2025 identified Resident #3 exhibited multiple incidents of verbal and physical aggression towards staff, including hitting a staff member with her shoe and slapping a staff member. The 2/20/25 IDT note documented Resident #3 had frequent verbal and physical behaviors that were increasingly aggressive in the afternoon. According to the note, the intervention was to add a new medication to increase the resident's comfort. The 3/10/25 alert note for Resident #3 identified the 3/10/25 witnessed physical altercation between Resident #3 and Resident #7. According to the note, the CNA asked the resident to apologize after Resident #3 pinched Resident #7 on the leg. Resident #3 apologized and then Resident #3 was assisted to her room. The March 2025 TAR did not identify Resident #3 exhibited behaviors on 3/10/25, the day she pinched Resident #7. The 30-day response history for behavioral symptoms for Resident #3 did not identify Resident #3 had physical aggression directed to others on 3/10/25. According to the response history, the resident did not have any behaviors on 3/10/25. The 3/10/25 eInteract situation, background, assessment, response (SBAR) summary for providers note documented Resident #3 had physical aggression. According to the note, the recommendation in response to the behavior was redirection and monitoring and reporting worsening behaviors. The 3/20/25 interdisciplinary note (IDT) note documented Resident #3 lacked impulse control, experienced cognitive decline related to disease process and required frequent redirection during episodes of verbal and physical aggression. The note identified the physician was notified and ongoing monitoring and behavior tracking continued. III. Resident interviews Resident #11 was interviewed on 4/1/25 at 11:12 a.m. Resident #11 said there was a resident who yelled all the time in the dining room. She said recently, the resident entered her room and started yelling at her. Resident #11 identified the resident as Resident #3. Resident #11 said staff were aware Resident #3 was yelling at her in her room. Resident #12 and Resident #13 were interviewed together on 4/1/25 at 11:25 a.m. Resident #12 said there was a resident that was always yelling and touching other residents. Resident #12 said she would pinch other residents. Resident #13 identified the resident as Resident #3. Resident #13 said Resident #3 would poke and hit staff. Both Resident #12 and Resident #13 denied being touched by Resident #3, but said they had seen it happen to other people. IV. Staff interviews CNA #3 was interviewed on 4/2/25 at 9:30 a.m. CNA #3 said Resident #3 was usually calm, easy to redirect and more cognizant in the morning. She said her behaviors usually increased after 2:00 p.m. and she was harder to redirect. The nursing home administrator (NHA) was interviewed on 4/2/25 at 10:25 a.m. The NHA said abuse prevention started with making sure the staff were appropriately trained to help prevent abuse occurrences. CNA #4 was interviewed on 4/2/25 at 10:42 a.m. CNA #4 said Resident #3 had good behaviors in the mornings but in the afternoons and evenings, she sundowned (increased confusion and agitation in the afternoon) and could be mean and aggressive. The DON was interviewed on 4/2/25 at 12:51 p.m. The DON said allegations of abuse should be reported to the nurse, the nurse leadership, including the DON, and the NHA should be alerted. She said the facility would then talk with staff and find out what happened. The NHA was interviewed again on 4/2/25 at 4:25 p.m. The NHA said after Resident #3 pinched Resident #7, the facility did a risk management review and felt the incident did not rise to the level of abuse. He said the pinching did occur but there was no potential for harm. The NHA said Resident #7 said ouch when he was pinched. He said Resident #7 may have said ouch out of a response to the pinching, but it might not have indicated he was in pain. The DON was interviewed again on 4/2/25 at 5:08 p.m. The DON said Resident #3 pinched Resident #7 on the leg and he said ouch. She said the incident was a resident-to-resident altercation. She said the IDT reviewed the incident and determined the pinching was intentional. She said the intervention after the incident was communicating with hospice and the resident's family. She said the family decided they wanted to move Resident #3 closer to other family members who could be more involved. The DON said the facility was currently in the process of seeking appropriate placement closer to the family. The DON said after the 3/10/25 incident, the facility implemented increased rounding and safety checks on Resident #3. She said the checks were not formal or documented. She said prior to the 3/10/25 resident-to-resident altercation, staff were not concerned about Resident #3's behaviors as a safety risk to other residents. The DON said since 3/10/25, Resident #3's behaviors had continued to progress. She said staff were now more aware and observant. The DON said resident-to-resident incidents were updated in the care plan as needed.

Based on observation, record review and interviews, the facility failed to ensure two (#9 and #65) of four residents reviewed for nutrition out of 46 sample residents received the care and services necessary to meet their nutritional needs and maintain their highest level practicable physical well-being. Resident #9 was admitted to the facility for long-term care on 11/6/15 with diagnoses of unspecified disorder of psychological development, cerebral palsy, and cerebellar ataxia (difficulty with balance). On 8/20/24, Resident #9 weighed 167.2 pounds (lbs). On 9/24/24, Resident #9 weighed 160 lbs., a weight loss of 7.2 lbs (4.3%) in one month, which was not significant. However, the facility failed to implement nutritional interventions or closer monitoring of the resident's weight to prevent further weight loss for the resident. The resident's care plan documented that the facility implemented a nutritional intervention on 11/5/24 which included providing the resident with nutritional supplements two times per day, however, the intervention did not assist the resident to gain weight and the resident's weight continued to decline. On 12/11/24, Resident #9 weighed 144.8 pounds. Resident #9 lost 15.2 lbs (9.5%) from 9/24/24 to 12/11/24, in less than three months, which was considered severe weight loss. The resident lost 22.4 lbs (13.4%) from 8/20/24 to 12/11/24, in less than six months, which was considered severe weight loss. -Despite the resident's severe weight loss, the facility failed to implement additional nutritional interventions. Due to the facility's failure to effectively implement nutrition interventions to prevent weight loss timely, Resident #9's weight sustained a severe weight loss of 9.5% in less than three months and 13.4% in less than six months. Additionally, Resident #65 was admitted to the facility on [DATE] with diagnoses of chronic kidney disease, asthma and adult failure to thrive. Upon admission, the resident weighed 268.4 pounds (lbs). On 12/3/24, Resident #65 weighed 248.8 lbs. Resident #65 sustained a 19.6 lbs (7.3%) weight change from 8/23/24 to 12/3/24, in less than six months, which was not considered significant weight loss. However, an interview with the registered dietician (RD) revealed that she was unaware Resident #65 was experiencing weight loss because the nursing staff cleaned the trigger alerting that the resident was losing weight. A nutritional assessment performed by the RD on 12/2/24 documented Resident #65 was malnourished, however, the facility failed to implement nutritional interventions to address the resident's malnourishment. Findings include: I. Facility policy and procedure The Food and Nutrition policy, revised October 2017, was provided by the nursing home administrator (NHA) on 12/19/24 at 5:38 p.m. It documented in pertinent part, The multidisciplinary staff, including nursing staff, the attending physician and the dietician will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. A resident-centered diet and nutritional plan will be based on this assessment. Meals and/or nutritional supplements will be provided within 45 minutes of either resident request or scheduled meal time, and in accordance with the resident's medication requirements. Reasonable efforts will be made to accommodate resident choices and preferences. The food and nutrition staff will be available and adequately staffed to assist residents with eating as needed. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the food service manager so that a new tray can be issued. Nourishing snacks are available to the residents 24 hours a day. The resident may request a snack as desired, or snacks may be scheduled between meals to accommodate the resident's typical eating patterns. The Nutritional Assessment policy, revised October 2017, was provided by the NHA on 12/19/24 at 5:38 p.m. It documented in pertinent part, As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident's risks for nutritional complications. Such interventions will be developed within the context of the resident's prognosis and personal preference. II. Resident #9 A. Resident status Resident #9, age greater than 65, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included unspecified disorder of psychological development, cerebral palsy and cerebellar ataxia (difficulty with balance). The 11/4/24 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of eight out of 15. He required set-up or clean-up assistance while eating and was dependent on staff for assistance with all other activities of daily living (ADL). The assessment documented the resident was 66 inches (5 foot, 6 inches) tall. The assessment documented the resident weighed 161 lbs. The assessment documented the resident had not experienced any weight loss or weight gain. The assessment documented the resident did not require a specialty or therapeutic diet. B. Observations and resident interviews During a continuous observation in the main dining hall on 12/16/24, beginning at 11:18 a.m. and ending at 12:40 p.m., the following was observed: At 11:18 a.m. 13 residents were in the dining room. Resident #9 was sitting at a table by himself. At 12:14 p.m. Resident #9 was served his lunch tray. Resident #9 was provided with thick-handled silverware and a tall divided plate. At 12:26 p.m. Resident #9 finished eating his meal and self-propelled himself in his wheelchair out of the dining room. -Resident #9 was not offered additional food after consuming 100% of his lunch meal. Resident #9 was interviewed on 12/17/24 at 10:21 a.m. Resident #9 said he knew he had lost weight but did not know how much. Resident #9 said he felt weaker now than he did before. Resident #9 said the food in the dining hall did not taste good, but he would eat it anyway. Resident #9 said he sometimes felt hungry after eating a meal. Resident #9 said facility staff did not offer him extra food when he finished eating all of his food. During a continuous observation on 12/18/24, beginning at 4:26 p.m. and ending at 6:02 p.m. the following was observed: At 4:44 p.m. Resident #9 self-propelled himself into the dining room in his wheelchair. Resident #9 sat at a table by himself. At 5:35 p.m. Resident #9 received his dinner tray which included one scoop of plain mashed potatoes, a small plastic cup half full of ice cream and one small glass of chocolate milk. At 5:36 p.m. Resident #9 slammed his cup down on the table and said This meal is stupid! At 5:48 p.m. Resident #9 received an additional plate containing two sunny-side up eggs. At 5:56 p.m. Resident #9 finished eating 100% of his meal and drank all of his chocolate milk. Resident #9 then self-propelled himself in his wheelchair out of the dining hall. Resident #9 was interviewed again on 12/18/24 at 6:01 p.m. Resident #9 said he ate all of his dinner and still felt hungry. Resident #9 said he would eat more food if they had something he liked to eat in the kitchen. Resident #9 said he was not offered additional food after eating his entire dinner meal today. -Resident #9 was not offered additional food after consuming 100% of his dinner meal. C. Record review The nutrition care plan, initiated 5/30/17 and revised 11/5/24, revealed a goal of maintaining Resident #9's weight through the review period and ensuring Resident #9 did not have signs or symptoms of malnutrition. Interventions included that the resident often skipped lunch, the resident was not allowed to drink coffee, obtaining and recording weights per the facility protocol, the RD to evaluate and make diet change recommendations as needed, occupational therapy to screen and provide adaptive equipment as needed, providing and serving diet as ordered, providing oral nutritional supplements and recording intakes every meal. -A review of the comprehensive care plan revealed there were no new or revised interventions implemented after the resident sustained severe weight loss on 12/11/24. Resident #9's weights were documented in the EMR as follows: -On 8/20/24, the resident weighed 167.2 lbs; -On 9/3/24, the resident weighed 162.2 lbs; -On 9/17/24, the resident weighed 160.8 lbs; -On 9/24/24, the resident weighed 160 lbs; -On 10/1/24, the resident weighed 160.8 lbs; -On 11/1/24, the resident weighed 161 lbs; -On 12/4/24, the resident weighed 142.2 lbs; -On 12/5/24, the resident weighed 145.6 lbs; and, -On 12/11/24, the resident weighed 144.8 lbs. -The resident lost 15.2 lbs (9.5%) from 9/24/24 to 12/11/24, in less than three months, which was considered severe weight loss. -The resident lost 22.4 lbs (13.4%), from 8/20/24 to 12/11/24, in less than six months, which was considered severe weight loss. A review of Resident #9's December 2024 CPO revealed the following physician's orders related to nutrition: Regular diet, regular texture, thin liquid consistency, ordered 8/1/23. Offer snacks three times a day, ordered 4/26/24. Nutritional supplement, two times per day, ordered 11/5/24. Mini-nutritional assessment documentation, dated 8/6/24, documented that Resident #9 was at risk of malnutrition because he had lost between 2.2 and 6.6 lbs in the last three months and had a moderate decrease in food intake. -Despite the resident's documented risk for malnutrition, the facility failed to implement additional nutritional supplements. Dietary profile documentation, dated 11/4/24, documented that Resident #9 required partial assistance with eating. The assessment documented that Resident #9 required special utensils and/or assistive devices to eat. The profile documented that Resident #9 received regular-sized portions, had a good appetite and his favorite meal was dinner. The profile documented Resident #9 enjoyed eating grains and fruits. The profile documented Resident #9 did not like vegetables. The profile documented Resident #9 enjoyed chocolate, peanut butter and bananas. The profile documented that Resident #9 was eating snacks in between meals. Mini-nutritional assessment documentation, dated 11/5/24, documented that Resident #9 had not lost any weight, and had no decrease in food intake. The assessment documented that Resident #9 had a normal nutritional status and was not at risk of malnutrition. -However, the resident had lost 6.2 lbs between 8/20/24 and 11/1/24. The interdisciplinary team (IDT) weight variance note, dated 12/6/24, documented that Resident #9's most recent weight was 145.6 lbs and the resident had experienced a weight loss of 9.3% since he weighed 161 lbs on 11/1/24. The note documented that Resident #9's average intake was 25% to 75% of his meals. The note documented the resident had recently tested positive for COVID-19, but his intakes were improving. -However, despite the identified severe weight loss, the facility failed to implement additional nutritional interventions. Resident #9's meal intake documentation was reviewed between 11/19/24 and 12/18/24. Out of 83 meal opportunities, Resident #9 ate more than 75% of 32 meals, 51% to 75% of five meal opportunities, 26% to 50% of 13 meal opportunities and less than 25% of three meal opportunities. The facility documented Resident #9 refused his meal on 22 occasions. -However, there was no documentation in the resident's EMR of the facility re-offering meals or other meal alternatives to the resident after he refused the offered meals. -Additionally, the resident's nutritional plan of care did not include interventions to address Resident #9's meal refusals (see plan of care above). Resident #9's snack intake documentation was reviewed between 11/19/24 and 12/18/24. In the 30-day review period, snacks were offered three times per day on five days. The facility documented snacks were offered to Resident #9 one time per day on 21 of those days. The facility documented no snacks were offered to Resident #9 on two of those days. -The facility failed to offer snacks three times per day as ordered by the physician (see physician's orders above). III. Resident #65 A. Resident status Resident #65, age greater than 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included chronic kidney disease, asthma and adult failure to thrive. The 11/30/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. She required moderate assistance with bathing and was independent of all other ADLs. The assessment documented the resident was 64 inches (5 foot, 4 inches) tall. The assessment documented the resident weighed 267 lbs. The assessment documented the resident had not experienced any weight loss or weight gain. The assessment documented the resident did not require a specialty or therapeutic diet. The assessment documented the resident did not have any rejections of care. B. Observations and resident interview Resident #65 was interviewed on 12/17/24 at 10:32 a.m. Resident #65 said she was new to the facility and did not like the food that was served. Resident #65 said when she was first admitted to the facility she would often eat breakfast in her room, however, she said the food that was delivered to her room was always cold. Resident #65 said she began going to the dining room in the last few weeks so she could eat her food when it was still warm. Resident #65 said sometimes she could not eat the food because it was room temperature. Resident #65 said she had lost weight because of the food at the facility. Cross-reference F804 for food palatability. During a continuous observation on 12/18/24, beginning at 4:26 p.m. and ending at 6:02 p.m., the following was observed: At 4:56 p.m. Resident #65 entered the dining room and sat at a table with Resident #9. At 5:36 p.m. Resident #65 received her meal tray. She received mashed potatoes with gravy, carrots, a small cup half full of ice cream and a breaded chicken breast. At 5:37 p.m. Resident #65 requested her meal be reheated because it was served cold. An unidentified staff member took Resident #65's tray to the kitchen to reheat it. At 5:39 p.m. an unidentified staff member brought Resident #65's plate of food back to her. Resident #65 began to eat her meal. At 5:59 p.m. Resident #65 left the dining room. Resident #65 had eaten only the gravy off the top of the mashed potatoes and a few carrots, but ate all of her breaded chicken and ice cream. Resident #65 was interviewed again on 12/18/24 at 6:02 p.m. Resident #65 said her food was delivered to her cold at dinner. Resident #65 said the dining staff reheated her food in the kitchen but the food was still cold. Resident #65 said she could not eat the mashed potatoes because they were cold but the gravy on top was warm enough to eat. Resident #65 said she felt very frustrated that the kitchen struggled to bring her food that was warm enough to eat. Resident #65 said she felt it was not important to the facility to serve decent food to residents. C. Record review The nutrition care plan, initiated 9/12/24 and revised 12/2/24, revealed a goal of maintaining Resident #65's weight through the review period, ensuring Resident #65 consumed more than 50% of two meals per day and ensuring Resident #65 did not have signs or symptoms of malnutrition. Interventions included providing and serving supplements as ordered, providing and serving diet as ordered and for the RD to evaluate and make change recommendations as needed. -However, the resident did not have a physician's order for nutritional supplements and there was no documentation in the resident's EMR to indicate she was receiving a nutritional supplement (see physician's orders below). Resident #65's weights were documented in the electronic medical record (EMR) as follows: -On 8/23/24, the resident weighed 268.4 lbs; -On 8/25/24, the resident weighed 266.8 lbs; -On 8/26/24, the resident weighed 267 lbs; -On 9/2/24, the resident weighed 258 lbs; -On 10/1/24, the resident weighed 254 lbs; -On 11/1/24, the resident weighed 251 lbs; and -On 12/3/24, the resident weighed 248.8 lbs. -The resident lost 19.6 lbs (7.3%), from 8/26/24 to 12/3/24, in less than six months, which was not considered significant weight loss. -A review of Resident #65's December 2024 CPO failed to reveal any physician's orders for nutritional supplements. The Mini-nutritional assessment, dated 9/1/24, documented that Resident #65 was of normal nutritional status and was not at risk for malnutrition. The assessment documented Resident #65 had experienced no weight loss and had no decrease in her food intake. The Mini-nutritional assessment, dated 12/2/24, documented that Resident #65 was malnourished. The assessment documented the resident had experienced a weight loss greater than 6.6 lbs and had a moderate decrease in food intake. The assessment documented that nutritional supplements would be provided and served as ordered. -However, a review of Resident #65's December 2024 CPO revealed there were no physician's orders for nutritional supplements (see physician's orders above). Resident #65's meal intake documentation was reviewed between 11/20/24 and 12/19/24. Out of 86 meal opportunities, Resident #65 ate more than 75% on 50 meal opportunities, 51% to -75% on 16 meal opportunities, 26% to -50% on 13 opportunities and less than 25% of her meal on five opportunities. Resident #65's snack intake documentation was reviewed between 11/20/24 and 12/19/24. In 30 days of opportunities, snacks were offered to Resident #65 on nine of those days. The documentation included 11 days that Resident #65 refused snacks. IV. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 12/18/24 at 8:57 a.m. LPN #2 said she did not know if Resident #9 or Resident #65 were losing weight. LPN #2 reviewed the EMRs for Resident #9 and Resident #65. LPN #2 said Resident #9 was losing weight according to what was documented in the EMR, but she said she did not know why the resident was losing weight. LPN #2 said that offering snacks, supplements and extra food at meal times could all help Resident #9 gain weight. LPN #2 said Resident #65 had lost weight as well but she did not know why. Certified nurse aide (CNA) #7 was interviewed on 12/18/24 at 6:04 p.m. CNA #7 said Resident #9 and Resident #65 were both good at eating at dinner and sometimes enjoyed sitting together. CNA #7 said she did not know if Resident #9 or Resident #65 were experiencing weight loss. CNA #7 said she thought Resident #65 did not enjoy her meal this evening (12/18/24) because she asked it to be heated up but then did not eat it all. CNA #7 said she did not offer Resident #65 additional food because she did not seem to like what she was given the first time. LPN #3 was interviewed on 12/19/24 at 8:49 a.m. LPN #3 said when a resident experienced weight loss, the care plan would be updated and nursing staff and the RD worked together to find a way to stop the weight loss. LPN #3 said what was offered to decrease weight loss was different for every resident. LPN #3 said she did not know if Resident #9 or Resident #65 had experienced weight loss. The RD was interviewed on 12/19/24 at 11:17 a.m. The RD said she had worked at the facility for two years. The RD said she came to the building once a week in the middle of the week. The RD said her nutritional assessment process included reviewing information documented in the EMR, speaking to the residents about their preferences and observing the residents in the dining room, if possible. The RD said when a resident experienced weight loss, she would perform an assessment of the resident, place a progress note in the EMR, discuss the situation weekly in the risk meeting and the resident's care plan was updated with new interventions. The RD said she input the interventions into care plans at the facility. The RD said if a resident continued to lose weight despite new interventions, the resident's care plan should be reviewed and nutritional interventions should be changed or modified. The RD said residents who experienced weight loss should have additional or alternative food offered if they ate their entire plate of food during a meal. The RD said if a resident enjoyed a dessert for example, she would see if the facility could provide a double dessert or a second serving of a food item the resident liked. The RD said it was always better for residents to get their nutrition from food rather than supplements, if possible. The RD said if a resident received a cold meal or a meal that was not palatable to them, she would want the resident to let staff know so they could fix the meal to be more palatable for the resident. The RD said she would discuss food preferences with the resident and update that information in the resident's EMR. The RD reviewed Resident #9's EMR. The RD said Resident #9 was on her radar for weight loss before she took a medical leave in September 2024, but she did not know exactly how much weight he had lost. The RD said a weight loss trigger was inaccurately cleared on 9/3/24 by registered nurse (RN) #3, during the time of her medical leave before she returned to work on 9/12/24. The RD said the clearing of the weight loss trigger caused a delay for the facility to implement interventions for Resident #9. -However, Resident #9's documented weights identified the resident sustained a 15.2 lb (9.5%) from 9/24/24 to 12/11/24, in less than three months, which was considered severe, and the facility failed to implement additional nutritional interventions for the resident (see record review above). The RD said she was not aware that Resident #65 was losing weight. The RD said that RN #3 had also cleared the weight loss trigger notification warning in the resident's EMR. The RD said without that notification, she would have to manually calculate weight loss in all residents which was not feasible. The RD said Resident #65's weight loss caught her by surprise. The RD said she had not performed further evaluation or assessment of Resident #65's weight loss. The RD said Resident #65 did not have physician's orders to obtain weights weekly and the facility should begin watching her weight more closely. The director of nursing (DON) was interviewed on 12/19/24 at 4:51 p.m. The DON said she expected the RD to identify residents who experienced weight loss. The DON said she discussed residents who experienced weight loss on a weekly basis and the IDT then determined if there were additional contributing factors to the weight loss. The DON said the IDT would find the cause for the weight loss and could recommend interventions, such as double portions or food alternatives. The DON reviewed Resident #9's EMR. The DON said Resident #9 was not offered enough snacks. The DON said residents who experienced weight loss and consistently ate their entire meal should have additional food offered to them. The DON said Resident #65 should have palatable food offered to her. The DON said Resident #65 was not being monitored for weight loss but would be monitored more closely going forward.

Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen.conditions in the kitchen. Specifically, the facility failed to: -Ensure the staff medications were not stored in the walk-in refrigerator with resident food; -Ensure the staff wore a beard net while preparing and serving meals; and, -Ensure the air vent above the food service line was free of dust and dirt. Findings include: I. Failure to ensure staff medications were not stored in the walk-in refrigerator A. Professional reference The Colorado Retail Food Establishment Rules and Regulations, Chapter 7-5, effective 3/16/24, was retrieved on 12/29/24, revealed in pertinent part, Medicines belonging to employees that require refrigeration and are stored in a food refrigerator shall be stored in a package or container and kept inside a covered, leakproof container that is identified as a container for the storage of medicines. B. Observations During the initial tour of the main kitchen on 12/16/24 at 9:57 a.m. the walk-in refrigerator had a plastic bag on the top shelf next to the resident's food. Inside the plastic bag was an insulin pen and glucose test strips. The medication and bag were not labeled. C. Staff interviews The dietary manager (DM) was interviewed on 12/16/24 at 1:00 p.m. The DM said the insulin pen belonged to a dining staff member. The DM said he put the insulin pen in the walk-in refrigerator because he had nowhere else to store it. The DM said he was not aware medications could not be stored in the refrigerator with food. II. Ensure kitchen staff wore appropriate hair restraints while preparing and serving food A. Professional reference The Colorado Retail Food Establishment Regulations, Chapter 2-21, effective 3/16/24, were retrieved on 12/29/24, revealed in pertinent part, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens. B. Observations During a continuous observation on 12/16/24, from 11:37 a.m. to 12:33 p.m., the following was observed: At 11:37 a.m., dietary aide (DA) #1 was at the kitchen serving window without a beard net or hair net on. His facial hair was approximately half an inch long. At 11:59 a.m., two unidentified male staff were in the kitchen without beard nets on. The cook (CK) had a beard that was roughly two inches long. At 12:00 p.m., an unidentified maintenance worker was in the kitchen walking around the food preperation area while food was being served without a beard net on. His beard was down to his chest, approximately six to seven inches long. During a continuous observation on 12/18/24, from 4:30 p.m. to 6:15 p.m., the following was observed: From 4:30 p.m. to 6:15 p.m. DA #1 was not wearing a beard net and his facial hair was longer approximately half an inch long. At 5:59 p.m. the CK returned to the kitchen and did not have his beard net on. His beard was approximately two inches long. C. Staff interviews The DM was interviewed on 12/16/24 at 1:00 p.m. The DM said he was informed beard nets were only required if the facial hair was longer than one-quarter of an inch. He said he never thought about having the kitchen staff wear beard nets. The DM was interviewed again on 12/19/24 at 6:11 p.m. The DM said he told the staff they needed to wear beard nets in the kitchen and was not sure why some of the staff continued to not wear anything. He said the staff member that had a long beard was a staff member from the maintenance department. The DM said he was not aware that the maintenance staff needed to wear a beard net in the kitchen too. III. Ensure the kitchen vents were free of dust and dirt A. Professional reference The Colorado Retail Food Establishment Regulations, Chapter 6-3, effective 3/16/24, were retrieved on 12/29/24, revealed in pertinent part: Attachments to walls and ceilings such as light fixtures, mechanical room ventilation system components, vent covers, wall mounted fans, decorative items and other attachments shall be easily cleanable. Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt and other materials. B. Facility policy and procedure The Sanitation policy, revised November 2022, was provided by the nursing home administrator (NHA) on 12/19/24 at 5:38 p.m. and read in pertinent part, All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. C. Observations During the initial tour of the kitchen on 12/16/24 at 9:57 a.m. the air vent above the stove and food service line was covered in black dust. Some areas were thick and built up more than other areas. During the meal observation on 12/18/24 at 4:30 p.m. the air vent above the stove and food service line remained covered in black dust. Some of the areas were thick and built up more than other areas. The air conditioning system was on and was blowing the black dust around. D. Staff interviews The DM was interviewed on 12/19/24 at 6:11 p.m. The DM said the air conditioning was not supposed to be on during meal service. He said he had not realized the vent was covered in thick, black dust. The DM said he was going to get the air vent cleaned.

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 possible development and transmission of infectious diseases. Specifically, the facility failed to implement an effective water management plan. Findings include: I. Professional reference According to Center for Disease Control (CDC), Controlling Legionella in Potable Water Systems, last reviewed 3/15/24, was retrieved on 12/31/24 from https://www.cdc.gov/control-legionella/php/toolkit/potable-water-systems-module.html It read in pertinent part, Operation, maintenance, and control limits guidance: Monitor temperature, disinfectant residuals, and pH frequently based on Legionella performance indicators for control. Adjust measurement frequency according to the stability of performance indicator values. For example, increase the measurement frequency if there's a high degree of measurement variability. Hot water: Store hot water at temperatures above 140 F (degrees Fahrenheit) or 60 C (degrees Celsius). Ensure hot water in circulation does not fall below 120 F (49 C). Recirculate hot water continuously, if possible. Cold water: Store and circulate cold water at temperatures below the favorable range for Legionella (77-113 F, 25-45 C). Legionella may grow at temperatures as low as 68 F (20 C). Flushing: Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits. Ensure disinfectant residual is detectable throughout the potable water system. Clean and maintain water system components, such as thermostatic mixing valves, aerators, showerheads, hoses, filters, and storage tanks, regularly. Consider testing for Legionella in accordance with the routine testing module of this toolkit. B. Facility policy and procedure The Legionella Water Management Program policy and procedure, dated 6/26/23, was provided by the maintenance director (MTD) on 12/17/24 at 2:03 p.m. It documented in pertinent part, Dead run: flush and drain, if possible. Ideally, remove dead legs or redesign to allow for water recirculation, along with unused equipment and water lines from the system. Eliminate or minimize the use of rubber, plastic and silicone gaskets in the plumbing system. These materials may serve as growth substrates for bacteria, including legionella and other pathogenic microbes. Location: Various locations throughout the building. Frequency: Biannual and ongoing projects . -However, the CDC recommended that all dead legs and low flow piping runs should be flushed at least weekly to prevent the growth and spread of legionella (see professional reference above). Risk factor: Electronic and manual faucets: visually inspect for biofilm, scale, dirt, and debris buildup and clean with mild biocide such as vinegar, acidic cleaner or other cleaner Location: All units. Frequency: weekly, 25% of fixtures on a rotational basis . -However, the CDC recommended that all dead legs and low flow piping runs should be flushed at least weekly to prevent the growth and spread of legionella (see professional reference above). Water systems: little-used outlets. Flush for several minutes and until temperature stabilizes and is comparable to supply water. Have a flush program defined in the water management plan by the team. The Housekeeping Cleaning procedure, not dated, was provided by the MTD on 12/17/24 at 4:24 p.m. It documented that housekeeping staff flushed toilets daily. C. Record review The water management maintenance logs were provided by the MTD on 12/17/24 at 3:14 p.m. The maintenance logs documented the facility tested for legionella on 11/6/24 which was negative. The maintenance logs documented the maintenance department was conducting weekly flushing for five minutes and checking water temperatures for many locations throughout the building which included the laundry room sink, boiler room mixing valve, kitchen sinks, therapy room sink, two staff bathrooms, both bathing room tubs and sinks, the salon sink, the basement bathroom, and the basement hot water mixing valve. -The facility failed to document when empty resident rooms had been appropriately flushed to prevent the growth of legionella. On 12/17/24 at 5:12 p.m., the nursing home administrator (NHA) documented that two resident rooms had been unoccupied for seven contiguous days or more in the last 60 days. The NHA documented one of those unoccupied rooms had been vacant for seven contiguous days on two separate occasions. -The water management plan failed to document when empty resident rooms had low flow piping runs and lead legs flushed. D. Observations Housekeeper (HK) #1 was observed cleaning room [ROOM NUMBER] on 12/19/24 at 12:24 p.m. During the room cleaning, the sink faucet was not turned on or flushed. D. Staff interviews The MTD was interviewed on 12/17/24 at 4:07 p.m. The MTD said she had taken a legionella water management class previously and understood how to prevent the growth of legionella. The MTD said she started in this role in October 2024. The MTD said the water management plan was not hers and she did not contribute to forming the water management plan. The MTD said a few resident rooms were chosen each month to be flushed. She said not all resident rooms were flushed every month because rooms were chosen on a rotational basis. The MTD said all of the toilets were flushed daily as part of resident use and daily cleaning by housekeeping. The MTD said dead legs and low flow piping runs were flushed biannually. The MTD was interviewed again on 12/17/24 at 4:27 p.m. The MTD said she was told to flush the resident's rooms monthly. The MTD said that housekeepers flush sinks daily as part of their cleaning, but there was no specific documentation that the sinks had been flushed to prevent the growth of legionella. The MTD said the housekeepers documented the type of cleaning that was performed and this was sufficient to prove that sinks had been flushed. The MTD and the regional maintenance director (RMD) were interviewed together on 12/17/24 at 5:06 p.m. The MTD and the RMD said that flushing dead legs and low flow piping runs biannually was sufficient to prevent the growth and spread of legionella. The RMD said if the facility were to create a new dead leg it would be managed in accordance with the written water management plan. HK #1 was interviewed on 12/19/24 at 12:31 p.m. HK #1 said she had worked at the facility for several years. HK #1 said she did not turn on the sink when she cleaned room [ROOM NUMBER] today (12/19/24). HK #1 said she received training on how to clean resident rooms, but she did not receive education or instruction to flush sinks while she cleaned rooms. HK #1 said she normally flushed the toilets during every room clean.

Based on observations, record review and interviews the facility failed to ensure 10 (#12, #64, #4, #15, #41, #55, #7, #44, #18 and #129) of 17 residents with an order for a mechanically altered diet texture out of 46 sample residents received food and fluids prepared in a form designed to meet their needs per physician orders. Specifically, the facility failed to: -Provide Resident #12, #64, #4, #15, #41, #55, #7, #44 and #18 with the correct altered mechanical soft diet texture: and, -Provide Resident #129 with the correct altered pureed diet texture. Findings include: I. Professional reference The comparison of National Dysphagia Diet (NDD) and International Dysphagia Diet Standardization Initiative (IDDSI), reviewed July 2021, was retrieved on 12/29/24 from https://iddsi.org/IDDSI/media/images/CountrySpecific/UnitedStates/NDD-to-IDDSI-Implementation.pdf. It read in pertinent part, NDD of 2002 is being replaced by the IDDSI Framework, founded in 2013. This is the only professionally recognized and supported diet framework as of October 2021. NDD level three dysphagia advanced is now IDDSI soft and bite-sized level six. The NDD description stated bite-sized, soft, moist and not sticky. However, bite-sized guidelines were larger than the typical diameter of an air way. The IDDSI name of soft and bite-sized is more descriptive of what food consistency the kitchens should produce. The Soft and Bite-sized Framework, finalized January 2019, was retrieved on 12/29/24: https://iddsi.org/IDDSI/media/images/ConsumerHandoutsAdult/6_Soft_Bite_Sized_Adult_consumer_handout_30Jan2019.pdf It read in pertinent part, Level six, soft and bite-sized foods: -Soft, tender and moist, but with no thin liquid leaking or dripping; -Ability to bite off a piece of food is not required; -Ability to chew bite-sized pieces so that they are safe to swallow is required; -Bite-sized piece no bigger than one and a half centimeters by one and a half centimeters (half an inch by half an inch) in size; -Food can be mashed or broken down with pressure from a fork; and, -A knife is not required to cut this food. Examples of soft and bite-sized food for adults: -Meat is cooked tender and chopped so pieces are no bigger than half an inch by half an inch lump size. If the meat cannot be served soft and tender, the meat needs to be served as minced and moist (chopped with a sauce); -Fish is cooked soft enough to break and serve pieces are no bigger than half an inch by half an inch; -Fruit is soft and chopped into pieces no bigger than half an inch by half an inch with any excess liquid drained. Do not use fibrous parts of the fruit; -Vegetables are steamed or boiled with the final cooked size no bigger than half an inch by half an inch. Stir-fried vegetables are too firm and are not suitable; -Cereal is served with pieces no bigger than half an inch by half an inch with their texture fully softened. Drain excess liquid before serving; -No regular bread due to a high choking risk; and, -Rice requires a sauce to moisten it and hold it together. Rice should not be sticky or gluey and should not separate into individual grains when cooked and served. Food characteristics to avoid are soup with pieces of food, cereal with milk, nuts, raw vegetables, dry cakes, bread, dry cereal, steak, pineapple, candies, marshmallows, raw carrot, raw apple, popcorn, peas, grapes, chicken or salmon skin, meat with gristle, overcooked oatmeal, lettuce, cucumber, uncooked baby spinach, crisp bacon, etc. The Pureed Framework, finalized January 2019, was retrieved on 1/2/5 from https://www.iddsi.org/images/Publications-Resources/PatientHandouts/English/Adults/4_pureed_adults_consumer_handout_30jan2019.pdf. It read in pertinent part, Level 4, pureed foods: -Are usually eaten with a spoon; -Do not require chewing; -Have a smooth texture with no lumps; -Hold shape on a spoon; -Fall off a spoon in a single spoonful when tilted; -Are not sticky; and, -Liquid (like sauces) must not separate from solids. Level 4 - Pureed Food may be used if you are not able to bite or chew food or if your tongue control is reduced. Pureed foods only need the tongue to be able to move forward and back to bring the food to the back of the mouth for swallowing. It's important that puree foods are not too sticky because this can cause the food to stick to the cheeks, teeth, roof of the mouth or in the throat. Pureed foods are best eaten using a spoon. Examples of foods to avoid: -Mixed thin and thick textures: Soup with pieces of food, cereal with milk; -Hard or dry food: nuts, raw vegetables (carrots, cauliflower, broccoli), dry cakes, bread, dry cereal; -Tough or fibrous foods: steak, pineapple; -Chewy: lollipops/candies/sweets, cheese chunks, marshmallows, chewing gum, sticky mashed potato, dried fruits, sticky foods: -Crispy; crackling, crisp bacon, cornflakes; -Crunchy food: Raw carrot, raw apple, popcorn: -Sharp or spiky: corn chips and crisps; -Crumbly bits: dry cake crumble, dry biscuits; -Pips, seeds: Apple seeds, pumpkin seeds, white of an orange; -Food with skins or outer shell: peas, grapes, chicken skin, salmon skin, sausage skin; -Foods with husks: corn, shredded wheat, bran; -Bone or gristle: chicken bones, fish bones, other bones, meat with gristle; -Round, long shaped food: sausage, grapes; -Sticky or gummy food: nut butter, overcooked oatmeal/porridge, edible gelatin, konjac containing jelly, sticky rice cakes; -Stringy food: beans, rhubarb; -Floppy foods: lettuce, cucumbers, uncooked baby spinach leaves; -Crust formed during cooking or heating: crust or skin that forms on food during cooking or after heating, for example, cheese topping, mashed potato; -Juicy food: where juice separates from the food piece in the mouth, for example watermelon; and, -Visible lumps: Lumps in pureed food or yogurt. II. Facility policy The Therapeutic Diets policy, revised October 2017, was provided by the nursing home administrator (NHA) on 12/19/24 at 5:38 p.m. It read in pertinent part, Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. The diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. Diagnosis alone will not determine whether the resident is prescribed a therapeutic diet. A therapeutic diet must be prescribed by the resident's attending physician. A diet order should match the terminology used by the food and nutrition services department. A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or alter the texture of a diet. If a mechanically altered diet is ordered the provider will specify the texture modification. Snacks will be compatible with the therapeutic diet. III. Facility diet manual for mechanical soft The Diet Manual, revised 2022, was provided by the NHA on 12/19/24 at 10:00 a.m. It read in pertinent part, Mechanical soft diet (dysphagia advanced level three, similar to IDDSI soft and bite-sized level six): this diet provides a texture modification of the regular diet for residents with mild oral and/or pharyngeal phase dysphagia. Foods must be soft, tender and moist with no thin liquid leaking or dripping from food. The ability to bite off a piece of food is not required. The ability to chew bite-sized pieces is required. Foods that are difficult to chew are chopped, ground, shredded or cooked to make them easier to chew and swallow. General guidelines: Ease of chewing may be increased by mashing, chopping or slenderizing; pour syrups, honey or juices over bread products such as pancakes, french toast, waffles and muffins; serve soft crackers and other breads in soup; use gravies, broths and sauces on ground meats, poultry and other dishes; well-cooked, soft (or mashed) vegetables without skin, mashed potatoes and vegetable juices are well-tolerated; there are two divisions of mechanical soft chopped half-inch pieces and ground eight-inch pieces. Pay attention to specific differentiations in how to prepare food for both. Avoid vegetables that are raw or crunchy, vegetables with skin or husks like peas and corn, no stringy or floppy vegetables like string beans, celery, lettuce, cucumber and baby spinach leaves; and potatoes with skins or crispy fried potatoes. Protein must be very tender, small pieces and chopped to half-inch pieces moistened with gravy or sauce. Avoid tough or dry meats, poultry or fish. IV. Resident #12 A. Resident status Resident #12, age greater than 65, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included Wernicke's encephalopathy (neurological disorder), malignant neoplasm of floor of mouth (oral cancer), dysphagia (difficulty swallowing) oral and oropharyngeal phase and alcohol dependence with alcohol-induced persisting dementia. The 10/7/24 minimum data set (MDS) assessment revealed Resident #12 was not assessed for a brief interview for mental status (BIMS). The assessment indicated Resident #12 was on a mechanically altered diet requiring a change in the texture of foods. B. Observations On 12/18/24 at 5:30 p.m., the cook (CK) served Resident #12 regular unthickened Italian Wedding soup with chopped vegetables in the soup and a regular dinner roll. Resident #12's meal ticket revealed the resident needed thickened Italian wedding soup and a soaked dinner roll. -The facility failed to serve the resident thickened soup with carrots no bigger than half-inch by half-inch in the soup. -The facility failed to serve the resident a soaked dinner roll that was very moist and soaked through the entire thickness of the roll. C. Record review Review of Resident #12's December 2024 CPO revealed a physician's order for a mechanical soft textured diet, ordered 11/1/24. Resident #12's dental care plan, initiated 3/19/24, revealed the resident was at risk for alteration of oral hygiene, mouth and or teeth due to a history of oral cancer. Interventions included assisting the resident with coordinating dental care, providing the resident with his diet as ordered and providing oversight management to the resident's care. V. Resident #64 A. Resident status Resident #64, age greater than 65, was admitted [DATE]. According to the December 2024 CPO, diagnoses included Alzheimer's disease with late onset, dysphagia oral and oropharyngeal phase, cognitive communication deficit and dementia. The 12/6/24 MDS assessment revealed Resident #64 had a severe cognitive impairment with a BIMS score of zero out of 15. The assessment indicated Resident #64 required substantial or maximal assistance with eating and was on a mechanically altered diet requiring a change in the texture of foods. B. Observations On 12/18/24 at 5:59 p.m., Resident #64 ordered the main entree, which was chicken cordon bleu. The cook (CK) served the resident a chicken cordon bleu that was cut into one-inch pieces and a whole regular roll. -The facility failed to cut the resident's chicken into no bigger than half-inch by half-inch sized pieces. -The facility failed to serve the resident a soaked dinner roll that was very moist and soaked through the entire thickness of the roll. C. Record review Review of Resident #64's December 2024 CPO revealed a physician's order for a mechanical soft textured diet, ordered 10/17/24. Resident #64's nutrition care plan, initiated 9/19/24, revealed the resident was on a regular diet. Interventions included occupational therapy screens and adaptive equipment as needed, providing and serving his diet as ordered, the registered dietitian (RD) to evaluate and make diet change recommendations and referring to the resident's likes and dislikes. -However, the facility failed to update Resident #64's care plan when he was ordered a mechanical soft texture change on 10/17/24. VI. Resident #4 A. Resident status Resident #4, age greater than 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included dementia, dysphagia oropharyngeal phase and Alzheimer's disease with late onset. The 10/30/24 MDS assessment revealed Resident #4 was unable to participate in the BIMS assessment due to rarely being understood. The staff assessment revealed Resident #4 had short and long-term memory problems. The resident's daily decision-making skills were severely impaired. The assessment indicated Resident #4 was on a mechanically altered diet requiring a change in the texture of foods. B. Observations On 12/18/24 at 6:04 p.m., the CK served Resident #4 chicken cordon bleu cut into one-inch pieces, and a regular roll cut into bite-sized pieces. -The facility failed to cut the resident's chicken into no bigger than half-inch by half-inch size pieces. -The facility failed to serve the resident a soaked dinner roll that was very moist and soaked through the entire thickness of the roll. C. Record review Review of Resident #4's December 2024 CPO revealed a physician's order for a mechanical soft textured diet, ordered 12/13/23. Resident #4's nutrition care plan, revised on 4/30/24, revealed the resident was easily distracted during meals. Interventions included providing and serving diet as ordered and referring to the resident's likes and dislikes. VII. Resident #15 A. Resident status Resident #15, age greater than 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included dementia and dysphagia oropharyngeal phase. The 10/8/24 MDS assessment revealed Resident #15 was unable to participate in the BIMS assessment due to rarely being understood. The staff assessment revealed Resident #15 had short and long-term memory problems. The resident's daily decision-making skills were severely impaired. The assessment indicated Resident #15 was on a mechanically altered diet requiring a change in the texture of foods. B. Observations On 12/18/24 at 5:09 p.m. the CK served Resident #15 chicken cordon bleu cut into one-inch pieces, a regular dinner roll was cut into bite-sized pieces and a bowl of regular Italian wedding soup. -The facility failed to cut the resident's chicken into no bigger than half-inch by half-inch sized pieces. -The facility failed to serve the resident a soaked dinner roll that was very moist and soaked through the entire thickness of the roll. -The facility failed to serve the resident soup with carrots no bigger than half-inch by half-inch in the soup. C. Record review Review of Resident #15's December 2024 CPO revealed a physician's order for a mechanical soft textured diet, ordered 8/2/23. Resident #15's nutrition care plan, revised 11/13/23, revealed the resident was on a mechanical soft diet. Pertinent interventions included having the resident eat at the assist table in the dining room, offering the resident brunch when she slept through breakfast, providing and serving her diet as ordered and referring to her likes and dislikes. VIII. Resident #41 A. Resident status Resident #41, age greater than 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included dementia, dysphagia oropharyngeal phase and senile degeneration of the brain. The 12/5/24 MDS assessment revealed Resident #41 had severe cognitive impairment with a BIMS score of one out of 15. The assessment indicated Resident #41 was on a mechanically altered diet requiring a change in the texture of foods. B. Observations On 12/18/24 at 5:14 p.m. the CK served Resident #41 regular Italian Wedding soup with a regular roll cut into bite- sized pieces. Resident #41's meal ticket revealed the soup needed to be thickened and the roll needed to be soaked. -The facility failed to serve the resident thickened soup with carrots no bigger than half-inch by half-inch in the soup. -The facility failed to serve the resident a soaked dinner roll that was very moist and soaked through the entire thickness of the roll. C. Record review Review of Resident #41's December 2024 CPO revealed a physician's order for a mechanical soft textured diet with extra gravy or sauce at each meal, ordered 5/6/23. Resident #41's nutrition care plan, revised 11/22/24, revealed the resident was on a mechanical soft diet. Interventions included providing and serving her diet as ordered and referring to her likes and dislikes. IX. Resident #55 A. Resident status Resident #55, age greater than 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included seizures, cognitive communication deficit and dysphagia oropharyngeal phase. The 9/17/24 MDS assessment revealed Resident #55 had severe cognitive impairment with a BIMS score of three out of 15. The assessment indicated Resident #55 was on a mechanically altered diet requiring a change in the texture of foods. B. Observations On 12/18/24 at 6:05 p.m. the CK served Resident #55 chicken cordon bleu cut into one-inch pieces with no sauce and a regular roll cut into bite-sized pieces. -The facility failed to cut the resident's chicken into no bigger than half-inch by half-inch sized pieces and serve it with extra gravy or sauce. -The facility failed to serve the resident a soaked dinner roll that was very moist and soaked through the entire thickness of the roll. C. Record review Review of Resident #55's December 2024 CPO revealed a physician's order for a mechanical soft textured diet with extra gravy or sauce at each meal and nectar thick liquids, ordered 12/13/24. Resident #55's nutrition care plan, revised 12/18/24, revealed the resident was on a mechanical soft diet. Interventions included providing and serving his diet as ordered and referring to his likes and dislikes. X. Resident #7 A. Resident status Resident #7, age greater than 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included epilepsy, dementia and dysphagia oropharyngeal phase. The 10/16/24 MDS assessment revealed Resident #7 had a mild cognitive impairment with a BIMS score of 12 out of 15. B. Observations On 12/18/24 at 5:25 p.m. the CK served Resident #7 chicken cordon bleu cut into one-inch pieces and a roll cut into bite-sized pieces. -The facility failed to cut the resident's chicken into no bigger than half-inch by half-inch sized pieces. -The facility failed to serve the resident a soaked dinner roll that was very moist and soaked through the entire thickness of the roll. C. Record review Review of Resident #7's December 2024 CPO revealed a physician's order for a mechanical soft textured diet, ordered 10/24/24. Resident #7's nutrition care plan, revised 7/15/24, revealed the resident was on a mechanical soft diet. Interventions included providing and serving her diet as ordered and referring to her likes and dislikes. XI. Resident #44 A. Resident status Resident #44, age greater than 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included a mild cognitive impairment and dysphagia oropharyngeal phase. The 10/25/24 MDS assessment revealed Resident #44 was cognitively intact with a BIMS score of 15 out of 15. The assessment indicated Resident #44 was on a mechanically altered diet requiring a change in the texture of foods. B. Observations On 12/18/24 at 5:28 p.m. the CK served Resident #44 two portions of chicken cordon bleu cut into one-inch pieces and two regular rolls cut into bite-sized pieces. -The facility failed to cut the resident's chicken into no bigger than half-inch by half-inch sized pieces. -The facility failed to serve the resident soaked dinner rolls that were very moist and soaked through the entire thickness of the roll. C. Record review Review of Resident #44's December 2024 CPO revealed a physician's order for a mechanical soft textured diet and double portions, ordered 7/20/22. Resident #44's nutrition care plan, revised 4/22/24, revealed the resident was on a mechanical soft diet. Interventions included providing double portions with each meal, providing and serving his diet as ordered and referring to his likes and dislikes. XII. Resident #18 A. Resident status Resident #18, age greater than 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included heart failure and dysphagia oropharyngeal phase. The 12/10/24 MDS assessment revealed Resident #18 was unable to participate in the BIMS assessment due to rarely being understood. The staff assessment revealed Resident #18 had short and long-term memory problems. The resident's daily decision-making skills were severely impaired. The assessment indicated Resident #18 was on a mechanically altered diet requiring a change in the texture of foods. B. Observations On 12/18/24 at 5:54 p.m. the CK served Resident #18 a bowl of regular Italian wedding soup and a whole regular roll. -The facility failed to serve the resident thickened soup with carrots no bigger than half-inch by half-inch in the soup. -The facility failed to serve the resident a soaked dinner roll that was very moist and soaked through the entire thickness of the roll. C. Record review Review of Resident #18's December 2024 CPO revealed a physician's order for a mechanical soft textured diet and nectar thick liquids, ordered 7/12/24. Resident #18's nutrition care plan, revised 3/7/24, revealed the resident was on a mechanical soft diet. Interventions included providing and serving her diet as ordered and referring to her likes and dislikes. XIII. Resident #129 A. Resident status Resident #129, age greater than 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included Alzheimer's disease with late onset and dementia. The 12/18/24 MDS assessment revealed Resident #129 had a severe cognitive impairment with a BIMS score of zero out of 15. B. Observation On 12/18/24 at 6:12 p.m., the CK served Resident #129 a bowl of watery pureed Italian wedding soup. -The facility failed to serve the resident pureed soup in a thick, mashed potato-like consistency. C. Record review Review of Resident #129's December 2024 CPO revealed a physician's order for a pureed textured diet, ordered 12/14/24. Resident #129's nutrition care plan, initiated 12/16/24, revealed the resident was on a pureed diet. Interventions included providing and serving the resident her diet as ordered and referring to her likes and dislikes. XIV. Staff interviews The dietary manager (DM) was interviewed on 12/18/24 at 4:45 p.m. The DM said residents who were on a mechanical soft textured diet were able to eat bread that was wet and cut into bite-sized pieces. The CK was interviewed on 12/18/24 at 5:13 p.m. The CK said the residents were able to eat bread if the bread was soft and cut into bite-sized pieces. He was unaware how big or small the pieces needed to be. Dietary aide (DA) #1 was interviewed on 12/18/24 at 5:59 p.m. DA #1 said the residents who received whole rolls did not like having their rolls cut up and that was how he always served the residents no matter what their diet textures were. The DM and the NHA were interviewed together on 12/19/24 at 6:11 p.m. The DM said he was unaware the facility had a diet manual that explained the difference in textures for mechanically altered diets. The NHA said she provided the DM with the diet manual. The DM said he was going to ensure he trained his staff on diet textures. He said if a resident was served the wrong diet texture, the resident could choke and the facility wanted to prevent that. The DM said the chicken needed to be cut in half-inch by half-inch pieces The DM said the CK should have soaked the dinner rolls

Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure food was palatable and served at the appropriate temperature. Findings include: I. Facility policy and procedure The Food and Nutrition Services policy, revised October 2017, was provided by the nursing home administrator (NHA) on 12/19/24 at 5:38 p.m. It read in pertinent part, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive and it is served at a safe and appetizing temperature. If an incorrect meal is provided to a resident, or a meal does not appear palatable, the nursing staff will report it to the food service manager so that a new food tray can be issued. II. Resident interviews Resident #11 was interviewed on 12/15/24 at 1:59 p.m. Resident #11 said the food was always served cold. Resident #11 said the food was bland and did not taste good. Resident #51 was interviewed on 12/16/24 at 9:02 a.m. Resident #51 said the food was served cold. Resident #10 was interviewed on 12/19/24 at 8:51 a.m. Resident #10 said the food was served cold. Resident #65 was interviewed on 12/18/24 at 6:02 p.m. Resident #65 said she received a chicken cordon bleu with hollandaise sauce, carrots, mashed potatoes with gravy and a dinner roll. Resident #65 said her meal was not good and the food was served cold. She said the staff offered to reheat the plate for the resident. She said after her plate was reheated her food was still cold. Resident #65 said her mashed potatoes were extremely cold. Resident #65 said each time she received cold food she did not want to eat it and felt it was not important to the facility to serve decent food to the residents. III. Resident group interview A group interview consisting of five residents (#229, #35, #8, #36 and #20) who were assessed by the facility to be interviewable was conducted on 12/19/24 at 5:58 p.m. The residents said meals were served cold and it did not matter if the residents ate in their rooms or the dining room. Resident #20 said the food was bland and most of the time cheese was not served melted. IV. Observations Dinner observations were completed on 12/18/24 and revealed the following: The cook (CK) prepared chicken cordon bleu with a hollandaise sauce, mashed potatoes with gravy, cooked carrots, dinner roll and ice cream. The alternative meal was served as Italian wedding soup with the residents choice of sides. A test tray for a regular diet was evaluated by three surveyors immediately after the last resident had been served their room tray for dinner on 12/18/24 at 6:16 p.m. The test tray consisted of chicken cordon bleu without the hollandaise sauce, mashed potatoes with gravy, a dinner roll and Italian wedding soup. The Italian wedding soup was 115.5 degrees Fahrenheit (F). The soup was salty and the vegetables were undercooked. The mashed potatoes were gummy and gritty. The chicken cordon bleu felt lukewarm and had a temperature of 121 degrees F V. Resident council notes Resident council notes from 12/6/24 revealed the residents were concerned they were still not receiving food that was hot, especially in the dining room. The residents said when they requested their food to be warmed up it was still served cold. VI. Staff interviews The dietary manager (DM), the NHA and the director of nursing (DON) were interviewed together on 12/19/24 at 6:11 p.m. The DM said he had to leave during the meal service and was confident in his team's ability to serve dinner. The DM said he failed to try the CK's food before he had to leave. The DM said the soup had been cooking for hours and the vegetables should have been softened by the time it was served. He said he did not know the soup was salty. The DM said when the kitchen ran low on a meal item the CK should start preparing more or delegate it to another staff member to get more food so the residents would not go without food items. The NHA said the facility was aware of the complaints of the food's palatability and that was the reason the facility experienced a lot of turnover in the kitchen. The NHA said with the current DM there have been improvements but the DM had only been in the facility for about a month. The NHA said the food was getting better and was going to continue to improve.

Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accident hazards for five (#63, #9, #2, #57 and #23) of ten residents out of 46 sample residents. Specifically, the facility failed to: -Implement and update fall care plans in a timely manner for Resident #63; -Ensure neurological checks were completed appropriately for Resident #63 and Resident #9 following an unwitnessed fall; -Ensure Resident #2 was safely transferred using a slide board; -Ensure Resident #57 was appropriately monitored while smoking; and, -Ensure safe transfer pole use for Resident #23. Findings include: I. Failure to initiate a timely fall care plan and interventions to prevent falls for Resident #63 and complete neurological assessments after a fall for Resident #63 and Resident #9. A. Professional reference According to [NAME], P.A., [NAME], A.G., Fundamentals of Nursing, 10 ed. (2020), Elsevier, St. Louis Missouri, pp. 1780, retrieved on 12/30/24, In the event of a fall, perform a post-fall assessment to identify possible causes. Monitor residents closely for 48 hours after a fall. B. Facility policy The Assessing Falls and Their Causes policy, revised March 2018, was obtained from the corporate consultant (CC) on 12/18/24 at 13:12 p.m. It documented in pertinent part, Falls are a leading cause of morbidity and mortality among the elderly in nursing homes. After a fall, if a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine and extremities. Observe for delayed complications of a fall for approximately 48 hours after an observed or suspected fall and document findings in the medical record. The falls - Clinical Protocol policy, revised September 2012, was provided by the CC on 12/18/24 at 3:12 p.m. It documented in pertinent part, Falls should be categorized as those that occur while trying to rise from a sitting or lying to an upright position, those that occur while upright and attempting to ambulate, and other circumstances such as sliding out of a chair or rolling from a low bed to a floor. Falls should also be identified as witnessed or unwitnessed events. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or that finding a cause would not change the outcome or the management of falling and fall risk. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try and get up and walk without waiting for assistance). The nurse evaluations required after falls list, revised 2/13/2020, was provided by LPN # 2 on 12/19/24 at 8:59 a.m. It documented that after a fall, resident vital signs must be obtained on 12 occasions in the seven hours following a fall. It documented the seven hour schedule included obtaining vital signs every 15 minutes for four assessments, then vital signs were obtained every 30 minutes for four assessments, then vital signs were obtained hourly for four hours. After frequent checks were completed for seven hours, vital signs were obtained every shift until 72 hours had passed since the fall event. C. Resident #63 1. Resident status Resident #63, age greater than 65, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included vascular dementia, atrial fibrillation (irregular heart rhythm) and anxiety. The 10/1/24 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of zero out of 15. He required set-up or clean-up assistance with eating, substantial assistance with oral hygiene and dressing and was dependent on staff to complete toileting hygiene and personal hygiene care activities. The assessment documented the resident required substantial or maximum assistance to roll left and right in bed and he required moderate assistance with all other acts of mobility. 2. Record review The fall plan of care, initiated 7/7/24 and revised 11/7/24, documented Resident #63 had experienced a fall. The plan of care documented Resident #63's goal was to be free from injury through the review date. Interventions included educating staff regarding toileting the resident and to monitor Resident #63 for 72 hours for signs and symptoms of pain, bruising, change in mental status, or any new onset of confusion, sleepiness, inability to maintain posture, or agitation. The fall risk care plan, initiated 7/7/24 and revised 11/21/24, documented that Resident #63 was a fall risk. Interventions included ensuring the resident's call light was within reach, adding a fall mat, non-skid socks, and to offer the resident toileting assistance before and after meals and at bedtime. The nursing progress note dated 7/7/24 documented that Resident #63 experienced a witnessed fall. The note documented Resident #63 was observed to slip out of his wheelchair while wheeling himself down the hallway. -The facility failed to initiate a fall prevention plan of care until after Resident #63 fell on [DATE]. The nursing progress note dated 9/16/24 documented Resident #63 experienced an unwitnessed fall in his room. The note documented staff found the resident between his bed and his night stand. The note documented the resident was unable to recall how the fall occurred. The note documented the resident's bed was not in the lowest position. The note documented Resident #63 reported pain in his knee. The neurological signs flow sheet, dated 9/16/24, documented the vital signs obtained and neurological assessments performed by nursing staff after Resident #63 fell on [DATE]. The flow sheet documented eight neurological assessments that occurred between 3:00 p.m. and 5:30 p.m. on 9/16/24. One hourly neurological assessment was documented at 7:30 p.m. The flow sheet documented Resident #63 refused one hourly assessment at 9:30 p.m. -The facility failed to perform neurological assessments per the facility's protocol (see interview below). An Interdisciplinary team(IDT) post-fall assessment dated [DATE] documented Resident #63 experienced an unwitnessed fall. The assessment documented Resident #63 was found on the floor of his room at 2:50 p.m. The neurological signs flow sheet, dated 10/11/24, documented the vital signs obtained and neurological assessments performed by nursing staff after Resident #63 fell on [DATE]. The flow sheet documented Resident #63 was assessed eight times out of 12 opportunities between 3:00 p.m. and 10:00 p.m. -The facility failed to perform neurological assessments per the facility's protocol (see interview below). An IDT post-fall investigation, dated 12/9/24, documented that Resident #63 experienced a witnessed fall on 12/9/24. The investigation documented new interventions included frequent checks, and that Resident #63 required assistance at times. The investigation documented the facility reviewed and updated Resident #63's plan of care. -However, review of Resident #63's fall plan of care revealed the care plan was not updated with the new fall interventions after the resident's 12/9/24 fall (see plan of care above). A nursing progress note dated 12/12/24 documented that Resident #63 experienced an unwitnessed fall. The note documented the resident was found on the floor of his bedroom between the bed and the recliner. The note documented the resident was wearing his non-skid socks. The Neurological signs flow sheet, dated 12/12/24, documented the vital signs obtained and neurological assessments performed by nursing staff after Resident #63 fell on [DATE]. The facility documented 10 assessments out of 12 opportunities between 8:30 a.m. and 3:30 p.m. on 12/12/24. The 8:30 a.m. on 12/14/24 vital sign and neurological assessment documentation was left blank and undocumented. -The facility failed to perform neurological assessments per the facility's protocol (see interview below). An IDT post-fall investigation, dated 12/14/24, documented that Resident #63 experienced an unwitnessed fall on 12/12/24. The investigation documented new interventions included assisting Resident #63 with transferring back to bed. The investigation documented the facility reviewed and updated Resident #63's plan of care. -However, review of Resident #63's fall plan of care revealed the care plan was not updated with the new fall interventions after the resident's 12/12/24 fall (see plan of care above). D. Resident #9 1. Resident status Resident #9, age greater than 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included unspecified disorder of psychological development, cerebral palsy and cerebellar ataxia (difficulty with balance). The 11/4/24 MDS assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of eight out of 15. He required set-up or clean-up assistance while eating and was dependent on staff for assistance with all other activities of daily living (ADL). The assessment documented the resident required substantial assistance to roll left and right in bed and was dependent on nursing staff for all transfers. 2. Record review The fall care plan, initiated 5/6/23 and revised 10/24/24, documented that Resident #9 was a fall risk. Interventions included ensuring the resident's call light was within reach, encouraging the resident to go to bed when he appeared fatigued, ensuring incontinence products were positioned correctly underneath the resident, providing the resident with rest periods, utilizing a soft-touch call light while the resident was in bed and a therapy recommendation to use a stand assist with all resident transfers. An IDT post-fall investigation, dated 10/14/24, documented Resident #9 experienced an unwitnessed fall on 10/14/24. The investigation documented that Resident #9 was found on the floor of his room. A review of Resident #9's electronic medical record (EMR) revealed there was no documentation of vital signs or neurological assessments performed after Resident #9's unwitnessed fall in his room on 10/14/24. Fall documentation for Resident #9's 10/14/24 fall was provided by the CC on 12/18/24 at 2:51 p.m. The fall documentation failed to include facility documentation of neurological assessments performed for Resident #9 after his unwitnessed fall on 10/14/24. -The facility failed to perform neurological assessments per the facility's protocol (see interview below). E. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 12/18/24 at 2:41 p.m. LPN #2 said when a resident experienced an unwitnessed fall, a registered nurse (RN) would assess the resident immediately and neurological assessments were performed. LPN #2 said she could not recall exactly what the neurological assessment schedule was but would find a copy of it. LPN #2 said the schedule was hand written in as fall vital signs on the list of nurse evaluations required after falls list. LPN #2 said neurological assessments must always be performed according to the schedule to make sure there was not a delayed head injury. LPN #3 was interviewed on 12/19/24 at 8:49 a.m. LPN #3 said neurological assessments were performed after a resident had experienced an unwitnessed fall or had a suspected head injury. LPN #3 said the neurological assessments were performed according to the schedule written on the list of required nursing evaluations after falls. LPN #3 said it was important to perform neurological assessments according to the schedule to make sure a resident was not injured after the fall. The director of nursing (DON) was interviewed on 12/19/24 at 4:51 p.m. The DON said a fall was any unplanned descent to the floor. The DON said when a resident experienced a fall, the DON should be notified immediately, the resident would be assessed by a RN and a resident's care plan should be updated with interventions to reflect the reason for the fall. The DON said neurological assessments should be performed according to the fall vital sign schedule documented on the list of nursing evaluations required after falls. The DON said it was important to perform neurological assessments according to the schedule in order to ensure residents did not develop a delayed head injury or brain bleed. The DON said neurological assessments could only be missed if the resident refused the assessment. The DON said the facility did not have a policy or protocol that dictated exactly how neurological assessments were to be completed in the facility, but she said nursing staff members knew what the schedule was because it was written on the nurse evaluations required after falls list. The DON reviewed Resident #63's fall documentation for the falls sustained on 9/16/24, 10/11/24, 12/9/24 and 12/12/24. The DON said nursing staff did not complete neurological checks appropriately after Resident #63's unwitnessed falls on 9/16/24 and 10/11/24. The DON said nursing staff did not document neurological assessments in accordance with the expected documentation schedule. The DON said Resident #63's plan of care was not updated after he experienced two falls on 12/9/24 and 12/12/24. The DON said Resident #63's plan of care should have been reviewed and updated after each fall. II. Failure to ensure a safe transfer using a slide board for Resident #2 A. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included acute and chronic respiratory failure, generalized muscle weakness and lack of coordination. The 9/14/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required set-up or clean-up assistance while eating, moderate assistance with oral hygiene and was dependent on staff for assistance with all other ADLs. B. Resident interview and observations Resident #2 and the director of rehabilitation (DOR) were overheard discussing Resident #2's fall on 12/16/24 at 1:59 p.m. Resident #2 informed the DOR that she was dropped on the floor this morning (12/16/24) while being transferred by two staff members using a slide board. The DOR said she was not aware of the fall and asked Resident #2 what happened. Resident #2 said the two certified nurse aides (CNA) that assisted her this morning (12/16/24) did not know what they were doing and the slide board slipped from their hands, which caused her to fall to the floor. The DOR said she had been working on educating staff members on how to use the slide board but not all staff members had received education. The DOR said all staff members were educated on using the hoyer lift and staff members should not have been using the slide board to transfer Resident #2 unless they were comfortable with doing so. Resident #2 said she was afraid to use the slide board again because she was dropped this morning (12/16/24) and requested to use the hoyer lift going forward. The DOR agreed and said she would enter an order to use a hoyer lift for the resident's future transfers. Resident #2 was interviewed on 12/16/24 at 2:04 p.m. Resident #2 said she had experienced a recent reduction in mobility in the last few days and had difficulty moving her legs. Resident #2 said she had used the slide board in physical therapy sessions but had not used the slide board with a CNA before this morning (12/16/24) when two CNAs dropped her while using the slide board. Resident #2 said she did not want to use a slide board ever again to transfer out of bed. Resident #2 said CNA #1 was one of the CNAs assisting her when she fell , but she was unsure who the other CNA was. CNA #1 and CNA #6 were overheard discussing Resident #2's fall on 12/16/24 at 2:13 p.m. in the Bookcliff Hall. CNA #1 said she was present when Resident #2 fell this morning (12/16/24) and asked CNA #6 for advice on how to prevent the fall incident from happening again in the future. CNA #6 provided CNA #1 education, including how to hold a slide board and how to safely brace a resident's knee if it began to buckle. C. Record Review An IDT progress note, dated 12/16/24, documented Resident #2 experienced a witnessed fall on 12/16/24. The note documented Resident #2 slid off a slide board during a transfer. The note documented this was the second time Resident #2 had slid off a transfer board in the last month and Resident #2 must now use a hoyer lift for all transfers. D. Staff interviews The DOR was interviewed on 12/16/24 at 2:02 p.m. The DOR said Resident #2 had experienced a decline in mobility in the last few days and the facility was working on finding the best way to transfer Resident #2. The DOR said she had used the slide board with Resident #2 in therapy sessions, which had gone well. The DOR said using the slide board was not typical in the facility and that was why she was providing education to staff members on how to use a slide board. CNA #1 was interviewed on 12/16/24 at 2:21 p.m. CNA #1 said she was present this morning (12/16/24) when Resident #2 slipped off the slide board. CNA #1 said she thought she had received training on how to use a slide board but she said she was not sure. CNA #6 was interviewed on 12/17/24 at 1:12 p.m. CNA #6 said she had received slide board education and was comfortable transferring residents with a slide board. CNA #6 said since the slide board incident with Resident #2, the resident's transfer orders had changed and now Resident #2 was to be transferred using a hoyer lift. CNA #6 said she did not know if all CNAs received education on how to use a slide board to transfer residents safely. The DON was interviewed on 12/19/24 at 4:51 p.m. The DON said staff members were provided education on how to use transfer equipment at the facility. The DON said the facility did not have documentation that slide board transfer education had been provided to staff members in the facility prior to 12/16/24. 48412 III. Failure to provide Resident #57 with appropriate monitoring while smoking A. Facility policy The Resident Smoking policy, revised August 2022, was provided by the nursing home administrator (NHA) on 12/19/24 at 5:38 p.m. It read in pertinent: Smoking is only permitted in designated resident smoking areas, which are located outside of the building. Smoking is not allowed inside the facility under any circumstances. Resident smoking status is evaluated upon admission. The evaluation includes current level of tobacco consumption, method of tobacco consumption, desire to quit smoking and ability to smoke safely with or without supervision (per a completed safe smoking evaluation). The staff consults with the attending physician and the DON to determine if safety restrictions need to be placed on a resident's smoking privileges based on the safe smoking evaluation. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by staff. Any smoking-related privileges, restrictions and concerns are noted on the care plan and all personnel caring for the resident shall be alerted to these issues. The facility may impose smoking restrictions on a resident at any time if it is determined the resident cannot smoke safely with the available levels of support and supervision. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. Residents who have independent smoking privileges are permitted to keep cigarettes and other smoking items in their possession. Residents are not permitted to give smoking items to other residents. Residents without independent smoking privileges may not have or keep any smoking items except under direct supervision. B. Resident #57 1. Resident status Resident #57, age greater than 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), chronic diastolic (congestive) heart failure, lack of coordination, cognitive-communication deficit, weakness and dementia. The 11/1/24 MDS assessment revealed Resident #57 had a moderate cognitive impairment with a BIMS score of nine out of 15. Resident #57 had no documented behaviors. 2. Observations During a continuous observation on 12/16/24, beginning at 11:00 a.m. and ending at 12:05 p.m., the following was observed: At 11:01 a.m. Resident #57 was sitting in his wheelchair on the smoking patio smoking without a smoking apron on or a staff member present. At 11:04 a.m. the only staff member observed to be present on the Grand Mesa Hall, where the smoking patio was located, was a housekeeper who was cleaning resident rooms. At 11:13 a.m. Resident #57 self-propelled his wheelchair from the smoking patio to the nurses' station. He asked CNA #2 for another cigarette. CNA #2 asked the resident to wait a couple of minutes. At 11:29 a.m. Resident #57 asked numerous staff members if it was time to smoke. At 11:48 a.m. Resident #57 self-propelled outside onto the smoking patio. An unidentified female resident was taken to the smoking patio by a family member. Resident #57 asked the female resident for a cigarette. The female resident declined to give the resident a cigarette and Resident #57 self-propelled back to the nurses' station. At 12:00 p.m. Resident #57 asked CNA #2 if she was able to provide him with a cigarette. CNA #2 told the resident to head to the smoking area and she would meet him there. During a continuous observation on 12/17/24, beginning at 1:15 p.m. and ending at 3:06 p.m., the following was observed: At 1:39 p.m. Resident #57 was on the smoking patio waiting for a cigarette. CNA #5 gathered the residents' smoking materials. At 1:41 p.m. CNA #5 gave Resident #57 a cigarette and assisted him with lighting the cigarette. Resident #57 was not wearing a smoking apron. At 1:44 p.m. CNA #5 placed a smoking apron on the supervised smokers, including Resident #57, after she lit all of the residents' cigarettes. At 2:10 p.m. CNA #5 assisted some of the residents back inside the building. At 2:16 p.m. Resident #57 returned to his bedroom which was located next to the smoking patio. At 2:28 p.m. Resident #57 self-propelled to the smoking patio. He went around the corner and had his back facing the door and was hunched over. Resident #57 was smoking a cigarette without a smoking apron on or staff supervision. At 2:34 p.m. Resident #57 disposed of his cigarette and was leaving the smoking patio when RN #1 approached the patio door and asked the resident if he was ready to come inside for his medications. 3. Resident interview Resident #57 was interviewed on 12/16/24 at 2:40 p.m. Resident #57 said the facility was a dump and he was not allowed to smoke whenever he wanted. 4. Record review Resident #57's smoking care plan, initiated 8/29/24, revealed the resident was a smoker and interventions included the resident was a supervised smoker. -However, the facility failed to document a smoking apron as an intervention and what staff needed to do when the resident smoked without supervision or inside the building. Resident #57's smoking safety evaluation, completed on 7/2/24, revealed the resident was safe to smoke independently. Resident #57's smoking safety evaluation, completed on 8/27/24, revealed the resident was no longer safe to smoke independently and required a smoking apron with staff supervision. -However, observations revealed the resident did not consistently wear a smoking apron while smoking and was not always supervised by staff when he was smoking. The 8/27/24 progress note revealed a CNA completed rounds and smelled smoke coming from Resident #57's room. The resident was found sitting on the side of his bed smoking. Resident #57 handed the CNA his cigarettes and lighter and apologized. Resident #57 said he had a nightmare and smoked a cigarette to ensure he was in reality. The 8/30/24 progress note revealed Resident #57 had a smoking safety assessment completed. The resident was able to smoke unsupervised but needed to keep his cigarettes and lighter at the nurses' station. Resident #57's smoking safety evaluation, completed on 10/29/24, revealed the resident was safe to smoke independently. -However, the resident's 8/27/24 smoking safety evaluation documented the resident was no longer safe to smoke independently and required a smoking apron with staff supervision (see above). Resident #57's smoking safety evaluation, completed on 12/5/24, revealed the resident was no longer safe to smoke independently and required a smoking apron with staff supervision. The 12/5/24 progress note revealed Resident #57 had been downgraded to a supervised smoker after a smoking safety evaluation was completed. The 12/8/24 progress note revealed Resident #57 was found outside of his room smoking a cigarette at 8:00 p.m. The smoking material was taken to the nurses' station and the nurse informed the resident he was able to ask for his materials when he wanted to smoke outside. The 12/9/24 social services note revealed Resident #57 was upset that his smoking materials were removed. The staff reminded the resident he had accidentally smoked in the building numerous times and that he needed to be a supervised smoker to ensure the resident did not smoke inside the facility anymore. The staff told the resident there were safety concerns and the resident needed to be supervised while smoking and pointed out the burn holes the resident had on his wheelchair. The 12/11/24 social services note revealed Resident #57 met with the NHA and the social services director (SSD) to discuss the resident wanting to be an unsupervised smoker. The staff reminded the resident he smoked inside the facility and that his hospice team found numerous cigarette butts disposed of improperly in his bedroom. The resident understood. The 12/12/24 progress note revealed Resident #57 was seen smoking numerous times without a smoking apron or staff supervision. The 12/14/24 progress note revealed Resident #57 was non-compliant with smoking restrictions even though the staff provided the resident with education. The resident was borrowing smoking materials from other residents and smoked without an apron or staff supervision. C. Staff interviews CNA #2 was interviewed on 12/16/24 at 12:05 p.m. CNA #2 said Resident #57 was a supervised smoker and wanted to smoke at all hours of the day instead of at the set smoking times. She said Resident #57 received cigarettes and lighters from other residents and often snuck outside to smoke without supervision. CNA #4 was interviewed on 12/19/24 at 2:10 p.m. CNA #4 said supervised smokers were able to smoke at 9:00 a.m., 1:00 p.m., 4:00 p.m. and 8:00 p.m. She said supervised smokers wore smoking aprons and smoked two cigarettes at each smoking time. She said the residents were not allowed to hold the smoking materials which were held at the nurses' station. CNA #4 said Resident #57 got smoking materials from other residents and often smoked unsupervised. CNA #4 said the resident was a supervised smoker due to staff finding the resident smoking in his bedroom during the night. CNA #4 said it was important for the supervised smokers to be supervised to ensure the residents' safety. RN #2 was interviewed on 12/19/24 at 2:20 p.m. RN #2 said supervised smokers were able to smoke at 9:00 a.m., 1:00 p.m., 4:00 p.m. and 8:00 p.m. She said supervised smokers wore smoking aprons and smoked two cigarettes at each smoking time. She said the residents were not allowed to hold the smoking materials which were held at the nurses' station. RN #2 said Resident #57 was not on her assigned hall but that she was informed the resident was caught smoking in his bedroom, which showed he was unsafe to smoke without supervision. RN #2 said the residents were not allowed to share smoking materials but the residents did anyway. The NHA and the DON were interviewed together on 12/19/24 at 6:34 p.m. The DON said if a resident failed the safe smoking evaluation, then the resident was unable to hold their smoking materials or smoke without supervision. The DON said Resident #57 was a supervised smoker due to the resident smoking inside the facility. The NHA said the facility's leadership team talked about Resident #57's noncompliance with the supervised smoking and discussed putting the resident on a behavioral contract. The NHA said one of the residents that was suspected of giving Resident #57 smoking materials was discharging on 12/20/24 and the IDT was hopeful Resident #57 would not be able to obtain further smoking materials from other residents. The NHA said there were a lot of safety concerns around Resident #57 smoking. 41032 IV. Failure to ensure safe transfer pole use for Resident #23 A. Facility policy and procedure The Assistive Devices and Equipment policy, revised February 2021, was provided by the NHA on 12/19/24 at 1:30 p.m. It read in pertinent part, Our facility maintains and supervises the use of assistive devices and equipment for residents. Recommendations for the use of the device and equipment are based on the comprehensive assessment and documented in the resident care plan. The following factors are addressed to the extent possible to decrease the risk of avoidable accidents associated with the devices and equipment. Staff and volunteers are trained to demonstrate competency on the use of devices and equipment prior to assisting or supervising residents. B. Manufacturer's recommendations The manufacturer's recommendations for the Stander Wonder Pole Slim transfer pole were provided by the NHA on 12/19/24 at 3:30 p.m. The recommendations read in pertinent part, This product is only intended to assist users to provide balance and support during the process of sitting and standing. This product should not be used by anyone who suffers from any paralysis, symptoms of dementia, sleeping disorders, incontinence, severe pain, uncontrolled body movement, or who are unable to walk safely without assistance. It should not be used by individuals who suffer from confusion, restlessness, terminal restlessness, or who are under the influence of any medications, drugs or any substance that could impair their balance or judgment or any other condition that could affect the user's physical and mental ability to safely use this product. Serious injury or harm can result if the product is not properly installed. This product may present entrapment and or fall hazards. In order to mitigate the hazards of entrapment or falls, this product must be installed in strict accordance with the instructions set forth herein. This product must not be used by anyone who has any condition that may cause confusion, who cannot walk without assistance or is otherwise at increased risk of injury because of the propensity to fall or lose their balance including individuals who are taking medication that makes them tired or dizzy. The user must have sufficient hand strength to grasp the product while standing up without slipping. Do not install product if the ceiling is angled or if there is a suspended ceiling or if the distance between the floor and the ceiling is more than 10 feet. If the product moves when used, the product is not safe to use and must be removed immediately. Pol[TRUNCATED]

Based on record review and interviews, the facility failed to ensure each resident had the right to formulate an advanced directive for one (#63) of two residents out of 46 sample residents. Specifically, the facility failed to ensure Resident #63's proxy selected or refused life-saving treatments within the power of a proxy. Findings include: I. Medical Orders for Scope of Treatment (MOST) form The MOST form documented that a Proxy-by-Statute (decision maker selected through a proxy process) may not decline artificial nutrition or hydration for an incapacitated resident without an attending physician and a second physician trained in neurology who certified that artificial nutrition or hydration would merely prolong the act of dying and was unlikely to result in the restoration of the resident to independent neurological functioning. II. Resident status Resident #63, age greater than 65, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included vascular dementia, atrial fibrillation (irregular heart rhythm), stroke and anxiety. The [DATE] minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of zero out of 15. III. Record review A proxy selection document, completed on [DATE], revealed that Resident #63 lacked decision-making capacity after experiencing multiple strokes and had a proxy appointed. Resident #63's MOST form, completed on [DATE], documented the resident was a do-not-resuscitate (DNR), indicating the resident did not want cardiopulmonary resuscitation (CPR). Resident #63's MOST form was completed by his proxy and the proxy declined artificial nutrition on [DATE]. -However, the facility failed to have a physician's note signed by the resident's physician and a neurologist declaring the artificial nutrition was only prolonging death, as was required and instructed on the MOST form (see above). IV. Staff interviews The social services director (SSD) was interviewed on [DATE] at 3:41 p.m. The SSD said he was not sure what the legal difference between a proxy and a power of attorney for healthcare was. The SSD reviewed the instructions printed on the back of Resident #63's MOST form. The SSD said he was not aware a proxy could not choose to decline artificial nutrition by tube without supporting documentation by a physician. The director of nursing (DON) and the nursing home administrator (NHA) were interviewed together on [DATE] at 4:51 p.m. The DON said a proxy was similar to a power of attorney with less legal power. The DON said she did not know if there was any part of the MOST form a proxy could not complete. The DON reviewed Resident #63's MOST form. The DON said she was not aware a proxy could not decline artificial nutrition by tube without supporting documentation by a physician. The NHA said a proxy could not complete the section outlining artificial nutrition on a MOST form. The NHA said Resident #63's MOST form would be updated today ([DATE]) to reflect only the decisions the resident's proxy could legally make.

Based on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal and influenza vaccinations for two (#28 and #43) of five residents out of 46 sample residents. Specifically, the facility failed to offer pneumococcal vaccinations to Resident #28 or Resident #43. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged [AGE] years or Older, United States, 2022, retrieved on 1/2/25, from: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, in pertinent part, Routine vaccination-pneumococcal: For those ages 19 to 64 with an additional risk factor or another indication was: One (1) dose PCV15 (pneumococcal 15-valent conjugate vaccine PCV15 Vaxneuvance) followed by PPSV23 (pneumococcal 23-valent polysaccharide vaccine PPSV23 Pneumovax 23)or one (1) dose PCV20 (pneumococcal 20-valent conjugate vaccine PCV20 Prevnar 20). For those over the age of 65 who meet age requirements and lack documentation of vaccination, or lack evidence of past infection was: One (1) dose PCV15 followed by PPSV23 or one (1) dose PCV20. Special situations: Age 19-[AGE] years with certain underlying medical conditions or other risk factors who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown: One (1) dose PCV15 or one (1) dose PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose. A minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak to minimize the risk of invasive pneumococcal disease caused by serotypes unique to PPSV23 in these vulnerable groups. Note: Immunocompromising conditions include chronic renal failure, nephrotic syndrome, immunodeficiency, iatrogenic immunosuppression, generalized malignancy, human immunodeficiency virus (HIV), Hodgkin disease, leukemia, lymphoma, multiple myeloma, solid organ transplants, congenital or acquired asplenia, sickle cell disease, or other hemoglobinopathies. Note: Underlying medical conditions or other risk factors include alcoholism, chronic heart/liver/lung disease, chronic renal failure, cigarette smoking, cochlear implant, congenital or acquired asplenia, CSF (cerebral spinal fluid) leak, diabetes mellitus, generalized malignancy, HIV, Hodgkin disease, immunodeficiency, iatrogenic immunosuppression, leukemia, lymphoma, multiple myeloma, nephrotic syndrome, solid organ transplants, or sickle cell disease or other hemoglobinopathies. II. Resident #28 A. Resident status Resident #28, over the age of 65, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included bipolar disorder, gastroesophageal reflux disease (GERD) and benign prostatic hyperplasia (BPH). The 10/29/24 minimum data set (MDS) assessment revealed the resident had no cognitive impairments with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment documented the resident had not received the pneumonia vaccine. The assessment documented the facility did not offer the pneumonia vaccine to the resident. B. Record review -Review of the resident's electronic medical record (EMR) did not reveal documentation of the most recent pneumonia vaccine offered or received by the resident. Documentation provided by the nursing home administrator (NHA) on 12/18/24 at 10:22 a.m. documented that Resident #28 had been offered the pneumonia vaccine on 12/18/24 (during the survey). -The facility failed to offer Resident #28 a pneumococcal vaccination prior to 12/18/24. III. Resident #43 A. Resident status Resident #43, over the age of 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included dementia, hypertension (high blood pressure) and depression. The 10/26/24 MDS assessment revealed the resident had severe cognitive impairment and was unable to complete a BIMS assessment because she was rarely understood. The assessment documented the resident received a pneumococcal vaccination on 10/13/24. -However, there was no documentation in the resident's EMR to indicate the resident received a pneumococcal vaccination on 10/13/24 or that a vaccination consent had been obtained prior to 12/18/24 (see record review below). B. Record review Review of Resident #43's EMR revealed the resident received a Prevnar 13 pneumococcal vaccination on 8/22/18. -There was no documentation to indicate the resident had received an updated pneumococcal vaccination prior to 12/18/24 (see below). Documentation provided by the NHA on 12/18/24 at 10:22 a.m. documented that Resident #43 had been offered the pneumonia vaccine on 12/18/24 (during the survey). -The facility failed to offer Resident #43 a pneumococcal vaccination prior to 12/18/24. IV. Staff interviews The infection preventionist (IP) was interviewed on 12/19/24 at 12:59 p.m. The IP said she had been in her role for a few months and only gained access to the state immunization system in November 2024. The IP said the normal process for the facility was to go through all residents' vaccination consents and declinations at the same time as influenza and COVID-19 immunizations in October of each year. The IP said Resident #28 and Resident #43 were not offered a pneumococcal immunization before 12/18/24. The IP said Resident #28 and Resident #43 should have had a pneumococcal immunization offered to them prior to 12/18/24 The director of nursing (DON) was interviewed on 12/19/24 at 4:51 p.m. The DON said vaccinations should be offered to residents according to the recommendations of the CDC. The DON said Resident #28 and Resident #43 should have been offered a pneumococcal vaccination prior to 12/18/24.

Based on observations, record review, and interviews, the facility failed to provide necessary respiratory care consistent with professional standards of practice, the resident's care plan, goals and preferences for two (#32 and #70) of two residents reviewed for respiratory care out of 46 sample residents. Specifically, the facility failed to: -Implement a care plan focus with purpose, goals and interventions to document Resident #32 and Resident #70's goals for using a Continuous Positive Airway Pressure/Bi-level Positive Airway Pressure (CPAP/BiPAP) machine; -Develop and implement effective interventions to maintain and clean Resident #32 and Resident #70's CPAP/BiPAP machines to ensure the non-invasive mechanical ventilators were maintained in a hygienic manner; and, -Develop and implement effective interventions for oxygen therapy for Resident #32 and Resident #70. Findings include: I. Manufacturer's recommendations The ResMed AirSense10 manufactures User Guide, dated 2021, was provided by the nursing home administrator (NHA) on 12/18/24 at 1:30 p.m. It read in pertinent part, It is important that you regularly clean your AirSense 10 device to make sure you receive optimal therapy. Regular cleaning of the tubing assembly, water tub, and mask prevents the growth of germs that can adversely affect health. Wash the water tube and air tube with warm water and mild detergent, rinse thoroughly and allow to dry thoroughly. Wipe the outer machine with a dry clean cloth. Clean the water tub and remove any white powder using a solution of one part household vinegar to 10 parts water. Replace any damaged parts. Check the air filter and replace it every six months or earlier if heavily soiled with dirt or dust. The filters are not washable or reusable. The device records your therapy data, so your care provider can view the data and make changes to your therapy if required. The VOCSN (ventilator, oxygen concentrator, cough assist, suction, and nebulizer) Clinical and Technical Manual, dated 2024, was provided by the NHA on 12/18/24 at 1:30 p.m. It read in pertinent part, Clean the outside of the machine between each use with a CaviWipe, Super Sani Cloth, Oxivir or Safetec SaniZide Plus cloth. Inspect the machine: Clean the air filters and fan filters every two weeks with warm water and mild detergent; rinse and allow to air dry. Do this to ensure the internal components are protected from dirt and dust. Replace the filters every six months. Replace the external bacterial and nebulizer filters every 30 days or when compromised, and the internal bacterial filter when it becomes contaminated. II. Facility policy and procedure The CPAP/BiPAP Support policy, revised March 2015, was provided by the NHA on 12/19/24 at 3:43 p.m. It read in pertinent part, Specific cleaning instructions are obtained from the manufacturers/suppliers of the PAP device. Machine cleaning: Wipe the machine with warm soapy water and rinse at least once a week and as needed. Humidifier is used: Fill with distilled water only in the humidifier chamber. Clean the humidifier weekly and air dry. To disinfect, place the vinegar water solution in the cleaned humidifier, soak for 30 minutes and rinse thoroughly. Filter cleaning: Rinse washable filter under running water once a week to remove dust and debris. Replace this filter at least once a year. Replace disposable filters once a month. Mask, nasal pillows and tubing: Clean daily by placing in warm soapy water and soaking/agitating for five minutes. Mild dish detergent is recommended. Rinse with warm water and allow it to air dry between uses. Headgear/strap: Wash with warm water and mild detergent as needed and allow to air dry. III. Resident #32 A. Resident status Resident #32, age 74, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), obstructive sleep apnea and respiratory failure with hypoxia (low levels of oxygen in the body's tissues). The 12/6/24 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment indicated the resident used a non-invasive mechanical ventilator. B. Resident interview and observation Resident #32 was interviewed on 12/16/24 at 3:30 p.m. Resident #32 said her CPAP machine was very important to her health and she needed to use the machine to get a good night's sleep. Resident #32 said the nursing staff did not take measures to clean her CPAP machine, so she did it herself. She said it was too hard to clean her CPAP equipment in the sink in her room and there was no good place to dry the tubing. She said when she was home, her husband cleaned her machine for her. Observation of Resident #32's CPAP machine, a ResMed AirSensor 10 model, and room revealed the resident had no vinegar or detergent to be able to effectively clean her CPAP per the manufacturer's recommendations (see above). The larger hose looked dusty and had some whitish sediment inside. The CPAP nasal mask foam and straps were soiled with black marks and a pinkish-orange stain. The mask was stained with a whitish cloudy substance and was hooked to the nightstand, exposed to air and was not protected from airborne debris and bacteria. Resident #32 said she was not sure when the CPAP mask had last been replaced, but she said it had been a while. She said she had used the CPAP machine for [AGE] years. C. Record review Review of Resident #32's December 2024 CPO revealed the following physician's order: Resident to use CPAP when napping/sleeping at the setting of 15, every shift, ordered 10/23/24. -A review of Resident #32's comprehensive care plan revealed the care plan failed to document the resident's use of a CPAP machine and oxygen therapy. IV. Resident #70 A. Resident status Resident #70, age less than 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included COPD, respiratory failure with hypoxia and heart failure. The 12/8/24 MDS assessment revealed the resident had intact cognition, however, the BIMS assessment was not completed. The assessment indicated the resident was receiving oxygen therapy and was using a non-invasive mechanical ventilator. B. Resident interview and observation Resident #70 was interviewed on 12/16/24 at 3:30 p.m. Resident #70 said he rented his BiPAP machine from a respiratory provider and the provider checked on the machine once in a while. Resident #70 said he was responsible for cleaning the machine, but he said he was unable to take the tubing and water reservoir apart to clean it due to his limited finger dexterity. Observation of the resident's BiPAP machine, a VOCSN model, revealed the resident had no supplies to clean the machine. The BiPAP mask was placed in the machine stand basket with miscellaneous items exposed to air and was not protected from airborne debris and bacteria. C. Record review Review of Resident #70's December 2024 CPO revealed the following physician's orders: Respiratory Orders: BIPAP with 6 LPM (liters per minute) of oxygen bled in at night to maintain O2 (oxygen) saturation between 87 to 94 percent (%) one time a day for COPD, ordered 8/27/24. Continuous oxygen at 6 LPM by nasal cannula. Titrate O2 to keep O2 saturation between 87% to 94%, every shift for COPD, ordered 8/27/24. -A review of Resident #70's comprehensive care plan revealed the care plan failed to document the resident's use of a BiPAP machine and oxygen therapy. V. Staff interviews Registered nurse (RN) #4 was interviewed on 12/18/24 at 11:25 a.m. RN #4 said the daytime nurses were not responsible for maintaining the residents' CPCP/BiPAP machines. She said the night shift nurses changed the oxygen in each of the residents' oxygen devices once a week. RN #4 said she thought the night nurses also cleaned the residents' oxygen machines at night but was not sure what they did to clean the machines. Licensed practical nurse (LPN) #3 was interviewed on 12/19/24 at 1:30 p.m. LPN #3 said the night nurses were responsible for maintaining and cleaning Resident #32 and #70's CPAP/BiPAP machines. The director of nursing (DON) and the NHA were interviewed on 12/19/24 at 4:00 p.m. The DON said the residents' CPAP and BiPAP machines were managed by the respiratory provider who supplied them to the resident. The DON said the company would come to the facility weekly to change tubing and maintain the equipment. The DON said the CPAP/BiPAP mask and tubing should be washed daily and believed the resident or their family were performing those tasks.

Based on interviews and record review, the facility failed to take steps to protect one (#10) of six residents reviewed for abuse out of 24 sample residents. Resident #10, who had a diagnosis of anxiety disorder and was always incontinent of urine and occasionally incontinent of bowel, was dependent on staff assistance for all activities of daily living (ADL), including toileting hygiene, showering, upper and lower body dressing, personal hygiene and transfers. She required maximal assistance from staff to propel her wheelchair. She was able to use her call light to call staff when she needed assistance. On 5/3/24, certified nurse aide (CNA) #2 provided a shower to Resident #10. After the resident's shower, CNA #2 placed Resident #10 in her wheelchair near the bathroom in her room. CNA #2 left Resident #10's room, without making the resident's bed and without telling the resident she would be back or why she was leaving the room and closed the door of the room. Resident #10 was unable to maneuver her wheelchair independently in order to reach her call light, which was left approximately eight feet away from her, to call for assistance. Resident #10 began to feel afraid and began yelling out for help because she could not reach her call light. After 20 minutes, the resident's family member arrived for a visit. The family member heard Resident #10 yelling from the hallway, opened Resident #10's door, found the resident crying and upset and went to find a staff member (CNA #1) who could provide assistance to the resident. Additionally, on several occasions between 3/1/24 and 5/5/24, Resident #10's call light was on for 15 minutes or more before staff provided assistance to the resident. Due to the facility's failure, Resident #10 was afraid when she was left unattended and without access to the call light for 20 minutes. She felt abandoned, like she did not matter and that staff would forget her. Findings include: I. Facility policy and procedures The Resident Abuse Prevention policy and procedure, dated August 2017, was provided by the executive director (ED) on 5/10/24 at 5:25 p.m. The policy documented each resident had the right to be free from physical, mental or sexual abuse, neglect, corporal punishment, involuntary seclusion, and physical or chemical restraints. Neglect was defined as a failure to provide agreed upon care or services to a resident, failure to make a reasonable effort to assess what care was necessary for the well-being of the resident, or failure to provide a safe and sanitary environment. The Resident Call System policy and procedure, dated August 2017, was provided by the ED on 5/10/24 at 5:25 p.m. The policy documented each resident was provided with a means to call staff directly for assistance, and calls for assistance were answered as soon as possible, but no later than five minutes. Urgent requests for assistance were addressed immediately. II. Resident #10 A. Resident status Resident #10, age 86, was admitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included rheumatoid arthritis, anxiety disorder, Parkinsonism (term for a group of brain conditions that cause movement symptoms, such as slow movements, stiffness, walking and balance problems and tremors) and weakness. The 3/6/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. She was dependent on staff for toileting hygiene, showering, upper and lower body dressing, personal hygiene and transfers. She had no hallucinations, delusions or refusals of care. She was always incontinent of urine and occasionally incontinent of bowel. She required substantial/maximal assistance with the use of her wheelchair. B. Resident interview and observations Resident #10 was interviewed on 5/7/24 at 11:08 a.m. Resident #10 said there were times when she had to wait for 30 minutes or more for assistance from staff when she needed help. She said there was an incident the previous Friday (5/3/24) when she was left in her wheelchair in her room by a staff member who had just helped her bathe but did not finish and she did not have access to her call light. Resident #10 said CNA #2 placed her wheelchair near the bathroom, which was approximately eight feet away from where her call light was. She said CNA #2 left the room, closed the door without telling her she would be back or why she needed to leave and left the resident alone for 20 minutes without ensuring the call light was within reach. Resident #10 said she began to feel afraid and started yelling out for help to get her back into bed. She said her bed did not have any linens on it and had not been made. She said she felt abandoned and as if she did not matter. Resident #10 began to cry during the interview and said she had so many fears about that, and did not like the door to her room closed because she felt like the staff was going to forget her. Resident #10 said after approximately 20 minutes, her family member arrived for a visit, heard her yelling out for help from the hallway and opened the door and found her crying and upset. She said her family member told her she would make her bed and went to find a staff member (CNA #1) who could provide them with linens and assistance. Resident #10 was interviewed again on 5/10/24 at 10:23 a.m. Resident #10 said if staff took too long to answer her call light, she was incontinent of urine which made her bottom sore. She said she wore an incontinence brief and needed to be changed routinely, which was usually why she pushed the call light for help. Resident #10 became tearful and said sometimes it took half an hour to answer her call light, which was too long, and she said it made her feel like she didn't matter and she didn't count. C. Record review The care plan, initiated 6/5/23 and revised 5/10/24, identified Resident #10 had limitations in her ability to perform activities of daily living. Interventions included she required extensive assistance of two staff with bed mobility, position changes, dressing, personal hygiene and bathing. The resident experienced incontinence and required extensive assistance of two staff with toileting and was encouraged to use a call bell to call for assistance. The Past Calls log for Resident #10's use of the call light was reviewed from 3/1/24 through 5/5/24 and revealed the following response times: -The call light elapsed response time was greater than 15 minutes 54 times. -Of those 54 occasions, the response time was greater than 20 minutes 16 times. -Further, on 4/13/24, there was a response time of 30 minutes and on 4/30/24, there was a response time of 56 minutes. III. Incident of neglect of Resident #10 by CNA #2 The investigation was reviewed for the incident that occurred on 5/3/24 when Resident #10 was left without access to her call light. In summary, CNA #2 left the resident's room when they returned from the bathing room to obtain sheets to make the bed. CNA #2 went to the laundry room to wait for the dryer to finish drying the linens and when she returned to the resident's room, the bed had already been made. CNA #2 left the room to request staff assistance to place the resident back in bed. CNA #2 was unfamiliar with Resident #10 and did not know her routine. The Investigatory Interview Form for the incident on 5/3/24, completed by the social services director (SSD), was reviewed and documented Resident #10 said she was left in her room without her sheets being changed, assisted back to bed and no call light was provided. The documentation revealed CNA #2 apologized to the resident when she returned to the room, and Resident #10 said she did not like that she was left. The incident was reported and submitted to the State agency. IV. Staff interviews The SSD was interviewed on 5/10/24 at 12:27 p.m. The SSD said she was asked to follow up with Resident #10 about the incident that occurred on 5/3/24. The SSD said Resident #10 told her she could not reach her call light for 20 minutes after her shower and said, It is not fair because I could not do anything when she was unable to get help. The SSD said it was important for residents to have access to their call lights because it was the only way they could get their needs met, especially if they were not mobile. She said having the call light within reach could prevent possible falls, in case of emergencies, if they needed medicines or had pain or if someone was in their room who should not be. CNA #1 was interviewed on 5/10/24 at 2:47 p.m. CNA #1 said she routinely worked with Resident #10. She said the resident required assistance with dressing, personal hygiene, transfers and toileting and the amount of care she could provide for herself changed over time. She said she thought the resident might be getting weaker. CNA #1 said the resident was incontinent of urine most of the time and was usually wet when she would use her call light to request personal hygiene assistance. CNA #1 said the resident used her call light purposefully and there had always been a reason she needed help when she pushed it. CNA #1 said, on 5/3/24, she was working on a different hall than Resident #10 was on. She said the resident's family member came and got her to request assistance for Resident #10. She said when she entered the resident's room, the resident was crying, frustrated and really upset. She said the call light was not on and was across the room and not within the resident's reach. CNA #1 said CNA #2 was new to the facility and not very familiar with the resident. She said CNA #2 had left Resident #10 in her wheelchair after her shower which the staff usually did not do. CNA #1 assisted the resident to finish putting lotion on her face, changed the bed linens and got her back into bed. CNA #1 said the resident was very particular, and the staff did get busy at times, but she said if it had been her in that position, she probably would have felt abandoned, been crying and upset as Resident #10 had been. CNA #1 said she dropped everything she was doing to take care of the resident as if it had been her in that position. CNA #1 said residents' call lights should be left right next to them, within reach, even for the independent residents, in case they needed assistance. The ED was interviewed on 5/10/24 at 6:22 p.m. The ED said residents should have their call lights within reach at all times. She said, in the past, if she had identified a resident who did not have their call light within reach, she would give it to them, then go to the nurses' station and tell the staff to go make a sweep of all of the residents on the floor to make sure everyone had their call light within reach. She said Star rounds were rounds conducted three times each week by a dedicated management staff and that was one of the things they checked on for each resident during those rounds. -During the survey, CNA #2 had been suspended pending the abuse investigation and was unavailable for an interview. V. Facility follow-up The facility provided additional documentation on 5/13/24, after the survey exit. The documentation included an investigation that was conducted into the call light wait time of 56 minutes on 4/30/24 at 8:39 p.m. The investigation documented Resident #10 became upset when an agency CNA entered her room to provide hour of sleep care and she preferred to not have someone new providing her care. She became visibly agitated and asked the agency CNA to leave the room. The registered nurse (RN) caring for Resident #10 that evening was then approached by another CNA with an urgent concern from another resident that needed to be addressed. The facility alleged that the call light in Resident #10's room was not turned off after care was provided to her by the RN and a different CNA because they forgot to turn it off. -However, there was no additional documentation provided to explain the 4/13/24 call light response time of 30 minutes or the other extended response times of greater than 15 or 20 minutes for Resident #10.

Based on observation, record review and interviews, the facility failed to ensure three (#1, #6 and #7) of four residents reviewed for nutrition out of seven sample residents received the care and services necessary to meet their nutritional needs and maintain their highest level practicable physical well-being. Specifically, the facility failed to prevent a significant weight loss, implement interventions after a significant weight loss was identified, consistently monitor weights and ensure meal intake records were accurate. Resident #1 experienced a significant, unplanned weight loss of 10.88% in less than two months. Resident #1's weight record/log identified Resident #1 lost almost 20 pounds (lbs) between 11/6/23 and 12/27/23. Resident #1's weight on 11/6/23 was 180.2 lbs. On 12/27/23 the resident's weight was 160.6 lbs. Weight loss was not identified as a potential concern in November 2023. Resident #1's meal intake record indicated the resident ate well. Interviews identified the resident had a poor appetite, however, his meal intake record indicated he ate well. Interviews related to Resident #1 and observations with other sample residents indicated potential and actual meal intake inaccuracies. The registered dietitian (RD) recommended Resident #1 to be placed on weekly weights on 12/6/23. The resident was not weighed weekly as recommended until 12/27/23, after the RD requested the weekly weights a second time. Additional interventions were not put in place after the significant weight loss was identified on 12/27/23 to prevent potential future weight loss. Record review did not identify documentation indicating the resident's potential weight loss or actual weight loss was deemed unavoidable and the resident was not on a weight loss plan. According to the resident's care plan, the goal for the resident was not to have significant weight loss. The 10/13/23 nutritional assessment read the resident's nutritional goal was to maintain adequate nutritional status as evidenced by maintaining his weight within 5%. In addition, Resident #6 and resident #7 were at nutritional risk, both with a diagnosis of dementia. Interventions were implemented by the registered dietitian due to the resident's nutritional risk and history of weight loss, however, these interventions and recommendations were based on by mouth (PO) meal intake documentation. Observations during the survey revealed the resident's intake of nutritional supplements were not accurately documented by nursing staff. The facility's failure to accurately document meal intake presented a potential risk for weight loss. Findings include: I. Facility policies and procedures The Weight Assessment and Intervention policy, dated March 2022, was provided by the nursing home administrator (NHA) on 3/18/24 at 7:29 p.m. The policy read in pertinent part: Resident weights are monitored for undesirable or unintended weight loss or gain. Residents are weighed upon a mission at intervals established by the interdisciplinary team. Weights are recorded in each unit's resident record chart and in the individual's medical record. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time. Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change had been met. The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. Individualized care plan shall address to the extent possible the identified causes of weight loss semicolon goals and benchmarks for improvement; and time frames and perimeters for monitoring and reassessment. Interventions for undesirable weight loss are based on careful consideration of the following: -Resident choice and preferences; -Nutrition and hydration needs other resident; -Functional factors that may inhibit independent eating; -Environmental factors they may inhibit appetite or desire to participate in meals; -Chewing and swallowing abnormalities and the need for diet modifications; -Medications that may interfere with appetite, chewing, swallowing, or digestion; -The use of supplementation and /or feeding tubes; and -End of life decisions and advanced directives. A weight loss regimen will not be initiated for a cognitively capable resident without his or her approval or involvement. The weight assessment intervention policy identified the threshold for significant unplanned and undesired weight loss was based on the following: -In one month 5% weight loss is significant; greater than 5% was severe. -In 3 months 7.5% weight loss was significant; greater than 7.5% was severe. -In 6 months 10% weight loss was significant; greater than 10% was severe. The Intake, Measuring and Recording policy, dated October 2010, was received from NHA on 3/18/24 at 7:29 p.m. It documented in pertinent part: -The following information should be recorded in the resident's medical record, per facility guidelines: -The date and time the resident's fluid intake was measured and recorded. -The name and title of the individual who measured and recorded the resident's fluid intake. -The amount of liquid consumed in milliliters (mL). -The type of liquid consumed -If the resident refused, the reason(s) why and the intervention taken. -The signature and title of the person recording the data. II. Resident #1 A. Resident status Resident #1, over the age of 65, was admitted on [DATE] and was discharged home on 2/2/24. According to the March 2024 computerized physician order (CPO), diagnoses included type II diabetes mellitus with diabetic chronic kidney disease, nutritional deficiency, gastroesophageal reflux disease without esophagitis (acid reflux), cognitive communication deficit and generalized muscle weakness. According to the 1/2/23 minimum data set (MDS) assessment, Resident #1 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The MDS assessment identified Resident #1 required set up assistance for eating. The MDS assessment did not indicate the resident was at risk for malnutrition. B. Representative interview Resident #1's representative was interviewed on 3/14/24 at 12:32 p.m. The representative said the resident had a history of poor appetite. The representative said the resident would rarely eat more than a couple bites of food. The representative said the facility documented the resident ate 100% of his meals but felt the documentation was inaccurate. C. Record review The nutrition care plan, initiated 8/9/23, read Resident #1 was at a nutritional risk. The care plan goal identified the resident would not have a significant weight loss change as identified by a weight loss of less than 2% in one week, less than 5% in one month, less than 7.5% in three months and less than 10% in six months. The interventions included to provide his diet as ordered, monitor meal intakes as ordered and monitor his weights as ordered. Resident #1's weight record/log identified Resident #1's admission weight on 8/9/23 was 183.2 lbs by use of the wheelchair scale. The resident was placed on weekly weights for three weeks. The 8/11/23 evaluation summary read Resident #1's appetite remained poor. The 8/11/23 physician order note read the physician ordered Remeron once a day at bedtime to stimulate his appetite. The 8/11/23 interdisciplinary team (IDT) note read the resident required assistance at the table for all meals with self feeding and cues for meal intake. Resident #1's weight record/log on 8/12/23 identified the resident's weight was 172.5 lbs by use of the mechanical lift scale. -The resident was not reweighed on 8/12/23 to determine the accuracy of the weight after the record indicated a 10.7 lb weight loss. The 8/12/23 communication note read Resident #1 was not eating well. The resident's representative was contacted and identified the resident preferred hamburgers, hot dogs, fried chicken, mashed potatoes, corn chips, string beans and ravioli. The preferences would be shared during the nursing report. Resident #1's weight record/log on 8/15/23 identified the resident's weight was 184.2 lbs by use of the wheelchair scale. The 8/17/23 CPO read the resident had orders for Glucerna nutritional supplement once a day. The 8/30/23 admission dietary profile identified Resident #1 had a regular texture, controlled carbohydrate diet with large portions. The resident ate independently and did not snack between his meals. The resident had a good appetite at the time of his admission to the facility. Resident #1's weight record/log on 9/6/23 identified the resident's weight was 184.0 lbs by use of the sitting scale. The 9/20/23 CPO read Resident #1's restorative dining program was discontinued on 8/31/23. The resident was able to feed himself without difficulty. According to the CPO, the resident was a picky eater. The CPO directed nursing staff to monitor his intakes. The 9/26/23 CPO identified orders for Remeron to stimulate the resident's appetite was discontinued. Resident #1's weight record/log on 10/3/23 identified the resident's weight was 182.2 lbs, indicating a 1.8 lb weight loss by use of the standing scale. On 10/4/23 the resident was reweighed. The reweight confirmed the resident's weight of 182.2 lbs. by use of the sitting scale. The 10/9/23 evaluation summary read staff attempted to educate the resident on his food choices. According to the note, the resident ate a lot of hot dogs. The resident was encouraged to make better food choices. The 10/13/23 nutritional assessment identified Resident #1 had normal nutritional status with a body mass index (BMI) of 23 or greater. According to the assessment, the resident had no weight loss and no decrease in food intake. The assessment read the resident's nutritional goal was to maintain adequate nutritional status as evidenced by maintaining his weight within 5%, show no signs or symptoms of malnutrition and eat greater than 50% of at least two meals daily. Interventions included the registered dietitian (RD) to evaluate and make diet change recommendations as needed. The 10/15/23 progress note read the resident seemed increasingly depressed since his toe amputation. The resident spent more time in bed and was withdrawn. The November 2023 meal intake record from 11/1/23 to 11/30/23 was reviewed. Out of 90 meals served at the facility, Resident #1 had 86 opportunities for meals at the facility. Four of the resident's meals were not documented. The intake record indicated Resident #1 ate 45 meals at 76% to 100%. The resident was recorded to have eaten 18 meals at 51% to 75%. Eight of his meals were recorded at 26% to 50% intake. The resident ate less than 25% of five meals according to the meal intake record. The resident refused 10 of his meals. The resident was marked unavailable for one of his meals. Resident #1's weight record/log on 11/6/23 identified the resident's weight as 180.2 lbs, indicating a 2.0 lb weight loss by use of the sitting scale. The 11/9/23 IDT note identified Resident #1 was reviewed in the at-risk meeting. The note identified the resident continued to receive physical and occupational therapy following a September 2023 toe amputation. The 11/16/24 IDT note identified Resident #1 was reviewed in the at-risk meeting. The note identified the resident was positive for COVID-19. The 11/28/23 read Resident #1 ate less than 50% of all meals in a 24 hour period. The resident was offered snacks and meal alternatives. Resident #1's weight record/log for 11/29/23 and 12/4/24 with weights of 167.8 lbs and 167.11 lbs were marked off with a black line on 12/6/24 with notations that read error and wrong chart by the staff development coordinator (SDC). -The review of the resident's weight record did not identify the resident was weighed after the removal of the wrong weights. The weight record did not identify the resident was weighed at the beginning of December 2023 to establish a monthly weight (see interviews below). The December 2023 meal intake record was reviewed for Resident #1. The facility served 93 meals between 12/1/23 to 12/31/23. Resident #1 had 82 opportunities for meals at the facility. Eleven of the resident's meals were not documented. Resident #1 was recorded to have eaten 61 meals at 76% to 100%. The resident was recorded to have eaten 12 meals at 51% to 75%. Three of his meals were recorded at 26% to 50% intake. The resident ate less than 25% of two of his meals according to the meal intake record. The resident refused four of his meals. A 12/6/23 email from the registered dietitian (RD) to the SDC was provided by the RD on 3/15/24 via email. The email read the RD identified the last two weights entered (on 11/29/23 and 12/4/23) for Resident #1 were entered as dialysis weights but the resident was not on dialysis. The RD asked the SDC to fix it. A 12/6/23 email from the RD to the facility interim director of nursing (IDON), assistant director of nursing (ADON) and the NHA was provided by the RD on 3/15/24 via email. The email read the RD looked at the weights for all residents for the month and she still needed weights for 16 residents completed. The IDON responded back to the RD and wrote the weights were completed for all but one resident who declined. The facility had 11 residents' weights she was having reweighed on 12/7/23 due to variances from their usual weight. -The email did not identify if Resident #1 was included in the weights needed or the residents who needed to be reweighed. The 12/6/23 RD weight change note read Resident #1's weight of 167.8 lbs triggered a weight warning (see above error note). Resident #1 recently tested positive for COVID-19 and had feelings of depression. He was currently receiving daily Glucerna diabetic dietary supplement. The resident's meal intakes ranged from 50% to 100%. The note read Due to his optimal intakes, the RD requests weekly weights to establish baseline weight. -Review of Resident #1's weight record between 12/6/23 and 12/26/23 did not identify the resident was placed on weekly weight at the request of the RD. The 12/7/23 IDT note identified Resident #1 was reviewed in the at risk meeting. The resident was expressing an increase in depression. -The note did not identify concerns in the resident's weight or that the RD requested the resident to be weighed weekly on 12/6/23. The note did not identify the potential weight and nutritional impact on the resident as a result of the resident having feelings of depression. The 12/18/23 quarterly nutritional assessment identified Resident #1 was at risk for malnutrition. The assessment identified the resident's last recorded weight was 180.2 lbs on 11/6/23. According to the assessment, the resident had a 2.2 lb to 6.6 lb weight loss in the last three months. The resident did not have a decrease in food intake. Resident #1's weight record/log on 12/27/23 identified the resident was 160.6 lbs, indicating a 19.6 lb weight loss by use of the wheelchair scale. The weight loss was significant at 10.88%. The 12/28/23 IDT note read Resident #1 was discussed in the at-risk meeting. The resident had noted weight loss but his PO (by mouth) intakes were 75% to 100% for three meals a day times seven days. According to the note the IDT recommendation was to wait for the next January 2024 weight to establish a baseline weight and continue to follow his care plan. -The IDT note identified no new interventions were implemented after the identification of an almost 20 lb weight loss since 11/6/23. Resident #1's weight record/log on 1/8/24 identified the resident's weight was 163.3 lbs, indicating a 2.7 lb weight gain by use of the standing scale. The 1/8/24 weight change note read the resident had a 7.5% loss with a current weight of 163.3 lbs. The resident continued to have 75% to 100% intake for three meals a day at seven days. The note read, due to optimal intakes, there would be no changes to the current plan of care. Staff would continue to follow the care plan and monitor with weekly weights. The 1/11/24 IDT note read Resident #1 was discussed in the at-risk meeting. The resident requested three egg McMuffin style sandwiches for every dinner. Resident #1's weight record/log on 1/11/24 identified the resident's weight was 164.4 lbs, indicating a 1.1 lb weight gain by use of the wheelchair scale. The 1/11/24 nutrition note read the RD spoke to Resident #1 about his weight loss. He said when he was first at the facility he did not feel like eating. He said now he was better. Resident #1 said he was satisfied with current weight with no desire to regain the lost weight. The 1/12/24 nutrition note read Resident #1's representative was contacted to inform them of the resident's weight change. The representative had questions and concerns regarding Resident #1's weight change and dietary habits. The representative did not agree with the RD and the RD informed the representative of resident rights. Resident #1's weight record/log on 1/17/24 identified the resident's weight was 164.0 lbs, indicating a 0.4 weight loss by use of the wheelchair scale. Resident #1's weight record/log on 1/23/24 identified the resident's weight was 162.8 lbs, indicating a 1.2 lb weight loss by use of the standing scale. The 1/25/24 IDT note read Resident #1 lost one to two lbs the week of 1/25/24. His care plan would be continued. Resident #1's weight record/log on 1/31/24 identified the resident's weight was 162.0 lbs, indicating a 0.8 lb weight loss by use of the standing scale. The 2/1/24 IDT note read Resident #1's weight stability was discussed in the at risk meeting and he planned to go home on 2/2/24. D. Staff interviews The RD was interviewed on 3/14/24 at approximately 11:45 a.m. The RD said Resident #1 had significant weight loss between November 2023 and December 2023. The resident was not placed on weekly weights in November 2023 because the 11/6/23 weight did not identify a concern and the meal intake record in November 2023 showed the resident was eating well. The RD said she was at the facility at least weekly and she frequently communicated with the facility. The RD said she recommended the resident to be weighed weekly on 12/6/23 when an error weight was logged. She said she sent an email to the SDC regarding the weight error on 11/29/23 and 12/4/23 (see above). The weights were entered as dialysis weights and the resident was not on dialysis. The RD said she put a weekly weight recommendation in the 12/6/23 progress note (see above). She did not know why the resident was not weighed after her recommendation. She said she would have hoped the DON or the ADON would have seen her recommendation of weekly weights. The RD said she identified Resident #1 still needed his weekly weight completed and requested the recommendation again on 12/27/23 for Resident #1 to establish a baseline weight. The RD said residents were reviewed in the at-risk meeting when a resident was triggered for weight loss or was at risk. The RD said Resident #1 was placed back on the at-risk meetings for weight loss after 12/6/23. The RD said she believed that Resident #1's weight loss was discussed during the 12/7/23 risk meeting but she did not know why it was not documented in the 12/7/24 IDT note. The RD said she did not know what caused the weight loss. She said the resident's meal intakes identified the resident was eating well. She said he did not have edema to contribute to the weight change. The RD said the resident had expressed some depression. She said mood changes could cause the resident to lose or gain weight. She said had been concerned about inconsistent weight methods but felt it had improved over the last five to six months. The RD said the resident had a nine pound weight fluctuation when he first admitted but she felt the recorded weight was not accurate. The facility's clinical consultant determined the restorative aides started weighing the residents to help with a consistent method to weigh residents (same approximate time, same scale, same person). The RD said in January 2024 she started logging resident weights herself to help with the weight accuracy. The resident had additional weight loss in January 2023. She said she did not implement new interventions after 12/27/23 other than request weekly weights because his meal intakes were optimal at 75% intake. The RD said the resident had been on Glucerna since 8/17/23 for supplementation and wound healing. The RD said the resident expressed he was happy with the weight loss on 1/11/24. The RD said if a resident wanted to lose weight they could. The RD said there were no prior conversations with the resident to determine if the resident had a desire to lose weight or be on a weight loss plan. The RD said she had concerns with the accuracy of meal intake charting and had discussed her concerns with the facility in the past. The RD said the certified nurse aides (CNA) were very busy and would quickly go in and out of the dining room. She said she was concerned the CNAs were not logging how much the resident accurately ate. The RD said if Resident #1's meal oral intakes were correct in November 2023 and December 2023, she did not know how he would have lost 20 lbs in that short of a time. The RD said she was scheduled to conduct an education on nutrition with staff in the next couple of weeks. She said she would include meal intakes and accuracy and frequency of weights in the training with the nursing staff. CNA #1 was interviewed on 3/14/24 at 4:44 p.m. CNA #1 said she was trained to review a resident's plate and then log the percentage of how much the resident ate. She said after the resident finished his meal, she would try to log the percentage right away or try to remember what the resident ate and then document it the next time she was available to chart. CNA #2 was interviewed on 3/14/24 at 4:50 p.m. CNA #2 said when she was determining a resident's meal percentage of what was eaten she would gather the different food items left on the plate and make a determination based on the group items. CNA #2 said during and after meal times was a very busy time period for her. She said when a resident finished their meal, she would try to make herself a quick note of the percentage the resident ate and log the percentage later when she had time. She said some residents would still be in the dining room eating when she would have to help answer call lights so she would go back and forth in the dining room so she could log what the resident actually ate. CNA #2 said she should not determine what the resident ate until he was finished with his meal. Restorative aide (RA) #1 was interviewed on 3/18/24 at 12:48 p.m. RA #1 said the restorative department primarily recorded the residents' meal intakes so there would be consistent and accurate charting. She said she and the other RA were not at the facility everyday or for every meal so it would be up to the hall CNAs to record resident intakes. RA #1 said it was important to accurately record the resident's meal intake because if staff correctly recorded meal intake, a potential weight risk for loss or gain could be determined. RA #1 was interviewed again on 3/18/24 at 3:44 p.m. RA #1 said Resident #1 was on a restorative program for dining when he first admitted to the facility because he was an aspiration (choking) risk. He was not on a restorative dining program in November 2023. She said he would spend a lot of time in bed and his appetite was poor. She said his appetite started to improve shortly before he was discharged because he knew he needed to get better to be able to go home. RA #1 said she and the other RA primarily weighed the residents. RA #1 said all residents were weighed monthly by the 5th of every month. She said if a resident's weight showed a weight loss or gained three pounds or more, then the resident would need to be reweighed. She said if there was an error logged on the weight record then an email would be sent to the RD. The RD would be notified of the weight changes and she would determine if the resident needed to be placed on weekly weights. RA #1 reviewed Resident #1's weight log. She said the resident's last weight in the beginning of November 2023 was 180.2 lbs. He was not on weekly weight because his weight was stable from the month before. RA #1 said Resident #1's next weight was not until the end of December 2023. The resident's weight was 160.6 lbs. RA #1 said she did not know why the resident was not weighed at the beginning of December 2023. She said she was out on leave for December 2023 but the other RA or staff should have weighed the resident. RA #1 said if the RD was aware of the weight loss, she would have placed the resident on weekly weights. RA #1 reviewed handwritten restorative communication notes. She said she did not see anything in the notes to identify the resident was to be weighed weekly in December 2023. RA #1 said after a 20 lb weight loss the resident should have been reweighed on 12/27/23 or within a couple of days of the initial weight. RA #1 said Resident #1 was not reweighed until 1/8/24. The resident was started on weekly weights and his weights started to go up. The SDC was interviewed on 3/18/24 at 4:05 p.m. The SDC said she trained staff to use the picture chart poster to determine what food percentages looked like on a plate of food. She said if all of the food was eaten off the plate then staff should record the meal percentage and not based on what the resident usually ate. The SDC said everything on the plate should be included when determining the meal percentage. The SDC said she occasionally would help the staff enter weights but restorative was primarily responsible for resident weights. The SDC said the RD would request weights to be done in the weight and risk meetings. The SDC said she documented another resident's weight in Resident #1's weight record for 11/29/23 and 12/4/24. When she identified the mistake she marked off the inaccurate weight from his record. She said it was a mistake and did not realize at the time she was logging the weights in the wrong chart. The SDC said she was not given Resident #1 weights to log in December 2023. The director of nursing (DON) was interviewed on 3/18/24 at 4:29 p.m. The DON said she was hired and orientated to the facility in December 2023 but started most of her DON responsibilities at the beginning of 2024. The DON said residents identified at risk for weight loss or having a history of weight loss would receive regular weights. New admissions and residents identified with weight loss would both be weighed weekly and have weights reviewed in the weekly risk meeting. The DON said the RD would track the residents' weights and email the facility if she identified concerns. She said the interdisciplinary team (IDT) would look at the potential causation factors for the weight loss identified. The IDT would review the resident's cognition, physical needs, food and snack intake and the resident's meal environment. The DON said the resident's care plan would be updated with new interventions based on the resident's identified nutritional needs. The DON reviewed Resident #1's weight record and said the resident should have been weighed before 12/27/24. The DON said she reviewed all the resident notes daily and provided oversight with the assistance of the assistant director nursing (ADON) and the staff development coordinator (SDC). She said in December 2023 there was no one consistently monitoring weights other than the RD. The DON said she received an email from the RD identifying Resident #1 still needed weekly weights. The RD said the facility started the weekly weights for Resident #1 on 12/27/23. The DON reviewed Resident #1's record and she said a significant change in condition was not completed for weight loss. The DON said significant changes in a resident's weight status was brought to her attention by the RD at the end of each month, where it was later reviewed and addressed in their IDT meetings. The DON said she recalled the IDT discussing concerns with Resident #1's intake and identified the resident as having a failure to thrive. She said the IDT had discussed how the resident would refuse food or only want to eat grapes. The DON said she could not find where the concerns were documented. 50314 III. Resident #6 A. Resident status Resident #6, over the age of 65, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included dementia, dysphagia (difficulty swallowing), generalized muscle weakness and hypertension (high blood pressure). According to the 11/16/23 minimum data set (MDS) assessment, Resident #6 had cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The assessment documented Resident #6 required set-up or cleaning assistance with meals. The resident was able to eat independently after set-up assistance was completed. B. Observation Resident #6 was observed on 3/14/24 in the dining room during lunch. -At 12:55 p.m. Resident #7 ate less than 10% of his meal of shepherd's pie and vegetable casserole. -At 12:56 p.m. the resident was provided an ice cream cup. The resident finished his ice cream cup. -At 1:09 p.m. the director of nursing (DON) collected his plate. She did not note how much the resident ate before she picked up his plate. On 3/18/24 at 1:04 p.m. Resident #6 left his room independently after eating lunch. The resident left more than half of his food on his plate including an entire biscuit, more than half of his meat and more than half of his vegetables. C. Record review PO intake dated 3/18/24 at 1:28 p.m. documented the resident consumed 51-75% of the meal eaten, which did not accurately portray the amount of food eaten by the resident. The dietary profile dated 2/19/24 documented the resident required mechanical soft food, regular liquids and could eat independently. The quarterly nutritional assessment dated [DATE] identified Resident #6 as at risk for malnutrition. This assessment identified interventions including nutritional supplements, adaptive eating equipment as necessary, and a registered dietitian evaluation. The quarterly nutritional assessment dated [DATE] identified Resident #6 was at risk for malnutrition. -This assessment did not identify additional interventions with the resident being at risk for malnutrition. The nutritional assessment dated [DATE] identified Resident #6 was at risk for malnutrition. The assessment documented the resident had a moderate decrease in food intake and weight loss between 2.2 and 6.6 pounds. The care plan dated 2/14/24 identified that Resident #6 was at risk for functional decline and he required set-up assistance for all meals. -The care plan failed to identify the resident's malnutrition risk or identify interventions to help prevent weight loss. The CPO documented nutritional supplements ordered by the physician on 8/10/23 to be consumed three times a day. The March 2024 medication administration record (MAR) documented the resident was receiving physician ordered nutritional supplements three times per day. The February 2024 and March 2024 MAR document a total of 141 nutritional supplement opportunities between 2/1/24 and 3/18/24. Of these 141 opportunities for nutritional supplementation, the resident refused the supplements three times, was not available fo[TRUNCATED]

Based on observations, record review, and interviews, the facility failed to ensure one (#35) of nine residents reviewed for weight loss out of 37 sample residents maintained adequate nutritional parameters. Specifically, Resident #35 had a condition change when she experienced a fall with a fracture on 4/2/23 (cross-reference F689 falls/accidents). Resident #35's weights, taken on 3/30/23 and 5/11/23, more than one month apart, demonstrated a 10-pound weight loss from 201.6 to 191 pounds, which was not followed up with timely nutritional assessments and interventions. Resident #35 was observed needing extensive to total assistance with dining although her assessments and care plan identified she was independent with setup help only; staff who provided care for Resident #35 said she had needed an extensive level of assistance for about one month. There was no evidence of a thorough assessment of the resident's current dining assistance needs as of 7/13/23. The facility failed to respond in a timely manner to Resident #35's dining assistance needs and failed to assess and implement measures to ensure she received the assistance and nutrition needed to prevent significant weight loss. These failures contributed to Resident #35 experiencing significant, unplanned weight loss of more than 10 percent within six months. Findings include: I. Facility policy and procedures The Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol policy, provided by the director of nursing (DON) on 7/14/23 at 5:01 p.m., included: The nursing staff would monitor and document the weight and dietary intake of residents in a format which permitted comparisons over time. The staff and physician would define the individual's current nutritional status (weight, food/fluid intake and pertinent laboratory values) and identify individuals with weight loss or gain and significant risk for impaired nutrition. The staff would report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. When medical conditions or adverse consequences were causing or contributing to altered nutritional status, the physician and staff would collaborate in adjusting interventions, taking into account the status of those causes and the resident's responses, goals, wishes, prognosis, and complications. II. Resident status Resident #35, age 96, was admitted on [DATE]. According to the July 2023 computerized physician orders, diagnoses included Alzheimer's disease, vascular dementia, type II diabetes mellitus with hyperglycemia, and need for assist with personal care. According to the 6/22/23 minimum data set (MDS) assessment, Resident #35 had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She had a delirium indicator of inattention, being easily distractible, and having difficulty keeping track of what was being said. She needed extensive two-plus person assistance with most activities of daily living (ADLs) and was independent with setup help only for eating. She had no chewing or swallowing difficulties. She weighed 198 pounds (lbs) and weight loss/gain was no or unknown. -The MDS was inaccurate in that the resident's need for dining assistance and her recent weight loss were not identified (see below). III. Observations and staff interviews According to the meal service schedule, breakfast was served from 7:00 to 8:00 a.m., lunch from 11:30 a.m. to 12:30 p.m., and dinner from 5:00 to 6:00 p.m. Per observations, room trays were served first. On 7/10/23 at 9:45 a.m. Resident #35 was sitting in the hallway by the nurses' station near the main dining room repeatedly saying she wanted to go to bed. After repeating herself several times, staff assisted Resident #35 to her room. (Per meal intake records she ate 76-100% for breakfast.) Observations afterward throughout the survey conducted 7/10/23 through 7/13/23, revealed Resident #35 spent her time in bed, sleeping off and on. She also ate her meals in bed. When Resident #35 was approached as she lay in bed, she would sometimes wake up, reach out with her hand and ask if there was anything to eat. Her meals were often left covered and out of her reach on her bedside table for extended time periods after meals were served and frequently no staff were observed nearby to assist her with eating. Specifically: -On 7/12/23 at 7:51 a.m., Resident #35 was lying in bed and her breakfast tray was covered and sitting on her bedside table out of her reach, not set up for her. At 8:10 a.m. it was in the same place. At 8:34 a.m., her breakfast tray was gone. At 8:43 a.m., certified nurse aide (CNA) #1 said he assisted her to eat her breakfast and she enjoyed it. (She ate 76-100% per the meal intake record.) -On 7/13/23 at 8:00 a.m., Resident #35's breakfast was covered on her bedside table and out of her reach. CNAs #1 and #9 were assisting another resident to get out of bed. After assisting the other resident, CNA #1 took Resident #35's plate of pancakes to heat them up in the microwave and assisted her to eat her breakfast, after cutting up her pancakes into bite-sized pieces and adding syrup for her. -At 8:45 a.m., CNA #1 said Resident #35 ate all her bacon and wanted more and he was going to get her more. CNA #1 said her milk was probably not cold anymore. He said she would drink milk but only if assisted. He said if they set up her room tray and left her food within her reach she would pull it onto herself from the bedside table. He said she had been wanting to sleep more and more lately. CNA #1 said Resident #35 needed total assistance with eating and had needed this level of assistance for about the last month. (She ate 76-100% per meal intake records, see below.) CNAs #1 and #9 were interviewed on 7/13/23 at 8:45 a.m. CNAs #1 and #9 said they did not have enough staff to assist residents with dining timely while also providing care for residents on their hall (cross-reference F725, sufficient nursing staffing). IV. Record review Resident #35's weights, reviewed in the weights and vitals section of her medical record for the previous seven months, revealed the following: 7/11/23 - 189.6 Lbs 7/6/23 - 190.4 Lbs 6/7/23 - 198.0 Lbs 5/25/23 - 195.8 Lbs 5/17/23 - 197.0 Lbs 5/16/23 - 196.6 Lbs 5/11/23 - 191.0 Lbs 3/30/23 - 201.6 Lbs 3/22/23 - 190.8 Lbs 3/16/23 - 195.0 Lbs 3/9/23 - 195.6 Lbs 2/23/23 - 207.4 Lbs 2/9/23 - 201.4 Lbs 1/3/23 - 211.8 Lbs -Between 3/30 and 5/11/23, the resident had a fall with fracture (on 4/2/23) and lost 10 pounds. However, contrary to facility policy (see above) there was insufficient evidence her weight and nutritional status were closely monitored after that weight loss. Further, there was no evidence the physician was notified of Resident #35's weight loss and new orders requested until 7/11/23 after the survey began (see below). Physician orders: Resident #35's July 2023 CPO documented the following pertinent orders: -Offer snacks between meals, prefers sandwiches three times daily for nutrition ordered 3/16/23; -Regular texture diet, thin consistency fluids ordered 3/23/23; -Nutritional supplement twice daily for weight loss ordered 7/11/23. However, there was no documentation in the July 2023 medication administration record that the supplement was given on 7/11, 7/12, or 7/13/23. The nutritional care plan, initiated on 12/26/18 and revised on 6/19/23, identified dementia, coronary artery disease, hypertension, and obesity, with a 13 lb weight loss in 180 days, but weight stable for 90 days. The goal was adequate nutritional status and consuming more than 50 percent of at least two meals every day. Interventions were: monitor intake and record every meal, obtain weight and record per facility protocol, offer snacks between meals, provide and serve diet as ordered, RD to make diet change recommendations as needed. Other pertinent care plan entries documented specifically: Resident #35's activity needs care plan identified the following on 10/6/22: I ask for food often and I believe I am hungry. It may or may not be a real physical hunger, but having food supplicates me when I'm feeling anxious or confused. Any offer to get me something helps ease my mind. The care plan identified ADL limitations, with eating/dining needs documented on 12/20/21 as prompting and cueing during meals. The care plan further identified on 3/14/19, I am at potential risk for sustaining injury while consuming foods/fluids due to my functional limitations to balance or grip steadily cups, utensils and/or plates. The goal was no injury and the intervention was assist me by providing cueing-verbally and visuals as appropriate. Resident #35's most recent nutritional assessment, dated and signed on 6/19/23 by the registered dietitian (RD), documented her most recent weight was 198 pounds on 6/7/23 (12 days before). There was no decrease in food intake and no weight loss. There had been no acute disease or stress recently (although the resident had a fall with a fracture on 4/2/23). Her score was 11, indicating risk of malnutrition. -The nutritional assessment was inaccurate or incomplete in that her weight was not current; her recent meal intakes, nutritional/fluid needs, and recent lab values were not documented; and her dining assistance needs were not assessed. Nutrition at risk (NAR) meeting minutes regarding Resident #35 were requested on the afternoon of 7/13/23 and the following note was the only documentation provided: On 7/11/23 at 1:27 p.m. the registered dietitian (RD) documented, WEIGHT WARNING: -10.0% change over 180 day(s) [ 10.4% , 22.0 ] Noted wt (weight) stability this week. Will cont (continue) to offer and encourage all meals, supplements, and snacks to promote wt stability. Will cont to follow care plan and monitor with weekly weights. -There was no evidence consistent weekly weights were implemented before 7/11/23 (see weight list above which showed gaps of more than one month at a time). -The care plan was not revised regarding actual weight loss and recommended interventions. -There was no physician order for weekly weights per the RD's recommendation. -Twice-daily supplements were not given on 7/11, 7/12, or 7/13/23 in keeping with the RD recommendation and physician order. Meal and snack intake records, reviewed from 6/29/23 through 7/13/23, revealed Resident #35 consumed: Breakfast - 76-100% 10 times, 51-75% three times, 0% twice (once during survey on 7/11/23) Lunch - 76-100% five times, 51-75% nine times, 25-51% once (during survey on 7/11/23) Dinner - 76-100% four times, 51-75% six times, 25-51% or 0% four times Snacks were accepted 24 times out of 45 opportunities. V. Interviews Resident #35's daughter was interviewed by phone on 7/12/23 at 3:52 p.m. She said last Sunday (7/9/23) when she visited Resident #35, her meal was sitting out, and she nibbled at it but didn't really eat it. She was dozing on and off too, maybe she was just too tired to eat. I tasted it and the ham was not hot. Resident #35's daughter said the room tray sat there for about an hour after she arrived, and when she saw a staff person she requested that they take it away and bring her mother some ice cream. Resident #35 was unable to use utensils to eat her ice cream, so her daughter assisted her to eat. Sometimes I wonder if they need more help. There's Mom's lunch and an hour later there's nobody there to assist her (cross-reference F725, sufficient nursing staff). The RD was interviewed on 7/13/23 at 4:14 p.m. She said she had not ever observed Resident #35 during meals, and this was the first she had heard of the resident needing extensive to total assistance with eating. She said if the resident chose not to go to the dining room she should receive assistance in her room. In my opinion therapy should have done an assessment. The first thing I would do is notify the therapy department to do an evaluation for self-feeding. That's how I would handle it if somebody had let me know that information. The RD said appetite decreased along with dementia for older adults, and she always used a food-first approach. She said Resident #35 triggered for significant weight loss in July 2023. She's now on weekly weights and we discuss her weekly. I think I started charting on (Resident #35) in February. We started weighing her weekly to establish the difference between true weight loss and diuretic use and then she sort of stabilized. They started sandwiches and bacon for snacks at the beginning of March. From the beginning of June to now there had been an almost 10-pound weight loss. Sandwiches are not working any longer. That's when I decided to put the supplements on board. We've been following her for better than four months now. The RD said Resident #35's intakes in May through June 2023 were stable, but in July there was a decrease in her intake: 25-50% for breakfast and lunch and 50-75% for dinner times seven days. The RD said she was not aware the supplements she recommended on 7/11/23 were not yet being given.

Based on record review, observations and interviews, the facility failed to provide adequate supervision and/or safety devices to prevent falls and accidents for three (#35, #20 and #8) of eight residents reviewed out of 37 sample residents. Specifically, the facility failed to ensure Resident #35 was not injured during a staff-assisted transfer out of her daughter's car on 4/2/23. The resident per facility assessments required two-plus person assist for transfers, but one staff person assisted Resident #35 to transfer out of the car into a wheelchair. The resident fell to the pavement and broke her foot causing her pain and discomfort and thereafter, reducing her mobility and contributing to a decline (cross-reference F692, weight loss/nutrition). Resident #20, who was at risk for elopement and had a wander guard, eloped from the facility on 6/21/23 and ambulated in her wheelchair into the parking lot toward the sidewalk. The sidewalk was adjacent to a busy four-lane street with fast-moving traffic. Before staff could find the alarming door through which the resident exited, a visitor had escorted and assisted the resident back into the facility. Resident #8 was at risk for falls and experienced multiple unwitnessed falls and a skin tear during a transfer due to inadequate assessments, assistance, equipment use and supervision. Findings include: I. Resident #35 A. Resident status Resident #35, age 96, was admitted on [DATE]. According to the July 2023 computerized physician orders, diagnoses included Alzheimer's disease, vascular dementia, type II diabetes mellitus with hyperglycemia and need for assist with personal care. According to the 6/22/23 minimum data set (MDS) assessment, Resident #35 had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She had a delirium indicator of inattention, being easily distractible and having difficulty keeping track of what was being said. She needed extensive two-plus person assistance with most activities of daily living (ADLs) including transfers. She had one fall with no injury. -The MDS was inaccurate as the resident had fallen and suffered a fracture on 4/2/23. -There had been no changes in the resident's assistance needs since the prior MDS assessment on 3/24/23 which documented no fall history. B. Observations Resident #35 was observed during the survey, conducted 7/10 through 7/13/23, spending her time in bed lying on her back. She was observed sitting up in her wheelchair one time on the morning of 7/10/23. C. Record review According to the Resident Roster Matrix provided by the nursing home administrator (NHA) on 7/10/23 at 10:00 a.m., Resident #35 had a fall with major injury. A fall risk assessment dated [DATE] revealed Resident #35 was at high risk for falls because she had 1-2 falls within the last 90 days, used a wheelchair, was not steady and unable to stand for three minutes, [AGE] years or older, and took medications that put her at risk for falls. A change in condition (COC) evaluation dated 4/2/23 documented Resident #35 had a fall on the afternoon of 4/2/23. The nurse documented Resident's legs are weak. Staff to assist with transfer using gait belt. The fall was reported to the physician and the recommendation was: Staff to use gait belt with all transfers. PT (physical therapy) for strengthening. The resident representative was present when the incident occurred. Nursing progress notes revealed: On 4/2/23 at 3:09 p.m., Resident's daughter came into facility to get staff to help her mom out of the car. Staff went out to help resident out of car and resident stood up to get into w/c (wheelchair) and sat down on her knees. Staff had to come and get 3 other staff members to get resident up off her knee in the parking lot. Resident was assessed, no redness noted to knees. A COC follow-up document dated 4/3/23 at 2:25 p.m. documented the resident had no pain. Interventions utilized to address the change in condition: pt (patient) not transferring in and out of car with family member. On 4/5/23 at 6:56 a.m., Spoke with resident's daughter. Gave her an update on (Resident #35's) right ankle discomfort and bruising. She is agreeable with the plan of care which includes an xray of the right ankle this day. She would like to be informed of the results when available as well. On 4/4/23 at 5:59 p.m., a COC form documented the resident had a little bit of pain. The intervention was Encourage family not to assist with transfers from vehicle. On 4/6/23 at 11:35 a.m., Spoke with (daughter) regarding xray results which were positive for a fracture. Informed her of the plan of care which includes applying boot to affected right foot. On 4/6/23 at 12:15 p.m., Received order for CAM boot to right ankle secondary to right mid/hind foot fracture. OTR (occupational therapist) issues CAM boot to resident this date. Multidisciplinary communication with CNA (certified nurse aide) and nurse on hall regarding orders, wear schedule and remove every day for skin check. OTR to fax physician for therapy orders. A COC form on 4/7/23 at 6:02 p.m. documented, fracture confirmed to right foot, boot in place non weight bearing. The resident had pain that hurts a little bit. The intervention was encourage family not to assist with transfers from vehicle. On 4/8 and 4/9/23 COC forms documented the resident was having pain that hurts a little bit. On 4/9/23 at 4:10 p.m., ice to right ankle (three times daily) as tolerated for seven days. On 6/1/23 at 9:50 a.m., an at-risk meeting was conducted with the interdisciplinary team (IDT) to discuss Resident #35. Physical therapy (PT) and occupational therapy (OT) were working toward safer transfers due to recent WBAT (weight bearing as tolerated) fracture on right foot. DOR (director of rehabilitation) updated the daughter regarding the transfer status and prognosis of therapy. Will continue to follow care plan. On 6/8/23 at 9:36 a.m., an IDT weekly at-risk meeting was held. Resident #35 was on PT and OT following her foot fracture, ambulated 10 feet with a walker on 6/7/23. Changed from full Hoyer to sit to stand device with nursing staff. On 6/28/23 at 10:46 a.m., an IDT note documented she was discharged from therapy due to limited participation and minimal functional progress. Resident #35's care plan for fall risk, initiated on 8/21/2020 and revised on 7/13/23 (during the survey) identified impaired mobility, decreased safety awareness and history of falling. The fall on 4/2/23 was identified as assisted to the ground. Interventions were: Therapy to eval/treat transfer safety and strengthening. Two staff to assist with car transfers for safety (4/3/23); OT eval/treat for transfer training. Encourage resident's daughter to obtain staff assistance with transferring in/out of car (7/13/22); Educate me and my family/caregivers about safety reminders and what to do if a fall occurs (8/4/21); My caregivers will ensure I am wearing appropriately fitting footwear and clothing (12/20/21); My caregivers will remind me to use my call light for assistance (12/20/21); Please do not tuck my blankets or sheets in at the bottom of my bed. I like to sit up on the side of my bed and my feet get tangled in the blankets (12/20/21). -The care plan was not updated regarding two-person assistance with transfers or transfers in/out of the car until 7/13/23 during the survey. -Although IDT meeting discussion of mechanical lifts was documented after the fall with fracture and the MDS (above) documented extensive two-plus-person transfer assistance, the care plan was not updated to indicate how the resident should be transferred. -Although the first COC form on 4/2/23 documented staff were to assist using gait belt, which indicated staff did not do so on 4/2/23, there was no evidence of a thorough investigation and follow-up staff training to ensure transfers were safe and did not lead to further resident injuries. -Although requested on 7/13/23, there was no evidence of staff training to follow-up on this incident with injury to Resident #35. D. Interviews Resident #35's daughter was interviewed by phone on 7/12/23 at 3:52 p.m. She said she blamed herself for her mother's injury during transfer. She said they had returned from an outing together and she went into the facility to ask for staff to help her mom transfer out of the car and into her wheelchair. She said one staff came out to assist, but they did not use a gait belt and her mom fell in the parking lot. She said the fall took away Resident #35's mobility. The director of nursing (DON) was interviewed on the afternoon of 7/13/23. She said she would have to check for the facility's investigation and follow-up actions taken after Resident #35's fall, whether or not staff used a gait belt, whether or not staff education was provided as a result, and if there was supporting documentation of the training. The DON had provided the documentation above, but was unable to provide further evidence of investigation and follow-up. During a follow-up interview on 7/13/23 at 6:30 p.m., the DON acknowledged the documentation of the incident was a little confusing but of course they (staff) should've used a gait belt. II. Resident #20 A. Resident status Resident #20, age 92, was admitted on [DATE]. According to the July 2023 CPO, diagnoses included disturbance, psychotic disturbance, mood disturbance and anxiety. According to the 5/3/23 MDS assessment, Resident #20 had severe cognitive impairment with a BIMS score of four out of 15. She had delirium and mood symptoms of disorganized thinking and trouble concentrating; and behavioral symptoms of physical and verbal aggression directed toward others, rejection of care and wandering. The section regarding impact on herself and others was left blank. She needed extensive assistance with dressing, toilet use and personal hygiene and used a wheelchair or walker for ambulation. She had two or more falls since her last assessment, some with injuries. An updated BIMS assessment on 6/21/23 documented a score of zero out of 15. B. Observations and staff interviews Resident #20 was observed throughout the survey, conducted 7/10 through 7/13/23, spending most of her time either in bed sleeping or ambulating throughout the facility. She and other residents set off the door alarms frequently with their wander guards. Upon entering the facility on 7/12/23 at 5:00 a.m., the survey team was able to enter the front door without setting off an alarm after pushing the accessible entry pad. The front doors opened automatically and remained open for several seconds. No staff were observed at the facility reception desk, in the dining room, at the front nurses' station, in the resident hallways and no staff were observed until arrival at the rehabilitation nurses' station near the back of the facility across from the chapel. Licensed practical nurse (LPN) #2 said in an interview at 5:10 a.m. she had just tested positive for COVID-19 and needed to leave the building after contacting a nurse to cover for her. Certified nurse aide (CNA) #16 was interviewed at 5:20 a.m. and said he had unlocked the doors at 5:00 a.m. for the dietary staff who usually arrived around that time, had seen the survey team members in the parking lot at that time, and afterward most other staff were probably assisting residents in their rooms. (Cross-reference F725, sufficient nursing staffing.) C. Record review Resident #20's care plan, initiated 2/17/23, identified I am an elopement risk/wanderer r/t (related to) dementia. Interventions were: -Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: (left blank). Date initiated 2/17/23. -Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Date Initiated: 2/17/23 -Staff aware of elopement risk. Date Initiated: 5/16/23 -Staff aware of wander risk. Date Initiated: 5/16/23 -Use of visual barriers, such as tape. Date Initiated: 5/16/23 -Wander guard placed for my safety. Check placement per facility policy and PRN (as needed). Check wander guard function per facility policy and PRN. Date Initiated: 2/17/23 -Resident #20's care plan was not person-centered, assessments called for were not documented as completed, and revisions were not documented after her 6/21/23 elopement (see below). Review of nursing progress and change of condition notes revealed the following: On 6/14/23, Resident continues to exit seek throughout the day and night and does not respond to redirect. Has wander guard on and will continue to attempt to leave building r/t confusion. Nursing progress notes on 6/21/23 at 7:30 p.m. by the director of nursing (DON) documented, Notified of elopement, arrived at approx. (6:20 p.m.) and ED (executive director) and maintenance and I tested doors with resident wander guard multiple times and multiple ways, with the guard working each time. We then tested doors with new wander guard and alarms went off appropriately. A COC evaluation dated 6/21/23 documented behavioral symptoms of exit seeking started on the night of 6/21/23. Resident #20 continued to get out of bed and exit seek without wheelchair or assistant throughout the night. She continued to exit seek throughout the day and night and did not respond to redirection. Has wander guard on and will continue to attempt to leave building r/t confusion. IDT notes on 6/22/23 at 9:51 a.m. documented in pertinent part Resident #20 was being reviewed for recent uptick in behavior issues, specifically exit seeking. Resident #20 was able to slip out the front doors as family came into the building using the handicap button, which holds the door open for several seconds. (Resident #20) frequently exit seeks, especially in the afternoons and evenings. Resident's wander guard was in working order and the door alarm was as well. Resident will be provided with the opportunity to engage in outdoor activities. Her wander guard will continue to be tested and ensured to be in good working order. She is on PT (physical therapy) and ST (speech therapy) services; she continues to trigger for weight. She enjoys ice cream and this is a good redirection tactic when she is exit seeking. Will continue to follow the care plan. IDT will continue to follow. Nursing notes on 6/29/23 at 9:34 a.m. documented, She has been more effectively exit seeking; she does redirect with offering ice cream. -The details of the 6/21/23 incident were not thoroughly documented and did not include how far into the parking lot toward the sidewalk and street Resident #20 was able to go, or that she was brought back into the building by a visitor not staff. (See staff interview below.) The nursing home administrator (NHA) provided the following undated document on 7/13/23 at 6:30 p.m.: On 6/21/23 at 6:32 p.m. a call was received that (Resident #20) had gotten out the front door and a family had been able to bring her back into the building. The family was upset and stated that (Resident #20) had been able to get out the door just by pushing on it. They stated that they were almost certain that the door had closed and latched behind them on entry. On entering the building I was able to confirm this statement with the family member and the wander guard on the resident was changed out. With the director of maintenance we tested the door with the old wander guard and despite all attempts at recreating a way for the resident to simply get out the door without the alarm going off and with it opening immediately we were unable to do so. This included pushing the door, pulling the door, pushing a number of times, using the handicap button, rushing to the door trying to get it open before the system may be able to detect the wander guard and lock it down. All attempts led to the door locking down and setting off the alarm. The only way to open the door with the wander guard was to hold it for 15 seconds. Doing this will allow the door to open but the alarm goes off on opening and gives warning sounds the entire time the door is being pressed. Staff responded to all attempts to test the door. The new wander guard on (Resident #20) was also tested and was in perfect working order. The director of maintenance also checked the door functioning to ensure to determine any potential issues with the system and was unable to identify any. Discussion with staff and based off of the reports from family it was determined likely cause was that the door had not fully closed and latched when (Resident #20) pushed it open and was able to exit at that time. Postings on doors telling visitors not to assist residents out were in place. Immediate actions taken: Door function was tested and determined to be in working order. Wander guard on resident replaced. Previous wander guard tested on door. Door tested with multiple other residents. Other wander guarded doors tested . Adjustment made to the door on Grand Mesa to widen detection range and ensure quicker alarm and lock down. Resident checked on frequently until placed into bed. Ongoing actions: Continue checks on function of wander guards and doors. Determine if replacing wander guard system on all doors with the exception of main door and alarming all other doors (on opening) would be appropriate and feasible. Reviewed with IDT: social services director (SSD), MDS coordinator, life enrichment director (LED), business office manager (BOM), staff development coordinator (SDC), director of rehabilitation (DOR), assistant DON (ADON), DON, director of maintenance (DOM). C. Staff interviews The DON was interviewed on 7/12/23 at 5:50 a.m. She said Resident #20 had gone out the front door recently and got to the parking lot. She said staff were already going to the front door because we were alerted by the alarm. She pointed out there was a device at each nurses' station that showed which door had been opened which showed a red light. She said Resident #20 was fast but easily redirectible. LPN #4 was interviewed on 7/12/23 at 10:27 a.m. She said she was present when Resident #20 eloped on 6/21/23. She was able to get out to the street and I reported it. She said she was helping residents in the dining room, heard the alarm going off, looked at the lights and staff were in the halls passing trays and assisting residents. A woman was bringing (Resident #20) in and she was irate. (The SDC) came up and asked what was going on. (The SDC) got (the NHA) here and they checked the doors. Visitors were leaving the building and the alarm did go off but the doors were all green because (Resident #20) didn't go out by herself. She was in the parking lot headed toward the sidewalk. The DON and NHA were interviewed on 7/13/23 at 6:37 p.m. They said that was the first time Resident #20 had left the building without staff knowing. The NHA said he talked with the visitor who let the resident out, and could not recall if he talked with other staff to investigate the incident. He talked to the maintenance director and everyone to make sure the wander guards were working. Resident #20's wander guard alarm worked at the time. The NHA said they were discussing utilizing a code system at the doors like one of their sister facilities had. He said the doors should be locked at night, and he believed they were. He said staff unlocked the front door at 5:00 a.m. and staff started arriving for the day shift at 5:45 a.m. During a follow-up interview on 7/13/23 at 8:00 p.m., the NHA said, What concerns me is there are so many exits. It might be better just to have a lockdown access where you need a code to go out the door. III. Resident #8 A. Resident status Resident #8, age 76, was admitted on [DATE]. According to the July 2023 CPO, diagnoses included autistic disorder, legal blindness, hearing loss, major depression and history of falling. According to the 4/8/23 MDS assessment, he had severe cognitive impairment with a BIMS score of two out of 15. He had mood symptoms of feeling down, depressed and hopeless. No behaviors or rejection of care were documented. He required limited assistance with bed mobility, dressing, toilet use and personal hygiene. He needed supervision with no setup or physical help to walk in his room and in the corridor. He used a walker for ambulation. He had one fall with injury but without major injury. -The MDS was inaccurate in that Resident #8 was observed using a wheelchair wheeled by staff on 7/10, 7/11, 7/12 and 7/13/23. He was never observed using a walker (see below). -Since his admission MDS assessment on 7/6/22, Resident #8 had experienced declines in cognitive status from a BIMS score of five down to two out of 15, and a continence status decline from continence to frequent incontinence of bladder. (Cross-reference F677, ADLs.) B. Observations Resident #8 was observed throughout the survey conducted 7/10, 7/11, 7/12 and 7/13/23 using a wheelchair pushed by staff. He spend most of his time in his room, in the dining room at meals or on the outside periphery of activities sitting alone at a dining room table (cross-reference F679, activities) or in front of the nurses' station. He was never observed using a walker. He was not observed to have a wide mattress on his bed (see fall documentation below). C. Record review The care plan initiated on 7/11/22 and revised on 7/5/23, identified risk for falls related to my vision and use of a four wheeled walker (4WW), decreased safety awareness and history of falling. I frequently turn and sit on my 4WW seat without locking my brakes. 11/15/2022 Found on floor 11/28/2022 Found on floor 12/1/2022 Found on floor 3/12/2023 Found on floor 4/3/2023 Witnessed slide from walker 5/2/2023 Found on floor 6/27/23 Found on floor next to bed 7/5/23 Found on floor. Interventions were: -11/21/22 Ongoing education and safety reminders to lock his brakes on his walker. Therapy to evaluate/treat. -11/28/22 Encourage resident to wear nonskid socks. Nonskid strips placed next to bed and in bathroom. Increased frequent monitoring due to acute illness. -12/6/22 Resident experiencing an acute illness, rolled out of bed. Occupational therapy evaluate/treat. -3/13/23 72-hour toileting trial. -4/5/23 Trial non-skid surface to walker seat. -5/3/23 Therapy evaluate and treat. Non-skid strips placed at bedside. -6/27/23 A larger mattress will be placed. Fax sent to physician for eval of medical conditions. -7/5/23 My curtain will remain open during the day so staff may monitor me better, it will be closed during cares and when I request it to be closed. -7/11/22 Anticipate and meet my needs. -11/21/22 Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. -7/11/22 Ensure the resident is wearing appropriate footwear when ambulating. -7/11/22 Keep resident bed in lowest practical position -7/11/22 The resident needs a safe environment with: floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, and personal items within reach. -Resident #8's care plan was not accurate in that he used a wheelchair, not a walker. Assessments and a toilet use plan were not documented. Although new interventions after the falls were documented on 5/3, 6/27 and 7/5/23, not all were implemented (mattress) or monitored for effectiveness. A. Fall on 3/12/23 According to the 3/12/23 at 5:07 p.m. COC evaluation and nurses' notes, Resident #8 was found squatting in the floor by the CNA, when asked via his sign language, he gestured that he fell . No injury was found, he can freely move extremities, strong grasps, alert and oriented, was able to gesture to ask for help to sit in his bed. Neuro checking initiated, VS (vital signs) were WNL (within normal limits). Faxed physician, called POA. The summary of observations, evaluation and recommendations read, Frequent monitoring is needed, call for assistance encouraged, use of call light reiterated. -There was no documentation of increased monitoring. Given the resident's BIMS score and history, encouraging calls for assistance and use of the call light were not effective interventions. The follow-up fall risk assessment dated [DATE] documented high fall risk score of 15 due to history of falls, highly or severely impaired vision, ambulates with problems and with devices, unsteady balance, one or two pertinent health conditions present and one or two pertinent medications. B. Fall on 4/4/23 A nursing note and COC evaluation on 4/4/23 at 1:30 a.m. documented, Res(ident) in hallway by the nurses station, sitting in his walker. Staff noted that resident slid out of the walker, landing on his knees while his arms continues to hang on to the walker. Once he let go of the walker, he landed on the floor. Did not hit his head, but received superficial bruising along bilat (bilateral, both) forearms. The COC follow-up documentation read in part, encourage resident to sit on walker frequently and the conflicting statement, Remind resident not to use walker as a seat. -It was erroneously documented that Resident #8 had had no falls within the last 90 days. The fall risk score on 4/4/23 was 10 but there was no description of the meaning of the score. The DON documented in nursing notes on 4/7/23 at 5:18 p.m., Weekly Falls Meeting with SDC and DON, Resident had a fall on 4/3/23 with no injury. Resident sat on his walker which has a lid that looks like a seat. Upon sitting on the walker he slid to the floor with his arms still on the handles. Bilateral bruising on bilateral arms from handles. Resident was helped up with Hoyer. Will continue to monitor resident and apply sticky tape to the seat of his walker to assist him to not slide. C. Fall on 5/2/23 A COC evaluation on 5/2/23 at 7:34 p.m. documented a fall in the morning with no further details about the circumstances involved other than vital signs and pain evaluations. The recommendation was more frequent monitoring. Interventions were listed as placement of call light, monitoring use of walker and non-slip socks. -These interventions had already proven ineffective. The resulting fall risk score was 24 with no explanation of what that meant, due to three or more falls in the last 90 days, cognitive status, impaired vision, need for assistance with elimination, ambulation with problems or devices, unable to attempt standing without physical help, three or more health conditions present, and one or two pertinent medications. Follow-up nursing and therapy notes documented no injuries or pain as a result of the fall. -Therapy offered no new interventions to prevent future falls. -No further details were documented regarding the circumstances of the 5/2/23 fall. D. Fall on 6/27/23 Nursing notes on 6/27/23 at 6:15 a.m. documented, Resident found on floor with head at foot of bed with pillow remaining on bed at foot of bed. Resident sleeping on floor next to low bed. No injury noted. ROM (range of motion) WNL (within normal limits). Neuro checks begun. Resident unable to describe what had occurred, but does not appear to be in any distress/pain. No guarding, able to bear weight. Hoyer (mechanical) lift back to bed. Stood to get into wheelchair without prompting by staff. The COC evaluation on 6/27/23 documented there was no injury and there had been a previous fall. The resulting 6/27/23 fall risk assessment score was 15 without explanation of what that meant. The assessment erroneously documented no prior falls in the last 90 days. Continence status was independent and incontinent. On 6/29/23 at 10:27 a.m. the DON documented in IDT notes Resident #8 was found on floor next to his bed, no injuries noted at time of fall. Plan to try a wider mattress for his movements in bed. Nursing notes on 6/29/23 at 4:44 p.m. documented, Resident on follow-up for fall of 6/27/23. Spoke with therapy as CNAs reporting resident no longer assisting with transfers. Eval to be performed. -No further interventions were documented including the new use of a wheelchair which had not been mentioned in the resident's fall assessments or nursing notes previously. There was no evidence of a therapy evaluation to follow-up on the 6/27/23 fall. Adding a wider mattress was not documented as done, although the care plan said it would be placed. Observations (above) revealed the resident's bed looked the same as the others in the facility. E. Injury during transfer on 7/1/23 An IDT note on 7/1/23 at 9:16 p.m. documented, Res was in bathroom with 2 assist CNA for transfer to toilet. While using sit to stand and on toilet, he obtained a skin tear to back of left hand. He had no s/sx (signs or symptoms of) infection to site. No s/sx pain. Scant blood. Area is 3cm x0.2 cm. No depth. Area was cleaned and dressed with steri strips and mepi border dressing. Res tol(erated) well. Supervisor notified. MD notified. -There was no documentation of staff follow-up training or transfer evaluation. F. Fall on 7/5/23 Nursing notes on 7/5/23 at 5:07 p.m. documented, 11:45 a.m. CNA made nurse aware resident was sitting on his bottom on the floor. Upon assessment, resident sitting on his bottom on the floor, unable to say what he was doing, denies pain when asked, able to move all extremities, vital signs stable. MD made aware via fax. POA made aware via phone. Neuro checks initiated. A follow-up nursing note on 7/6/23 at 10:39 a.m. documented, IDT met to discuss and care plan was changed for door to be open and curtain pulled back during the day so staff may monitor resident better. Curtain and door may be closed when resident requests and during care. Resident appears to be having a steady physical and mental decline. Will continue to monitor. On 7/6/23 at 7:06 p.m., nursing notes documented, Resident on follow up for fall. Noted small ecchymotic (bruised) area to back of left hand. Denies pain. ROM WNL. Appetite good. W/C (wheelchair) for mobility. -No COC evaluation or fall risk assessment were found or provided. Although the need for frequent monitoring and a decline in Resident #8's physical and cognitive status were documented after falls, no related interventions were added to the care plan. The wheelchair for mobility documented in 7/6/23 nursing notes was not added to the resident's care plan. On 7/12/23 at 12:28 p.m., a Fall Friends Report documented by the activity director read: This writer went to check on (Resident #8's) interventions in room. His c/l (call light) was next to his bed on his tray table, where he can access it. Non-skid strips are on the floor per his care plan, the floor is free of clutter and the bed was in a lower position, but not completely to the floor. (Resident #8) was at activities, then got a haircut. He is wearing non-skid socks per his interventions. IV. Staff interviews The DON was interviewed on the afternoon of 7/13/23 and fall investigations, follow-up and actions taken were requested. She said she would have to look. Nothing further was provided beyond the documentation above. The nursing home administrator (NHA) and DON were interviewed on 7/13/23 at 8:00 p.m. regarding qualify assurance/process improvement. Regarding falls and accidents, the NHA said, Yes, we are looking at ways to address those different supervision needs, differences in the building, there's a lot of different approaches we can look at.

Based on interviews and record review, the facility failed to thoroughly and timely investigate an allegation of sexual abuse and protect one (#43) of two residents out of 30 sample residents during and after the investigation and, failed to investigate a subsequent allegation reported in resident council of staff's rough treatment. Resident #43 alleged sexual abuse by registered nurse (RN) #4 on 3/12/22. The facility failed to timely respond, thoroughly investigate and protect Resident #43, and allowed RN #4 to continue working with Resident #43. As a result, Resident #43 said she felt very upset and angry that she was not believed, and was fearful of RN #4. There was insufficient evidence the facility took measures to reassure Resident #43 and ensure she felt safe in her home. The facility's failures contributed to Resident #43 experiencing anger and fear over a month after the allegation was reported. Record review also revealed the facility further failed to investigate an allegation during a resident council meeting on 5/6/22 that some certified nurse aides were a little rough. Findings include: I. Facility policy The Abuse Prevention Program policy, revised in 2016, was provided by the interim nursing home administrator (NHA) on the morning of 5/16/22. The policy included in pertinent part that residents had the right to be free from abuse. The administration would investigate and report any allegations of abuse within the time frame as required by federal regulations, and protect residents during abuse investigations. The Report Abuse, Neglect and Exploitation of Vulnerable Adults policy, revised 8/11/21, was provided by the interim NHA on the morning of 5/16/22. The policy documented that signs of abuse included residents being withdrawn, passive, fearful and reports or suspicions of sexual abuse. II. Allegation of abuse reported by Resident #43 A. Resident status Resident #43, age 78, was admitted [DATE]. According to the May 2022 computerized physician orders, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 4/13/22 minimum data set (MDS) assessment, Resident #43 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She felt down, depressed or hopeless one day during the review period. She had no behavioral symptoms and no care rejection. She needed extensive assistance for bed mobility, transfers, ambulation with her wheelchair, dressing, and toilet use. B Resident interview Resident #43 was interviewed on 5/16/22 at 10:07 a.m. When discussing abuse, she said a male nurse had grabbed her breast a month ago when he was applying her clothing protector. She said it happened in the dining room, nobody else was around, and it was at noon. She was sitting at the dining room table. He put my clothes cover on me and then he grabbed me. She said she did not say anything to him or anyone else at the time, and she reported it afterward to the DON (director of nursing) and other nurses and everybody. Resident #43 said she survived a trauma when she was young, and this incident brought that back and I'm really angry about it because I am afraid of him, and he's the nurse . he knows manners. She said when she reported the incident, they did not believe her. She said after she reported the allegation, They keep asking me if I'm sure and saying that no one else has had a problem. She said the facility's disbelief made her very upset. She said, I'm not senile, I don't have dementia, I can remember about everything. She said RN #4 was not allowed to come in her room alone now; he had to have a female certified nurse aide (CNA) with him when he came into her room. She named the RN, and said he still worked with her. She was unable to say how often he provided care for her because nursing staff switched halls frequently. II. Facility investigation of Resident #43's allegation A. Staff knowledge of the alleged abuse incident 1. The NHA was interviewed on 5/16/22 at 1:47 p.m. She said she started as interim NHA about a month ago and said she may have heard about the resident's allegation of abuse. She said as the NHA, she was the facility abuse officer but the DON had been handling the investigation. (The DON was not in the facility during the survey and was not available for an interview.) The NHA said she thought the social services director (SSD) might recall the allegation. 2. The SSD was interviewed with the NHA on 5/16/22 at 1:52 p.m. The NHA said she had found the State Agency report and said the incident involved RN #4, and it had happened on 3/12/22 when neither she nor the SSD were working at the facility. The NHA explained she started at the facility on 3/16/22, and the SSD explained she had been gone for a month, since 2/21/22, and returned on 3/21/22. The SSD said, however, that she was familiar with the incident. She said the DON investigated the resident's allegation and said it was reported and investigated. She said they unsubstantiated it based on interviews with everybody that was there and because the staff member was putting her clothing protector on. The SSD said she did not know if she could access the investigation and supporting documents, but she remembered asking the DON if RN #4 was scheduled to work with Resident #43 and he had said no. The SSD said Resident #43 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Regarding emotional support for Resident #43, she said Resident #43 has a mental health counselor who comes in and sees her weekly. The SSD said she (the SSD) was in constant communication with Resident #43, and that she kind of comes and goes through cycles. When she cycles, we start seeing allegations, like a large amount of lost money. It's kind of her cycle to go in and out of those things. During those times, her counselor and I will communicate back and forth to see if it's a rough week, a good week. I do visit with her regularly, ask her how she's doing, and ask her if she's going to see (her counselor) this week. The SSD said, We did have a care conference with her daughter. We didn't discuss the allegation, and she didn't bring it up. Regarding facility follow-up on the resident's allegation, the SSD said, What was intended was that he (RN #4) was not interacting with her (Resident #43) at all. We'll double check the schedule. No other residents have complained about (RN #4). 3. On 5/16/22 at 2:15 p.m., the NHA said she received a call from the DON who said he investigated the allegation and the report was in his office. The NHA said she would find the report and share it. The NHA said the staff development coordinator (SDC) was with the DON when he was investigating the allegation and Resident #43 had agreed with the investigation outcome and plan. The NHA said the investigative report was provided to the State Agency, which she printed and provided. 4. The SDC was interviewed on 5/16/22 at 3:06 p.m. The SDC said she was aware of Resident #43's allegation and said the DON had learned about the allegation from Resident #43's daughter on 3/16/22. She thought the daughter had gone straight to the DON and told him that on the previous weekend, her mom had told her that the nurse had groped her breast. The SDC said she remembered the DON doing interviews on 3/17/22 but she only sat through the interview with Resident #43 and the DON on 3/17/22. She said during the interview, Resident #43 didn't seem upset that day, didn't seem urgent or anything like that. It was a simple interview. The SDC said they had decided two persons would care for Resident #43, and if RN #4 was on the resident's hall, another nurse would provide care for Resident #43 while he was there. She said they had two persons going in for her care at all times because of her previous allegations. The SDC said she had worked in the facility for a long time and this was not the first allegation of abuse Resident #43 brought to their attention. All of them have been unfounded. 5. The assistant DON (ADON) was interviewed on 5/16/22 at 3:30 p.m. She said Resident #43 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON said she had worked at the facility for four years and had known Resident #43 to report an allegation of abuse three times. She reviewed the care plan (see below) which did not document other incidents, and said there should be a previous care plan but due to their corporation change, it might be difficult to acquire. B. Failures in facility response to Resident #43's allegation of abuse. 1. Resident care plan - not resident specific and without reference to incident 3/12/22 Review of Resident #43's care plan, dated 3/17/22 (five days after the alleged abuse incident with no history or more current revisions), revealed no evidence of a history of allegations by the resident. One incident was documented in the care plan as follows: I have potential for alteration in mood/behaviors aeb (as evidenced by) making unsubstantiated allegations. The goal was: I will have less evidence of behavior issues through the next review date. Interventions were: -Administer medications as ordered. Monitor/document side effects and effectiveness (cross-reference F758) -Anticipate and meet my needs. -Assist me to develop the most appropriate methods of coping and interacting. Encourage me to express feelings appropriately. -Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm and controlled manner. Redirect. Remove from situation and take to alternate location as needed. -Minimize potential for allegations by performing all cares in pairs. -Monitor behavior episodes and attempt to determine underlying etiology/cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes and recommendations for avoidance of behavioral episodes. -Provide activities of interest and accommodate my status. -Provide positive reinforcement/praise. The care plan was based on one incident and did not document a history of unsubstantiated allegations as stated by the SSD, SDC and ADON. There were no interventions for checking in with the resident, reassuring the resident and ensuring her comfort and safety in her home. There was no identification of her vulnerability or trauma-informed care needs. There was no mention that the resident was not to receive care from a certain staff member, who could have been documented without naming RN #4. 2. Investigation documents - The investigation was initiated and reported late, and the facility action plan was not followed. An investigation document provided by the NHA, revealed a sexual abuse allegation by Resident #43, reported on 3/16/22 at 5:00 p.m., that had happened on 3/12/22 at 12:00 p.m. The DON documented that Resident #43 reported to a staff member that a male staff member had groped her while placing a clothing protector on her while in the dining room. Six staff and six residents were immediately interviewed. The resident was care planned to have two staff members for care at all times. Her daughter was informed and stated she agreed with this plan. The daughter further stated that her mother told her on Wednesday, but my mom makes allegations often. If for a moment I thought she was serious I would have reported it immediately. Mother just smiled and winked at me. The residents who were interviewed all denied concerns with staff being inappropriate with them or witnessing such behavior and stated they felt safe. Six staff members were interviewed and denied witnessing inappropriate behavior by any staff members. Staff interviewed were staff that frequently worked with the alleged staff member. The resident's daughter was interviewed over the phone. Residents were kept safe by ensuring the alleged staff member was not scheduled to work during the investigation. Due to the seriousness of the allegations, the investigation was completed as quickly as possible for resolution. The care plan was updated for two staff to provide all interactions with Resident #43. It was explained to the resident that her daughter was also notified and she agreed to care plan changes and that the alleged staff member would not be assigned to her. The resident said, I feel you have addressed the situation. Thank you. The conclusion of the internal investigation was: Allegations were found to be unsubstantiated. Care plan updated as needed and alleged staff will not be assigned direct care for resident. The statement that the alleged staff would not provide direct care of the reporting resident was repeated three times throughout the document. -The document was inaccurate and not implemented in that RN #4 was in fact working with residents on 3/12/22, and did work with Resident #43 after she alleged abuse by him. On 5/18/22 at 1:34 p.m., the NHA provided medication administration records (MARs) for Resident #43 and said that RN #4 had, in fact, administered medications to Resident #43 but said there was a staff person with him every time. Per MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . -Further, RN #4 was neither reassigned nor suspended immediately upon learning of Resident #43's allegation and pending the investigation. Further, he was not reassigned to ensure he did not provide care for Resident #43 after 3/12/22. (See interviews below) The supporting documentation provided by the facility was reviewed and revealed the following: The police were notified on 3/17/22 and took a report but did not document conducting an onsite investigation at the facility. The DON documented an interview with Resident #43 on 3/18/22: We discussed having 2 staff at all times for cares. To provide safety for (Resident #43) as well as staff and resident. (Resident #43) agrees to help remind staff that they need to have 2 and be part of the team! I feel you addressed the situation. Thank you. Signed by resident, DON and SDC on 3/18/22. -The DON and SDC did not tell Resident #43 that RN #4 would not provide care for her as documented in their investigative report to the State agency. -The care plan was not specifically revised with this plan. -The responsibility for ensuring two staff provided care was given by staff to the resident, instead of ensuring and monitoring it was done. -There was no documentation of an interview with RN #4, the alleged assailant. -No investigative summary was written. -The investigation was reported and investigated late, and was not thorough in that only six residents were interviewed, including Resident #43. -Although Resident #43 alleged abuse on 3/12/22, the investigation was not initiated until 3/16/22 per the documents above. The NHA learned that the DON did not know of the allegation until 3/16/22 and he reported it to the State and started an investigation on 3/16/22, four days after the incident. The NHA said the dietary manager initiated an investigation when it was reported to him on 3/12/22, and he notified the former NHA. C. Follow-up staff interviews - confirmation of delay and incomplete investigation and failure to implement plan to protect Resident #43 1. The dietary manager (DM) was interviewed on 5/18/22 at 1:18 p.m. when it was learned that he initiated the investigation of Resident #43's allegation on 3/12/22. He said he was the manager on duty on 3/12/22, and the former NHA had him do the investigation into Resident #43's allegation. He said the activity assistant (AA) had told one of the certified nurse aides (CNAs) that Resident #43 alleged RN #4 had groped her. The CNA reported to him and he interviewed the AA, the CNA and Resident #43. The DM said he had written it all down and gave it to the former NHA on 3/16/22, but she no longer worked in the facility and they were unable to find it. He said the allegation was reported to him on 3/12/22 after lunch, around 1:00 or 2:00 p.m. by a CNA. He said some of the interviews were contradictory regarding the circumstances and where the incident allegedly occurred. The DM said he did not recall seeing RN #4 in the dining room at lunch time on 3/12/22, that he was just in the hallway, and another nurse said she was the one who helped Resident #43 don her clothing protector. The DM said when he interviewed Resident #43 she did not express fear, and did not say what she wanted the facility to do. He reassured her he would look into it and pass it along to the NHA. The DM said he did not interview any other residents except Resident #43. He said the former NHA told him to let RN #4 know there had been an allegation and an investigation was underway but they did not tell the DM to tell RN #4 to stay away from any particular residents. He said he interviewed the AA, the CNA and Resident #43. He said after the interviews, he called the NHA and she asked if it was founded or unfounded, so he told her what his investigation concluded and she did not suspend RN #4 at that time. He said he was not concerned that RN #4 was not suspended. He said the NHA told him that Resident #43 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] #4 or any other residents. When the NHA returned to work on Monday, the DM said he gave her the investigative documents and he did not know how she handled the situation after that. He said he was asked if RN #4 was Resident #43's nurse and he was not working on that hall that day, he was working on Grand Mesa hall. 2. The AA was interviewed on 5/19/22 at 9:40 a.m. She said she was the first person Resident #43 reported the incident to, when she was taking her out to smoke after lunch on 3/12/22. Resident #43 told her she did not like RN #4 as they passed by him in the hall, and said he touched her breast when he was applying her clothing protector. The AA said that is not okay, and told a CNA who must have notified management and an investigation was initiated. She said she did not know what was done about it but when she spoke to Resident #43 a few days later she told the AA she was not pleased with the facility follow-up because they still allowed RN #4 to come in her room with someone else. She said she had observed RN #4 giving Resident #43 medications from the medication cart in the hallway, but she did not observe him going in her room. She said Resident #43 had told the DON in her presence that she was not pleased with the outcome of the investigation. 3. RN #4 was on vacation during the survey, conducted 3/16 through 3/19/22, and was not available for an interview. 4. The NHA, interviewed on 5/19/22 at 9:58 a.m., said she thought that, based on the interview with Resident #43's daughter, it was okay if RN #4 went in Resident #43's room with another staff person. She said she would have preferred that he had not taken care of her, that another nurse would have given her medications. She said she also would have preferred he was assigned to a different hall. That's what I'm doing now. She said when the allegation was first reported, RN #4 should have been suspended by the former NHA. On 5/19/22 at 11:15 a.m., the NHA said she had just talked with Resident #43, reassured her and told her RN #4 would not be working with her anymore, was out of the facility this week, and would be assigned to a different hall from now on. The NHA said Resident #43 was grateful. 5. The ADON and regional nurse resource (RNR) were interviewed on 5/19/22 at 5:30 p.m. The ADON said the first she heard of Resident #43's allegation was on 3/16/22 when she was discussing it with the DON. She said they were now educating staff on reporting to the department head immediately, either the manager on duty or charge nurse, and ensure they notify the NHA and the NHA will come in to investigate. The ADON said if an abuse allegation was reported to her, she would definitely come into the facility to investigate. The ADON and RNR said RN #4 was suspended on 3/16 and 3/17/22, after the DON found out about the allegation. The former NHA was in the facility all day on 3/16/22 and was terminated on 3/17/22 at noon. She had all day to take care of it but she didn't. We went through the drawers to see if we could find any investigation but couldn't find it. (The current interim NHA) didn't know about it because (the DON) had handled it. They felt like what they did was okay but it wasn't and it won't happen again. It's a learning experience for (the DON). (The DM) had the interviews he said but they disappeared when (the former NHA) was terminated. D. Outcome to Resident #43 Resident #43 said she was not satisfied with the outcome of the facility's investigation, felt staff did not believe her, and felt afraid of RN #4. Record review revealed little evidence of emotional support and reassurance was provided to Resident #43 by facility staff, to check in to ensure she felt safe, and to provide reassurance the facility was following up on her concerns. Specifically: Review of the resident's medical record revealed: There was no documentation in interdisciplinary team IDT progress notes on 3/12/22 or thereafter regarding the abuse allegation by facility staff. Review of IDT progress notes for the previous six months revealed no documentation of abuse allegations or inappropriate behavior with staff members. A mental health provider (MHP) note on 3/24/22 documented in part she received an email from the SSD today related to Resident #43's increased depression. She talked with the resident after talking with staff. She's recently accused a staff person and it is being investigated. She did talk about this today. She also said she is depressed and feels it more than usual. She reported feeling neglected and ignored by staff. The MHP documented she would let the SSD know and increase frequency of sessions. A social services review note dated 4/13/22 that documented in part, (Resident #43) was showing increased signs and symptoms of depression for several weeks, she reports she is feeling better and this is reflected in her interactions with others. (Resident #43) often makes false allegations and can be sexually inappropriate with others when she is more depressed. A mental health provider (MHP) note on 4/15/22 at 4:28 p.m. documented a session was held with Resident #43 who was able to work through feelings of not feeling like her life has meant anything. She discussed old trauma and this was communicated to facility staff. When interviewed on 5/16/22 (see above), Resident #43 mentioned the abuse allegation from 3/12/22. She said she was very upset and angry about the incident and that she was not believed, and fearful of RN #4. III. Resident council grievance/concern - failure to investigate allegation of rough treatment Review of the 5/6/22 resident council meeting minutes revealed under new business, Residents state some CNAs are being a little rough. There was no evidence of a facility investigation regarding this comment by residents until the survey was conducted (cross-reference F565, grievances of the resident group). The NHA was interviewed on 5/18/22 at 8:41 a.m. to follow up on grievances regarding resident council concerns. She said the facility management team did not initiate any grievances or investigations related to resident council meetings. She said they would develop an action plan and start doing so this month, as it was not done before to her knowledge. The NHA and SSD initiated an investigation regarding the allegation of rough treatment, which was ongoing on 5/19/22. Cross-reference F565 for details.

Based on observations, record review and interviews, the facility failed to provide one (#8) of two residents reviewed out of 30 sample residents, the care and services necessary to prevent the development of a stage 4 pressure injury to the resident's left foot, third digit (toe) that became infected and painful and was amputated within two months of admission. Resident #8 was admitted to the facility on [DATE] with no documented pressure injuries but at risk for such injuries. He was a diabetic and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to consistently assess, monitor and document the condition of Resident #8's feet despite his history of diabetes and toe ulcers until 3/21/22, although wound clinic notes documented a superficial ulceration of the third digit, left foot a week earlier. The 3/21/22 nurses' note read the resident's toe was red, inflamed and tender. He was diagnosed with [CONDITION(S)] and antibiotics were started. Resident #8 was taken to the wound clinic on 3/21/22, but the facility did not consistently document and implement the wound physician's recommendations, revise the resident's care plan, or document specifics about resident education and follow-up when the resident refused assessments and treatments. On 4/1/22, less than two months after admission, Resident #8 had a stage 4 pressure injury on his left foot, third digit, with bone exposed. On 4/20/22, the resident was diagnosed with a pseudomonas infection to the wound and [CONDITION(S)], a bone infection. Resident #8 was hospitalized on [DATE] after a fall and change of condition and was readmitted to the facility on [DATE]. His toe was amputated on 4/28/22 while hospitalized . The facility's failures contributed to Resident #8's pressure wound on his third left toe progressing to a stage 4 pressure injury that was associated with infection and pain and amputation. Cross-reference F689, adequate supervision and assistance to prevent falls with injury. Cross-reference F880, infection control. Findings include: I. Facility policy The Skin and Wound Management Program Overview policy, revised 11/26/18, was provided by the staff development coordinator (SDC) on 5/19/22 at 1:22 p.m. The purpose of the policy was to provide care and services to promote the prevention of pressure injury development, promote the healing process of pressure injuries that were present, prevent the development of additional pressure injury, and ensure the resident's pain was monitored during treatment. Pertinent definitions of pressure injuries included: -Stage 2 pressure injury: partial-thickness loss of skin with exposed dermis. The wound bed is viable, pin or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear. -Stage 4 pressure injury: full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the injury. Slough and/or eschar may be visible. Policy guidelines included: -An interdisciplinary approach, which includes screenings, comprehensive evaluations, reviews and monitoring, and plans of care. -The program is the responsibility of everyone who provides care to the residents, each with their own set of responsibilities. -A licensed nurse performs a visual 'head-to-toe- skin review within 8 hours of admission or readmission to determine general skin condition and identify any pre-existing skin concerns and/or wounds. Findings are documented. -A visual 'head-to-toe' skin review is performed by a certified nursing assistant (CNA), preferably during a bath/shower, to identify any new areas of skin concerns or other types of skin breakdown. Results are verified and documented by a licensed nurse. The skin check and verification are documented. -Whenever a new wound is identified, a licensed nurse conducts a comprehensive evaluation and documents the findings on the Initial Wound Review Form. Pressure injuries are numerically staged, by a registered nurse or licensed nurse with a current certification as a wound care nurse. -All wounds are monitored daily (as required) by a licensed nurse, with documentation on the Daily Wound review form that includes date observed, status of the wound if no dressing and status of the dressing if present, whether dressing is intact, whether drainage is present, review of the surrounding skin that can be observed without removing the dressing, presence of possible complications, and presence of pain. -All wounds are monitored at least weekly by a licensed nurse during wound rounds, with documentation on the Weekly Wound Progress Review Form. The weekly wound tracking form is completed by the certified wound care licensed nurse during weekly wound rounds. It is reviewed by the IDT during the weekly IDT meeting to monitor improvement toward healing. This form is not part of the resident's medical record. II. Resident status Resident #8, under age 70, was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 2/15/22 admission minimum data set (MDS) assessment, Resident #8 had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. He had [CONDITION(S)] symptoms of inattention and trouble concentrating; and a verbal behavioral symptom of threatening, screaming and cursing directed toward others but there was no evidence of care rejection. -For activities of daily living (ADLs), he needed supervision/oversight/cueing and physical assistance for bed mobility, transfers, toilet use and personal hygiene. He needed limited assistance for dressing. His balance was unsteady, and he had upper and lower extremity range of motion impairments on both sides. He used a walker or wheelchair for ambulation, and needed supervision and set-up help only for ambulation. He needed physical assistance for bathing. -There was no end-of-life prognosis and no hospice care. He was underweight at 72 inches tall and 139 pounds. -He rarely experienced pain, but moderate pain was present. -He was at risk but had no pressure injuries, ulcers or skin problems. He had pressure relieving devices on his bed and wheelchair. II. Record review A timeline of the resident's skin conditions, interdisciplinary team notes (IDT) and physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . These documents revealed the facility failed to consistently assess, monitor and document the condition of Resident #8's feet despite his history of diabetes and toe ulcers until 3/21/22, although wound clinic notes documented a superficial ulceration of the third digit, left foot a week earlier. The 3/21/22 nurses' note read the resident's toe was red, inflamed and tender. He was diagnosed with [CONDITION(S)] and antibiotics were started. The documents further revealed Resident #8 was taken to the wound clinic on 3/21/22; however, the facility did not consistently document and implement the wound physician's recommendations, revise the resident's care plan, or document specifics about resident education and follow-up when the resident frequently refused assessments and treatments. On 4/1/22, less than two months after admission, Resident #8 had a stage 4 pressure injury on his left foot, third digit, with bone exposed. On 4/20/22, the resident was diagnosed with pseudomonas infection to the wound and [CONDITION(S)], a bone infection. Resident #8 was hospitalized on [DATE] after a fall and change of condition and was readmitted to the facility on [DATE]. His toe was amputated on 4/28/22 while he was hospitalized . A. Skin condition on admission - failure to comprehensively assess and respond to resident risk factors for skin breakdown. A timeline of the resident's skin conditions was provided the afternoon of 5/19/22 by the staff development coordinator (SDC)/wound nurse. It read that on 11/19/21, prior to admission, Resident #8 had a wound to the left third digit diagnosed as a hyperkeratotic lesion. The accompanying 11/29/21 podiatry note documented the resident presented to the wound care clinic for evaluation of prior foot amputations and diabetic foot care. Patient reports that he has been diabetic for years. He notes that the toe amputations happened for gangrene and were performed by a physician in a nearby city . At the time, the resident had right transmetatarsal (all or part of the forefoot) amputation and left 1st and 2nd digit amputations, hammertoe deformities to remaining digits left. -See below; in an interview on 5/19/22 at 3:09 p.m., the SDC/wound nurse agreed Resident #8 was admitted with the hyperkeratotic lesion to his left 3rd digit, and described it as a stage 2, open and red. On 2/9/22, per admission progress notes by registered nurse (RN) #3, the resident was a new admit with a medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He is insulin dependent. He is A&O (alert and oriented) X2. On 2/10/22, the registered dietitian documented the resident had amputation of toes on bilateral feet, his skin was free from breakdown, and his Braden score was good at 22. (A score of 19-22 equals no risk.) On 2/10/22, a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/11/22 a nursing note documented an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply small amount in clean, dry socks daily. The resident's response was documented as, I don't need it anymore. On 2/11/22, a nursing evaluation summary documented Resident #8 can be resistive to cares, and refuses occasionally, wear nonskid footwear when up OOB (out of bed). The summary included no documentation of the resident's feet or skin. Notwithstanding the resident's history, risks for skin breakdown and order for Miconazole (antifungal) powder, record review revealed no documentation of a full skin assessment on admission and no documentation regarding the condition of the resident's feet. Further, notwithstanding the MDS assessment above that identified the resident at risk for pressure injury, record review revealed no care plan addressing the resident's pressure injury risk. B. Skin condition following admission - failure to identify skin breakdown on resident's left foot, third digit. 1. 2/16 to 3/1/22 On 2/16, 2/23 and 3/1/22, facility skin assessments documented no new wounds or changes per the SDC's timeline notes. However, on 2/25/22, a wound/podiatry clinic note documented the resident was seen for diabetic foot care. He presents to clinic in his diabetic shoes and inserts. Left 3rd digit PIPJ (proximal interphalangeal joint or middle knuckle) superficial ulceration measuring 0.6x0.6x0.1cm with a granular base and no surrounding [CONDITION(S)] or [CONDITION(S)] or drainage, stable eschars to excoriations to right dorsal foot. Debrided nonviable tissue from ulceration and cleansed with carraklenz and dressed with [MEDICATION(S)] and a bandage. Dispensed a small surgical shoe for the left foot. Order placed for new shoes with neoprene topcovers. Order placed for sensifeet compression socks as I wonder if his nonslip socks are bunching in his shoe and causing problems. Patient to RTC (return to clinic) in approx. 2 weeks for follow up. -There was no documentation that anyone from the facility accompanied the resident to this appointment to document the above orders and recommendations. -This first documentation of a wound to the resident's left third toe was not included in the documentation provided by the facility in the SDC's timeline. There was no nursing note regarding the resident's 2/25/22 clinic visit. -Although a care plan was opened on 3/14/22 that read the resident had open areas to his left 3rd digit and left 1st metatarsal, there was no care plan update regarding the above interventions, recommendations/orders. There was no care plan for staff on how to address the resident's diabetic foot care. Rather, the 3/14/22 interventions included to off load heels as needed, wheelchair cushion, encourage good nutrition and hydration, keep fingernails short and skin clean and dry; use lotion on dry skin as needed. -On 3/3/22, a nurse practitioner (NP) note documented the resident was seen, dictation to follow. However, there was no corresponding NP note or evidence of concerns about the resident's wound. -On 3/5/22, nursing notes documented the resident was given acetaminophen for right foot pain. On 3/6/22, nursing notes documented the resident was given acetaminophen for left foot pain. However, there was no documentation on either date that the resident's feet were assessed after he complained of pain. 2. 3/15/22 to 3/18/22 On 3/15/22, per SDC timeline notes, the skin assessment documented no new wounds or changes. However, three days later, on 3/18/22, per wound care clinic notes, there was a follow up visit for the ulcer to the resident's left digit. The wound assessment revealed the resident's left 3rd digit PIPJ full thickness ulceration measuring 0.7x1x0.1cm with a granular base probing very close to bone with mild surrounding [CONDITION(S)] and [CONDITION(S)] but no significant drainage. The exam findings were explained to the resident, the ulceration was cleansed with carraklenz and dressed with puracol and a bandage the resident received follow up on the ulcer to his left 3rd digit. The clinic notes also read the resident presented to the clinic in his new diabetic shoes and inserts, but not wearing his surgical shoe prior to getting his new shoes with soft material over the toes. (See 2/25/22 wound clinic note above that read a small surgical shoe was dispensed for the left foot.) Orders were placed for [MEDICATION(S)] 100mg Q (every) 12 hours for 14 days, order placed for bil(ateral) foot Xrays, patient to RTC in 1 week for follow up. -While the care plan was updated to read oral antibiotics to treat wounds on left foot, there were no directions to staff on how to protect the resident's feet and what type of footwear he needed. -There was no documentation that nursing staff had accompanied the resident to the appointment to ensure the orders were implemented. There was no corresponding nursing note in the resident's chart on 3/18/22 other than the order for [MEDICATION(S)], documented by the nurse as given for mild pain related to type 2 diabetes mellitus. A potential drug interaction was flagged due to the resident's [MEDICATION(S)] sulfate (iron) which might decrease the antimicrobial effectiveness of [MEDICATION(S)]. C. Further decline in resident's third toe, left foot pressure injury - failure by facility to accurately document injury, and monitor and treat the injury as ordered, contributing to stage 4 wound with infection, pain and [CONDITION(S)]. 1. 3/21/22 On 3/21/22 the SDC timeline notes documented a wound to the left toe, received antibiotics for [CONDITION(S)], red, inflamed, tender, [MEDICATION(S)] 100 mg BID (twice daily). The corresponding nurses' note documented infection on his Rt. (right) toes. He is on [MEDICATION(S)] for his infection. Wound is not draining or has odor, but is red and inflamed. It is tender to touch. Ongoing assessment continues. -This was the first wound note for Resident #8, almost a month after it was diagnosed at the wound clinic, and three days after it was identified as a full thickness wound at the wound clinic. The nursing note referred to the wrong foot, as the SDC documented in her timeline notes says right, but should be left. The right foot wound was also documented on 3/23 and 3/24/22. -There was no evidence of sizing or staging of the wound, IDT review, change of condition note, or conversation with the resident's physician other than the new antibiotic order. 2. 3/25/22 The 3/25/22 wound clinic visit notes revealed the resident was not wearing a dressing, was not accompanied by nursing staff to the appointment, and clinic orders were not fully followed. According to the clinic notes, bone was exposed and amputation was likely. On 3/25/22, the wound clinic note documented the resident presents to clinic in his new diabetic shoes and inserts. There is no dressing on his toe and the order from the prior note did not make it into his orders for his facility. -The assessment documented full thickness ulceration measuring 0.4x0.8x0.1cm with bone exposed and granular borders and mild surrounding [CONDITION(S)] and [CONDITION(S)] but minimal sanguinous drainage on sock. -Evaluated patient and explained exam findings to patient. Cleansed ulceration with carraklenz and dressed with puracol and a bandage and wrote orders for facility to do the same MWF and driver will make sure the director of nursing is aware and that the wound care orders make it into (stet). It looks like he is on [MEDICATION(S)] per his orders for his facility. Reviewed results of Xrays but explained that there is bone exposed and he will likely need the toe amputated in the future. Patient to RTC in 1 week for follow up. In contrast to the above orders, the SDC timeline on 3/25/22 read, new order for cleansing, [MEDICATION(S)], dry dressing. It was not until three days later, on 3/28/22, that a nurses' note read, Cleanse ulcer to left foot on Monday/Wednesday/Friday and dress with puracol plus with silver. Cover with D/D (dry dressing) one time a day every Mon., Wed., Fri. In contrast to the wound clinic physician note above, the SDC timeline for 3/27, 3/28, and 3/30/22 documented, wound note, healing. 3. 4/1/22 to 4/7/22. Worsening pressure wound - bone exposed, increased [CONDITION(S)] and [CONDITION(S)], small amount of purulent looking drainage and pain On 4/1/22, the SDC timeline documented a wound clinic/podiatrist appointment revealed bone exposed, 1.3x1.2 cm. New order for Dankins, [MEDICATION(S)], gauze. Continue [MEDICATION(S)] 100mg BID. -A corresponding nurses' note documented, Resident went to podiatry appointment this day. New orders: 1. Continue [MEDICATION(S)] for 2 more weeks (new end date 4/15/22). 2. Clean left foot wounds with Dankin daily and dress left 3rd toe with [MEDICATION(S)] and left 1st metatarsal head with puracel and secure with tape and gauze. Resident noted to have had a wound culture at appointment. 3. Appointment for CTA with runoff (computed tomography [MEDICATION(S)] for imaging of arteries and blood flow to lower extremities) on 4/6/22 at 130pm. 4. RTC (return to clinic) 1 week for follow up. MD also noted resident will have to have toes amputated in near future. Resident aware and returned upset. Noted. The 4/1/22 wound clinic note documented a superficial ulcer to the distal left 1st metatarsal head measures 0.6 x1.1x0.1cm and full thickness ulcer with exposed bone to 3rd digit PIPJ measuring 1.3x1.2cm with increased [CONDITION(S)] and [CONDITION(S)] and small amount of purulent looking drainage that was sent for culture, HPK sub 5th metatarsal head left, no ulcerations to the right foot. -The plan was: evaluated patient and explained exam findings to patient. Cleansed ulceration with dakins and cultured drainage from 3rd toe, dressed left 3rd digit with [MEDICATION(S)] and left 1st metatarsal head with puracol plus and secured with gauze and tape with puracol and a bandage. Order placed for 2 more weeks of [MEDICATION(S)] and will change antibiotics if needed based on culture. He will have CTA with runoff on 4/6 and will have more information regarding the plan next week depending on how that looks. Patient will need amputation of his remaining 3 toes and possible tendoachilles lengthening at that time. Patient to RTC in 1 week for follow up. The SDC timeline documented the 4/1/22 appointment, the orders were documented on 4/2/22, a wound note on 4/6/22 documented 1.0cm, and the wound clinic was called for orders on 4/7/22 resident refusing to change except on baths. On 4/8/22, dressing orders to leave dressing until seen at (wound clinic) podiatry. Corresponding nurses' notes revealed there was nothing documented about the resident's toe wound until 4/6/22 when RN #3 documented the resident had a bath and wound care to left foot completed after his bath. Assessment as follows: third toe on the Lt foot has a stage 2; 1 cm, open wound; there is bloody drainage which stopped after cleaning, surrounding tissue is pink, warm, without odor. He has pedal pulses bilaterally, CMS (circulation, motor, sensory) checks (+) on foot and remaining toes, CRT (capillary refill test) < 3 sec on remaining toes as well. Wound is clean, and new dressing applied. It is tender to touch, and resident verbalized that he only wants his dressing changed on his bath days. He is following the wound clinic every Friday for his foot wound. -In contrast to the nurses' assessment 4/6/22, the wound clinic notes documented since 3/18/22 that the pressure injury on the resident's third digit, left foot was a full thickness ulcer [stage 4]. Further, RN #3 documented the wound as a stage 2, although the wound physician documented that bone was exposed. The 4/7/22 physician communication note by RN #3 documented Lt. (left) toes and the wound care/orders. Called (wound clinic) and requested podiatry and spoke with (physician) who is following (Resident #8). (Physician) said she has known about his wound on his Lt. third toe since 2/25/22. She has specific orders for his wound care for M,W,F every week. He follows the podiatry every Friday. Dressing change on 4/6/22 as follows (described as above). C/o (complained of) pain and tenderness with palpation/touch. Recommendations: He is to follow D.O. (doctor orders) for care, eat and drink to maintain his nutrition, monitor his DM II. He has an appt every Friday. (Wound care physician) sent over notes which were given to the wound nurse (SDC). Podiatry phone number (documented). 4. On 4/8/22 - bone excision - failure to accurately document status of pressure wound On 4/8/22, wound clinic notes documented the resident presented to the clinic for follow up on the ulcer to his left 3rd digit with his driver. The wound(s) were assessed as follows: superficial ulcer to distal left 1st metatarsal head measures 0.7 X 1 x0.1 cm. Full thickness [stage 4] ulcer with entire head of proximal phalanx exposed to the left 3rd digit with reduced [CONDITION(S)] and [CONDITION(S)] and small amount of purulent looking drainage, HPK sub 5th metatarsal head left. -The physician explained to Resident #8 that the bone is exposed and I would like to send a specimen in for a culture in attempts to best target the bacteria growing and also to reduce the amount of bacteria in the wound in attempts to avoid needing to amputate any more toes. He says to do whatever I think. Cleansed ulcerations with carraklenz and cut piece of exposed bone off and sent for culture and flushed site with dakins and applied sorbact inside of wound and dressed with kling and secured with tape, swabbed macerated interspaces with [MEDICATION(S)], dressed 1st metatarsal head ulcer with puracol plus and [MEDICATION(S)]. -Order placed for the dressing to be left clean, dry, and intact until his next visit on Wednesday next week. Driver is aware of the vascular consult and they are expecting a call today or early next week to schedule. Explained to patient why I want him to see the vascular doctors to give him the best chance of healing. Asked if he knew what state his emergency contact on his contact information lived in - he does not know who he would have listed. Patient to RTC next week for follow up and will get noninvasive labs that day as well. On 4/8/22 at 4:09 p.m. the SDC/wound nurse documented, Visited with resident on a couple of occasions regarding his wound to toe(s) He goes to the podiatrist every Friday, notes received. Res(ident) is not allowing the nurses to change the dressing to the toe every day and only on bath days. This nurse attempted to change dressing on 4/7 to get a picture of it and check progress, but resident did not want me to do that. He stated 'I will be going to the podiatrist on Friday.' Dressing was intact, not saturated and secured Res did not c/o pain to the area. Examined the heel and the other toes, no apparent injuries. Podiatrist has n/o (new order) today, do not change dressing and she will see him on Wed of next week. She is aware that res does not want us to change dressing. However, there was no documentation in the resident's facility record that the resident had a full thickness [stage 4] pressure ulcer with bone exposed, had a bone excision at the wound clinic that day, or that amputation was being discussed. 5. 4/10/22 - failure to report new signs of further decline in wound On 4/10/22 at 1:44 p.m., a nurse documented L. toes bleeding onto sock this shift, sock changed, dressing reinforced per last (wound clinic) note. Res encouraged not to wear shoes bc (because) of dressing reinforcement not fitting into shoe comfortably but non-skid socks and to be careful not to stub toes. Odor noted. Res did not c/o pain or discomfort, area around dressings normal temp. & color. Although bleeding and odor were noted by the nurse, there was no documentation this observation and concern was reported to the physician, the SDC/wound care nurse or the director of nursing. There was no evidence of any IDT meetings since the resident's wound was first observed. There was no documentation or care plan update regarding how the resident's foot would be protected from further injury. 6. 4/13/22 - wound clinic visit - second antibiotic treatment On 4/13/22 at 10:17 a.m., the SDC/wound nurse documented, Res is going to podiatrist at the (wound clinic) today for wound dressing changes. Orders are not to change dressing until seen in office. Will attempt to get a picture of the wound while at (wound clinic) today. Res is not c/o pain to the toes at this time and dressing is in place. This was only the second note from the SDC/wound nurse for Resident #8, and the first time she accompanied him to a wound clinic appointment. On 4/13/22 the wound physician documented the resident presented for follow up on the ulcer to his left 3rd digit with his driver and the wound nurse from (the facility). He will have his noninvasive vascular studies today and will see vascular surgery on 5/5. He was pleasant and less agitated today. The assessment revealed the superficial ulcer to distal left 1st metatarsal head measures 1.2x0.2.0.1cm, full thickness ulcer to the left 3rd digit measuring 0.7x1x1 with reduced [CONDITION(S)] and [CONDITION(S)] and sanguinous drainage, HPK sub 5th metatarsal head left, no ulcerations to the right foot. The ulcer left 3rd digit had [CONDITION(S)] and [CONDITION(S)]. The ulcerations were cleansed with carraklenz and cultured left 3rd digit, dressed both ulcerations with puracol plus, [MEDICATION(S)], kling, and tape and facility to do the same M/W/F. Order placed for [MEDICATION(S)] x 14 days. Patient to RTC in 1 week for follow up. On 4/14/22 at 9:30 a.m., RN #3 documented the resident had an infection on his LLE (left lower extremity) on his toes. He has [CONDITION(S)] and recovering from PNA (pneumonia). He is following the wound clinic/podiatry every week and the facility wound nurse is following resident as well. He was started on ABX (antibiotic) therapy as follows: he is finishing [MEDICATION(S)] and started on [MEDICATION(S)]. Orders per (wound physician). On 4/14/22 at 11:22 a.m., the MDS coordinator documented an IDT note, Weekly weight and skin meeting with IDT, please see attached notes, care plan updated. However, there were no attached notes. This was the first IDT meeting mentioned in Resident #8's nursing notes. On 4/14/22 at 11:43 a.m., the SDC/wound nurse documented Resident #8 had two wounds to his left foot that are being seen by the (wound clinic) podiatrist. Wound #1 to the left foot 3rd toe started on 2/25/22 and has improved. Wound measures 1.8x2.3x1.0, is red and no s/sx of infection this week. (Wound physician) did a wound culture this week and awaiting results. (Wound physician) did a bone biopsy and he has a dx of [CONDITION(S)]. New dressing orders for Mon, Wed, Fri. Wound #2 to the metatarsal is unstageable 0.9x0.7x0cm and has been ongoing for greater than 6 months, per the (wound physician). New orders for dressing care. Start [MEDICATION(S)] BID x 60 days. Res has DM and has had chronic foot ulcers and wounds prior to admission treated at the (wound clinic) and resulted in amputation. Res is not always cooperative with dressing changes and foot care. Educated on the risk of amputation when not following recommendation for foot care by the (wound clinic) podiatrist and nursing. On 4/14/22 at 12:00 p.m. the registered dietitian (RD) documented the resident had a stage 4 wound to his left 3rd digit and an unstageable wound to his left foot 1st metatarsal. His weight was 145.8# which was improved since admission. Intakes were good at 75-100% at each meal; he also receives Glucerna BID with good acceptance at 85%. He has increased protein needs of approximately 92-99g/day. Current intakes are adequate to meet his needs but will add Arginaide Extra BID to provide l-[MEDICATION(S)], zinc and vitamin C to promote healing. Care plan updated. On 4/14/22 at 12:04 p.m., the social services director documented, Resident is historically resistant to assistance with cares and self neglect. Resident refuses to follow recommendations of physician and other professionals. Will continue to educate and support resident on potential effects of self neglect. On 4/19/22 at 3:11 p.m., RN #3 documented the resident wouldn't allow nurse to assess his foot this shift although he is following (wound clinic) every Wednesday. Surrounding skin on his Lt. foot is warm, pink, without [CONDITION(S)] and intact. Remains on ABX therapy without s/sx of adverse reaction. However, review of the resident's medical record did not reveal how the resident was specifically educated. There was documentation in the record about occasional refusals of various medications and procedures, but frequent refusals of dressing changes or wound care were not documented. Resident #8's MDS assessments did not document refusals of care and there were no interventions on his care plan on how to minimize his refusals. 8. 4/20/22 - further decline in condition On 4/20/22 the resident was seen at the wound clinic with his driver. The wound physician documented, He had the noninvasive vascular studies this morning. He will see vascular surgery on 5/5. The superficial ulcer to the distal left 1st metatarsal head measures 1.3x0.3x0.1cm, full thickness ulcer to the left 3rd digit measuring 0.45x0.7x1cm with dramatically reduced [CONDITION(S)] and [CONDITION(S)] and no drainage, HPK sub 5th metatarsal head left. The plan included: Order placed for labs as requested by (primary care physician). Cleansed ulcerations with carraklenz and debrided a small amount of nonviable tissue and cultured left 3rd digit, dressed both ulcerations with puracol plus, [MEDICATION(S)], kling, and tape and facility to do the same M/W/F. Order placed for ciproflaxacin x 14 days. Patient to RTC in 1 week for follow up. A 4/20/22 communication with physician note documented, Provide IV (intravenous) fluid due to elevated K+ (potassium) level. (The primary care physician) called the medical power of attorney and they discussed the need for the IV. It was e

Based on record review and interviews, the facility failed to ensure residents were free from abuse, neglect and exploitation for three (#1, #2, and #3) out of four residents reviewed for abuse out of 12 sample residents. Specifically, the facility failed to ensure Resident #1 was free from physical abuse from two other residents on two separate occasions. On 3/16/22, Resident #1 was hit on the head by Resident #2. On 3/17/22, Resident #1 was hit in the knee with a chair by Resident #3. Resident #1, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #4, identified as a friend to Resident #1, stood guard outside the room to provide Resident #1 protection from other residents. The facility substantiated both allegations of physical abuse against Resident #1. Findings include: I. Facility policy and procedure The Abuse Prevention Program policy, last reviewed December 2016, was provided by the facility on 3/21/22 by the nursing home administrator (NHA). The policy read in part, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.This includes but is not limited to freedom from corpal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and phsical and chemical restraints not required to treat the resident's symptoms. As part of the resident abuse prevention, the administration will: Protect our residents from abuse by anyone including but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors and any other individual .Require Staff training orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior .Identify and assess all possible incidences of abuse; investigate and Report any allegations of abuse within time frames as required by federal requirements; protect residents during abuse investigations; establish and implement a QAPI review and analysis of abuse incidences; and implement changes to prevent future occurrences of abuse . II. Resident #1 A. Resident status Resident #1, age 72, was admitted on [DATE] and readmitted on [DATE]. According to the March 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/4/22 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. According to the MDS assessment, the resident required limited physical assistance of one person with bed mobility transfers and dressing. She required supervision of one person with personal hygiene and locomotion on and off the unit. Resident #1 needed extensive assistance from one person for toileting. The MDS identified the resident did not have behaviors or rejections of care. The impaired cognition care plan, last revised on 8/26/2020, identified Resident #1 was developmentally delayed. According to the care plan, staff should communicate with her regarding her capabilities and needs. -The care plan for Resident #1 did not reveal the resident was care planned as an at risk adult for potential or actual abuse. The care plan did not direct staff to provide additional support after incidents of potential or actual abuse. The care plan did not identify how staff should address Resident #1 safety concerns or fearfulness after incidents of potential or actual abuse. B. Resident observation and interview Resident #4 was observed outside the room of Resident #1 on 3/21/22 at 3:15 p.m. Resident #4 said he was protecting Resident #1 from other residents. He said Resident #1 was hit with a chair. The resident pointed to a green metal rimmed chair two doors down from the room of Resident #1. Resident #4 said he did not feel his safety was at risk by trying to protect Resident #1 from other residents. Resident #1 was interviewed on 3/21/22 at 3:17 p.m. She said Resident #4 was her friend and he was standing guard at her door because she was attacked by a male resident who was new to the facility. Resident #1 said the other resident (Resident #3) threw a napkin at her and then picked up a green chair from the hallway, entered her room, and hit her knee with the chair. Resident #1 lifted up her pant leg to reveal a small bruise above her knee and an eraser size skinned mark under the bruise. The resident said she obtained both the bruise and the small skinned mark when the male resident hit her with the chair. Resident #1 said she no longer felt safe in her own room. She said staff have not spoken with her after she was hit with a chair regarding safety concerns. She said Resident #4 was helping protect her safety. She said she should be able to feel safe in her room and in the facility. Resident #1 did not identify additional incidents with other residents during the interview. III. Incident on 3/16/22 A. Record review The 3/16/22 internal investigation report was reviewed with the director of nursing (DON). The internal investigation report pertained to the incident on 3/16/22 at 2:10 p.m. According to the investigation report, Resident #1 was hit on the head by another resident when he attempted to take an item off the nursing cart. According to the investigation, Resident #1 said the resident (Resident #2) was messing with something on the cart. Resident #1 said she told him to stop and that was when he hit her head with an open hand. According to the incident report, Resident #1 was assessed for injury, appropriate parties were notified and vitals were taken. -The report did not indicate neurological checks were started after the resident was hit on the head. The 3/16/22 at 2:10 p.m. change of condition evaluation summary for providers read there was no changes to Resident #1's mental or functional status. The summary documented the resident's vitals, diagnosis, mental and functional status, recommendations and primary care provider feedback. According to the summary, there was no changes to Resident #1's mental or functional status and the no new recommendations from the provider. Under nursing observations, evaluation and recommendations, the summary read: Praised resident for not striking back. -The change of condition summary did not include the reason the change of condition summary was prompted or information leading up to why the facility praised Resident #1 for not striking back. No additional information was provided on the summary. The 3/16/22 eInteract change of condition evaluation form identified the above information in the evaluation summary however also included the provider was notified of the change of condition on 3/16/22 at 2:30 a.m. and Resident #1's family was notified on 3/17/22 at 10:25 a.m. -No additional pertinent information was documented in the evaluation. Review of the medical record of Resident #1 and #2 did not reveal additional information pertaining to the incident between Resident #1 and Resident #2 was documented. B. Resident #2 1. Resident status Resident #2, age 85, was admitted on [DATE]. According to the March 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was a new admission to the facility. His MDS assessment had not been completed for review. 2. Record review The cognition care plan, initiated on 3/15/22, indicated Resident #2 had an impaired cognitive function related to dementia and impaired thought process. -No additional information was provided in the cognition care plan. The behavior care plan, initiated on 3/17/22, indicated Resident #2 could become physically and/or verbally aggressive towards staff and others due to poor impulse control. The elopement/wanderer care plan, initiated on 3/18/22, identified Resident #2 was at risk for wandering related to his dementia. According to the care plan the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The activities of daily living (ADL) care plan, initiated on 3/15/22, identified Resident #2 had limitations in his ability to perform his ADLs related to dementia and limited mobility. The ADL care plan indicated he had deformities to his right hand. According to the care plan, he needed supervision with bed mobility. He needed supervision to limited assistance with dressing, and personal hygiene. Resident #1 required limited assistance of one person for toileting. The impaired mobility care plan, initiated on 3/22/22, identified Resident #1 had impaired mobility due to balance and impulse control. He needed supervision to limited assistance with transfers. According to the care plan, the resident was able to ambulate short distances without his wheelchair. 3. Observations Resident #2 was observed throughout the 3/21/22 and 3/22/22 survey period wandering up and down the halls and attempting to exit seek. Staff was observed to redirect the resident. IV. Incident on 3/17/22 A. Record review The 3/17/22 pain data collection assessment indicated Resident #1 reported pain to her left knee on 3/17/22 at 7:15 p.m. According to the pain data collection, she had current pain from her bad left knee with a chair that was pushed into her lap and knee. The resident identified the pain as aching and tender. The behavior note for Resident #3 at 3/17/22 at 7:15 p.m. read Resident #3 propelled his wheelchair to the doorway of another resident (Resident #1). Resident #3 threw a napkin at Resident #1 and then proceeded to push a chair from the hallway into Resident #1 (as she sat in her room doorway), hitting her lap and left knee with chair. According to the note, the hallway chair was removed from the knee of Resident #1 and Resident #2 was immediately removed from the proximity of Resident #1. The 3/18/22 at 6:23 a.m. event note for Resident #2 read Resident #2 showed physical aggression towards another resident (Resident #1). According to the note, Resident #2 had shown aggressive behavior since his admission. The 3/18/22 at 2:20 a.m. nurse note identified Resident #3 threw a napkin at Resident #1 and then proceeded to push a chair from the hallway into Resident's #1 lap and left knee on 3/17/22 at 7:15 p.m. Resident #1 reported a pain level of six out 10 (with 10 being the worst pain on the scale). There was no immediate bruising at the time of the incident. According to the note, the resident was in tears as a result of pain and the physical aggression towards her. Resident #1 was provided Tylenol for the pain. On follow up, Resident #1 reported no pain relief from the medication. A small bruise was observed on the knee of Resident #1 and she reported 10 out of 10 as her pain level. A warm towel was applied to her knee and Tylenol at 650 milligrams (mg) was administered. The 3/18/22 internal investigation report file was reviewed with the DON on 3/21/22 at 3:43 p.m. The file indicated between 3/16/22 and 3/18/22, five staff members were interviewed for the abuse investigation. The staff interviews were conducted in response to both the 3/16/22 incident with Resident #1 and Resident #2 and the 3/17/22 incident with Resident #1 and Resident #3. The staff chosen for the interviews included a dietary cook, a dietary aide and three certified nursing assistants (CNA). Review of the staff interviews revealed staff were asked if they felt safe and felt the residents were safe. The staff was also asked if they were aware if anyone was touched inappropriately. The staff were not asked if they had routine interactions with Resident #1, Resident #2 or Resident #3. The staff chosen to be interviewed were not asked if they had specific concerns or information pertaining to either witnessed behaviors or actions of Resident #2 an Resident #3 that could be relevant to the investigation and/or future abuse prevention. The review of the staff interviews identified four out five of the staff stated they felt the residents and themselves were safe, and they were not aware of anyone inappropriately touched. According to one staff interview, CNA #1 stated she would feel safer if there were more staff at night. The review of the resident interviews identified eight residents were interviewed between 3/16/22 and 3/18/22 in response to both the 3/16/22 incident with Resident #1 and Resident #2 and the 3/17/22 incident with Resident #1 and Resident #3. Six out of the eight chosen residents interviewed for the abuse investigation indicated they felt safe and have not been inappropriately touched. Two of the eight residents expressed a concern or awareness of safety concerns impacting residents. Resident #5 stated in the interview that he has not seen (safety concerns) but has heard about it from other people. Resident #6 was identified as a witness to the incident on 3/16/22 between Resident #1 and Resident #2. According to the Resident #6, he stated a female resident was slapped on the head pretty hard. The investigation interview of Resident #6 did not indicate he was asked additional follow questions as a witness. The review of the investigation file with the DON, did not identify a separate witness statement initiated for Resident #6. The 3/21/22 Resident #1 investigation interview was reviewed with the DON on 3/22/22 at 9:50 a.m. regarding the 3/17/22 incident with Resident #3. The investigation interview with Resident #1 was conducted four days after the event. According to the interview, Resident #1 said she felt mostly safe but did not want (Resident #3) to enter her room and move the chair into her knee again. The resident requested all chairs to be moved away from her room (which the facility had done, see interviews below). B. Resident #3 Resident #3, age 81 , was admitted on [DATE]. According to the March 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/16/22 minimum data set (MDS) assessment indicated Resident #3's cognition was severely impaired and a brief interview for mental status could not be completed. The MDS identified the resident had an impaired short and long term memory deficit with inattention, disorganized thinking and an altered level of consciousness. Resident #3 had short tempered behaviors and was easily annoyed. The MDS identified the resident had delusions with additional physical and verbal behaviors directed towards others. According to the MDS assessment, the resident required limited physical assistance of one person with locomotion, Resident #3 needed extensive assistance from two or more persons for toileting, dressing, transfers and bed mobility. The mood and behavior care plan, initiated on 3/18/22, indicated Resident #3 had physical and verbal aggression towards staff and other residents. According to the care plan, he needed one-on-one supervision. V. Staff interview The nursing administrator (NHA) was interviewed on 3/21/22 at 3:33 p.m. She said she just started at the facility. The NHA said she had only been at the facility for the past four days but was aware of two incidents involving Resident #1 with two other male residents over the past week. The NHA said she did not know all the details but was under the understanding that Resident #1 was hit on top of her head by a resident and then the following day was bumped in the knee by another resident. She said the director of nursing (DON) conducted the investigations. The DON was interviewed on 3/21/22 at 3:43 p.m. The DON said Resident #1 was the victim in a incident on 3/16/22 with Resident #2 and a separate incident with Resident #3. He said both residents were new to the facility. He said Resident #1 had increased behaviors such as wandering leading up to the 3/16/22 incident. The DON said the first incident occurred when Resident #2 entered the room of Resident #1. Resident #2 attempted to pick up a gait belt that had fallen on the floor. Resident #1 argued with Resident #2 regarding the gait belt. Resident #2 then hit her with his fist on top of Resident #1's head. The DON said the following day on 3/17/22, Resident #3 threw a napkin at Resident #1 when she was sitting in her doorway. Resident #1 and Resident #3 then exchanged words. Resident #3 then proceeded to push a chair into the knee of Resident #1. -At 4:06 p.m. the NHA joined the interview with the DON. The DON said management conducted interviews with staff and eight residents. He said the general consensus was staff and residents felt safe. Resident #2 was promptly moved to a room closer to the nurses' station. The DON said to increase resident safety, a one-to-one sitter was added for weekend supervision of Resident #2 and a medication review was conducted by his physician and [MEDICATION(S)] was ordered for Resident #2. The DON said the providers, the police, the family and the ombudsman were all notified after the incident. The DON one set of staff and the residents interviews were conducted because the incidents were on back to back days. He said Resident #1 was not interviewed after the second incident on 3/17/22 but the investigation was not finalized yet. The DON said he was not aware the resident felt she no longer felt unsafe in the facility. The second incident was reviewed with the DON and the NHA. The DON said Resident #3 was admitted a week prior the 3/17/22 incident involving Resident #1. He said Resident #1 was assessed for injury and the facility removed the green chair used in the incident from the hallway near her room. Lab work was conducted on Resident #3 and he was seen by his physician. There were no new medications changes made. Staff were instructed to keep an extra eye on Resident #3. His room was not changed because he already resided near the nurses' station. The DON said a one-on-one staff supervision was not implemented for Resident #3. He said Resident #2 had a one-to-one supervision over the weekend because he exhibited more aggressive behaviors towards staff following the 3/16/22 incident. The DON was interviewed on 3/22/22 at 4:05 p.m. The medical record was reviewed with DON. The DON confirmed there was limited documentation and details of the incident in the medical record for Resident #1 and Resident #2, after the 3/16/22 incident. The DON said a progress note was not conducted for Resident #1 or Resident #2 which could provide tracking and details of the incident immediately following the event. The progress note could have also served as additional communication to staff of Resident #1's behaviors. The DON said the facility needed to continue to improve their documentation process regarding details. He said the facility had a recent change in companies which could have also added to the charting confusion as staff continue to learn the new system. The DON said the facility would provide the staff with new documentation training right away to ensure all needed documentation was in place. The DON and the NHA were interviewed on 3/22/22 at 9:50 p.m. Staff and resident investigation interviews were reviewed with the DON and the NHA. The DON said the staff and residents interviews could have been more in depth and expanded, asking additional follow up questions to any addressed staff and resident concerns. The NHA said she was not sure why Resident #5 was interviewed related to his BIMS score at a three out of 15. She said the interviewer could have focused on another resident with increased cognitive status. The DON said he had not directly followed up with CNA #1 regarding her safety concerns at night but were aware of staffing concerns and continuing to try to improve. He said the facility continues to work with their corporate office on recruitment. He said they have ongoing postings to advertise for new staff and are working with the facility management for additional coverage during the evening and night shifts. The DON said more information or questions could have been asked of Resident #6 who witnessed the incident on 3/16/22. The DON said Resident #1 was interviewed after the 3/16/22 incident and she felt safe. He said he responded to the question of safety that she did not feel safe. The DON acknowledged the second incident of physical aggression towards her, a day apart, could have triggered feelings of not being safe in her room. The DON agreed that the 3/21/22 interview with Resident #1 could have been conducted directly following the 3/17/22 incident. The facility actions following the 3/16/22 incident were reviewed with the DON and the NHA. The DON said Resident #1 did not have swelling or a bump to her head after being hit by Resident #2. Resident #1 was monitored for pain for 72 hours. He said her vital signs were taken but her neurological checks were not. The DON said anytime there was a potential head injury should there have been neurological checks completed. He said would provide staff training on the steps after a resident had a potential head injury. The DON said the facility was continuing to monitor Resident #2 and would be implementing a restorative program with Resident #2. He said the resident was on a respite stay and would be discharging in a few weeks. Resident #2's wife was interviewed and she was able to offer additional interventions to help potentially decrease his behaviors such as hot chocolate and Tylenol. The DON said his pain has been monitored and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] The NHA said she would like the facility to create a relaxation area to assist with residents with dementia and expand upon their independent activity, identifying their past leisure interests in pursuit to decrease potential future behaviors with residents diagnosed with dementia. The events following the 3/17/22 incident between Resident #1 and Resident #3. The DON said he was informed of the incidents the following morning on 3/18/22. The DON said he nor other members of administration were informed of the allegation of potential abuse until the next day. He said he did not report the allegation of potential abuse until several hours later. He said he initiated the investigation right away on the morning of 3/18/22 but was not aware the allegation of abuse had to be reported to the State Agency within two hours when there was no substantial physical injury (Cross-reference F609, failure to report an allegation of physical abuse timely). The NHA said the facility substantiated physical abuse between Resident #1 and Resident #2 because there was a witness of the incident. The NHA said the facility substantiated physical abuse between Resident #1 and Resident #3 because there was evidence of the incident with a bruise to the Resident #1's knee. The DON said moving forward, he would create a resource folder that staff would have access to following an incident of potential abuse of a resident. He said he would include steps to take such as who and when to contact the appropriate parties and how to document the incident or allegation of abuse. The DON and the NHA said staff should have reported to him all potential allegations of abuse right away. The DON said he would also provide proper training of managers in the abuse training on what to look for after the incident and what to ask residents and staff. The DON said the facility would continue to focus on overall improvement. -No additional staff education was provided before survey exit on 3/22/22.

Based on observations, record review, and interviews, the facility failed to develop and implement appropriate quality assurance and performance improvement (QA/QAPI) plans of action to correct identified quality deficiencies, potentially affecting all the residents in the facility. Findings include: I. Failure to prevent repeat citations Cross-reference F641 (accuracy of assessments), F684 (quality of care), F695 (respiratory care), F761 (label/store drugs and biologicals), and F880 (infection prevention and control). These deficiencies were cited previously during a recertification survey ending 3/19/19. Although the facility corrected the deficiencies, based on the findings below, the facility had not maintained compliance with these regulatory requirements with the additional failures of resident rights/exercise of rights, advanced directives, free from abuse and neglect, activities of daily living (ADL) care provided for dependent residents, activities to meet the interests and needs of each resident, treatment and services to prevent/heal pressure ulcers, increase/prevent decrease in range of motion (ROM)/mobility, accident hazards, free from unnecessary [MEDICAL CONDITION] medications, kitchen sanitation, facility assessment, and QAPI. II. Failure to identify quality deficiencies and initiate effective action plans to correct Cross-reference F550, F578, F600, F641, F677, F679, F684, F686, F688, F689, F695, F758, F761, F812, F838, F867, and F880. The following deficiencies were cited on the recertification survey completed 12/16/19: -F550, resident rights/exercise of rights -F578, request/refuse/discontinue treatment; formulate advanced directives -F600, free from abuse and neglect -F641, accuracy of assessments -F677, ADL care provided for dependent residents -F679, activities meet interest/needs of each resident -F684, quality of care -F686, treatment/services to prevent/heal pressure ulcers -F688, increase/prevent decrease in ROM/mobility -F689, free of accident hazards/supervision/devices -F695, respiratory/[MEDICAL CONDITION] care and suctioning -F758, free from unnecessary [MEDICAL CONDITION] meds/PRN (as needed) use -F761, label/store drugs and biologicals -F812, food procurement, store/prepare/serve-sanitary -F838, facility assessment -F867, QAPI data improvement activities -F880, infection prevention and control III. Review of QA action plan/staff interview The nursing home administrator (NHA) and regional director of operations (RDO) were interviewed on 12/16/19 at 5:20 p.m. The NHA confirmed the QA committee met monthly, and included the department heads, medical director, and pharmacy consultant. Regarding accuracy of assessments, she said they had completed minimum data set (MDS) accuracy audits and identified issues that required corrections. However, they had done that a while ago, not recently. Regarding quality of care, the NHA said it had not been identified as a needed area to focus on. Regarding respiratory care and equipment, the NHA said they had been monitoring equipment like oxygen concentrators and tubing to ensure it was stored in a sanitary manner. She said the facility would now include the functional status and ensure the working condition of [MEDICAL CONDITION] (continuous positive airway pressure) machines. Regarding labeling and storage of medications, she said the facility had a QAPI in place to ensure items were labeled and dated properly. However, medications and vaccines were still undated when they were first opened. Regarding infection prevention and control, the NHA said that had been an ongoing quality assurance measure since their last recertification survey in (MONTH) 2019. However, handwashing and improper use of personal protective equipment (PPE) were still identified. Review of the facility's QAPI program, deficiencies cited during the recertification survey, and NHA interview, revealed the facility had identified and effectively addressed other quality deficiencies throughout the previous months. However, the committee had not effectively identified and developed action plans to address the quality deficiencies, including the repeat deficiencies, identified above.

Based on observations, record review and interviews, the facility failed to provide the required structures and processes to ensure four (#50, #36, #52 and #70) of four residents reviewed for abuse and neglect were free from neglect, out of 30 sample residents. Specifically, the facility failed to ensure residents were free from neglect by failing to: -Provide appropriate resident-centered care; -Ensure accurate and effective documentation and communication between all facility staff; -Maintain necessary medical equipment in working order; and -Provide timely emergent care in accordance with professional standards of practice. Findings include: I. Facility policy and procedure The Abuse, Neglect, and Exploitation Prohibition and Prevention Program policy and procedure, dated [DATE], was provided by the human resources coordinator (HRC) on [DATE] at 11:10 a.m., and included the following: The purpose of the policy were to provide a mechanism for prompt identification, investigation, and reporting of any allegation or complaint of abuse, neglect, or exploitation-whether made by a resident, family or staff member, visitor, or another person; Educate staff about state and federal regulations regarding reporting suspected abuse, neglect, and/or exploitation as well as any reasonable suspicion of a crime against a resident or other individual receiving care at a (corporation name) community, and comply with the Elder Justice Act, which requires the detection, prevention, and prosecution of elder abuse, neglect, and exploitation. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. Abuse also included the deprivation by an individual, including a caretaker, of goods or services that were necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. Neglect was a failure of the community, its employees, or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect may be intentional (such as withholding or omitting care) or unintentional (e.g., the caregiver should have known that care was needed, but it was not provided). Deprivation was a caretaker's failure to provide goods or services that were necessary to meet, maintain, and avoid harm to an individual's physical, mental, and psychological well-being. Self-neglect was an adult's inability, due to physical or mental impairment or diminished capacity, to perform essential self-care tasks, including obtaining essential food, clothing, shelter, and medical care; and obtaining goods and services necessary to maintain physical health, mental health, or general safety. Every resident had the right to be free from verbal, sexual, physical, and mental abuse; corporal punishment; neglect; exploitation; involuntary seclusion; and any physical or chemical restraint not required to treat the resident's medical symptoms or conditions. Each community was to take reasonable, appropriate steps to ensure that each resident was free from neglect by anyone, and to prevent cases of self-neglect of which the community had reasonable notice. Prompt, thorough investigations were conducted in response to complaints or allegations of abuse, neglect, and/or exploitation, and all proper and required notifications were made to the proper individuals and authorities according to applicable state and federal regulations. Residents and staff were protected during incident investigations by ensuring reports were made without fear of retaliation and that anonymous reports were investigated. The administrator was responsible for the oversight and implementation of the Abuse, Neglect, and Exploitation Prohibition and Prevention Program. A zero-tolerance policy with regard to abuse, neglect, exploitation, and misappropriation of resident property, along with reporting directions, was posted in the community. All employees were informed of their responsibility to immediately report any allegation of abuse, neglect, exploitation, mistreatment, and misappropriation of resident property to the community's administration for investigation, remediation, and reporting to the appropriate state agencies. The community maintains an abuse-prevention training/Elder Justice Act program for all new and existing staff and volunteers that is consistent with their expected roles. In-service attendance records were maintained in accordance with applicable law. In responding to any allegation of abuse, neglect, or exploitation of a resident, the first priority is to protect the resident and to prevent further potential abuse, neglect, or exploitation. In the event of physical abuse or neglect allegations, the director of nurses (DON) or designee immediately arranged for a physical examination of the resident. The time, date, and person completing the examination were recorded in the medical record. If there was a reasonable suspicion of a crime or injury, the police were notified. The resident was monitored for 72-hours post-allegation. All allegations of abuse, neglect, and exploitation were promptly investigated in accordance with (corporation's name) policy on conducting internal investigations. The administrator was ultimately responsible for initiating and overseeing the investigation process. If neglect was suspected, a determination was made as to what services were not provided and what physical harm, mental anguish, mental illness, or deterioration in the resident's mental or physical condition resulted. Neglect was also evaluated as a result of indifference, carelessness, or deliberate negligence. II. Resident #50 [NAME] Resident #50 status Resident #50, age 83, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The [DATE] minimum data set (MDS) assessment revealed the resident had short- and long-term memory problems, adequate vision, and clear speech. He required extensive assistance with bed mobility, transfers, and eating, and total assistance with dressing, toilet use, and personal hygiene. [MEDICAL CONDITION] behaviors included hallucinations and delusions that were present and he had verbal behavioral symptoms directed toward others that occurred one-to-three days. His symptoms did not interfere with his care and he had no rejection of care. He was always incontinent of urine and bowel. A trial of a toileting program had not been attempted and he was not currently on a toileting trial or program. B. Record review The care plan, initiated [DATE] and last revised [DATE] (over 11 months ago), identified limitations in his ability to perform activities of daily living (ADLs). The goal was the staff would assist him to maintain his functional status and decrease his risk for functional decline to perform and/or assist with completing his ADLs. The approaches included offer choices, explain all procedures, and do not rush. He required extensive assistance from staff for toilet use and was incontinent, to be checked and changed upon arising, before and after meals, at hour of sleep, and as needed. He required extensive assistance from staff for personal hygiene. C. Observations During continuous observation of Resident #50 on [DATE] from 4:23 p.m. to 5:20 p.m., the resident was heard moaning nearly continuously and he yelled out from his room multiple times. Statements heard from the hallway included: -I've got to go in there for a couple minutes. Oh! Oh! Oh! He said, I'm just warning everybody that I'm going in there and I will be in there for a couple minutes. -Is anybody going to be in there before I get in there? Is somebody going to be bothered by .inaudible . and he continued to moan loudly. -Resident #50 was heard moaning in his room, and the resident's roommate yelled, I've got to get the (expletive) out of here! No one responded to his yelling. -I'm going now! I'm going now, so don't pound on the door! and he continued to moan loudly. -Here I go! Don't anyone pound on the door for a while. He continued to moan. A total of 13 different staff members, which included the nursing home administrator (NHA), a nursing supervisor (NS), the staff development coordinator (SDC), a registered nurse (RN), a licensed practical nurse (LPN), a restorative certified nurse aide (RCNA), the business office manager (BOM), multiple certified nurse aides (CNA), and the maintenance director (MNTD) walked past his room without helping him. For 44 minutes, his bladder and toileting needs were not addressed while he was calling out for help. He was taken to the dining room without being offered the opportunity to use the restroom or change his incontinence brief. D. Staff interviews The director of nursing (DON), nursing home administrator (NHA), and regional director of health services (RDHS) were interviewed on [DATE] at 11:35 a.m. The NHA said moaning and calling out by residents could mean different things, depending on each resident. She stated, For some it would mean they were in pain or needed assistance. We have some who that is their behavior. She clarified some residents who had dementia repeatedly said things or moaned, and that was normal behavior for them. She said if a resident was moaning and calling out for help, the staff should absolutely respond by knocking on the door, announcing themselves, and finding out what they needed. The DON said neglect was Not meeting a need, but could also include not giving them a choice. She said in reference to using the bathroom, if a resident did not get that choice, staff should give them that choice to say no and stated, Give them an opportunity to help direct their independence or care. The NHA said neglect was not meeting the needs of the person you were caring for by ignoring the need for care, not providing them with food, not getting them medical treatment, or not giving them any social interaction. The observations on the evening of [DATE] were shared with them. The NHA said Resident #50 was a check and change. The DON said that was typical behavior for him and stated, Sometimes he is herding cows and he will say, 'shut the (expletive) gate,' and it is repetitive and continuous. We should be documenting it as a behavior. She explained they had several different interventions for him that were sometimes effective. She said he moaned constantly all day and stated, If he is quiet, that is the exception. The DON said they had not been able to figure out why he was moaning and said sometimes he did not know why he was doing it. She looked in the computer to see if any mental health evaluations had been completed, and confirmed he had not been evaluated since (YEAR). The NHA agreed Resident #51's moaning meant he had an unmet need and explained he was challenging because he was unable to tell the staff what was wrong. She said staff routinely went through the list of potential needs including if he was in pain, needed toileting, if he was tired, cold, or hot. Because the resident said the words, bathroom, Go! Go! Go! and I'll be in the toilet, a reasonable person would be able to conclude Resident #50 needed to use the bathroom. The DON provided an update on [DATE] at 2:32 p.m., of the neglect investigation she was conducting related to Resident #50 that occurred on the afternoon of [DATE]. She clarified the investigation was not complete and was still on going. She said he had not received a three-day bowel and bladder baseline evaluation, so they were currently conducting one to see if he was able to go to the bathroom and see what that looked like for him. She said none of the staff could recall hearing him ask to go to the bathroom in over a year. She explained the three-day assessment was not completed before because it is a paper thing we have to pull out and do. She said their electronic medical record did not have that function and it had to be hand-written. She said the facility had completed neglect training and staff interviews related to Resident #50's baseline behaviors and the moaning, and a total of six employees and 10 residents had been interviewed so far. She said the facility contacted the licensed clinical psychologist to see why she quit seeing Resident #50, and she said he had poor cognitive reasoning, short- and long-term memory problems, repetitive talking, and progressive, severe, depressive dementia and was not able to express insightful thoughts. She said she would put a plan in place to address his bowel and bladder needs when the three-day assessment was completed, and would review his care plans to make sure they were all up to date. F. Facility follow-up On [DATE] at 5:00 p.m., after exit, the facility provided additional documentation on the follow up for Resident #50. The three-day bowel and bladder flowsheet was still in progress. A therapy evaluation reviewed his use of the sit-to-stand lift and recommended the change to utilize the dependent Hoyer lift for all transfers when he was unable to stand. The staff were provided education on neglect and a future neglect training would be provided to facility staff by the SDC. Cross-reference F677, failure to provide ADL care for dependent residents. III. Resident #36 [NAME] Resident #36 status Resident #36, age 72, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The [DATE] MDS assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required extensive assistance for bed mobility, toileting and transfers and was totally dependent upon staff for bathing. She was at risk for pressure injuries and had not rejected any care. The annual MDS assessment section G0400A, Functional Limitation in Range of Motion for upper extremity (shoulder, elbow, wrist, hand), was coded as no limitation. B. Observations On [DATE] at approximately 11:30 a.m., Resident #36 was observed seated in her wheelchair facing towards the exit door of the Grand Mesa hallway. Her left arm was bent at the elbow and her completely bandaged left hand was in a stationary position across her chest. The resident politely declined to be interviewed. Wound care for Resident #36 was observed on [DATE] at 10:43 a.m. The wound care was provided by staff development coordinator (SDC) who was a registered nurse (RN) and RN #4. The resident said the whole wound care process was extremely painful. The SDC held the hand of Resident #36 while she spread the resident's fingers and removed the old spacers from between her fingers. The wounds were red and there was a fissure in the crease of the fingers. Open wounds were visualized between the third, fourth and fifth fingers of the resident's left hand. The resident moaned and yelled out in pain and said she wanted to hold onto something. C. Record review 1. The care plan did not identify the resident's left hand contracture and associated potential risk for pressure injury until [DATE] while the survey was in process. Prior to the initiated care area for her left hand contracture and associated pressure ulcers on [DATE], the resident's care plan did not address her left hand contracture or other potential risks associated with decreased ROM. 2. Skin and wound evaluation notes dated [DATE], were provided by the NHA on [DATE] at 11:00 a.m. The evaluations identified the following: -A stage 2 pressure injury on the fifth digit of the left hand; -A stage 2 pressure injury on the third digit of the left hand; -A stage 2 pressure injury on the radial axis of the fourth digit of the left hand; and -A stage 2 pressure injury on the lateral axis of the fourth digit of the left hand. 3. An incident report form was provided by the receptionist (REC) on [DATE] at 1:52 p.m. The form revealed Resident #36 was burned by hot coffee on [DATE] at 5:00 p.m. 4. A skin and wound evaluation note dated [DATE] was provided by the NHA on [DATE] at 11:00 a.m. The note revealed Resident #36 had a second degree burn to her right-lateral thigh which was sustained on [DATE]. D. Staff interviews The nursing supervisor (NS), who supervised Resident #36's hallway, was interviewed on [DATE] at 3:20 p.m. She said the resident was at a high risk for skin breakdown due to nutrition and hydration issues, inability to reposition herself, her left hand contracture and poor skin condition. She said the pressure wounds were first noticed by the DON in the middle or latter part of November. She said she assumed daily skin checks were not being done by nurse aides prior to the wounds being identified on [DATE]. The MDS #1 and MDS #2 coordinators were interviewed on [DATE] at 1:52 p.m. They said they were responsible for the compilation of all the resident data to ensure they submitted accurate MDS data. They said they saw almost every aspect of care that was charted by nurses and certified nurse aides (CNAs). They said they accessed hospital and physician visit records to gather MDS data. MDS #1 said Resident #36 had a LUE contracture and it had become progressively worse over time. They said contractures or other limitations in ROM in LUE should be coded under section G0400[NAME] They reviewed past submitted MDS assessments and confirmed section G0400A was repeatedly miscoded. The DON was interviewed on [DATE] at 3:10 p.m. She said there was a breakdown in the sharing of information via incident reports, with the 24-hour nursing report and problems with the care planning program. She said these issues could impact resident care and she was in the process of problem solving. E. Facility follow-up Further documentation related to Resident #36 was received from the facility after the survey exit via email on [DATE] at 4:59 p.m. Included in the documentation was an action plan related to the accuracy of MDS assessments. The cause of the inaccuracies was identified as: Inaccurate and/or incomplete nursing evaluations and documentation. F. Summary of failures Resident #36 has been a resident of the facility since [DATE]. Through the course of her residence and 11 submitted MDS assessments she was never correctly assessed for functional limitations in her LUE. The resident's care plan did not address her LUE ROM or provide any relevant interventions. The care plan, nor any other provided documentation, supported any facility assessments and/or interventions for restorative nursing services. Her care plan did not identify her contracted left hand as a focus area with interventions until [DATE], during the recertification survey, and some 37 days after four stage 2 pressure ulcers on her left hand were first documented. An interdisciplinary screening form, submitted by nursing on [DATE], led to an occupational therapy (OT) evaluation and plan of care dated [DATE]. The resident was seen again by OT on [DATE] and subsequently discharged from OT services before the plan of care was signed by the physician on [DATE]. Multiple nursing progress notes documented Resident #36 had a contracted left hand and had to feed herself with her right hand. A staff interview revealed the resident frequently spilled liquids on herself during meals. Neither the resident's diet order or instructions on her meal tray tickets specified any adaptive equipment or safety measures put in place to ensure safe independent dining. On [DATE], the resident was served coffee estimated to be 180 degrees F and sustained second [MEDICAL CONDITION] her lap. The aforementioned documentation, received after the survey exit, confirmed multiple structure and process failures which created a neglectful environment and resulted in resident harm. Cross-reference F686, failure to provide treatment to prevent and heal pressure ulcers; F688, failure to prevent decrease in range of motion (ROM); F689, failure to prevent accidents hazards; and F641, failure to ensure accuracy of assessments. III. Resident #52 [NAME] Resident #52 status Resident #52, age 76, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The [DATE] MDS assessment revealed no BIMS was completed. The [DATE] MDS assessment documented moderate cognitive impairment with a BIMS score of 11 out of 15. The resident required supervision for transfers, ambulating in her wheelchair, eating and toileting. She needed limited assistance for bed mobility and personal hygiene. She required extensive assistance for dressing and bathing. B. Summary of findings The facility had knowledge that Resident #52 carried several respiratory [DIAGNOSES REDACTED]. The facility was also aware the resident often refused to use the [MEDICAL CONDITION] machine because it caused discomfort, and the [MEDICAL CONDITION] had been broken and unusable for an undetermined period of time, but possibly several weeks. However, there was no evidence the physician was notified of the [MEDICAL CONDITION]'s malfunctioning, the resident's frequent refusals when it did function, and that there were no clear parameters for use of the [MEDICAL CONDITION]. The facility failed to accurately document the type of respiratory equipment the resident used ([MEDICAL CONDITION]), educate the resident and staff on [MEDICAL CONDITION] use, parameters and benefits; and the risks for failing to use it. The facility failed to identify the reasons for the resident's discomfort with the [MEDICAL CONDITION]; and failed to assess and implement measures to address and resolve the resident's concerns and encourage compliance. The facility failed to ensure the [MEDICAL CONDITION] was repaired in a timely manner. The facility failed to implement hospital recommendations on [DATE] for an outpatient sleep study. These failures contributed to Resident #52's reduced oxygen saturation levels which fell as low as 44 percent, and two hospitalization s during (MONTH) 2019 for [MEDICAL CONDITIONS] and [MEDICAL CONDITIONS] complications. The resident said it was very scary, she felt anxious when she had difficulty breathing, and the facility's failure to repair her [MEDICAL CONDITION] was neglectful. Cross-reference F695, failure to provide required respiratory care and services. IV. Resident #70 [NAME] Resident #70 status Closed record review revealed Resident #70, age 78, was admitted on [DATE]. According to the CPO, [DIAGNOSES REDACTED]. According to the most recent MDS assessment completed on [DATE], the resident was cognitively intact with a BIMS score of 13 of 15. The resident did not have a condition or chronic disease that may result in a life expectancy of less than six months, nor did the resident use any special treatments such as oxygen therapy. The resident was not on hospice care. B. Record review 1. The Colorado medical orders for scope of treatment (MOST) form, completed [DATE], showed the resident wanted no cardiopulmonary resuscitation (CPR) in the event of no pulse and not breathing. Under Section B, selective treatment was chosen with a goal to treat medical conditions while avoiding burdensome measures. It further read to use intravenous (IV) antibiotics and IV fluids as indicated, may use noninvasive positive airway pressure, and transfer to hospital if indicated while avoiding intensive care. 2. A progress note by RN #2 on [DATE] showed: -At 7:30 a.m. the resident's vitals were: temperature 99.5, blood pressure ,[DATE], oxygen saturation 89% on 4 liters nasal cannula, Nebulizer with [MEDICATION NAME] administered via mask. Per report from the night shift nurse a chest x-ray was scheduled. Resident was responding at this time with garbled breathing and attempts to push the nurse's hand away from his face. Washing the resident's face and removing matter from his eyes disturbed him, the head of the bed was up at over 45 degrees to facilitate respiratory efforts. -At 8:45 a.m. the nurse noted she had crushed the resident's medications and urged the resident to take and swallow. Three-quarters of medications were visibly swallowed but the nurse was hesitant to provide water to wash down. -At 10:10 a.m. the nurse noted she placed a call to the x-ray vendor to check on arrival time as they had said they would be at the facility at 9:00 a.m. Office help stated at this time the technician was on his way. Resident's temperature was documented as 98.9 and the resident was nonresponsive to stimuli at this time. -At 10:20 a.m. it was noted the x-ray technician had arrived and RN #2 was attempting to contact the doctor. The resident's primary care doctor (PCP) was unavailable, the nurse attempted to contact the on call doctor who was previously contacted by the night shift nurse as she had been made aware of the resident's condition, the nurse noted she was on hold for some minutes after being relayed a message by the receptionist to call the primary care provider. The nurse called again to the primary care provider's office and let the receptionist know that leaving a message was not acceptable and requested the on call physician's name and number, it was noted the PCP's nurse came to the line. The PCP's nurse, according to the note, told RN #2 she could use the on-call doctor's order from the previous night that if the resident worsened he was to be shipped to the hospital. At this time RN #2 noted she had spoken to the Resident's daughter/POA and informed her that her father was not doing well and that she was attempting to get him to the hospital. The nurse noted the daughter felt this was a very good idea and would be up to see her dad as soon as she could. -At 10:45 a.m. RN #2 noted the x-ray was completed and the resident's POA had arrived at the facility. -At 11:00 a.m. the nurse noted she had called 911 to request transport, she had provided paperwork for EMS and the hospital and the resident was out of the facility at 11:30 a.m. 3. Emergency medical services (EMS) documentation The EMS run sheet showed the call to service was made at 11:10 a.m. with a situation of a [AGE] year old male that was unresponsive and presented with difficulty breathing. Staff stated the resident was awake upon the beginning of shift at 6:00 a.m. ([DATE]) and was given his medications but the patient was reported to have been lethargic at that time and staff had to crush medications for the resident to swallow them. Staff reported to EMS when they returned to the resident around 10:00 a.m. the resident was minimally responsive to painful stimuli and having increased difficulty breathing with a 70% oxygen saturation rate. Upon arrival the resident was unresponsive with a clear airway but with snoring respirations and paradoxical abdominal breathing, lung sounds were clear on the right and severely diminished to absent on the left with ataxic (complete irregularity of breathing with irregular pauses and increasing periods of apnea) respirations noted. Skin was pale, cool, and slightly diaphoretic with central cyanosis noted. The assessment of the resident was noted to be unresponsive with respiratory distress. The resident was placed on a non rebreather mask with oxygen set at 10 LPM with improvement in oxygen saturation from high 50's to mid 70's percent. The resident was transferred to the hospital via EMS at 11:26 a.m. with arrival at the hospital at 11:30 a.m. 4. emergency room documentation emergency room (ER) documentation from [DATE] for Resident #70 showed the resident arrived with acute [MEDICAL CONDITION]. After consulting with family and POA upon arrival at the hospital, the family elected comfort measures only. The resident expired at 3:00 p.m. C. Staff interviews The medical director was interviewed on [DATE] at 11:45 a.m. She said she would expect the facility to follow its own policy on transferring a resident to the hospital and to honor the resident's advanced directives. The DON was interviewed on [DATE] at 2:43 p.m. The DON said the process for sending a resident to the hospital was to first determine that need. They would call the family and doctor to report their findings and see if the doctor would want to treat them in the facility or send them out. She would consider a respiratory emergency someone who was choking, that couldn't catch air, or was not breathing at all. She said to call 911 it would have to be a CPR situation and they had to be a full code, but they would pretty much have to have a doctor's order on anyone to send them out to the hospital. She said the facility's policy on sending residents to the hospital was a good guideline, but she would expect the staff to at least honor a resident's advanced directives. Cross-reference F684, failure to provide the highest practicable quality of emergent care.

Based on interviews and record review, the facility failed to ensure one (#70) of 30 sample residents received timely treatment and care in accordance with professional standards of practice and facility policy. Specifically, the facility failed to enter and follow the on-call physician orders [REDACTED]. The facility failed to ensure timely emergency transport for the resident in accordance with his advance directives and facility policy, while attempting to reach the on-call physician, after the resident experienced a change in level of consciousness to the point he was nonresponsive to external stimuli and with abnormal respiratory patterns and vital signs. A registered nurse identified the resident status was declining as evidenced by an oxygen saturation rate reported to be as low as 80% requiring the RN to increase the oxygen settings to 5 LPM, above the ordered physician rates of ,[DATE] LPM. The RN then according to her words wasted time while trying to get ahold of two physicians and/or receive permission to call 911 from the DON while the resident was crashing. The facility's failures resulted in a delay of transport to the hospital for up to 60 minutes. The resident expired shortly after transport to the hospital. Cross-reference F600, failure to ensure residents were free from neglect. Findings include: I. Facility policy and procedure The Resident Condition Changes that Require Physician Notification Guidelines policy, revised [DATE], provided by the human resources coordinator (HRC) on [DATE] at 4:24 p.m. read, a situation/condition that warrants immediate physician notification and intervention (if the physician response was not immediate, determine if the resident should be sent to the emergency room ), such conditions include, but are not limited to: -Deviation of vital signs where intervention must be immediate; and -Any change in level or loss of consciousness. II. Resident Status Resident #70, age 78, was admitted on [DATE]. According to the computerized physician orders [REDACTED]. According to the most recent minimum data set (MDS) assessment completed on [DATE], the resident was cognitively intact with a brief interview for mental status exam (BIMS) score of 13 of 15. The resident did not have a condition or chronic disease that may result in a life expectancy of less than six months, nor did the resident use any special treatments such as oxygen therapy. The resident was not on hospice care. III. Record review [NAME] Resident advanced directives The Colorado medical orders for scope of treatment (MOST) form, completed [DATE], showed the resident wanted no cardiopulmonary resuscitation (CPR) in the event of no pulse and not breathing. Under Section B, selective treatment was chosen with a goal to treat medical conditions while avoiding burdensome measures. It further read to use intravenous (IV) antibiotics and IV fluids as indicated, may use noninvasive positive airway pressure, and transfer to hospital if indicated while avoiding intensive care. B. Nursing summary report The most recent nursing summary report completed on [DATE], showed the resident had no signs or symptoms of shortness of breath, was alert and oriented to person and place, and memory and judgment were appropriate and intact. There were no changes to the resident's cognitive status as his ability to express ideas and wants were understood, he was able to hear with minimal difficulty, and his ability to see in adequate light was adequate. C. Progress notes On [DATE] at 4:30 a.m. registered nurse (RN) #5 wrote the resident was experiencing increased confusion, wheezing, and a low oxygen saturation rate of ,[DATE]% on room air. The nurse contacted the physician who ordered [MEDICATION NAME] (nebulizer breathing treatment) every 6 hours for wheezing and oxygen ,[DATE] liters per minute (LPM) as needed and to titrate to maintain oxygen saturation rate of greater than 89%. On [DATE] at 6:19 a.m., RN #5 wrote in a health status note, staff reported the resident was experiencing increased weakness and low oxygen saturation rates. The RN's assessment showed the resident had audible expiratory wheezes with an oxygen saturation rate of ,[DATE]%, the resident was responding appropriately when asked questions, she had contacted the physician prior and received orders for oxygen as needed and [MEDICATION NAME]. The nurse noted the resident responded positively post [MEDICATION NAME] administration with oxygen saturation of 92% on room air. On [DATE] at 4:05 p.m. RN #2 wrote she had placed a call to the resident's daughter/POA to inform her of the resident's needs for oxygen as needed and nebulizer treatments, as well as the resident was mostly somnolent with difficulty staying awake and falling asleep with food in his mouth. The resident had a productive cough with audible rales and was not following simple directions at this time. On [DATE] at 3:01 a.m., RN #6 wrote the resident was seen in bed with eyes closed and was not as alert as before. He was observed to be almost snoring with the way he breathed, while responding to his name, but was drowsy most of the time. The resident was observed during the day to have poor intake of liquid and food. No urine output was observed at this time. The resident took his meds crushed in pudding and drank around 60 milliliters of fluids with medications. A physical exam of lungs showed lungs had equal chest expansion and use of accessory muscles were noted with expiratory wheezes heard with or without the stethoscope. Rales were also heard. Vitals were good and noted (blood pressure: ,[DATE], pulse 69, temperature 98.0, and oxygen saturation ,[DATE]% on ,[DATE] LPM, respirations ,[DATE]). Nebulizer treatment was given for wheezing and a call was made to the on call physician. The physician ordered for blood work and a chest x-ray in the morning and if the BP and oxygen saturation rates dropped down, to send the patient out (to the hospital). At this time the daughter/POA had called and was informed of the resident's condition and agreed to send the resident to the hospital if the vitals were poor. D. Professional standard According to Fundamentals of Nursing by Potter, Perry, Stockert, and Hall, 9th edition (copyright (YEAR)), page ,[DATE]: Acceptable vital sign ranges for adults are: Temperature: 96.8 to 100.4 degrees fahrenheit Pulse: 60 to 100 beats per minute (BPM), strong and regular Pulse Oximetry: greater than or equal to 95% Respirations: 12 to 20 breaths per minute deep and regular Blood pressure: Systolic (top number) ,[DATE], Diastolic (bottom number) less than 80 [MEDICAL CONDITION] (low blood pressure): 90 systolic or below. E. physician's orders [REDACTED].>All physicians orders including completed, discontinued, current, and struck out were reviewed. No order was input in the electronic medical record to transport the resident to the hospital. IV. Facility response and failure The facility failed to enter the on-call physician's orders [REDACTED]. A progress note by RN #2 on [DATE] showed: -At 7:30 a.m. the resident's vitals were: temperature 99.5, blood pressure ,[DATE], oxygen saturation 89% on 4 liters nasal cannula, Nebulizer with [MEDICATION NAME] administered via mask. Per report from the night shift nurse a chest x-ray was scheduled. Resident was responding at this time with garbled breathing and attempts to push the nurse's hand away from his face. Washing the resident's face and removing matter from his eyes disturbed him, the head of the bed was up at over 45 degrees to facilitate respiratory efforts. -At 8:45 a.m. the nurse noted she had crushed the resident's medications and urged the resident to take and swallow. Three-quarters of medications were visibly swallowed but the nurse was hesitant to provide water to wash down. -At 10:10 a.m. the nurse noted she placed a call to the x-ray vendor to check on arrival time as they had said they would be at the facility at 9:00 a.m. Office help stated at this time the technician was on his way. Resident's temperature was documented as 98.9 and the resident was nonresponsive to stimuli at this time. -At 10:20 a.m. it was noted the x-ray technician had arrived and RN #2 was attempting to contact the doctor. The resident's primary care doctor (PCP) was unavailable, the nurse attempted to contact the on call doctor who was previously contacted by the night shift nurse as she had been made aware of the resident's condition, the nurse noted she was on hold for some minutes after being relayed a message by the receptionist to call the primary care provider. The nurse called again to the primary care provider's office and let the receptionist know that leaving a message was not acceptable and requested the on call physician's name and number, it was noted the PCP's nurse came to the line. The PCP's nurse, according to the note, told RN #2 she could use the on-call doctor's order from the previous night that if the resident worsened he was to be shipped to the hospital. At this time RN #2 noted she had spoken to the Resident's daughter/POA and informed her that her father was not doing well and that she was attempting to get him to the hospital. The nurse noted the daughter felt this was a very good idea and would be up to see her dad as soon as she could. -At 10:45 a.m. RN #2 noted the x-ray was completed and the resident's POA had arrived at the facility. -At 11:00 a.m. the nurse noted she had called 911 to request transport, she had provided paperwork for EMS and the hospital and the resident was out of the facility at 11:30 a.m. C. Emergency medical services (EMS) documentation The EMS run sheet showed the call to service was made at 11:10 a.m. with a situation of a [AGE] year old male that was unresponsive and presented with difficulty breathing. Staff stated the resident was awake upon the beginning of shift at 6:00 a.m. ([DATE]) and was given his medications but the patient was reported to have been lethargic at that time and staff had to crush medications for the resident to swallow them. Staff reported to EMS when they returned to the resident around 10:00 a.m. the resident was minimally responsive to painful stimuli and having increased difficulty breathing with a 70% oxygen saturation rate. Upon arrival the resident was unresponsive with a clear airway but with snoring respirations and paradoxical abdominal breathing, lung sounds were clear on the right and severely diminished to absent on the left with ataxic (complete irregularity of breathing with irregular pauses and increasing periods of apnea) respirations noted. Skin was pale, cool, and slightly diaphoretic with central cyanosis noted. The assessment of the resident was noted to be unresponsive with respiratory distress. The resident was placed on a non rebreather mask with oxygen set at 10 LPM with improvement in oxygen saturation from high 50's to mid 70's percent. The resident was transferred to the hospital via EMS at 11:26 a.m. with arrival at the hospital at 11:30 a.m. D. emergency room documentation emergency room (ER) documentation from [DATE] for Resident #70 showed the resident arrived with acute [MEDICAL CONDITION]. After consulting with family and POA upon arrival at the hospital, the family elected comfort measures only. The resident expired at 3:00 p.m. V. Staff interviews RN #2 was interviewed on [DATE] at 10:30 a.m. She said in order to send a resident to the hospital she would usually call the family and assess if there was a preference to which hospital they would like their family member sent, and she would also usually call the doctor first. She said even in the event of an emergency she would still need a doctor's order for an ok to send a resident to the hospital. She said she would consider someone with altered mental status an emergency especially if it was quick onset. She said DNR means do not resuscitate, but does not mean do not treat. She said she would call 911 if someone was dying in front of her, but she also said nurses still could not call 911 and send a resident to the hospital without a physician's orders [REDACTED]. RN #2 said she came on shift that day on [DATE] and received report from the night shift, which told her that Resident #70 had not been acting the normal way he usually does as he was not as responsive. She said the resident had just come off antibiotics about two weeks previous, and that he had [MEDICAL CONDITION] but did not have a fever and none of his vitals were bad. She said around 7:30 a.m. he wouldn't talk to her but just roll his eyes. They were taking vital signs frequently, but she could tell he was working extra to breathe and having troubles at this time. RN #2 said the resident got to where he was not able to talk or look at her, with minimal response to painful stimuli. She said he acted sick like he had before and was not his baseline. She said the resident's oxygen saturation had plunged to about 80% and she had to turn the oxygen up to 5 liters (above physician's orders [REDACTED]. She said he was holding an oxygen saturation of high 80's to 90's after turning the oxygen up to 5 liters but still wanted him out of the facility and to the hospital because a DNR does not mean do not treat. She said there was difficulty getting hold of the physician. She even had tried to call the on call doctor who did not want to cover, and a lot of time was wasted while trying to get hold of both of the doctors and waiting on hold as well. She said she wanted to send the resident to the hospital with or without the chest x-ray because the resident was crashing, but she had to get permission from the director of nursing (DON) to call 911 and send the resident. RN #1 was interviewed on [DATE] at 3:29 p.m. She said the process for sending a resident to the hospital was to notify the on call nurse manager and call the physician to get an order to transfer the resident, unless it was an emergency, then call 911 first. She said there was some transfer paperwork that would be completed if there was time when not an acute emergency transfer. She said DNR does not mean do not treat and a respiratory emergency to her would be uncontrolled tachypnea, shortness of breath, oxygen saturation below 88% and not coming up with oxygen, or respiratory arrest. She said altered mental status would be an emergency depending on the code status of the resident and family wishes, but if an acute change it would be an emergency. She said a resident with a no CPR status, selective treatment on the MOST form, and having abnormal breathing patterns while nonresponsive to stimuli would be an appropriate situation to call 911. She said she did not need to call anyone or get permission to call 911 if she felt the need. She said waiting less than 5 minutes for a physician response before calling 911 would be appropriate. LPN #4 was interviewed on [DATE] at 4:08 p.m. She said sending a resident to the hospital usually depended on the circumstances and code status of the resident, but generally call the doctor if it's not an emergency. If it was an emergency she would call 911. She said she would call 911, then follow up with the MD after. She said an emergency would be things such as low oxygen saturation rates, a fall with a break, choking, altered mental status, or respiratory distress. She said DNR does not mean do not treat, and for residents not on hospice who were having respiratory distress and nonresponsive, she would call the paramedics, then the family. She said nurses working in the facility could call 911 and send a resident to the hospital without anyone's permission or a physician order. The medical director was interviewed on [DATE] at 11:45 a.m. She said she would expect the facility to follow its own policy on transferring a resident to the hospital and to honor the resident's advanced directives. The director of nursing (DON) was interviewed on [DATE] at 2:43 p.m. The DON said the process for sending a resident to the hospital was to first determine that need. They would call the family and doctor to report their findings and see if the doctor would want to treat them in the facility or send them out. She would consider a respiratory emergency someone who was choking, that couldn't catch air, or was not breathing at all. She said to call 911 it would have to be a CPR situation and they had to be a full code, but they would pretty much have to have a doctor's order on anyone to send them out to the hospital. She said the facility's policy on sending residents to the hospital was a good guideline, but she would expect the staff to at least honor a resident's advanced directives.

Based on observations, record review, and interviews, the facility failed to ensure one (#36) of four residents reviewed for pressure ulcers of 30 sample residents received care consistent with professional standards of practice to prevent pressure injuries. Specifically, the facility failed to identify and implement resident specific care interventions to prevent four stage 2 pressure injuries on the contracted left hand of Resident #36. Facility failures contributed to the resident developing multiple pressure injuries which she described as extremely painful. Cross-reference F600, failure to ensure residents were free from neglect; F641, accuracy of assessments; F688, range of motion; and F689, accident hazards. Findings include: I. Professional standards According to the National Pressure Ulcer Advisory Panel (NPUAP), Prevention and treatment of [REDACTED].internationalguideline.com/static/pdfs/Quick_Reference_Guide-04Dec2019.pdf, 12/17/19, interventions for prevention of pressure ulcers included: -Consider individuals with limited mobility, limited activity and a high potential for friction and shear to be at risk for pressure injuries; and -Develop and implement a risk-based prevention plan for individuals identified as being at risk for pressure injuries. II. Facility policy and procedure The Skin and Wound Management Program Overview policy and procedure, revised 11/26/18, was provided by the nursing home administrator (NHA) via email on 12/17/19, and included the following guidance: -The highest practicable physical well-being regarding wound prevention was achieved through appropriate screenings, comprehensive evaluations, reviews and monitoring and plans of care. -The skin and wound management program was the responsibility of everyone who provided care to residents, each with their own set of responsibilities. -Since an at risk resident can develop a pressure injury in two to six hours of the onset of pressure, all residents are screened using the Braden Scale. -Any resident with a Braden Scale of 18 or less was defined as at risk for a pressure injury. -The licensed nurse performed a weekly visual head-to-toe skin assessment and a certified nurse aide (CNA) performed a visual head-to-toe skin review preferably during bathing. Results were verified by a licensed nurse and documented on the weekly skin check form. III. Resident #36 [NAME] Resident status Resident #36, age 72, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 10/31/19 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required extensive assistance for bed mobility, toileting and transfers and was totally dependent upon staff for bathing. She was at risk for pressure injuries and had not rejected any care. The annual MDS assessment section G0400A, Functional Limitation in Range of Motion for upper extremity (shoulder, elbow, wrist, hand), was coded as no limitation. (Cross-reference F641, accuracy of assessments). B. Observations Wound care for Resident #36 was observed on 12/16/19 at 10:43 a.m. The wound care was provided by staff development coordinator (SDC) who was a registered nurse (RN) and RN #4. The resident said the whole wound care process was extremely painful. The SDC said she hoped the tylenol given earlier would help. The SDC held the hand of Resident #36 while she spread the resident's fingers and removed the old spacers from between her fingers. The wounds were red and there was a fissure in the crease of the fingers. Open wounds were visualized between the third, fourth and fifth fingers of the resident's left hand. The resident moaned and yelled out in pain and said she wanted to hold onto something. The resident was transferred back to her bed for treatment of [REDACTED]. (Cross-reference F689, free from accident hazards) C. Record review 1. The care plan, initiated 6/4/17 and last revised 12/11/19, identified the the resident at risk for skin breakdown due to impaired mobility and incontinence. Interventions included: -Routine skin care (initiated 6/4/17); -CNA (certified nurse aide) to observe skin daily with care and report changes to the nurse (initiated 8/16/17); and -Dry completely in between the resident's fingers after hand washing (initiated 8/11/19). The care plan did not identify the resident's left hand contracture and associated potential risk for pressure injury until 12/11/19 while the survey was in process. 2. Skin and wound evaluation notes dated 11/4/19, were provided by the NHA on 12/16/19 at 11:00 a.m. The evaluations identified the following: -A stage 2 pressure injury on the fifth digit of the left hand; -A stage 2 pressure injury on the third digit of the left hand; -A stage 2 pressure injury on the radial axis of the fourth digit of the left hand; and -A stage 2 pressure injury on the lateral axis of the fourth digit of the left hand. Each of the four notes revealed the wounds were first observed on 11/4/19 and acquired in the facility. 3. A faxed communication to the resident's physician dated 11/1/19, and noted by the physician on 11/4/19, was provided by the NHA on 12/16/19 at 11:00 a.m. The communication form read: On (Resident #36's) left hand (the contracted one) between her second, third and fourth fingers it is raw and there is a blister between the third and fourth finger and some minimal bleeding. It was very painful. There is a lot of smell and I am worried it may be or may become infected. There were no associated progress notes or records of treatment until the initial skin and wound evaluations completed by the director of nursing (DON) on 11/4/19. 4. Weekly skin assessments were provided by the NHA on 12/16/19 at 11:00 a.m. The assessments revealed the following: -10/23/19, normal skin condition and no new wounds; -10/30/19, normal skin condition and no new wounds; and -11/6/19, normal skin condition and no new wounds. The weekly skin assessment prior to the faxed physician communication form on 11/1/19 and following the the skin and wound evaluations on 11/4/19 did not identify any wounds or skin issues. 5. Bathing records were provided by the NHA on 12/16/19 at 11:00 a.m. The (MONTH) 2019 bathing record documented the resident was bathed on 10/1/19, 10/8/19, 10/11/19, 10/15/19, 10/18/19, 10/22/19, 10/25/19 and 10/29/19. There were no corresponding progress notes or other documentation provided indicating any skin breakdown issues. The (MONTH) 2019 bathing sheets documented the resident was bathed on 11/1/19. There were no corresponding progress notes or other documentation provided indicating any skin breakdown issues. 6. An occupational therapy (OT) plan of care note dated 8/22/19 and signed by the resident's physician on 9/12/19, was provided by the NHA on 12/16/19 at 11:00 a.m. The note revealed the resident was at increased risk for skin breakdown and pain due to a left hand contracture. The short term goal was nursing staff would demonstrate donning/doffing of palm protector to promote healthy skin integrity and manage pain. The long term goal was staff would be educated to provide a splinting program for the left hand as determined. An OT daily treatment note dated 8/22/19, was provided by the NHA on 12/16/19 at 11:00 a.m. The note revealed the resident was discharged from OT services without nursing staff receiving the recommended training. 7. Braden scale assessments scores The Braden scale assessment, used to assess the resident's risk of pressure ulcer development, were as follows: -7/29/19, total score was 11.0 = high risk -9/7/19, total score of 12.0 = high risk -9/14/19, total score of 15.0 = mild risk -10/30/19, total score of 15.0 = mild risk IV. Staff interviews CNA #13 was interviewed on 12/11/19 at 9:40 a.m. She said she evaluated a resident's skin when she provided bathing care. She said she would look at the resident's hands but would not do anything that would hurt the resident. She said it would not be possible to see between Resident #36's fingers without spreading them apart. The staff development coordinator (SDC) was interviewed on 12/11/19 at 3:45 p.m. She said Resident #36 should have weekly nursing skin assessments. She said she was not aware of any care planned interventions for prevention of skin breakdown related to the resident's left hand contracture. The assistant director of nursing (ADON) was interviewed on 12/12/19 at 2:51 p.m. She said Resident #36 was in an overall state of decline. She said her risk factors for skin breakdown included decreased mobility, inadequate nutrition and her contracted left hand. She said all residents received a weekly head-to-toe skin assessment by the nurse. She said the facility tried to have a standard care plan for skin care and build from there. She said Resident #36 received routine skin inspections and she was not aware of any additional pressure ulcer prevention interventions in place for Resident #36. The nursing supervisor (NS), who supervised Resident #36's hallway, was interviewed on 12/12/19 at 3:20 p.m. She said the resident was at a high risk for skin breakdown due to nutrition and hydration issues, inability to reposition herself, her left hand contracture and poor skin condition. She said the pressure wounds were first noticed by the DON in the middle or latter part of November. She said she assumed daily skin checks were not being done by nurse aides prior to the wounds being identified on 11/4/19. The director of nursing (DON) was interviewed on 12/16/19 at 3:10 p.m. She said there was a breakdown in the sharing of information in the 24-hour nursing report and problems with the care planning program. She said these issues could impact resident care and she was in the process of problem solving. V. Facility follow-up Further documentation related to Resident #36 was received from the facility after the survey exit via email on 12/17/19 at 4:59 p.m. Included in the documentation was an action plan related to the accuracy of MDS assessments. The cause of the inaccuracies was identified as: Inaccurate and/or incomplete nursing evaluations and documentation.

Based on observations, record review and interviews, the facility failed to ensure one (#36) of one resident reviewed for range of motion (ROM) of 30 sample residents received appropriate treatment and services to prevent further decrease in ROM. Specifically, the facility failed to assess, provide services, care, and equipment to maintain or improve ROM for Resident #36. The facility failed to assess the level of the resident's contracture and whether her hand contracture had worsened during her stay in the facility. Recommendations for the treatment of [REDACTED]. These failures contributed to the resident developing pressure injuries and suffering extreme pain. Cross-reference: F600, failure to ensure residents were free from neglect; F641, accuracy of assessments; F686, treatment and services to prevent pressure ulcers; and F689, accident hazards. Findings include: I. Facility policy and procedures The Range of Motion policy and procedure, effective 9/1/18, was provided by the receptionist (REC) on 12/16/19 at 11:00 a.m. The purposes of ROM activities included: -Increased mobility; -Decreased pain; -Prevent deformities; and -Improve sense of well-being and self-esteem. The policy identified ROM exercise as helpful for residents with decreased ability or total inability to move one or more joints as may often be seen in the [DIAGNOSES REDACTED]. II. Resident #36 [NAME] Resident status Resident #36, age 72, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 10/31/19 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required extensive assistance for bed mobility, toileting and transfers and was totally dependent upon staff for bathing. She was at risk for pressure injuries and had not rejected any care. There were no coded minutes for physical therapy, occupational therapy or restorative nursing ROM activities. The annual MDS assessment section G0400A, Functional Limitation in Range of Motion for upper extremity (shoulder, elbow, wrist, hand), was coded as no limitation. (Cross-reference F641, accuracy of assessments). B. Observations On 12/10/19 at approximately 11:30 a.m., Resident #36 was observed seated in her wheelchair facing towards the exit door of the Grand Mesa hallway. Her left arm was bent at the elbow and her completely bandaged left hand was in a stationary position across her chest. The resident politely declined to be interviewed. On 12/16/19 at 10:43 a.m, Resident #36 was observed during wound care to her left hand pressure injuries and the burn wound on her right thigh. She said the entire wound care process was extremely painful and she frequently yelled out in pain. On 12/16/19 at approximately 2:00 p.m., Resident #36 was observed seated in her wheelchair. She was positioned towards the exit door of the Grand Mesa hallway and her left arm was bent at the elbow. Her hand was in a static position across her chest. Her hand was covered by a white washcloth. C. Record review 1. The care plan, initiated 12/11/19 during the survey, identified the resident had a left hand contracture with pressure wounds between her fingers. She needed the assistance of two staff members to cleanse her left hand; one to hold her hand and distract her and the other to clean the hand. Additional interventions included not allowing her hand to be unopened for a long period of time, do not force her hand open or move her fingers too quickly, and use finger contraction cushion daily as the resident chose. Prior to the initiated care area for her left hand contracture and associated pressure ulcers on 12/11/19, the resident's care plan did not address her left hand contracture or other potential risks associated with decreased ROM. A written request for all physical therapist (PT), occupational therapist (OT) and restorative nursing assessments and notes from (MONTH) 2019 through 12/16/19 were submitted to the nursing home administrator (NHA) on 12/16/19 at 8:00 a.m. There were no PT notes or assessments provided by the facility. 2. Speech therapy (ST) Documentation received from the NHA on 12/16/19 at 11:00 a.m.indicated the resident was seen by ST for reduced swallow safety on 12/10/19, 12/11/19, 12/12/19 and 12/13/19. 3. Occupational therapy (OT) A nursing request for interdisciplinary rehabilitation screening form was submitted on 8/6/19. The request stated the resident's left hand was contracted and she had areas of skin irritation between two of her fingers which required a splint device to separate her fingers. The resident was seen by OT on 8/9/19. The OT plan of care stated therapy was necessary to decrease the resident's risk for skin breakdown and increased pain. Goals for OT included staff donning/doffing a palm protector for the resident's left hand to promote healthy skin integrity and manage pain. An OT daily treatment note dated 8/22/19 revealed the resident tolerated the palm protector and wanted it removed at night. The note documented a plan to consult with nursing to confirm the palm protector wearing schedule and plan. The resident was discharged from OT services on 8/22/19. The OT plan of care was signed by the resident's physician on 9/12/19. There were no additions or revisions to the resident's care plan associated with the OT assessment and plan of care. A request for OT to evaluate Resident #36 for a splint for her left hand due to pressure injuries on her third, fourth and fifth digits of her left hand was submitted on 11/4/19 and finger separator was supplied on 11/7/19. A request for an order for [REDACTED]. (Cross-reference F689, failure to prevent accidents. The resident was burned by scalding coffee on 11/20/19.) An OT daily treatment note, dated 12/6/19, read it was a difficult evaluation due to resident agitation. There were no additions or modifications made to the resident's care plan and assessment or plan of care submitted by facility An OT daily treatment note, dated 12/12/19, revealed the resident was educated on adaptive feeding utensil options and received ROM for her right upper extremity (RUE). An OT daily treatment note, dated 12/13/19, stated she declined treatment that day. The facility did not submit any restorative nursing assessments or other documentation in response to the written request made 12/16/19. Documentation received after the survey exit via email from the NHA on 12/17/19 at 4:49 p.m. included restorative weekly log forms for the following weeks: -4/25/19 through 5/2/19; continued to decline offered restorative services -4/27/19 through 5/2/19; declined restorative program -7/26/19 through 8/1/19; offered and declined restorative services -10/21/19 through 10/27/19; encouraged restorative program resident continues to refuse The forms were formatted for daily documentation and contained no daily notes. The forms did not indicate the nature of what, if any, restorative services had been offered. There was no restorative nursing services assessment submitted and the resident's care plan did not document any restorative nursing interventions. III. Staff interviews The assistant director or nursing (ADON) was interviewed on 12/12/19 at 2:51 p.m. She said Resident #36 had decreased mobility and a contracture to her left hand. She said she was not able to answer what restorative activities were care planned for Resident #36. She said the resident had refused restorative activities and she was not able to recall what activities had been offered. She said she hoped whatever recommendations were made by therapy services would be in the resident's care plan. She said since the resident was burned from hot liquids on 11/20/19 they moved her to the restorative area of the dining room. Registered nurse (RN) #2 was interviewed on 12/16/19 at 10:50 a.m. She said recommended ROM therapies should be in a resident's care plan. She said she was unaware of any care planned ROM activities for Resident #36. The medical director (MD) was interviewed on 12/16/19 at 11:59 a.m. She said Resident #36 had a progressive neurological condition and PT and OT worked with the resident in the past. She said all therapy and restorative related interventions should be in the resident's care plan. The nursing supervisor (NS) was interviewed on 12/12/19 at 3:20 p.m. She said she was unaware of what restorative services were provided for Resident #36. She said the resident was moved to the restorative dining room after she was burned. She said once a need or an issue was identified it was added to the resident's care plan. LPN #8 was interviewed on 12/16/19 at 4:21 p.m. She said she had seen the resident with some kind of splint in the past and helped take it off. She said she was not aware of any ROM or restorative activities for Resident #36. The director of nursing (DON) was interviewed on 12/16/19 at 3:10 p.m. She said Resident #36 had decreased ROM since she was admitted . She said she was not aware of care planned interventions related to ROM or restorative services for the resident. She said there were problems with the care planning program and methods of shared communication that she planned to correct.

Based on record review and interviews, the facility failed to ensure an environment as free from accident hazards as possible for two (#36 and #50) of 30 sample residents. Specifically, the facility failed to provide appropriate supervision and ensure safe functioning of equipment to prevent Resident #36 being served scalding hot coffee, which resulted in the resident receiving a second degree burn with blistering. The facility further failed to ensure Resident #50 received a safe transfer using a mechanical lift. Findings include: I. Resident #36 burned with hot coffee [NAME] Facility policy and procedure The Incident Report and Investigation policy and procedure was provided by the nursing home administrator (NHA) on 12/16/19. The policy revealed incidents with an adverse outcome, such as burns, were reported immediately to the supervisor of the staff member who observed the incident and should include all changes to care plan or service plan. The incident report should be reviewed and signed by the NHA or director of nursing (DON). B. Resident status Resident #36, age 72, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. She was on a regular, mechanical soft texture diet. The 10/31/19 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required extensive assistance for bed mobility, toileting and transfers and was totally dependent upon staff for bathing. She required limited assistance with eating and had not rejected any care. The annual MDS assessment section G0400A, Functional Limitation in Range of Motion for upper extremity (shoulder, elbow, wrist, hand), was coded as no limitation. (Cross-reference F641, accuracy of assessments). C. Record review 1. The care plan, initiated 11/2/18 and revised on 2/2/19, identified the resident at risk for sustaining injury while consuming hot liquids due to her functional limitations to steadily grip cups or utensils. Interventions to decrease risk for injury included: -Be careful not serve fluids at scalding temperatures (initiated 3/2/19); and -Close observation and supervision while consuming meals (initiated 11/2/18, revised 2/2/19). 2. An incident report form was provided by the receptionist (REC) on 12/11/19 at 1:52 p.m. The form revealed Resident #36 was burned by hot coffee on 11/20/19 at 5:00 p.m. The report stated the skin was checked and barrier cream was applied. The form was signed by the DON and NH[NAME] Neither of the signatures were dated. The final outcome/disposition section documented there was a new coffee machine in the dietary department and dietary staff was adding ice to resident's coffee and an order was placed for a consultation for adaptive equipment for Resident #36. The hand-written disposition statement was not signed or dated. 3. A skin and wound evaluation note dated 12/3/19 was provided by the NHA on 12/16/19 at 11:00 a.m. The note revealed Resident #36 had a second degree burn to her right-lateral thigh which was sustained on 11/20/19. 4. A nursing progress note, created 12/11/19 at 11:34 a.m. during the survey, with an effective date of 11/21/19 at 11:30 a.m., revealed the resident spilled coffee on her lap during the evening meal on 11/20/19. She was brought back to her room and the nurse noticed redness on her lap and applied barrier cream. She washed off the barrier cream and applied ice. On the morning of 11/21/19 a certified nurse aide (CNA) noticed a blister on the resident's right thigh which opened during the provision of care. D. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on 12/11/19 at 3:55 p.m. She said she worked the evening of 11/20/19 when the resident was burned by hot coffee. She said nursing aides brought Resident #36 back from the dining room because she had spilled coffee on her lap. She said the resident spilled liquids on herself, three times per day, every single day. She said she was not aware of any adaptive equipment utilized by Resident #36 in the dining room. She said she applied barrier cream to the burned area and washed it off when she heard how hot the coffee was. She said she could not recall what she was told the temperature the coffee was on 11/20/19. The registered dietitian (RD) was interviewed on 12/12/19 at 5:19 p.m. She said she was not aware of any adaptive equipment Resident #36 utilized in the dining room. She said she would have to look at her care plan and any interventions for safety should be in the care plan and be printed on the resident's tray ticket. She said she believed it was facility policy to serve hot beverages below 150 degrees Fahrenheit (F). She said dietary staff was measuring the temperature of the coffee since the resident was burned on 11/20/19. The dietary manager (DM) was interviewed on 12/12/19 at 5:50 p.m. He said the facility had received a new coffee brewing machine in early November. He said the temperature of the coffee served to the resident on 11/20/19 was approximately 180 degrees F. He said he had been in contact with the vendor who provided the coffee machine and the minimum water temperature for brewing coffee was 185 degrees F. He said the dietary department started adding ice to insulated coffee pitchers and ensuring the temperature was less than 155 degrees F after the resident was burned. He said the dietary staff started to document the cooled coffee temperatures on 12/1/19. He said the resident's tray ticket did not specify any adaptive equipment and the comment add ice to coffee'' was added some time after she was burned. The DON was interviewed on 12/16/19 at 3:10 p.m. She said there was a breakdown in the incident reporting system and information shared in the 24 hour report. She said the coffee machine arrived when she was away and there were multiple process failures that lead to the resident being burned by the hot coffee. She said the temperature of hot liquids were now monitored by the dietary staff, and as of 12/11/19 interventions for supervision for Resident #36 in the dining room had been added to her care plan. II. Failure to safely transfer Resident #50 using a mechanical lift [NAME] Facility policy and procedure The Mechanical Lifting Devices Program (MLD) policy and procedure, dated 9/1/18, was provided by the human resources coordinator (HRC) on 12/12/19 at 11:10 a.m. It stated the facility strived to create a safe work environment for team members and residents, particularly when residents were lifted and transferred. Team members were trained to practice proper transfer techniques and back care at all times. Mechanical lifting devices were used for residents who required weight-bearing assistance for transfers, when indicated. When properly used, mechanical lifting devices could assist in the reduction of injuries related to transfers. The administrator was responsible for the overall supervision to ensure lifting equipment was available and team members had been trained properly on its use. Each resident was assessed as appropriate for mobility, transfer status and the need for lifting assistance including via mechanical lifting equipment. The nursing services team reviewed all residents to confirm that transfer status designations were current and appropriate. B. Resident status Resident #50, age 83, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 11/14/19 MDS assessment revealed the resident had short- and long-term memory problems, adequate vision, and clear speech. He required extensive assistance with bed mobility, transfers, and eating, and total assistance with dressing, toilet use, and personal hygiene. Transfers required the assistance of two plus person physical assistance, and he was not steady moving from a seated to standing position or surface-to-surface transfers. He had functional limitation in range of motion with impairment on his upper and lower extremities bilaterally and he used a wheelchair for mobility. C. Observations On 12/10/19 at 1:31 p.m., Resident #50 was sitting in his wheelchair in his room. He was moaning loudly and he could be heard in the hallway. At 1:32 p.m., CNA #4 and CNA #12 entered the resident's room with a sit-to-stand mechanical lift to check and change him and place him in bed. CNA #4 donned gloves without washing her hands and removed the foot pedals from the wheelchair. The CNAs leaned the resident forward and placed the sling behind his back. They pushed the lift up to his anterior shins, placed his legs in the kneepads, and buckled them in with a strap behind his calves. The loops on the sling were hooked on the lift and his hands were placed on the handlebars. CNA #4 engaged the lift and raised him upwards from his wheelchair seat. His feet were not on the lift foot platform to support his weight, but instead, all of his weight was on the front of his shins below his knees, which were resting on the kneepads. (Cross-reference F677, ADL Care Provided for Dependent Residents) Resident #50 continued to moan as the lift was moved in front of the bed and he was lowered down onto it. They removed the sling and assisted him to lay down on the bed. D. Record review The care plan, dated 5/23/17 and revised 8/14/19, identified the resident had functional status limitations in his mobility and ability to transfer. The approaches included staff should use a sit to stand mechanical lift with two staff assistance, which was implemented on 5/23/17. Another approach was added on 9/7/17, if the resident was unable to stand, a full Hoyer lift should be used. An additional approach, dated 8/14/18, was repeated again that he would need a Hoyer lift for transfers. The User Instruction Manual for the Hoyer Elevate Patient Lift was provided by the HRC on 12/12/19 at 11:10 a.m. The lift was suitable for patients in the sitting position only who have a degree of weight-bearing ability but require assistance to stand. Position the Elevate lift so that the patient's feet fit in the foot tray and knees rested against the kneepad. The lift had an adjustable kneepad and the range was approximately seven inches. Once the ideal position was found, the operator should release the handle and the kneepad would automatically lock into position. The Elevate Lift competency checklist or CNA #4 and CNA #12 was requested from the DON on 12/16/19 at 4:38 p.m. She provided the competencies at 5:14 p.m. The instructions on the checklist included the Elevate lift was used for semi-dependent residents who can bear weight. CNA#4 completed the competency checklist successfully on 8/9/18 and #12 completed the competency checklist successfully on 9/3/18. E. Staff interviews CNA #4 was interviewed on 12/16/19 at 1:46 p.m., and confirmed she routinely worked with Resident #50. She said he was unable to provide any care for himself and he used a mechanical lift for transfers. She said the process for using the sit to stand lift included placing his feet on the platform with his shins right up against the kneepads, and then belting those in with a strap. She said when he was secured in place and the sling was around his back, the lift would assist him to stand up. She stated, He can bear weight or he would not be in that piece of equipment. She confirmed his knees rested on top of the kneepads during the transfer on 12/10/19 rather than up against then for support and stated, He's good at that. He often brings his feet up and puts his knees resting on there. She said when he did that it was probably not a safe transfer. The DON was interviewed on 12/16/19 at 4:38 p.m. She explained the process for using the sit to stand lift included placing the resident's knees in the kneepad rests and buckling the strap behind their legs. She confirmed the residents who used the lift must have the ability to assist with standing; otherwise, they should use the full Hoyer lift for their transfers. She said staff were taught how to use the lifts on hire and then it was part of their annual training thereafter. She was informed of the observation of Resident #50's transfer on 12/10/19, said it was not a safe transfer and stated, I would have hoped they would have put him down and gotten a Hoyer full body lift.

Based on observations, record review and interviews, the facility failed to provide required respiratory care consistent with standards of practice for one (#52) of one resident reviewed out of 30 sample residents. The facility had knowledge that Resident #52 carried several respiratory [DIAGNOSES REDACTED]. The facility was also aware the resident often refused to use the [MEDICAL CONDITION] machine because it caused discomfort, and the [MEDICAL CONDITION] had been broken and unusable for an undetermined period of time, but possibly several weeks. However, there was no evidence the physician was notified of the [MEDICAL CONDITION]'s malfunctioning, the resident's frequent refusals when it did function, and that there were no clear parameters for use of the [MEDICAL CONDITION]. The facility failed to accurately document the type of respiratory equipment the resident used ([MEDICAL CONDITION]), educate the resident and staff on [MEDICAL CONDITION] use, parameters and benefits; and the risks for failing to use it. The facility failed to identify the reasons for the resident's discomfort with the [MEDICAL CONDITION]; and failed to assess and implement measures to address and resolve the resident's concerns and encourage compliance. The facility failed to ensure the [MEDICAL CONDITION] was repaired in a timely manner. The facility failed to implement hospital recommendations on 11/7/19 for an outpatient sleep study. These failures contributed to Resident #52's reduced oxygen saturation levels which fell as low as 44 percent, and two hospitalization s during (MONTH) 2019 for [MEDICAL CONDITIONS] and [MEDICAL CONDITIONS] complications. The resident said it was very scary, she felt anxious when she had difficulty breathing, and the facility's failure to repair her [MEDICAL CONDITION] was neglectful. Cross-reference F600, failure to ensure residents were free from neglect. Findings include: I. Facility policy and procedure The General Administration of [MEDICAL CONDITION]/[MEDICAL CONDITION] (Bilevel Positive Airway Pressure) with a Mask policy, revised 9/1/18, documented the purpose of administration of a [MEDICAL CONDITION] with a mask was to provide positive pressure at end exhalation and enhance oxygenation to prevent alveolar collapse. Caution should be exercised in applying a snug or tight fitting full face mask (nasal/oral). Close clinical and physiological monitoring should be continuously conducted. Staff should discontinue the procedure if adverse reactions were noted and notify the physician. II. Resident status Resident #52, age 76, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 11/28/19 minimum data set (MDS) assessment revealed the resident did not have a brief interview for mental status (BIMS). The 11/14/19 MDS assessment documented moderate cognitive impairment with a BIMS score of 11 out of 15. The resident required supervision for transfers, ambulating in her wheelchair, eating and toileting. She needed limited assistance for bed mobility and personal hygiene. She required extensive assistance for dressing and bathing. III. Resident/family interviews Resident #52 was interviewed with a family member present on 12/9/19 at 11:44 a.m. They said the water reservoir tray on her [MEDICAL CONDITION] machine had been broken for several weeks, the staff knew it was broken, and had not done anything about it. Resident #52 was interviewed on 12/10/19 at 10:38 a.m. She said she did not know how to use the [MEDICAL CONDITION] machine that was currently in her room. She said she had two or three different machines in her room over the past few months, but they were all [MEDICAL CONDITION] machines and not [MEDICAL CONDITION]. She said she had not used the [MEDICAL CONDITION] in a couple of weeks and that was too long for her to go without it. She could not recall who she told about the machine being broken. The resident was interviewed on 12/10/19 at 5:36 p.m. She said the facility finally fixed her [MEDICAL CONDITION] machine that afternoon and she planned on using it that night. The resident was interviewed on 12/11/19 at 8:31 a.m. She said she had a good night, but did not use the [MEDICAL CONDITION] as it was not working again. Resident #52 was interviewed on 12/11/19 at 3:30 p.m. She said she thought her [MEDICAL CONDITION] machine had been broken for about a month. She said, I don't know what that machine is for exactly. She said it was very scary for her when she wanted to take a deep breath and could not. She said that experience made her anxious. She said she understood the [MEDICAL CONDITION] machine had been fixed, but it took quite a bit of time and a lot of talking to get it done, The resident's family member was interviewed on 12/12/19 at 9:40 a.m. He said he was appreciative that his mother's [MEDICAL CONDITION] machine was finally repaired. He said he was an EMT (emergency medical technician) and knew his mother required that equipment to breathe and sleep better. He said the resident had never had a [MEDICAL CONDITION] machine while in the facility. Resident #52 was interviewed on 12/12/19 at 11:15 a.m. She said she felt it was neglectful of the facility to have taken so long to get her equipment repaired. She said she did not understand why it took so long, but said they may have delayed the request because staff knew she did not really like the [MEDICAL CONDITION] machine. IV. Record review [NAME] Physician orders The (MONTH) 2019 CPO included an order for [REDACTED].@ 4 LPM (liters per minute) continuously. Resident to wear [MEDICAL CONDITION] at night every shift. B. Medication administration records (MARs) and treatment administration records (TARs) The (MONTH) 2019 MARs/TARs revealed no orders for administration of C-PAP or [MEDICAL CONDITION] (see below - staff were alternately documenting [MEDICAL CONDITION] and [MEDICAL CONDITION] incorrectly). C. Care plans The care plan related to alteration in sleep patterns, dated 11/19/19, documented the resident used a [MEDICAL CONDITION] machine at night. Staff were to observe and evaluate the resident's sleep patterns with the use of the machine. The care plan related to [MEDICAL CONDITION], dated 11/19/19, documented the resident used a [MEDICAL CONDITION] while sleeping and staff was to encourage the resident and remind her to put the [MEDICAL CONDITION] on. The [MEDICAL CONDITION] was inaccurately referred to as a [MEDICAL CONDITION] in the care plans. Neither care plan addressed the resident's occasional refusal to use her [MEDICAL CONDITION] machine, or instructed staff to contact the resident's son to convince her to accept treatments. There was no evidence of staff documenting sleep patterns with the use of the [MEDICAL CONDITION] machine as care-planned. (See record review below.) D. Resident hospitalized from [DATE] through 11/7/19 1. Progress notes The health status note dated 11/1/19 at 9:58 p.m. documented the resident's oxygen saturations were progressively dropping this date. She was around 77% at 4:00 p.m. After dinner, the resident dropped to around 72%. The resident said she felt fine, but she was taking short, shallow breaths. Her lips were ashen and she was told she needed to go to the doctor, but the resident refused. Around 7:00 p.m., the resident dropped to 58%. Staff tried to give her an as needed (PRN) duo-nebulizer treatment, but the resident's saturations dropped to 44%. The resident was placed on six liters of oxygen per minute, but her oxygen saturations were still under 70%. A call was made to the on-call doctor, who advised the resident be transported to the emergency room . The resident was told of the physician's recommendation and refused to go to the hospital. The resident's son and power of attorney was contacted and he convinced her to go to the hospital. The resident's son was present in her room when the ambulance arrived to transport her to the hospital at 9:30 p.m. Her oxygen saturations were 69% at the time of transport. The primary care physician was contacted and the resident's son followed the ambulance to the hospital. The social services late entry note dated 11/7/19 documented the resident was admitted to a local hospital from 11/1/19 through 11/7/19 for acute [MEDICAL CONDITION]. The resident had been educated she needed to be more compliant with her [MEDICAL CONDITIONS] at night and the resident was discharged from the hospital with those respiratory therapy orders. The health status note dated 11/7/19 at 8:55 p.m. documented the resident was ordered to wear a [MEDICAL CONDITION]/[MEDICAL CONDITION] machine, but the progress note documented the machine in the resident's room was not working, the resident's son was notified about the malfunctioning machine and the facility would try to figure out what to do about it the following morning. The son said the physician at the hospital was going to order [MEDICATION NAME] (anti-anxiety medication) to help Resident #52 sleep so she would wear the ordered [MEDICAL CONDITION] all night long. The hospital physician did not follow through with the order and the resident's primary care physician (PCP) was notified. The daily skilled nurse's note dated 11/8/19 at 11:31 p.m. documented the resident used a [MEDICAL CONDITION] at night, but it was not working the evening prior and the day nurse had been informed. The resident required daily skilled teaching and training for respiratory therapy compliance. The daily skilled nurse's note dated 11/21/19 at 6:15 p.m. documented the resident had become more compliant with wearing her [MEDICAL CONDITION]. The daily skilled nurse's note dated 11/23/19 at 5:32 a.m. documented the resident was on oxygen and used her [MEDICAL CONDITION] at night. However, the resident would only wear the [MEDICAL CONDITION] machine for a few hours before removing it and complaining that she did not breathe comfortably while wearing it. There was no documentation in the resident's chart that the physician was notified about the resident's complaints about the [MEDICAL CONDITION] machine, or that the facility attempted to address the resident's discomfort with the [MEDICAL CONDITION]. 2. Hospital discharge summaries The discharge summary dated 11/7/19 documented the resident's [DIAGNOSES REDACTED]. The recommendations to the primary care team included the need to resume her [MEDICAL CONDITION] at her previous settings with 4L/nc (four liters via nasal cannula) of oxygen during the day and [MEDICAL CONDITION] every night, otherwise we'll be at risk for CO2 narcosis recurrence. Consider outpatient sleep study to titrate settings, but continue prior settings at this time. This resident was admitted on [DATE] for shortness of breath. She was off her [MEDICAL CONDITION] overnight. The hospital was able to confirm that the resident had a [MEDICAL CONDITION] that she was supposed to be using and could be resumed, so the hospital's plan was to send her back to the facility to resume her [MEDICAL CONDITION] and consider an outpatient sleep study. The summary documented the resident was at very high risk to develop recurrent carbon [MEDICATION NAME] narcosis and subsequent return to the hospital if she was non-compliant with her [MEDICAL CONDITION]. 3. Nurse practitioner (NP) note The NP note dated 11/8/19 documented the resident had been recently hospitalized for [REDACTED]. The NP spoke with facility staff who said the resident's vital signs were stable, but her [MEDICAL CONDITION] was not working and the staff had a call into someone to get it looked at. The resident did not want to keep going in and out of the hospital. The resident said her breathing was better, but that her [MEDICAL CONDITION] was not working. The NP's plan was for the resident to wear her [MEDICAL CONDITION] nightly. The resident was counseled and the facility staff was working on getting her equipment checked out. E. hospitalized from [DATE] through 11/30/19 1. Progress notes The health status note dated 11/28/19 at 2:16 p.m. documented Resident #52 was having difficulty breathing and her oxygen saturations were less than 80%. Her son was called and he wanted her hospitalized . Emergency services were called and the resident was taken to the local emergency room via ambulance. The health status note dated 11/30/19 at 9:34 p.m. documented the resident returned from the hospital around 3:00 p.m. that date. The health status note dated 12/1/19 at 5:08 a.m. documented Resident #52 was unable to use her [MEDICAL CONDITION] because it fell on the floor and was broken. It needed to be repaired. 3. Hospital discharge summary The discharge summary dated 11/30/19 documented the resident's [DIAGNOSES REDACTED]. The resident was admitted to the hospital on [DATE] and presented with shortness of breath secondary to an acute exacerbation of [MEDICAL CONDITION]. The shortness of breath had improved by the morning after admission and she had been placed on oxygen and a nasal cannula. The resident required [MEDICAL CONDITION] in the emergency department. The recommendation to the primary care team was to encourage the resident to continue to use her [MEDICAL CONDITION] in the facility every night as directed. The resident was discharged to the facility in stable condition on 11/30/19. According to the timeline provided by the director of nursing (DON) on 12/17/19, the after visit summary did not include the orders for the [MEDICAL CONDITION], but the above mentioned discharge summary did. The facility failed to clarify those orders in a timely manner or unsure the respiratory orders were transferred to the (MONTH) 2019 MAR/TAR. F. Subsequent progress notes The health status note dated 12/4/19 at 9:58 p.m. documented a call was placed to the respiratory supply company to report Resident #52's [MEDICAL CONDITION] needed repair, as the chamber that held the water was broken. The health status note dated 12/5/19 at 9:45 p.m. documented the respiratory supply company phoned back and would have a new part for the [MEDICAL CONDITION] sent by overnight mail. The company said they would send it to the attention of the nursing home administrator (NHA) or the registered nurse who phoned in the repair request the day prior. The health status note dated 12/11/9 at 4:04 p.m. documented Resident #52's [MEDICAL CONDITION] machine was repaired the afternoon of 12/10/19 (during survey, after being called to the facility's attention). The resident had three [MEDICAL CONDITION] masks in her room and the preferred mask was placed on the machine with extra supplies stored in the resident's closet. The evening nurse working 12/10/19 was notified that the machine was now functioning and ready to go. Today's day shift nurse reported Resident #52 wore her [MEDICAL CONDITION] for one hour last night. The health status note dated 12/14/19 at 1:20 a.m. documented the resident had been refusing to wear her [MEDICAL CONDITION], which was offered to her three times. Staff documented the resident made up excuses and created delays. The resident agreed to wear her [MEDICAL CONDITION] when her oxygen saturations improved when wearing the machine. The interdisciplinary progress notes were reviewed for the past 30 days and Resident #52's non-compliance with wearing her [MEDICAL CONDITION] was documented for five of the 30 days reviewed: 11/19/19, 11/25/19, 12/11/19, 12/12/19 and partially on 12/14/19. After record review related to Resident #52's hospitalization s of 11/1/19 and 11/28/19, the facility had no systems or processes in place for clear documentation as to when the resident's respiratory equipment was functioning or in disrepair, no processes to ensure timely repair of the equipment and no processes to ensure the resident's non-compliance with her [MEDICAL CONDITION] was addressed in the care plan by interventions such as a thorough investigation into why the resident was non-compliant, following through with a recommended sleep study or involving the family in addressing the non-compliance to aid in the resident's fear and discomfort with her equipment. V. Staff interviews The assistant director of nurses (ADON) was interviewed on 12/10/19 at 10:49 a.m. She said she was aware Resident #52's [MEDICAL CONDITION] machine was currently broken. She said she knew the resident had been in and out of the hospital recently and that she had two [MEDICAL CONDITION] machines in her room and was not sure which machine was still in her room. She said she had never seen a [MEDICAL CONDITION] machine in the resident's room. She said she was told the resident said she did not know how to use the machine and said it had been too long since she used it, as she was supposed to use it nightly. The ADON said she would have to check the MARs. The ADON was interviewed a second time on 12/10/19 at 12:19 p.m. She said she did not see an order for [REDACTED]. She said the order should have been on the MARs, but it was not for some reason. She said, after the situation was called to her attention, she added the order earlier that morning. She said she did not feel the missing order was the reason the resident's malfunctioning machine was not addressed in a timely manner. She said she currently did not have an answer why Resident #52's [MEDICAL CONDITION] machine was not repaired in a timely manner. The ADON was interviewed again on 12/10/19 at 2:23 p.m. She said, after researching the issue, the order for the [MEDICAL CONDITION] was on the facility's MARs from (MONTH) through (MONTH) 2019. The resident went to the hospital for issues with [MEDICAL CONDITION] and [MEDICAL CONDITION] on 7/2/19 and was discharged back to the facility on [DATE]. When the resident returned to the facility, the staff failed to place the [MEDICAL CONDITION] order back on the MARs and the order had been left off the MARs ever since. She said she put the order back on the MARs earlier that morning when the issue was called to her attention and used the parameters given to her by the medical director (MD) on 11/11/19. The parameters were to use the [MEDICAL CONDITION] when the resident required 5 liters of oxygen/minute or if her oxygen saturations were 85% or less. She said the parts to repair the resident's [MEDICAL CONDITION] machine were sent via overnight express and the facility received the parts yesterday. She said the machine had yet to be fixed, but she was planning on fixing it later today. She said the resident's son would be coming in to speak to the resident about being more compliant with using the [MEDICAL CONDITION]. She was asked how a resident could be non-compliant with a malfunctioning machine and the ADON had no response. Registered nurse (RN) #4 was interviewed on 12/11/19 at 8:32 a.m. She said she worked the evening prior and Resident #52 did use her [MEDICAL CONDITION] for an hour, as it was working. She said the resident was becoming forgetful and more confused and she wondered what the resident's expectation for using the [MEDICAL CONDITION] was. The RN said she had not asked the resident that question, but would. RN #4 was interviewed a second time on 12/11/19 at 9:13 a.m. She said she had spoken with Resident #52, who stated she had no idea why she was supposed to be using the [MEDICAL CONDITION] machine, so RN #4 provided re-education to the resident. She said she told the resident the machine helped push the oxygen into her body so she could sleep better at night. She said the resident had been educated many times, but was forgetful. RN #4 said she worked one week and was off the next, and the resident's [MEDICAL CONDITION] had broken before her week off, which just ended. She said the resident's [MEDICAL CONDITION] must have been broken for over a week if it had just been repaired yesterday. She said the facility got her a larger mask in the last day or so, which should help with the resident's comfort when using the machine. Licensed practical nurse (LPN) #4 was interviewed on 12/11/19 at 3:46 p.m. She said she was aware Resident #52's [MEDICAL CONDITION] machine had not been functioning and knew the machine had broken when she was working on 12/1/19. She was told that the [MEDICAL CONDITION] machine's cartridge which held the reservoir water had broken and needed to be replaced. She said when she returned to work on 12/4/19, the machine was still broken and no one had contacted the manufacturer yet. LPN #4 said she called the manufacturer herself and was told the manufacturer would call her back that day, but they did not. She said she called the manufacturer again on 12/5/19, and she was told a replacement part would be sent overnight on 12/6/19, which would be received by the facility on 12/7/19. LPN #4 said Resident #52 was non-compliant with her [MEDICAL CONDITION] machine, as she hated it. She said the resident would allow staff to put it on her, but the resident would often remove it later. She said the resident's baseline oxygen saturations ranged from the mid-80s to the low-90s. She said the resident wore her oxygen with nasal cannula all day long with no issues. She said she thought the [MEDICAL CONDITION] mask was scary for the resident. She said the facility managed respiratory care for this resident, who was resistive to using her [MEDICAL CONDITION] consistently and required recent hospitalization s for respiratory issues, by calling the resident's son, who was a paramedic, to encourage his mother to use the prescribed equipment for her respiratory care. She said the resident was compliant when her son told her to do something (not care planned - see above). She said she could not recall when the primary care physician (PCP) was notified about the [MEDICAL CONDITION] machine being broken. She said she would research the PCP's notification. LPN #4 was interviewed on 12/11/19 at 4:03 p.m. She said she could find no documentation that the PCP had been notified about Resident #52's [MEDICAL CONDITION] being broken. Restorative nurse aide (RNA) #3 was interviewed on 12/16/19 at 10:05 a.m. She said if a resident had a piece of equipment the physician had ordered and was malfunctioning for whatever reason, it should be replaced as soon as possible, especially if it was a piece of respiratory equipment. She said the facility usually ensured equipment was functioning in a timely manner, but if management was aware of malfunctioning equipment and did not address it in a timely manner, it could be considered neglectful. Certified nurse aide (CNA) #10 was interviewed on 12/16/19 at 10:25 p.m. She said the repair of malfunctioning equipment would depend on the circumstances and if the resident or the facility owned the equipment. She said she knew Resident #52 had an order for [REDACTED]. She said she was aware the resident had dropped the machine a few weeks ago and it was not working. She said she called the malfunctioning machine to the attention of the night nurse working at the time and to RN #3. She said, to her knowledge, the [MEDICAL CONDITION] machine had been repaired, but was uncertain as to when the repair was made. CNA #8 was interviewed on 12/16/19 at 11:15 a.m. She said she was aware the resident did not like her [MEDICAL CONDITION] machine and had problems wearing it because the mask did not fit her correctly. She did not know if the facility had tried different sizes of masks for this resident. She said she was not aware anything had been wrong with the machine other than an incorrectly fitting mask. She said if a resident did not have a piece of equipment when ordered or if that equipment had not been working properly, it was neglectful if the facility did not address the needs in a timely manner. The medical director (MD), who was also Resident #52's primary care physician (PCP), was interviewed on 12/16/19 at 11:55 a.m. She said she was aware the resident did not want to wear her [MEDICAL CONDITION] machine in the facility, but was willing to wear it while in the hospital. She said different masks had been tried with the resident, but those attempts did not help with her level of compliance. She said the resident had very tenuous heart failure and [MEDICAL CONDITION]. She said she had cared for Resident #52 for over five years and her cognition was declining and at this point, the resident could not see the pros and cons of using a [MEDICAL CONDITION] machine. She said the [MEDICAL CONDITION] had been ordered by the hospital for her [MEDICAL CONDITION], who did everything by the book and did not take resident nuances into consideration. She said she had not been aware the order for the [MEDICAL CONDITION] had dropped off the facility's MARs after (MONTH) 2019 until the ADON shared this with her on 12/10/19 and the order was reinstated with the last parameters the physician ordered back in (MONTH) 2019. She said Resident #52 had an order for [REDACTED]. She said she was aware this issue had not been on the facility's radar until the resident and her son again stated on 12/9/19 the [MEDICAL CONDITION] machine had not been working for some time. She said she had not been alerted the [MEDICAL CONDITION] had broken again after 11/7/19. She said she was not aware the [MEDICAL CONDITION] was not repaired until 12/11/19. She said the resident had been non-compliant with the [MEDICAL CONDITION] when it was working and the rate of the resident's non-compliance was the same regardless if the machine was working or not. She said maybe the facility had been in a conversation about Resident #52's non-compliance for so long, the facility just dropped the order and cried uncle. She said the resident had been hospitalized twice for respiratory issues since (MONTH) 2019 and said the non-use of the [MEDICAL CONDITION] would be a piece of the puzzle, but the reason for Resident #52's respiratory exacerbation was multifaceted. She said she was aware that Resident #52 was often non-compliant with using her respiratory equipment when the equipment was working. She said the known non-compliance should have been addressed and should have been care planned with interventions in place to address the resident's non-compliance. The director of nurses (DON) and the NHA were interviewed together on 12/16/19 at 1:15 p.m. The DON said the resident had been non-compliant with her [MEDICAL CONDITION] machine 95 percent of the time since returning from the hospital. She said the resident would return from the hospital, wear the [MEDICAL CONDITION] for a few days and then start refusing it. She said the resident had been known to hide parts of her machine after taking them apart. The NHA said the facility tried different masks and different machines. She thought, at one time, the resident had three different [MEDICAL CONDITION] machines in her room. The NHA was uncertain who owned the [MEDICAL CONDITION] machines, but knew the facility was not being billed for them. The DON said she would have to look at the stickers on machines to see who owned which machine. The DON thought one of the machines was functional when the resident went to the hospital in early November. The NHA said she went to the hospital 11/1/19 and returned 11/7/19, and also was hospitalized [DATE] and returned 11/30/19. The DON said the doctor may have mentioned [MEDICATION NAME] while the resident was in the hospital, but the doctor never followed up with the prescription. The DON said the [MEDICAL CONDITION] machine currently in the resident's room was functioning as of 12/13/19. The NHA said the resident was very self-directed and non-compliant with various aspects of her care besides the use of the [MEDICAL CONDITION]. The DON and the NHA said they were not aware the order for the [MEDICAL CONDITION] had been dropped off in (MONTH) of 2019. They said they both expected the resident's non-compliance to be part of her care plan, including interventions. They said Resident #52 did have an order for [REDACTED]. The order was to continue the [MEDICAL CONDITION] for OSA QHS (every hour of sleep) with no parameters. They said this order should have been transferred to the (MONTH) 2019 MAR, but was not. The DON said the order should have been on the MAR and did not know how the most recent order from the hospital had gotten missed on their current MAR. The DON said the resident's non-compliance with the respiratory equipment was probably on her care plan back in July, but it got left off for some reason. The social services director (SSD) was interviewed on 12/16/19 at 3:25 p.m. She said the resident had two different [MEDICAL CONDITION] machines currently in her room. She said the machine the family owned had stopped working and the SSD put the non-working machine on the top shelf in the resident's closet. She said the second machine had a problem with the cord and was not working when the resident returned from the hospital on [DATE]. The SSD said she got the number from the respiratory company off the machine's sticker and called the company and was transferred to six different people. She said she saw a representative from the company in the facility, explained the situation to him and the representative was able to get another cord and the machine repaired within the hour of reporting it to the company. She said the respiratory company was good to work with and they fixed their equipment in a timely manner. She said no one notified social services about the broken water reservoir or when it had broken. She said she learned the equipment was broken when she saw it in an internal communication note dated 12/9/19. She thought it broke sometime around 12/1/19 and she had seen a progress note in which the ADON repaired the [MEDICAL CONDITION] with the replacement part on 12/11/19. After researching the issue, the SSD said an initial call was placed to the respiratory company on 12/4/19. She saw a note the respiratory company responded on 12/5/19 and said they would be overnighting the part, which the facility could expect on 12/6/19. She said she did not see any further progress notes in the chart about this issue other than the ADON had fixed the [MEDICAL CONDITION] on 12/11/19. She said she knew the equipment was working on 12/11/19, as there was a progress note documenting the resident wore her [MEDICAL CONDITION] for about an hour that evening before removing it. She did not comment on whether she had intervened to assess and address the resident's non-compliance, education regarding risks/benefits, or family notification to encourage the resident's compliance with [MEDICAL CONDITION] use. According to the above staff interviews, the facility had inadequate systems and processes in place to ensure orders for the respiratory equipment were up to date, to update the care plan to address the resident's non-compliance with her [MEDICAL CONDITION], to educate the staff as to the difference between [MEDICAL CONDITION] and [MEDICAL CONDITION], to ensure the equipment was functional and to update the PCP as to all issues related to Resident #52's respiratory care in a timely manner. The facility relied solely on re-educating a resident, whose cognition was deteriorating and fluctuating, on why she needed to use her [MEDICAL CONDITION]. The intervention was ineffective on assisting with keeping Resident #52 out of the hospital for respiratory distress.

Based on observations, record review, and interviews, the facility failed to provide necessary and appropriate assistance with incontinence care, toileting and transfers for one (#50) of four residents who were unable to carry out activities of daily living (ADLs) out of 30 sample residents. Specifically, the facility failed to thoroughly assess Resident #50's urinary incontinence, identify and respond to his requests for help with toileting and provide timely assistance with incontinence care or transfer to the toilet, and not ignore his requests for the bathroom and treat them as a behavioral symptoms instead. These failures contributed to Resident #50's agitation, exhibited by moaning, talking to himself, and calling out for help. His requests for toileting assistance were ignored by staff and his needs were not acknowledged for more than 44 minutes. His moaning was dismissed by staff with comments that included: Just relax, It gets to the point where he tires himself out and then he just stops, I think he might like to hear himself and maybe it is his own little quirk, and It seems to keep him plenty content. Cross-reference F600, failure to ensure residents were free from neglect. Findings include: I. Facility policy and procedure The Toileting Program policy and procedure, dated 9/1/18, provided by the director of nurses (DON) on 12/16/19 at 5:02 p.m., documented a toileting program improved and/or maintained a resident's ability to control his elimination and decrease episodes of incontinence. A toileting program referred to activities and exercises that included: Regularly contacting the resident to provide an opportunity to toilet; Encourage or help (by cueing or directing) the resident to go to the bathroom or use a urinal, commode or bedpan to attempt to void; Provide toileting when a resident gave an affirmative response to the prompt to void; Establish some type of timed voiding schedule; and Establish an individual pattern of voiding and toileting based on the resident's habits. The goals of a toileting program were to enable the resident to control urination or reduce episodes of incontinence, and improve the resident's morale and sense of dignity and self-worth. Residents who were incontinent were assessed specifically to identify the cause of the incontinence and to decide if it was reversible. Residents who were not fully functional in ADLs had a greater potential to become incontinent. The resident who was unable to transfer due to lower extremity weakness, joint limitations, pain, balance problems, sight or communication problems may be compromised in his ability to get to a bathroom. II. Resident status Resident #50, age 83, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 11/14/19 minimum data set (MDS) assessment revealed the resident had short- and long-term memory problems, adequate vision, and clear speech. He required extensive assistance with bed mobility, transfers, and eating, and total assistance with dressing, toilet use, and personal hygiene. [MEDICAL CONDITION] behaviors included hallucinations and delusions that were present and he had verbal behavioral symptoms directed toward others that occurred one-to-three days. His symptoms did not interfere with his care and he had no rejection of care. He was always incontinent of urine and bowel. A trial of a toileting program had not been attempted and he was not currently on a toileting trial or program. III. Record review The care plan, initiated 5/23/17 and last revised 3/30/18 (over 11 months ago), identified limitations in his ability to perform ADLs. The goal was the staff would assist him to maintain his functional status and decrease his risk for functional decline to perform and/or assist with completing his ADLs. The approaches included offer choices, explain all procedures, and do not rush. He required extensive assistance from staff for toilet use and was incontinent, to be checked and changed upon arising, before and after meals, at hour of sleep, and as needed. He required extensive assistance from staff for personal hygiene. The Bowel and Bladder Continence Evaluation, dated 11/14/19, documented the resident had bladder incontinence for an unknown duration and his bladder symptoms were stable over the past six months. He had urinary incontinence accidents greater than once a day that included soiled/wet undergarments. The following sections of the form were void of documentation: How frequently he went to the toilet on average each day, if he used any incontinence products, and approximately how many incontinence products he used in a 24-hour period. The following sections of the form were marked, Unknown/unable to answer: Do you have to rush to the bathroom when you feel the urge to void? Do you leak urine on the way to the bathroom? On average, how long can you hold on after feeling the first urge? Do you feel you have completely emptied your bladder when you pass urine? Are you aware of your urge to void? Are you aware of urine being passed? Are you aware when you are wet? Do you have trouble starting to pass urine? Do you have to strain or push to start to pass urine? Do you experience dribbling after you finish passing urine? IV. Observations 12/9/19 Continuous observation of Resident #50 on 12/9/19 from 4:23 p.m. to 5:20 p.m. revealed the following: At 4:23 p.m., Resident #50 had just been transferred from his recliner to his wheelchair. He was moaning continuously, which could be heard in the hallway, and he was agitated and restless. He asked loudly if someone was going to use the bathroom and stated, I've got to go in there for a couple minutes. Oh! Oh! Oh! He said, I'm just warning everybody that I'm going in there and I will be in there for a couple minutes. At 4:24 p.m., the nursing home administrator (NHA) walked past the room and did not stop to check on him, and he continued to moan loudly. At 4:25 p.m., certified nurse aide (CNA) #11 walked past his room and did not stop. He continued to moan and could be heard from the hallway. He said, Is anybody going to be in there before I get in there? Is somebody going to be bothered by .inaudible . and he continued to moan loudly. At 4:26 p.m., CNA #11 pushed another resident in a wheelchair past Resident #50's room, looked inside, and then walked back down the hall and talked to another CNA at the nurses' station without stopping to see what he needed. He continued to moan at 4:29 p.m., and still could be heard in the hallway. At 4:30 p.m., two CNAs (#5 and #2) walked past Resident #50's room while he was moaning, and entered the tub room directly across the hall without stopping to see what he needed. At that time, the resident's roommate yelled, I've got to get the (expletive) out of here! No one responded to his yelling. At 4:33 p.m., restorative nurse aide (RNA) #2 was pushing a resident in their wheelchair past Resident #50's room and he looked inside the room and kept walking. Licensed practical nurse (LPN) #8 pushed her medication cart past his room while he was moaning and did not stop to check on him. At 4:34 p.m., an unidentified staff member was pushing a resident in their wheelchair past the resident's room as he continued to moan loudly and did not stop to check on him. At 4:36 p.m., the maintenance director (MNTD) walked past the resident's room and did not stop to check on him as he continued to moan loudly. At 4:38 p.m., the business office manager (BOM) walked past his room and did not stop to check on him as he continued to moan. She saw the mental health consultant (MHC) walking towards her in the hallway and said to her, Cute overcoat, and then walked back to the nurses' station without checking on the resident. At 4:39 p.m., the NHA walked to a bulletin board directly across the hall from the resident's room to post something, and then continued walking away without checking on him. At 4:40 p.m., CNA #11 entered the resident's room and offered him a drink of water. He continued to moan as she left the room and he said loudly, I'll be on the toilet. She did not stop or assist him to use the bathroom. At 4:41 p.m., registered nurse (RN) #2 and the DON walked past his room and did not stop to check on him, and he continued to moan loudly. At 4:42 p.m., Resident #50 stated, I'm going now! I'm going now, so don't pound on the door! and he continued to moan loudly. At that time, RNA #2 was walking past his room and did not stop to check on him. At 4:43 p.m., CNAs #5 and #2 walked back by his room and did not stop to check on him as he continued to moan loudly. At 4:44 p.m., a visitor walked past his room and slowly looked inside to observe the moaning, and continued to walk by. RN #2 walked past his room again and went to the nurses' station to wash her hands. At 4:45 p.m., LPN #8 walked past his room and she was carrying a cup. She stopped in the hall at the entrance to his room, looked inside, and then continued walking and did not stop to check on him. At 4:46 p.m., Resident #50 yelled, Here I go! Don't anyone pound on the door for a while. He continued to moan. CNA #11 walked to his room entrance and stopped, looked in, and then continued walking without checking on him. His moaning was continuous and he said, I've got to go! I've got to go! At 4:47 p.m., CNA #5 was sitting at the nurses' station next to the resident's room, and continued to work on the computer without checking on the resident while he was moaning. At 4:49 p.m., CNA #12 entered Resident #50's room. He continued to moan and she checked her hair in the mirror, made an adjustment to it, and then washed her hands and said, What's the matter, (Resident #50)? His response to her was not audible from the hallway and at 4:50 p.m., she left his room and he continued to moan. At 4:57 p.m., Resident #50 was asked if he needed to use the restroom and he stated, Yah, need the bathroom, and continued to moan. At 4:58 p.m., CNA #11 looked inside his room from the hallway, and continued walking. A female visitor walked past his room and looked in, then continued walking. LPN #3 walked past the resident's room without stopping to see what he needed as he continued to moan. At 4:59 p.m., an unidentified staff member walked past his room and did not stop to check on him and he was moaning loudly and appeared to be uncomfortable. At 5:00 p.m., Resident #50 yelled, I've got to go right now! and continued to moan loudly. CNA #11 entered his room at 5:02 p.m. and asked him if he needed something. He did not respond and she told him they were going to have dinner soon, and he continued to moan. He did not respond to her verbally and she sanitized her hands and left the room. At 5:03 p.m., the staff development coordinator (SDC) heard his moaning from the hallway, entered his room, and asked him if he was feeling okay and he said, Yah. He stated, I need to go to the bathroom. The SDC did not hear his response and she offered him a drink of water. She washed her hands and told him she would go get his nurse really quick. She left the room at 5:05 p.m. and he said, I want to go. At 5:07 p.m., the nursing supervisor (NS) entered his room and asked him if he was hurting, and he said No. She told him his nurse was going to bring him his pain medicine. At 5:08 p.m., the SDC returned to his room, brought a warm towel, and put it around his neck. He complained that it was too warm, so she moved it to his hands, which he preferred. The SDC said Resident #50's moaning reminded her of when her kids would be in the back seat of a car and they would just hum and then would fall asleep. At 5:11 p.m., RN #2 returned to his room with his pain medication. He continued to moan, and he took the crushed medication at 5:12 p.m. She told him she was going to go see if his supper was ready, and explained that his moaning was normal for him. She said she thought it was a comfort thing. The RN was asked if Resident #50 was having pain and she said, I will ask him. She asked him if he was having pain, and he said no. At 5:18 p.m., Resident #50 was pushed to the dining room in his wheelchair by CNA #11 and placed at a table in the assisted dining room. She placed a clothing protector around his neck, and he was fed his dinner meal without being toileted. A total of 13 different staff members walked past his room without helping him. For 44 minutes, his bladder and toileting needs were not addressed while he was calling out for help. He was taken to the dining room without being offered the opportunity to use the restroom or change his incontinence brief. He ate 75-100% of his meal, for an additional amount of time without being toileted. 12/10/19 On 12/10/19 at 12:45 p.m., Resident #50 was observed sitting in his wheelchair at a table in the dining room, eating his noon meal. RN #3 was seated at the table assisting him and he was calm and quiet. At 12:57 p.m., he was finished with his lunch and CNA #12 pushed him out of the dining room and placed him in his room facing the TV. He was not offered or provided toileting after the meal. At 1:31 p.m., Resident #50 was still sitting in his wheelchair in his room. He was moaning loudly and he could be heard in the hallway. At 1:32 p.m., CNA #4 and CNA #12 entered the resident's room with a sit-to-stand mechanical lift to check and change him and place him in bed. They did not offer the resident the use of a urinal or to sit on a toilet or commode. CNA #4 donned gloves without washing her hands and removed the foot pedals from the wheelchair. She doffed the gloves and donned a clean pair without washing her hands. The CNAs leaned the resident forward and placed the sling behind his back. He continued to moan and CNA #12 told him, You're okay. They pushed the lift up to his anterior shins, placed his legs in the leg rests, and buckled them in with a strap behind his calves. The loops on the sling were hooked on the lift and his hands were placed on the handlebars. CNA #4 engaged the lift and raised him upwards from his wheelchair seat. His feet were not on the lift foot platform to support his weight, but instead, all of his weight was on the front of his shins below his knees. (Cross-reference F689, failure to prevent accident hazards) Resident #50 continued to moan as the lift was moved in front of the bed and he was lowered down onto it. They removed the sling and assisted him to lay down on the bed. CNA #4 told him, Just relax, (Resident #50). At 1:39 p.m., CNA #12 removed his pants and his brief, which was saturated with urine, and provided peri care. CNA #4 told him, Just relax. It's okay, and he said, It's not okay. His face was ruddy red and he continued to moan. At 1:47 p.m., the CNAs covered the resident with a blanket, placed a fall mat on the floor beside his bed, and left the room. At 1:50 p.m., RN #2 said Resident #50 was routinely resistive to peri care and it was a struggle. At 2:00 p.m., after the lights in his room were turned off and he was left alone, he continued to moan and it could be heard from the hallway. It was shift change and there were five nursing staff members seated in chairs at the nurses' station next to his room. None of them got up to check on him until CNA #12 went into his room at 2:25 p.m. (He moaned loudly for 25 minutes without being checked on or assisted). On 12/11/19 at 8:30 a.m., Resident #50 was sitting in his wheelchair in the assist section of the main dining room. His eyes were closed and he was quiet and calm. At 8:50 a.m., his breakfast was served, and he ate approximately 25% of the meal with assistance. He was taken back to his room at 9:01 a.m. by MDS #2 and placed in his room in the dark. He was not offered toileting or checked and changed immediately after the meal. Continuous observation was conducted from 9:01 a.m.-10:02 a.m., and he was not offered toileting or checked and changed. He remained quiet and calm. On 12/11/19 at 12:28 p.m., Resident #50 was sitting in the assist section of the dining room eating his lunch. He was calm and alert. On 12/12/19 at 9:26 a.m., Resident #50 was sitting in his wheelchair in his room talking with a male visitor. He was calm and alert. On 12/16/19 at 8:40 a.m., Resident #50 was sitting in his wheelchair in his room. A CNA was in the room with him assisting him to sit upright in his wheelchair. He was calm and cooperative with her. V. Initial staff interviews CNA #11 was interviewed on 12/11/19 at 3:37 p.m. and she confirmed she routinely worked with Resident #50. She said he was totally dependent on staff for ADL care, he was always incontinent of bowel and bladder, and never refused care. She said if a resident was moaning loudly, We should go in there and approach him and do comfort measures for them. She said Resident #50 moaned often and said she thought he did not know he was doing it. She said they had a weighted blanket they used on him but she did not know where it was. She said he denied being in pain frequently and usually food makes him quiet. She said he was supposed to be checked and changed every two hours, which included immediately after meals, and he was incontinent of urine every time they changed him. She said they did not offer for him to use the toilet because he is just incontinent. She said since she had worked at the facility, for two and a half years, We just change him. She said, We should probably put him on the toilet. We could probably do a commode, and explained the mechanical lift would not fit in his bathroom. She said, Maybe that would be better for him. She explained Resident #50 was usually up in his recliner rather than his wheelchair, because he tolerated it better. She said if he was up in his wheelchair for more than an hour, she thought that caused the moaning and said, I don't know if it is painful, or if it is just he is awake and it is something to do. LPN #2 was interviewed on 12/11/19 at 3:55 p.m., and confirmed she routinely worked with Resident #50. She said when a resident was calling out for help or moaning, Definitely something is wrong. They are in some kind of distress. She said staff should always go and check on them because there was something going on if they were moaning, which might be a way they were trying to communicate something. She said Resident #50 was not able to provide much care for himself but was able to tell her if he was in pain. She said his moaning had decreased in frequency since September, and during the night shift when she normally worked, he did really good. She said she had not seen him demonstrate any inappropriate behaviors and he did not refuse care. She explained he was incontinent of urine and was changed on routine rounds, so he is pretty incontinent every two hours. She said he was not offered to sit on the toilet or a commode during those rounds and stated, That is just what I have experienced since I've been here. I think he is not weight bearing so they are not putting him on a commode. She said she had noticed his moaning in the past and did not know if it was a comforting thing for him, but it gets to the point where he tires himself out and then he just stops. Poor thing. She explained they addressed his moaning by giving him pain medication, repositioning him, and laying him down. She said to her knowledge, his moaning was not related to being wet, and she did not think he was able to tell staff when he needed to use the bathroom. The social services director (SSD) and admissions director (AD), who was also the social services assistant, were interviewed on 12/11/19 at 4:17 p.m. The SSD said her job duties were psychosocial, and included digging deep into the resident's lives and asking those questions about who they were and where they came from, so they could better understand them. She said neglect was when residents were not being taken care of the way they should be and stated, When someone was ignoring a problem. The AD said neglect was anything that would cause harm to the resident if something was not done, could also be a form of abuse if it was not addressed. The SSD said if a resident was moaning and calling out for help, staff should go in and find out what was wrong and what their needs were, if something was wrong and following up. The AD said if a resident was unable to verbalize their needs, the staff should try to anticipate their needs; make sure they had food, water, and were changed within a reasonable amount of time. The SSD said she was very familiar with Resident #50 and worked more with his family because he was really not that verbal. Mostly just moaning and groaning. She said sometimes he was able to make his needs known and did not know why he moaned. She said, I think he might like to hear himself and maybe it is his own little quirk. She said they had tried non-pharmacological interventions in the past that included music therapy, TV, teddy bears, and Lincoln Logs, but he had not wanted any of those things recently. She stated, I don't know where his mind is at and don't know what to do to prevent the moaning. It seems to keep him plenty content. VI. Additional record review The Toilet Use documentation entered by the CNA and nursing staff for Resident #50 was reviewed from 10/1/19 through 12/11/19. It included if the resident used the toilet room, commode, bedpan or urinal, transfers on/off toilet, cleansing self after elimination and adjusting clothes. It revealed the resident required one or two person physical assistance for a total of 80 times over the 72 day period. The majority of the entries documented, Not applicable for a total of 133 times. The Urinary Continence documentation entered by the CNA and nursing staff for Resident #50 was reviewed from 12/1-12/16/19. It revealed the resident was checked for incontinence two to four times each 24-hour period, and he was incontinent all but once, on 12/10/19. A Comprehensive Psychological Progress Note, written by a licensed clinical psychologist, dated 2/1/18, was reviewed. The documentation revealed he had sun-downing issues and verbal outbursts, especially in the evening, loneliness, boredom, he was homesick, and missed his rancher lifestyle. He wanted to go back home but he knew he could not. Less angry and anxious. Smiles easily. This was the most recent psychological assessment completed by the psychologist, which was one year and nine months old. (Cross-reference to F679, Activities Meet Interest/Needs of Each Resident) The CPO for (MONTH) 2019 revealed the following orders: -[MEDICATION NAME] sprinkles (off label use as mood stabilizer for behaviors in dementia), 250 mg by mouth twice a day for behaviors. The medication was started on 3/18/19. -[MEDICATION NAME] (antidepressant) 10 mg by mouth once a day for [MEDICAL CONDITION]. The medication was started on 4/11/18. -Document behaviors for [MEDICATION NAME] every shift that included mood changes, withdrawn and crying. The interventions included redirection, remove from the environment, and give PRN (as needed) medication. The number of episodes, interventions, outcomes and side effects were to be documented. -[MEDICATION NAME] (antipsychotic) 150 mg by mouth every morning and at bedtime for dementia with behavioral disturbance. The medication was started on 8/9/18. -Document behaviors for [MEDICATION NAME] every shift that included danger to self or others and striking out or hitting. The interventions included redirection, removal from the environment, and give a PRN medication. The number of episodes, interventions, outcomes and side effects were to be documented. The behavior monitoring and tracking for the [MEDICAL CONDITION] medications were documented on the treatment administration record (TAR). The TAR for (MONTH) 2019 revealed the resident had one episode of striking out/hitting on 11/18/19, he had one episode of being withdrawn on 11/12/19, two episodes of yelling/screaming at his roommate (11/4 and 11/10), and one episode of verbal/physical aggression on 11/17/19. The TAR for (MONTH) 1-11/19 revealed the resident had two episodes of verbal/physical aggression, on 12/10/19. Redirection and removed from environment interventions were done with same and improved outcome results obtained. VII. Additional staff interviews CNA #4 was interviewed on 12/16/19 at 1:46 p.m., and she confirmed she worked with Resident #50 frequently. She explained the Toilet Use documentation that read, Not applicable meant the resident did not physically sit on the toilet or use a bedpan and stated, It is a check and change. She said the CNA charting was not completed immediately after they toileted a resident, but rather once at the end of their shift, so it did not reflect how many times the resident was assisted with toileting. She said Resident #50 was not toileted, but instead, checked and changed every two hours. She said he was never offered to sit on a commode or use the urinal and stated, I just think probably because his thought processes isn't complete enough. She confirmed he was incontinent of urine a couple times each eight-hour shift she worked and he was not able to provide any care for himself. The DON, NHA, and regional director of health services (RDHS) were interviewed on 12/12/19 at 11:35 a.m. The DON said the facility had a bowel and bladder check and change program and stated, It is kind of unwritten. She said it included taking residents to their room, checking them for incontinence, and changing them and providing peri care if they needed it. They said it should be provided for residents before and after meals, at bedtime, and as needed because some people were more frequent than others. The DON said not all residents were offered the use of a commode, toilet or urinal, and it depended on their individual cognition level. She clarified if they were verbally capable of answering when they were asked if they needed to go to the bathroom or be changed, it should be offered. The NHA said moaning and calling out by residents could mean different things, depending on each resident. She stated, For some it would mean they were in pain or needed assistance. We have some who that is their behavior. She clarified some residents who had dementia repeatedly said things or moaned, and that was normal behavior for them. She said if a resident was moaning and calling out for help, the staff should absolutely respond by knocking on the door, announcing themselves, and finding out what they needed. The DON said neglect was Not meeting a need, but could also include not giving them a choice. She said in reference to using the bathroom, if a resident did not get that choice, staff should give them that choice to say no and stated, Give them an opportunity to help direct their independence or care. The NHA said neglect was not meeting the needs of the person you were caring for by ignoring the need for care, not providing them with food, not getting them medical treatment, or not giving them any social interaction. The observations on the evening of 12/9/19 were shared with them. The NHA said Resident #50 was a check and change. The DON said that was typical behavior for him and stated, Sometimes he is herding cows and he will say, 'shut the (expletive) gate,' and it is repetitive and continuous. We should be documenting it as a behavior. She explained they had several different interventions for him that were sometimes effective. She said he moaned constantly all day and stated, If he is quiet, that is the exception. The DON said they had not been able to figure out why he was moaning and said sometimes he did not know why he was doing it. She looked in the computer to see if any mental health evaluations had been completed, and confirmed he had not been evaluated since (YEAR). The NHA agreed Resident #50's moaning meant he had an unmet need and explained he was challenging because he was unable to tell the staff what was wrong. She said staff routinely went through the list of potential needs including if he was in pain, needed toileting, if he was tired, cold, or hot. Because the resident said the words, bathroom, Go! Go! Go! and I'll be in the toilet, a reasonable person would be able to conclude Resident #50 needed to use the bathroom. The medical director (MD), who was also Resident #50's primary care physician, was interviewed on 12/16/19 at 11:50 a.m., and confirmed she knew the resident well. She said the resident's moaning, or vocalizations, were important for the staff to make sure it was not a symptom of discomfort versus just a symptom of expression. She clarified if he was saying words that made sense, the staff should check on him. She said, If a resident is making vocalizations that he needed something, they should check on him. The DON provided an update on 12/16/19 at 2:32 p.m., of the neglect investigation she was conducting related to Resident #50 that occurred on the afternoon of 12/9/19. She clarified the investigation was not complete and was still on going. She said he had not received a three-day bowel and bladder baseline evaluation, so they were currently conducting one to see if he was able to go to the bathroom and see what that looked like for him. She said none of the staff could recall hearing him ask to go to the bathroom in over a year. She explained the three-day assessment was not completed before because it is a paper thing we have to pull out and do. She said their electronic medical record did not have that function and it had to be hand-written. She said the facility had completed neglect training and staff interviews related to Resident #50's baseline behaviors and the moaning, and a total of six employees and 10 residents had been interviewed so far. She said the facility contacted the licensed clinical psychologist to see why she quit seeing Resident #50, and she said he had poor cognitive reasoning, short- and long-term memory problems, repetitive talking, and progressive, severe, depressive dementia and was not able to express insightful thoughts. She said she would put a plan in place to address his bowel and bladder needs when the three-day assessment was completed, and would review his care plans to make sure they were all up to date. VIII. Facility follow-up On 12/17/19 at 5:00 p.m., after exit, the facility provided additional documentation on the follow up for Resident #50. The three-day bowel and bladder flowsheet was still in progress. A therapy evaluation reviewed his use of the sit-to-stand lift and recommended the change to utilize the dependent Hoyer lift for all transfers when he was unable to stand. The staff were provided education on neglect and a future neglect training would be provided to facility staff by the SDC.

Based on observations, record review and family and staff interviews, the facility failed to ensure one (#4) of seven residents reviewed for medication administration of 22 sample residents was free from a significant medication error. Specifically, resident #4 was given 20 times the prescribed amount of liquid oral [MEDICATION NAME] than was prescribed. The resident became lethargic, difficult to arouse, and required multiple doses of [MEDICATION NAME] (narcotic antagonist antidote) to reverse the overdose. She was transferred to a local emergency department where she was given additional doses of [MEDICATION NAME], and she died . The findings included: I. Professional Standard According to Perry, Potter & Ostendorf, Clinical Nursing Skills & Techniques, 8th Edition (copyright 2014), pages ,[DATE]: Safe Medication Administration: -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: The right medication The right dose The right patient The right route The right time 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. II. Facility Policy On [DATE] at 5:28 p.m., the nursing supervisor provided the facility's policy and procedure titled General Dose Preparation and Medication Administration, last revised [DATE], which included: Facility staff should use an oral dose syringe for measuring small and/or fractioned volumes of liquid medications (e.g., 0.3 milliliters, 2.5 milliliters) .Facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident .Confirm that the MAR (medication administration record) reflects the most recent medication order .After medication administration, facility staff should document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given) .PRN (as needed) medications .on appropriate forms. III. Resident Failures A. Resident #4 Resident #4, age 81, was admitted to the facility on [DATE]. According to the current care plans, [DIAGNOSES REDACTED]. The resident was not present in the facility long enough for a minimum data set assessment to be completed. B. Family Interview Resident #4's son was interviewed on [DATE] at 2:26 p.m. He said he received a phone call from licensed practical nurse (LPN) #3 on [DATE]. She informed him she had over-medicated his mother with [MEDICATION NAME] and said she got the dosage wrong. He stated, If she didn't know .she should have asked somebody for help. My mom got 95 milligrams (MG) more of [MEDICATION NAME] than what was ordered .to me it is unfathomable . -Resident #4's son explained his mother had recently broken her hip, had surgery to stabilize it, and had to be placed in the facility for care afterwards. He said, I'm not saying she (LPN #3) did it on purpose. What she did made my mom pass sooner than she was ready to go. -Resident #4's son said [MEDICATION NAME] was administered to his mother at both the facility and the local emergency department (ED). He was present with her in the ED and said, She woke up for about a minute in the ER and she had that glazed look when you have too many drugs in you, and then she went right back to sleep. C. Record Review The care plan, initiated [DATE], identified the resident had an increased risk for actual and potential limitations in her ability to perform ADLs (activities of daily living). The interventions included providing assistance with bed mobility, eating, oral care, personal hygiene, and toilet use as necessary. She required the use of a mechanical lift for transfers and was currently receiving hospice care. The facility care plans were reviewed in their entirety and did not include a care plan that addressed pain or discomfort. The progress notes dated [DATE] at 9:01 p.m. documented, Resident has refused all treatments and medications to this point in shift. This nurse has attempted multiple times to encourage resident to allow staff to administer medications to no avail. Resident currently resting in bed with eyes closed. The current physician orders [REDACTED]. -[MEDICATION NAME] solution (100 milligrams/5 milliliters), take 5 milligrams (MG) by mouth or sub-lingual every two hours for pain/shortness of breath, transcribed by LPN #3. An additional hand-written note was inserted directly above the order that read, (0.25 milliliters). The Medication Administration Record [REDACTED]. However, a progress note written by LPN #3 dated [DATE] at 7:01 p.m. documented, Resident agitated all shift. Refused care, combative to staff. Took some meds and refused others. Resident medicated with [MEDICATION NAME] at 2:00 p.m. A hospice progress note dated [DATE] at 6:30 p.m. documented the following: Received call from (LPN #3) . She is calling to report a medication error. She reports that patient was to get 0.25 milliliters (ML) of [MEDICATION NAME], and got five ML instead. Asked if the dose is 20 milligrams (MG)/ML (100 mg/5ML). (LPN #3) verified this. She reports they have called the primary care physician and received orders to administer [MEDICATION NAME] 5 mg which they have done . A second hospice progress note dated [DATE] at 6:30 p.m. documented the following: Upon arrival .was unresponsive with agonal respirations (shallow breathing patterns often related to [MEDICAL CONDITION] and death) .RN (registered nurse) requested oxygen and mask, facility provided .repeat order for [MEDICATION NAME] 1 mg IM now at 7:00 p.m. and again at midnight .patient however remains unresponsive except to painful stimuli . A progress note dated [DATE] at 7:15 p.m. documented the following: Hospice nurse in to see resident and new orders received (to) administer [MEDICATION NAME] 1 mg IM (intramuscularly) now and at midnight. Hold [MEDICATION NAME] and [MEDICATION NAME] until 7:00 a.m. on [DATE]. Take patient's vital signs every 20 minutes until 5:00 a.m. and notify physician if out of parameters specified in orders. A physician's telephone order dated [DATE] at 7:15 p.m., included:: -Take VS (vital signs) every 20 minutes, call if systolic blood pressure (SBP) less than 90, heart rate greater than 135, respiratory rate less than 10 breaths/minute. A progress note dated [DATE] at 12:20 a.m. documented the following: Resident is arousing with verbal stimulation, VS are within normal parameters for resident. Resident resting quietly, no signs or symptoms of distress noted at this time. There were no additional progress notes until [DATE] at 6:30 a.m., which documented: This nurse (RN #14) obtained first set of VS for shift: BP (blood pressure) ,[DATE], pulse 118 .Resident non-responsive . The nurse placed phone calls to hospice triage and the resident's physician and was awaiting return calls. A progress note dated [DATE] at 8:00 a.m. documented the following: Hospice RN .in facility, updated on resident current status. VS: BP ,[DATE], pulse 122 . A progress note dated [DATE] at 9:38 a.m. documented the following: Provider on-call .gave order for family to decide if they would like to transfer resident to hospital ED .son states he would like resident transferred to (local ED) for evaluation and treatment .VS remain unstable. Non-emergent dispatch contacted by hospice RN for transport .Resident transported via ambulance to (local ED). The local ED notes dated [DATE] documented the following: The patient was inadvertently given 100 mg of oral immediate release [MEDICATION NAME] at 4:30 p.m. yesterday afternoon. The patient had been sleepy and somnolent throughout the night. She required three doses of [MEDICATION NAME] with last dose given around midnight last night. The patient was transferred to our hospital for evaluation stating that they ran out of [MEDICATION NAME] .In discussion with .the patient's family and the hospice care workers . given the move towards comfort care we have elected to forego further testing and intervention at these times for these issues. There is a bed available at the hospice care center and this patient to be transferred to fill that bed where they can administer additional [MEDICATION NAME] if needed . D. Staff Interviews A hospice RN case manager (RN #15) was interviewed on [DATE] at 12:58 p.m. She explained the routine hospice procedures in place with the facility. She clarified that residents who received hospice care who resided in the facility would be provided [MEDICATION NAME] either delivered from the pharmacy or obtained from the emergency kit (e-kit). She said the standard [MEDICATION NAME] oral solution concentration was 20 mg/ML, and the pharmacy would list it as 100 mg/5 ML. She stated, It causes some confusion. For safety reasons, if it is 5 mg, we will write '[MEDICATION NAME] 20 mg/ML concentration to give 5 mg (0.25 ML) by mouth or sublingual every four hours as needed for pain or shortness of breath.' LPN #2 was interviewed on [DATE] at 12:45 p.m., and was unable to correctly calculate the dose of liquid oral [MEDICATION NAME] to be given to a resident. She explained she would routinely have another nurse double check her dose prior to administration. LPN #16 was interviewed on [DATE] at 1:48 p.m., and he was able to correctly calculate the dose of liquid oral [MEDICATION NAME] to be given to a resident. He explained the pharmacy routinely included a one ML syringe with the liquid [MEDICATION NAME] when it was delivered to the facility. RN #4 was interviewed on [DATE] at 1:52 p.m., and she was able to correctly calculate the dose of liquid oral [MEDICATION NAME] to be given to a resident. She stated, The only time it doesn't come with a syringe is when we get it from our e-kit. LPN #3 was interviewed on [DATE] at 9:18 a.m., and confirmed she was the nurse caring for resident #4 on [DATE] during the day shift. She said the resident was highly agitated all morning. She explained the hospice nurse came in and felt the resident might have been in pain due to her recent hip surgery and maybe she was demonstrating it physically because she wasn't able to verbalize it due to her dementia. -LPN #3 stated, The hospice nurse wrote an order and I transcribed it to be able to get it from the emergency kit at (name of facility). She said when she faxed the paperwork to the pharmacy she had written 0.25 MLs which equals 5 MG of [MEDICATION NAME]. The LPN explained the resident had been resting comfortably and then her certified nurse aides (CNAs) asked her if they could get her up for dinner. She said she told them, Yes, just let me medicate her, because she was getting combative again. -LPN #3 explained, I couldn't find the paperwork that I had faxed to pharmacy that said, '0.25.' It was on my med (medication) cart, which I realized at the end of my shift, under all my paperwork. But I referred to the telephone order and the order said, '[MEDICATION NAME] sulfate 100 mg/5 MLs,' and then it said, 'Give five' and I didn't see the milligrams, so I accidently gave five MLs instead. That's where my error was. She stated, It didn't feel right to me, but I kept on looking at the same paperwork and thought it must be okay because that is what it says. -LPN #3 said it was not a routine standard of practice for her to double check oral [MEDICATION NAME] doses with another nurse to verify it was correct before administering it to a resident. She stated, Only when one nurse is coming on and one going off. She explained that was when they found her medication error, during the shift narcotic count. The LPN said a CNA approached her at that time and informed her resident #4 was unresponsive. She stated, That's when we got an order for [REDACTED]. LPN/unit supervisor #7 was interviewed on [DATE] at 2:09 p.m. She confirmed she was the oncoming nurse who received report from LPN #3 for the evening shift on [DATE] and they did the narcotic count together. She explained they were doing the narcotic count and when she asked how much oral [MEDICATION NAME] was in the vial, she questioned the dose. She stated, I had worked earlier in the shift and I knew they were going to do an e-kit pull. I didn't think there should be that much missing from the vial. -LPN #7 said the resident's VS had remained within the physician's acceptable parameters throughout the night. However, she was informed the following morning that the resident's vital signs were going outside the parameters so she called the doctor and received another order for [MEDICATION NAME]. She stated, I knew we had exhausted all of our [MEDICATION NAME] and asked if we could just ship her to the hospital. The director of nurses (DON) was interviewed on [DATE] at 4:55 p.m. She said it was the facility's practice for nurses to document every medication that was administered to a resident. She said as a result of the medication error, LPN #3 had a documented medication observation audit completed by administrative nursing staff and had been suspended until the investigation was completed. The DON said, When issues were identified, we contacted the doctor immediately. She said the [MEDICATION NAME] was ordered and they administered it right away after they accessed it from their e-kit. She did not speak to any specific failures LPN #3 made during the process from obtaining the order, through and including administering the incorrect dose of [MEDICATION NAME]. -The DON said they provided pharmacological education to the nursing staff that included how [MEDICATION NAME] was metabolized by the body and it included a post-quiz with how to calculate medication dosages. -The DON said in an effort to prevent a medication error like this from happening again, medication audits were done on all of their nurses and education had been provided on [MEDICATION NAME]. She said their pharmacy had supplied the facility with a stop sign that would be posted that included common doses of [MEDICATION NAME]. She said nurses were supposed to double check [MEDICATION NAME] doses with another nurse. -The DON said moving forward, the hiring process for any new oncoming nurses would include education about [MEDICATION NAME] and how to correctly calculate dosages. She said medication observations would be conducted annually as a formal audit of the nurses and observations by leadership would increase to quarterly for the time being. The DON said their pharmacy was aware of the error that occurred and have been very helpful. She stated, We are trying to put as many safety nets in place as possible so this doesn't happen again. Pharmacist consultant #17 was interviewed on [DATE] at 10:00 a.m. He said the [MEDICATION NAME] oral concentrate was 20 mg/ML, which was a standard dose frequently used by hospice residents. He explained the amount depended on the person's tolerance over time with opiates, and they were only taking 0.25 ML, and some hospice patients took the medication every hour. He confirmed this was the concentration of the [MEDICATION NAME] solution provided in the facility's e-kits. -The pharmacist said the label on the [MEDICATION NAME] oral concentrate included a warning label that said it was for use in residents who were opioid-tolerant, but it didn't include anything more specific beyond that. He said it was a good standard of practice for nurses to double-check the dosage with another nurse prior to administration. -The pharmacist confirmed the [MEDICATION NAME] was supplied to the facilities with a dropper that actually indicated the MLs and mgs on the dropper. He said the dropper would hold approximately one ML of [MEDICATION NAME]. -The pharmacist said the medication was available in a more dilute solution of 20 mg/ 5 ML and did not have to be supplied in such a strong concentration of 100 mg/ 5 ML. E. Additional Record Review The autopsy report, signed by the local county coroner on [DATE], documented the cause of death was a result of complications of [MEDICATION NAME] intoxication .In the afternoon/early evening of [DATE] she reportedly was accidently given 100 mg of liquid [MEDICATION NAME] instead of the 5 mg prescribed dose. Her medical condition subsequently deteriorated and she became unresponsive despite the administration of [MEDICATION NAME] ([MEDICATION NAME]) .Autopsy revealed pneumonia, which is a common finding in deaths due to drug intoxication, especially from drugs like [MEDICATION NAME] that cause respiratory depression .

Based on record review and interviews, the facility failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing and prevent infection for one former resident (#95) reviewed for pressure ulcers out of 29 sample residents. Specifically, the facility failed to: - Adequately address the resident's risks for developing complications from skin breakdown. - Properly assess an open area on the resident's coccyx identified in the initial Admission/Readmission Skin Review. - Timely and consistently assess, monitor, and track the status of the resident's open area. These failures contributed to the development of an infected stage IV pressure ulcer that required hospitalization and three surgical wound debridements. The findings included: 1. Resident #95, age 57, was admitted to the facility on [DATE] from the hospital. Resident #95 was transferred back to the hospital on [DATE] for a wound with profuse bleeding & fever, according to the SBAR (situation, background, assessment, appearance, review) form. According to hospital records, received at the Department on 2/3/17, resident #95 had surgical debridement on 1/7/17 of an infected stage IV sacral pressure sore that measured 10 x 15 x 5 cm, prior to debridement. According to the National Pressure Ulcer Advisory Panel, a Stage IV Pressure Injury is defined as: 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. Resident #95's Operative Report read Incision and sharp debridement of the sacral pressure sore taken down through the level of the muscle and sacrum itself. The wound required surgical debridement two more times, once on 1/9 and again on 1/12/17. 2. Resident #95's risk factors on admission for complications from skin breakdown. Although the Braden scale completed on 12/14/16 scored the resident at 21 - not at risk for pressure ulcer, the resident entered the facility with a number of factors that put her at risk. a. Diagnoses [DIAGNOSES REDACTED]. Review of admission records and the December 2016 and January 2017 medication administration records revealed the resident was an insulin dependent diabetic with blood sugars ranging from 48 to 470. According to www.mayoclinic.org, Health problems that can affect blood flow, such as diabetes and vascular disease, increase the risk of tissue damage. b. Skin breakdown on admission The resident's hospital discharge summary, dated 12/14/16, identified the resident had a chronic sacral wound that is healing over at this time. The initial Admission/Readmission Skin Review, dated 12/14/16, read that in addition to a diffuse body rash, the skin diagram identified a sm(all) wound approximately 2 cm by 2 cm circled in the coccyx area. The type of wound was marked as excoriated. The narrative note read, in part, Res(ident) has opening from moisture associated abrasion to L (left) gluteal fold buttock (crease between thigh and buttocks). c. Weight A nutritional assessment dated [DATE] revealed resident #95 was 61.5 inches tall and weighed 225 pounds. Her BMI (body mass index) was 41.9. According to the Centers for Disease Control and Prevention, a BMI of 30 or higher is obese and 40 or higher is extreme or severe obesity. According to the National Pressure Ulcer Advisory Panel, 2/17/15, patients who are higher risk for pressure ulcers are the very thin and overweight-to-obese individuals. d. Immobility The care plan, initiated on 12/14/16, identified Alteration in assistance with daily living activities related to disease process.' She required two person assist with dressing, toileting, and one person assist with grooming, and bathing. The amount of assistance required for bed mobility was blank. However, the 12/21/16 minimum data set (MDS) revealed the resident required limited assistance of one person for bed mobility, walking in the room, dressing and bathing and limited assistance of two persons for transfers. 3. Facility response to resident's risk factors for skin breakdown Review of the resident's care plan revealed Alteration in skin integrity, other than pressure (ulcers), body rash' as a problem on 12/14/16; and generalized [MEDICAL CONDITION] on 12/20/16. Interventions included prescribed creams and antibiotics for skin infection. Under Alteration in skin integrity ulcers related to pressure/arterial, dated 12/14/16, a location or description of an ulcer was not included although pre-printed interventions indicated the presence of a pressure ulcer. These interventions included apply me with a therapeutic wheelchair or chair pad or pressure reduction pad; reposition me off the area that has a PU (pressure ulcer) and every 1-2 hours. A handwritten note, 12/14/16, included continuing education on repositioning, diabetic teaching, off-loading, hygiene teaching. 4. Facility failure in managing resident #95's coccyx wound. a. See care plans above; the care planned interventions to address Alteration in skin integrity - ulcer, while designed to relieve pressure on the resident's coccyx, were pre-printed interventions, not specific to the resident's high risk for complications due to the resident's history of a chronic sacral wound, her medical conditions, and immobility/weight. b. Failure to properly assess and document the resident's coccyx wound Although resident #95 was admitted to the facility with multiple factors that placed her at pressure ulcer risk (see above) including identification of an open area on her coccyx on the initial Admission/Readmission Skin Review, record review revealed the resident's coccyx wound was not accurately and comprehensively assessed on and after admission. The Initial Wound Review, completed by the staff development coordinator/treatment nurse on 12/14/16, noted only an abrasion to the gluteal fold area, measuring 2 cm by 2 cm. Likewise, the resident's 12/21/16 MDS assessment documented the resident had moisture associated skin damage, but no unhealed pressure ulcers at stage I or higher. c. Failure to assess, monitor and track the condition of the resident's coccyx wound after admission The Skin and Wound Management Program revised 3/10/15, provided by the facility on 2/1/17, included in part: A visual head to toe skin review will be performed at least weekly by a Certified Nursing Assistant (CNA). Results will be verified and documented by a licensed nurse. The skin check and verification will be documented on the Weekly Skin Check Form. All wounds will be monitored daily, as required by a licensed nurse, with documentation on the Daily Wound Review form. Review of the Daily Wound Review form, the Weekly Wound Progress Reviews, the weekly head to toe skin checks, the daily skilled Medicare documentation revealed staff failed to routinely monitor and track the worsening condition of resident #95's coccyx wound. When assessed 1/4/17, almost three weeks after her admission, resident #95's coccyx wound exhibited signs of infection with foul smelling drainage. Specifically: Daily Wound Review forms: Review of the December 2016 Daily Wound Review Form, from 12/14/16 (admission) through 12/31/16, read, Gluteal fold, Keep dry & clean. [MEDICATION NAME] as needed. The coccyx wound noted in the initial assessment (see above) was not included on the form and the status of the wound was not documented as monitored daily by a licensed nurse as expected per the Skin and Wound Management Program (see above). Review of the January 2017 Daily Wound Review Form for the Gluteal fold wound revealed no documentation the coccyx wound was checked until 1/4/17 when a nurse documented the gluteal fold wound bed was yellow, with copious drainage, an odor and pink/red peri-wound. The form included a second wound with instruction that read [MEDICATION NAME] to coccyx until new order from physician. There was only one day of documentation, 1/5/17, that read the dressing was CDINN (clean, dry, intact, normal surrounding skin). Weekly Wound Progress Reviews: Record review revealed no Weekly Wound Progress Review until 12/27/16; there was no progress review for the week of 12/18/16 - 12/24/16. The Weekly Wound Progress Review Form dated 12/27/16 was the first document to identify the resident's coccyx wound since the initial Admission/Readmission Skin Review on 12/14/16. The progress review read the coccyx wound was identified as other, and the wound measured 8 cm by 3.5 cm, unknown depth. The narrative written by the treatment nurse on 12/27/16 indicated a specialty mattress was in place and the resident was encouraged to side lie when in bed. The next progress review on 1/3/17, described the coccyx wound as presenting with copious yellow drainage with an odor. The narrative written on 1/3/17 read the wound bed was white slough with copious yellow drainage, a strong odor and a hard area to the left crease of the buttock. A physician appointment was scheduled for two days later. The resident was encouraged to reposition frequently. Weekly head to toe skin checks: The December 2016 and January 2017 Treatment Administration Records (TARs) included instruction for weekly skin assessments. There were skin assessments documented by the licensed nurse on 12/19/16 and 1/6/17. There were no weekly assessments documented for 12/21/16 and 1/2/17. Weekly Skin Check forms included the initial assessment of 12/14/16, with findings (see above) that included the coccyx wound. -A skin check on 12/19/16 marked rash to the face, hands and legs. The skin check did not identify the coccyx wound. -A skin check on dated 12/26/16 (see above: not documented on the TAR), marked redness and rash to face, hands and legs. This skin check, too, did not identify the coccyx wound. -There was no skin check dated 1/2/7. -The final skin check, dated 1/6/17, 11 days after the previous head to toe skin assessment on 12/26/16, had a circle in the coccyx region, with open wound documented on the body map. The type of wound was not documented. No narratives were provided by the facility for the assessments on 12/19 and 12/26/16 and 1/6/17. Medicare Daily Skilled Nursing Notes: Medicare Daily Skilled Nursing Notes, from 12/14/16 through 1/3/17, included an area to document skin integrity. Staff documented rash, multiple skin issues, multiple open areas, and rash with multiple open areas. Narratives included changing treatments for the rash; however, no head to toe skin assessments were included in the notes and there was no further documentation of the open areas to the coccyx and gluteal folds noted on admission. 5. Status of coccyx wound 1/4/17 - 1/5/17 and facility response On 1/4/17, the Medicare Daily Skilled Nursing Note read coccyx/gluteal fold open area has 100% yellow slough to wound bed. Purulent thick yellow drainage and a mild foul odor. When borders press(ed), large am(ounts) of the drainage pours out. Unable to determine if tunneling is present due to the thickness of slough. Firmness noted to (left) side of wound. On 1/4/17, under Other skin related issues, the care plan documented Change of condition to coccyx, (right and left) buttock wound to area. The type of wound was not identified and there were no interventions included on the care plan. (Cross refer F279). On 1/5/17, the nurse documented a verbal order to clean the area and apply [MEDICATION NAME] ointment twice daily, keep off bottom and Zinc 220 mg daily. At 3:30 p.m. on 1/6/17, the resident was found with profuse bleeding to proximal end of coccyx wound. A large clot was found in the resident's incontinence brief. Bleeding was stabilized with pressure. The resident was sent to the emergency department at 3:40 p.m., and admitted to the hospital. On 1/5/17, a physician's assistant (PA) office progress note read the resident was being seen for complaint of a pressure ulcer. Nursing staff state they had been taking care of the generalized rash, that was significant in the peri area, that was clearing, then yesterday they noted a large area in sacrum that looked like a large blister and then top skin sloughed off and she had some discolored drainage and it was malodorous. The note said the resident had an unstageable wound that would require surgical debridement. The wound measured 10 cm in length by 4 cm wide. An order was written for the resident to be seen at a wound clinic as soon as possible. See above; the resident was admitted to the hospital 1/6/17 for treatment of [REDACTED]. 6. Staff Interviews The treatment nurse was interviewed on 2/2/17 at 9:40 a.m. She did not hold a wound certification; however, in 2016 she had completed 12 continuing education credits in wound care. She reviewed the skin assessment of 12/14/16 that indicated a 2 cm x 2 cm wound on the coccyx. She said the resident had so many blisters, she did not believe the wound was a pressure ulcer. She had documented other on the 12/27/16 and 1/3/17 weekly wound assessments, because there were a lot of blisters on her buttocks and coccyx area and we could not really see what was going on. She said, As (the blisters) moved away we could see the blister on her coccyx and crease of her right and left buttock, almost butterfly shape. We could not determine if it was pressure or part of the infection with the blisters. The director of nursing (DON) was interviewed on 2/2/17 at 10:15 a.m. She said resident #95 had an extensive rash on her back and as it started to clear, they had identified that spot on the coccyx. They had educated the resident on repositioning herself, because she was independent (with repositioning). However, the CNA tracking did not reflect the resident's independence. Specifically, review of the CNA documentation, from 12/14/16 to 1/6/17, revealed resident #95 required the following assistance: For bed mobility, extensive assistance by one person three times and limited assistance of one person 16 times; for transfers, she required extensive assistance by two persons once and by one person four times and limited assistance of one person 33 times; and for toileting, she required extensive assistance of two persons once, one person six times; and limited assistance of one person 36 times.

Based on observation, record review, and family and staff interview, the facility failed to provide care, supervision and safety devices in a manner that prevented accidents with injuries, for one of five sample residents (#1). Specifically, the resident, who was dependent on staff for her care: - Experienced repeated skin tears and bruising, and a finger avulsion ("a tearing away forcibly of a part or structure") during care provision; and - Had an ill-fitting quarter side rail added to her bed without prior safety assessment, creating a potential accident/entrapment hazard. These failures resulted in the resident suffering an infection in one of the skin tears; and a painful finger avulsion that required emergency room treatment. The findings included: Resident #1, an [AGE] year-old female, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was receiving hospice care. Minimum Data Set (MDS) According to her 5/7/12 MDS, resident #1 was severely cognitively impaired, unable to communicate verbally, and had no behavioral symptoms. She was totally dependent for all activities of daily living, used a wheelchair pushed by others for ambulation, and needed a Hoyer lift for transfers. Care Plan The resident's care plan, initiated 9/14/10, and most recently updated on 7/29/12, identified "risk for skin breakdown, skin tears & bruising secondary to decreased mobility, trace edema to bilat(eral) lower ext(remities) at times and incontinent of B&B (bowel and bladder), (and) frail, thin skin d/t (due to) aging process." Listed injuries included the following: - 7/1/12 skin tear to L calf when changing res in bed - 7/18/12 bruise R arm - 7/25/12 ST R hand & L upper arm - 7/29/12 L ring finger avulsion Nine skin tears and/or bruises were documented prior to 7/1/12. Goals were for skin to remain intact, and for skin tears to heal without infection. Approaches included: - Assess skin condition daily, with every bath, and PRN - Notify nurse of any persistent redness, open skin areas, bruises, abrasions, and/or skin tears - Apply lotion after every bath and PRN - Monitor healing of ST/bruising and notify physician of changes - Reposition/weight shift frequently in wheelchair & bed - Dressing change per doctor orders until healed - Full assist with ADLs and transfers - staff take care with all assist - Staff to provide sling for Hoyer correctly to avoid potential bruising or skin tears - Staff encouraged to monitor skin closely when moving bed during changes - Left ring finger: keep elevated for comfort - leave dressing in place & dry x 36-48 hours, then change dressing twice daily and clean with mild soap & water, apply Bacitracin to laceration, cover with gauze dressing. 1. FINGER AVULSION INJURY A. Hospital Record Review (1) The 7/29/12 emergency department (ED) report, documented the resident presented with a "L (left) ring finger injury ... avulsion L ring finger tip & nail - caught btwn (between) bed railing & wall/window when bed raised. Pt. unable to provide hx (history) with dementia ... L distal ring finger pad avulsion, nail absent ... bone tip - rongeur* off tip to allow skin coverage with subq (subcutaneous) tissue overlying." The final [DIAGNOSES REDACTED]." - The nursing assessment portion of the ED report, noted at 2:09 a.m., stated, "Pt to ER ... via EMS - per report pt got finger smashed between bed & wall. Assessment complete, family @ BSD (at bedside)." - 2:35 a.m., "Xray @ BSD. 3:05 a.m. (suture set up @ BSD ... Wound anesthetized with (illegible) via digital block to L ring finger, pt. tolerated. Wound irrigated ... suture @ 0345. Wound dressed ... Hospice notified @ 0415 to transport pt as discussed hospice will arrange for transport. Awaiting for non-emergent transport @ 0430 ... DC'd ... @0451." (*A rongeur is "an instrument for removing small amounts of tissue, particularly bone; also called bone nippers. A rongeur is a spring-loaded forceps with a sharp blade that may be either end cutting or side cutting." - Source: "Taber's Cyclopedic Medical Dictionary") (2) The 7/30/12 hospital emergency report, noted the resident's final assessment was "Amputation left ring fingertip." The summary read: "This patient's finger was caught as a bed railing was raised. The patient is demented. She has amputated approximately 9 mm of her left ring fingertip with a visible distal phalanx. She was digitally blocked. The bone tip was rongeured down and soft tissue coverage was afforded over this. She was given a gram of Ancef as this is technically an open fracture. We advised a short dose of Keflex in prescription form and prescribed tramadol, and she is to follow up with (her primary care physician) for wound check in 2 days." - Emergency department procedure: treatment of [REDACTED]." B. Initial Staff Interviews On 8/3/12, at approximately 1 p.m., the nursing home administrator (NHA) and the resident's unit manager (UM) were interviewed. They said they surmised the resident's finger was caught between her bed and the windowsill when CNA #1 (certified nurse aide) raised her bed from the low position to provide night time care. They said the bed had been provided by hospice, and they were not sure when, but after the accident they had hospice bring in a different mattress, and did "a whole house check to rule out danger to other residents." They found out there were no other mattresses like this in the building. - They said pain management was "in place" for the resident, and the nurse did "immediate education which we continued and did some return demos and spot checks." They said the accident occurred the previous Saturday night, when CNA #1 was checking the resident for incontinence. The NHA said they had received no prior negative reports on CNA #1, and that "she was very remorseful." C. Resident Observations The resident was observed sitting up in her wheelchair at approximately 1:20 p.m. on 8/3/12, and staff were preparing to put her in bed after lunch. The resident did not respond when she was spoken to. Her left ring finger was bandaged. A quarter bed rail was observed on the outer side of the resident's bed, in the up position. No bed rail was observed next to the wall/window. One side of the resident's bed was positioned parallel to the wall and window. Three of the resident's family members were present, and an interview was requested (see below). At 2:30 p.m. on 8/3/12, the resident was observed again. She was lying in bed on her back. It was observed that there was a large gap between the resident's bed rail and mattress, creating a potential accident hazard (see findings below). The resident was grimacing and fidgeting, and moving her hands around. The resident's hand was not elevated per her care plan (see above) and physician orders. The resident's nurse was notified about the resident's grimacing and fidgeting, and said, "That's her typical way - she just had a dressing change." The nurse said the resident was unable to use the bed rail to reposition herself or support herself. At 2:45 p.m. on 8/3/12, the NHA and UM were notified of the observation of the bed rail on the resident's bed, and the gap between the rail and the mattress. Later that afternoon, a maintenance person was observed working on the resident's bed and she was sitting up in her wheelchair. At approximately 5 p.m., the bed was observed again and no side rails were present. The mattress the resident had on her bed the night of her injury was observed on the afternoon of 8/3/12. The maintenance director said he had brought it in from storage for observation. The lipped mattress had insets on each side that appeared to be handles. The insets were reinforced with a hard material that felt like plastic, and were positioned near the head of the bed/mattress. D. Family Interviews (1) The resident's daughter and son-in-law were interviewed at 1:30 p.m. on 8/3/12, and they were asked what they knew about the resident's injury. They said, "They called us at 12:30 Saturday night. The nurse said it was really bad. The CNAs were very upset. It had bled through two gauze pads already, and they said she needed to go to the hospital. The firemen came and we went with them." The resident's son-in-law said he held her hand during the treatment process at the hospital. - Asked how they were told the accident occurred, they said there was "a metal piece on the mattress that holds the padding on," and the resident's finger was caught between that and the windowsill. "She's had several injuries here with transfers. (CNA #1) felt so bad. She admitted it. She said she didn't see her hand (that the resident's hand between the bed and the wall). Some of her finger is gone - that's all we know. My sister said they need to slow down and be more careful. They (staff) all feel bad about it." - When asked what they would like to see happen as a result of the accident, they said, "They need to be more careful, observe before they flip up the bed, that hands and feet are where they should be. She took a face plant awhile back, so they need to put a seat belt across her lap or observe her to keep her safe. I think it's just observe more to prevent accidents. Be more careful and gentle. More training - ongoing training - orientation for new staff. (The family is) here three to four times a day, my sister feeds her breakfast, then puts on her makeup. We come at lunch and feed her and stay with her until she lies down ... All you can do is make sure it doesn't happen to her or anybody else." (2) The resident's daughter/representative was interviewed by phone at 2:10 p.m. on 8/3/12. She said, "They've been doing a good job of controlling her pain. I think we'll never know for sure how it happened. I don't think she (CNA #1) purposely hurt her. She was hurrying too fast. I think they (staff) do hurry too fast. She (the resident) had a deep laceration to her foot and ankle (earlier). To me that was nothing but hurrying and not watching where her feet were. They need to watch her hands and feet and be careful with her. I can understand how (her finger could be punched), but for them to take off her finger? I'm not bitter toward (CNA #1) but I think it has to be addressed. It was so unnecessary. More time should be spent and they need to slow down. How long does it take to pull down a blanket and check to see where their hands and feet are? ... Mother has been hurt, and she's like a baby. I want them to make sure the aides are slowing down. I think they need to take it more seriously and listen to the residents and their family." - "I've complained several times in the past about them rushing and injuring Mom, bruises on her hands, etc. I'll call them in, show them the injury, and ask them to be more careful. When they call me about injuries I tell them I don't understand how this could happen. She fell out of her wheelchair on her face about nine months to a year ago. The little thing is getting hurt too often ... She can say "ow" or "no" but not much more. I don't know if it's just because she's so quiet and can't speak." - "I think they need more aides who take time, and when using the lift, see where her hands and feet are, and how her bottom is, and take care. I'm concerned they don't take the time to feed them, give the residents more time to eat, I just think they let their aides be 'hurrying' - I know they've done training. They follow through and then the aides hurry. (Some of our family members are) scared they'll take it out on Mom. I'm not, because I still have the trust in them that they won't take it out on her. Please quote me on this." - "I don't think the management staff know how much the staff hurry. The nurses sometimes supervise and observe transfers, but not very often. I don't see the management staff doing it." E. Staff Interviews (1) The nursing home administrator (NHA) and unit manager (UM) were interviewed on 8/3/12 at 2:45 p.m. The NHA said the resident's primary care physician had just visited the resident and they wanted him to assess pain control - he said he thought she was comfortable. When asked for details about the resident's finger injury, the NHA said the night nurse "called me at home" the night of the resident's injury. The NHA interviewed the nurse Monday 7/30/12. The UM said she interviewed CNA #1 by phone the morning of 7/30/12, and "followed up to get more details on Wednesday night when I came in to do one-on-one education myself with her." The UM said, "According to (the night nurse) they had this unfortunate incident, and (CNA #1) came to get her because the resident's facial expression changed and she had a high pitched scream - she said it wasn't a scream, it was her high pitched vocalization. (CNA #1) saw that her hand was caught. The CNA reacted by pulling the resident over and pulling her hand back. (CNA #1) said she kind of panicked and pulled her (the resident's) hand back, then they saw that there was blood, and there was tissue on the bed. It was wedged pretty tight. (The nurse) went back and got gauze and cleaning supplies and dressed it, and the first call she made was to hospice. It had been bleeding more than an hour before they got the doctor in here. She was taken to the hospital, it was X-rayed - I have a picture - and it was stitched up, and she was back to us before 6 a.m. Family was with her the whole time." - (The night nurse) said she educated the CNA right away. She told (the NHA) and I exactly what she said: She should have pulled the covers back to check her (the resident's) hands and feet. I did clarify Wednesday that the lights were on; she said, 'I don't work in the dark.' I do know (the resident) likes to be bundled up, or the family likes her bundled up. The other thing they talked to her about was that it would've been better to lower the bed than pull her hand. It was probably a gut reaction to pull her hand back." The NHA and UM acknowledged it was a double injury to the resident, first crushing and then pulling her finger. Asked what their response had been to the resident's injury, the NHA and UM said: - They instructed CNA #1 to not provide care for resident #1. She continued to work on the night shift. - They changed the location of the resident's bed, then moved it back to where it was, and did an assessment of the room and the mattress, then checked all the other mattresses in the building to ensure there were no others. (However, see below, a formal evaluation of the resident's bed safety had not yet been conducted.) - They started education immediately informally with the staff on the next shift. - They were randomly pulling CNAs and observing transfers, and provided training for all the CNAs who provided care for resident #1. They conducted an audit and an investigation to rule out abuse, and notified the ombudsman. - There was a report that there were three aides that residents felt possibly rushed people more, but no names were provided. - The resident's family said they felt (another CNA) was really good, but sometimes a little rushed, so they did an individual return demonstration with her. The family members said the staff were too "rushed and careless, and need to slow down." - The UM said, "I talked to (CNA #1) about rushing, and she said that didn't play into it; it was a quiet night and she was just doing her room checks and room rounds that she'd normally do starting at midnight." - The NHA said, "We had our medical director come in and we had a QA meeting on Thursday, discussed the incident report with him, did a plan of action, reviewed her pain control and any suggestions he had, told him our plan of action and got advice from him. He wanted the resident interviews to continue and he agreed the education needs to continue." (2) The night nurse was interviewed by phone at 11:15 p.m. on 8/17/12. Asked what she recalled about the incident with resident #1, she said, "My CNA was doing her rounds, to report and check on (resident #1) for pain. Around midnight she raised her bed, (resident #1) screamed as if someone hurt her. She ran to get me, and said her facial expression changed. She raised her left hand because (resident #1) was holding the bed. Blood was pouring and I noted her nail was off ... The light was on ... She raised the left hand. I didn't see her pull it or I would have stopped it. I was focused on her face. (Her hand) was caught between the wall and the bed. The resident was awake. Her face was different. She was looking around; she looked like she had pain ... (CNA #1) was moved from nights to days. There were lots of concerns about her. I don't know really what happened. She's a good worker, but she talked loud and I had to remind her several times (to talk more softly when residents were sleeping). After this incident she didn't take care of (resident #1) at all. (3) CNA #1 was interviewed at approximately 5 p.m. on 8/20/12. Upon relating what occurred when the resident's finger was injured, she said, "I came in at 10 p.m., my usual shift. The nurse told me to watch her facial expressions. They said the whole day she'd moan. I started with (resident #1), lifted the bed, and noticed her facial expressions. I watched her face and uncovered her, and looked at her hand. I told the nurse, 'Look, her hand is caught,' so I took her hand, saw blood, and held her hand." When asked to relate exactly what happened from the moment she entered the resident's room that night, she said, "I went in to check and change her. I turned the lights on, got gloves, got supplies, got what I'm going to need: a diaper, wipes, peri wash. I go to her bed, raise the bed up. After I raised the bed, she looked normal. I went to get the nurse. The nurse came back in. We started observing her. Her finger was caught between the bed and the wall. I pulled her hand, no force was required at all. There was no crying out. She didn't say anything." - When asked what happened as a result of the resident's injury, CNA #1 said, "I got education from my nurse and a disciplinary action. She gathered us all together, and said we need to ensure their hands and feet are uncovered or in the bed before we do anything to them. I got a write-up and more education, and I'm not to provide care for (resident #1)." Asked about her assignment being changed to day shift, CNA #1 said, "That has nothing to do with it - I asked to move." The UM, who was present during the interview per CNA #1's request, asked CNA #1 if she had felt rushed. She responded, "We had enough staff. I always take my time." F. Record Review (1) CNA #1 Record: Review of CNA #1's record on 8/3/12, revealed no documentation of counseling, disciplinary action, or training. (2) Facility Investigation: The facility incident report form and investigative report, revealed on 7/28/12 at 12:15 a.m., "CNA reported to this nurse that res has different facial expression, R screamed when she lifted her bed up. Res caught her L hand @ BS next to wall, noted blood to BS. L ring fingernail & skin tissue was off." Documentation was requested of the interviews conducted during the investigation. The documentation read as follows: - Interview by phone with CNA #1 7/30/12: "Was told in report to watch (resident #1's) facial expressions for pain when giving care. On midnight rounds, went to room, raised the head of the bed, saw (resident's) facial expression change and ran and got the nurse. Said 'I panicked.' First reaction was to pull her hand out. Said (nurse) was in room when left ring fingernail was found and saw all the blood. Finger was caught between the metal part inside the mattress and the window sill." - "(Nurse) called (UM) to report the incident at 9 a.m., Sunday. Said that she had saved the nail and tissue that the resident lost when the hand was pulled from under the window sill. Said that after cleaning, dressing and applying pressure to the wound she had first called hospice and was told by hospice nurse to 'watch it for now.' (Nurse) did not agree with hospice decision to wait and talked to the resident's daughter about sending her out. She then called the doctor on call who said if it was still bleeding, then she wanted her to go to the hospital. The resident's daughter agreed with this decision. EMS was called and she was transferred to (the local hospital) for intervention. (The nurse) said resident came back about 5:30. [DIAGNOSES REDACTED]. Surgical intervention was required. She said she also had an order for [REDACTED]. Stated the daughters thanked her for sending her out and said she did the right thing." - "(Nurse) was called again Monday morning and asked to give additional details regarding Sunday morning's incident. Stated she was in nurse's station when (CNA #1) came and got her. She said she noticed blood on bed and wall and the left hand was caught under the sill. After the hand was freed, she put a clean dressing on it and went to call the hospice nurse. In addition, after calling the daughter she also called the on-call doctor, (name), and then called EMS." - "Bed and mattress were assessed by nursing managers and maintenance director on Monday morning. The bed frame is working correctly, but there is a metal part inside the mattress (to use as a handle) and this appears to be what held the finger so tightly against the window sill. Maintenance director recommended we have hospice replace this lipped mattress with one that does not have metal handle inside of it. (Note: (resident) has been using this mattress for over two years.) All mattresses in the facility were inspected to insure that there are no others that have this internal metal handle." - "Immediate education was given to the CNA by the charge nurse regarding the importance of making sure that all extremities are visualized and protected before raising and lowering a bed. Education regarding safety and care of residents during transfers including proper placement and protection of extremities was given to on-coming staff later that day and will be on-going." - "The bed was moved from the west wall to the north wall on Sunday." 2. BED RAIL ENTRAPMENT HAZARD Please see the findings above under resident observations, where the resident was observed to have a quarter side rail or U-bar rail on her bed, with a large gap between the bed and the mattress, which created a potential accident/entrapment hazard. Record review revealed no care plan for the use of a side rail or positioning rail. The resident's nurse (see above interview) said the resident was unable to use the side rail for self-positioning. A physician telephone order (TO) dated 7/30/12, called for an "OT eval (1 initial & 1 follow-up) for safety with positioning & transfers s/p recent hand/finger injury." Upon the first onsite visit to the facility on [DATE], there was no evidence that therapy had evaluated the resident's bed for safety with positioning. On 8/20/12, during the second onsite visit, a copy of occupational therapy progress notes was reviewed and revealed the following documentation: "Met with nsg staff today to look at bed to see if she needs to have the U-shaped grab bar on her bed. OT doesn't think this is necessary as pt req. max (assistance with) all bed mobility. Pt has a deep lipped air mattress on her high/low bed that provides protection for pt in the event she does move in her bed. The bed is placed in the low position with a landing strip whenever the patient is in bed." Although the resident had suffered an injury during a position change in her bed, her mattress had been replaced, a rail had been added, and the location of her bed had been changed since her accident, there was no evidence of a formal safety evaluation of the resident's room for four days. 3. MULTIPLE SKIN TEARS AND BRUISES A. During the second onsite visit to the facility, on the afternoon of 8/20/12, the resident was observed with a large, purplish-red bruise to the top of her left hand. Interviews and record review, revealed the resident had experienced three new injuries since her finger avulsion incident on 7/30/12 (see below). (1) Review of the 8/10/12 incident report form, revealed the time of the incident was unknown, and the resident had a "purple/blue bruise to posterior L hand." The nurse noted she had observed the bruise when the resident was sitting in her wheelchair in the hallway, and had not seen the resident "for weeks prior." She drew a diagram showing a large bruise to the top of the resident's hand from her index finger to her thumb. The nurse wrote, "Staff needs to be more aware of res extremity positioning?" under what should be done to prevent injury recurrence. The final outcome/disposition noted by the UM read: "Reviewed by IDT. Will request CBC & CMP from (physician) to see if this might be contributing to bruising/frail skin. Staff suggested geri-sleeves. Daughter refused to allow their use. Will again ask staff to be very careful with dressing/transfers." (2) Review of an 8/11/12 incident report at 5 p.m. revealed "Res daughter notified this nurse that res has new bruise to R upper arm, noticed (after) taking off her clothes." The bruise was noted as purple, and approximately 3/4 inch to one inch in diameter. The nurse noted, "Be extra careful of holding her upper extremities." The final outcome/disposition, noted by the UM on 8/13/12 was, "Reviewed by IDT> Res easily bruised. Will ask the PCP about drawing blood (liver function tests) to see if this could be reason she bruises so easily. Will have staff continue to be very careful when dressing/undressing and transferring her ... Family agreeable to lab work." (3) Review of an 8/5/12 incident report at 5:30 p.m. revealed, "I was notified by RN that resident had sustained a skin tear while in restorative dining area ... R index finger - skin tear joint - 2nd-3rd phalynx." The final outcome/disposition was: "Reviewed by IDT. Res will stay at TCU nurses' station until TCU trays come down - will not be left in dining room unless CNA or family are present. Maintenance will check table & w/c to ensure all are free of any rough edges." B. Review of the resident's medical record, specifically from faxes to her physicians, from 6/1/12 until her finger avulsion injury on 7/30/12, revealed a history of multiple injuries (also see family interviews above), documented as follows: (1) 6/1/12 - "Resident has new skin tear on R wrist area, wound edges defined, no drainage, no odor, no signs or symptoms of infection. May we have an order to apply telfa and clean and change dressing every 3 days and PRN?" (2) 6/5/12 - "Pt suffered a skin tear to the lateral affect of her L foot during a transfer 5/29/12. This skin tear now appears infected with pus drainage, redness, swelling & warm to touch. Family requesting oral antibiotic be started ASAP as well as topical antibiotic care. Pt is allergic to Bactrim. Unable to swallow tablets, but can crush tablets or open capsules. Please write orders for po antibiotic & topical antibiotic below." (The physician's undated responses written below and to the side of the fax communication documented, "I talked w/ nurse yesterday about this" and "see verbal order for Keflex." (3) 6/8/12 - "Please sign orders per our conversation regarding pt's infected skin tear L foot improving on Keflex while culture requests pending. Did request (PCP) be paged, but no response." (4) 7/1/12 - "R noted to have skin tear on L calf. Skin approx 2 cm x 2 cm approximated. Dressing applied. Change daily til healed?" (5) 7/12/12 - "Res has new bruises noted to R arm. Staff unclear how it happened. Will continue to monitor." The facility failed to provide adequate interventions to prevent resident #1 from suffering repeated painful injuries, resulting in multiple bruises and skin tears, an infected skin tear, and a finger avulsion.

Based on staff interview, record review and observations, the facility failed to provide adequate pressure ulcer prevention and management to prevent the development and promote healing of a pressure ulcer for one (#47) of 34 sample residents. Specifically: -The facility failed to consistently identify, assess, monitor and implement timely interventions that would provide adequate pressure ulcer prevention and management for resident #47; -failed to consistently document all open areas or the stage of each ulcer; -failed to consistently update the care plans. Resident #47 Resident #47, an [AGE] year-old female, was admitted to the facility, on 11/5/10 and readmitted on [DATE], after a hospital stay for scheduled surgery for [REDACTED]. Minimum Data Set (MDS) The 11/12/10, MDS coded five day assessment documented as follows: resident #47 required assistance with bed mobility, transfers, dressing, personal hygiene and toilet use, was coded at risk for pressure ulcer, had one stage 1 pressure ulcer, and one stage 4 pressure ulcer (the stage 4 pressure ulcer present on admission was on her left foot/heel; the wound had developed into osteo[DIAGNOSES REDACTED], and was amputated in January 2011). The MDS coded skin and ulcer treatment in part as follows: no surgical wound, pressure reducing device for the chair and bed, no turning/repositioning program, and nutrition/hydration interventions to manage skin problems. The MDS, dated [DATE], documented in part as follows: Resident #47 was at risk for developing a pressure ulcer, had one stage 2 pressure ulcer, and was coded with no stage 3 pressure ulcers and also coded that she had one stage 4 pressure ulcer. The other wound was coded as a surgical wound. There were skin and ulcer treatments- a pressure reducing device for the chair and bed, she was not on a turning/repositioning program, and had nutrition/hydration intervention to manage skin problems. [MEDICAL TREATMENT] Center Notes Review of the notes from the [MEDICAL TREATMENT] center documented in part as follows: (Resident #47 was readmitted to the facility, on 1/29/11, status [REDACTED]. 1/3/11 resident had low [MEDICATION NAME] at 3.7, improved from 3.2, goal was to trend toward [MEDICATION NAME] of 4.0 or greater. Resident was to receive positive reinforcement and encouragement to continue high quality protein foods and supplement drinks. Care Plans The care plan, dated 2/11/11, documented in part as follows: Problem- Resident #47 had history of Osteo[DIAGNOSES REDACTED] of her left lower leg and status [REDACTED]. Goal- Resident's wounds will demonstrate progressive healing. Resident will be free of further skin impairment. Approaches- Monitor skin with baths, weekly skin assessment, assist resident to turn and reposition frequently, pressure reducing mattress on bed, notify nurse when problems occur, notify physician when appropriate, 2/16/11-wound rounds every month with medical director. 3/6/11 Skin impairment of the right heel, coccyx, and left stump. Potential for further skin impairment. Interventions: 4/5/11- No dressing needed for the coccyx, right heel clean with Dakins solution, wound clinic notes for further details. 4/21/11- To gluteal wound apply santyl to wound, cover with foam dressing every day. 4/22/11- Trinova mattress and sage boot. Problem- Nutrition care plan, dated 2/11/11 and updated 3/3/11, Resident #47 at risk for nutritional problems. Goal- Minimize nutritional changes in weight over the next 90 days. Improve skin integrity over the next 90 days. Approaches- Fortified foods in menu plan, supplements per registered dietician or physician recommendations, diabetic boost twice per day, follow-up with interdisciplinary team for nutritional recommendations. Record Review 1. Nurses' Notes Review of the Nurses' Notes documented in part as follows: On 11/16/10, bilateral heels elevated, right heel red. On 1/2/11, resident has wounds to left ankle, right heel, coccyx, and posterior left thigh, all dressings clean dry and intact. Resident self propels wheelchair for ambulation. 2. Weekly Skin Sheets Weekly Wound Progress Notes in part as follows: 11/6/10, Wound #1 coccyx pressure ulcer acquired at home, length ? cm X ? cm, stage not documented, depth not documented; Wound #2 left thigh had a cut acquired at home 3 ? cm in length, with no depth documented. Wound #3, left medial malleolus pressure ulcer, acquired at home length 2 ? cm X 1 cm, stage not documented, no depth documented. Wound #4 right heel stage 1, redness, acquired at home, 2 cm X 2 cm. Wound #5, right buttock abrasion, no wound stage documented, acquired at home 1 cm X 1 cm, and no depth documented. 11/19/10 Wound #1 left lateral malleolus, unstageable pressure ulcer, length 2.5 cm X 1.0 cm, no depth documented, weekly summary note in part documented wound #1 with mostly black eschar, odorous serosanguineous drainage; resident currently on [MEDICATION NAME] for pseudomonas and osteo[DIAGNOSES REDACTED], physician appointment 11/22/10, decision for possible amputation. Wound #2 coccyx pressure ulcer acquired at home, 0.5 cm X 0.5 cm, no depth documented, weekly summary documented in part wound #2 pink, sheering/excoriation, no drainage, no sign of infection. (No mention of other wounds). 11/24/10 Weekly Wound Progress Note documented: Wound #1 at left lateral malleolus, unstageable pressure ulcer, length 2.5 cm X 1.0 cm, no depth documented. Wound #2 coccyx pressure ulcer, no stage documented, no depth documented. (No mention of other wounds). 12/1/10 Weekly Skin Check form documented: The groin and peri area bright red. (Nurse draws line to body chart, points to the right heel) wound is black at wound bed. (No documented wound measurements). (Missing Weekly Wound Progress Note between 11/24/10 and 12/8/10). 12/8/10 Weekly Wound Progress Note documented: Wound #1 left ankle pressure ulcer unstageable, length 3.0 X 3.5 cm, no depth documented, (No mention of other wounds). 12/10/10 Weekly Skin Check documented open wound at coccyx and the left inner ankle area, (No measurements of wounds documented. 12/15/10 Weekly Wound Progress Note documented: Wound #1 left ankle pressure ulcer unstageable, length 2.3 X width 2.1, no depth documented. Wound #2 right heel pressure ulcer stage 3, length 2.3 X 3.7, no depth documented. The 12/15/10 Weekly summary documented in part: Wound #2 wound bed with black eschar. (No other wounds mentioned). 12/23/10 Weekly Wound Progress Note documented: Wound #1 coccyx pressure ulcer stage 3, length 2.4 X 2.2 width, depth 0.2, wound bed covered with yellow slough. Wound #2 right heel pressure ulcer stage 3, length 2.2 X 3.6, depth 0.3, wound #2 has yellow slough with black eschar. Wound #3 left ankle pressure ulcer no stage documented, length 1.9 X 1.7, no depth documented. Wound #3 with black wound bed. 1/2/11 Weekly Wound Progress Note documented: Wound #1 coccyx pressure ulcer stage 2, length 2.1 X 1.9 width, no depth documented. Wound #2 left ankle stage 3, length 1.7 X 1.4 width, no depth documented. Wound #3 right heel pressure ulcer stage 3, length 2.1 X 3.1 width, no depth documented. 1/7/11 Weekly Wound Progress Note documented: Wound #1 coccyx pressure ulcer stage 2, length 1.9 X 1.7 width, no depth documented. Wound #2 left ankle stage 3, length 1.7 X 1.4 width, no depth documented. Wound #3 right heel pressure ulcer stage 3, length 1.9 X 2.8 width, no depth documented. 1/14/11 Weekly Wound Progress Note documented: Wound #1 coccyx pressure ulcer stage 2, length 1.8 X 1.7 width, no depth documented, wound bed noted to have slough. Wound #2 left ankle stage 3, length 1.9 X 2.8 width, no depth documented. Wound #3 right heel pressure ulcer stage 3, length 1.9 X 2.8 width, no depth documented. 1/21/11 Weekly Wound Progress Note documented: Wound #1 coccyx pressure ulcer stage 2, length 1.5 X 1.1 width, no depth documented, wound bed noted to have slough. Wound #2 left ankle stage 3, length 1.7 X 1.5 width, no depth documented. Wound #3 right heel pressure ulcer stage 3, length 1.7 X 2.8 width, no depth documented. 1/29/11 Braden Scale documented in part as follows: Total score= 15, Score of 15-18= at risk, risk factors: needs assist with activities of daily living, diabetic, chronic end stage [MEDICAL CONDITION], (on [MEDICAL TREATMENT]) history of coccyx ulcer, current coccyx ulcer, left below knee amputation, 2/4/11 Weekly Wound Progress Note documented: Wound #1 coccyx pressure ulcer stage 2, length 0.8 X 0.5 width, no depth documented. Wound #2 right heel stage 3, length 1.3 X 2.0 width, no depth documented, right heel has brown yellow eschar to wound bed. No other wounds mentioned. 2/10/11 Weekly Wound Progress Note documented: Wound #1 coccyx pressure ulcer acquired in house, stage 2, length 0.8 X 0.5 width, depth none documented. Wound #2 right heel pressure ulcer acquired in house stage 3 length 1.5 X 2.0 width, depth none documented. Summary note 2/10/11 dressing changed during wound rounds, right heel has black eschar to wound bed, yellow slough to outer aspect of wound. (Black with eschar would be unstageable). 2/18/11 Weekly Wound Progress Note documented: Wound #1 coccyx pressure ulcer stage 2, length 0.8 X 0.4 width, no depth documented. Wound #2 right heel stage 3, length 1.5 X 2.0 width, no depth documented. 2/24/11 Weekly Wound Progress Note documented: Wound #1 coccyx pressure ulcer stage 2, length 0.7 X 1.1 width, depth 0.1. Wound #2 right heel stage 3, length 3.0 X 3.1 width, no depth documented. 3/3/11 Weekly Wound Progress Note documented: Wound #1 coccyx pressure ulcer stage 2, length 0.8 X 0.5 width, no depth documented. Wound #2 right heel stage 3, length 2.9 X 3.1 width, no depth documented. 3/10/11 Weekly Wound Progress Note documented: Wound #1 right heel stage 3, length 2.6 X 2.6 width, no depth documented. Wound #2 coccyx pressure ulcer stage 2, length 0.3 X 0.1 width, no depth documented. 3/17/11 Weekly Wound Progress Note documented: Wound #1 right heel stage 2, length 2.1 X 2.3 width, no depth documented, right heel wound bed had brown/yellow eschar. (Brown eschar would be unstageable wound). Wound #2 coccyx pressure ulcer stage 2, length 0.1 X 0.2 width, no depth documented. 3/24/11 Weekly Wound Progress Note documented: Wound #1 right heel stage 2, length 2.0 X 2.2 width, no depth documented. Wound #2 coccyx pressure ulcer stage 2, length 0.1 X 0.1 width, no depth documented. 3/31/11 Weekly Wound Progress Note documented: Wound #1 right heel stage 2, length 1.9 X 2.4 width, no depth documented. Wound #2 coccyx pressure ulcer stage 2, length 0.1 X 0.1 width, no depth documented. 4/7/11 Weekly Wound Progress Note documented: Wound #1 right heel stage 2, length 1.4 X 2.7 width, no depth documented, wound bed is pink with granulating tissue present, had yellow eschar present as well. (No other wound documented). 4/14/11 Weekly Wound Progress Note documented: Wound #1 right heel stage 2, length 1.3 X 2.4 width, no depth documented. Wound #2 coccyx pressure ulcer stage 2, length 0.4 X 0.3 width, no depth documented. Summary note 4/14/11 documented in part: Coccyx wound had yellow slough, right heel wound had yellow slough as well. Resident often non-compliant with laying down or having pressure off of right heel, encouragement needed from staff. 4/21/11 Weekly Wound Progress Note documented: Wound #1 right heel stage 2, length 1.5 X 2.4 width, no depth documented. Wound #2 coccyx pressure ulcer unstageable, length 3.1 X 3.3 width, no depth documented. Weekly summary 4/21/11 Buttock wound has worsened, increased in size, had yellow and green eschar. Peri wound tissue broke down in several places with measurements of: 7.0 x 4.2 cm, 4.1 x 3.8 cm and 9.0 x 2.9 cm, [MEDICATION NAME] applied and foam to cover all areas. Resident encouraged to lay down frequently. 4/28/11 Weekly Wound Progress Note documented: Wound #1 right heel stage 2, length 1.4 X 2.4 width, 0.3 depth. Wound #2 coccyx pressure ulcer unstageable, length 3.1 X 3.3 width, no depth documented. (No other wounds mentioned). 3. Physicians Orders Review of physician orders [REDACTED]. On 11/20/10 per Fax to physician- No open sores noted to resident #47's coccyx area, only multiple small shearing. Can we have an order to discontinue dressing change and have an order for [REDACTED]. 12/13/10 per Fax to physician- Resident #47 noted to have small open sore and red blanchable excoriation to coccyx and also open area to posterior left lateral thigh. Both areas cleaned with wound cleanser and covered with a foam dressing. 12/24/10 per Fax to physician- Open area present to coccyx, stage 3, with slough in wound bed. On 3/10/11 per Fax to physician resident had blood from coccyx area, skin peeled off during dressing change. Pressure dressing applied and bleeding controlled. Physician reply- is this a wound complicated by skin tear? Does resident need pressure reduction mattress? On 3/22/11 per Fax to physician, the facility night nurse expressed that resident #47 was short of breath last night and slept in her wheelchair. On 3/24/11 per Fax to physician, resident #47 had shortness of breath and anxiety last night. Resident requested help to sit up and ended up sleeping in her chair. Would you consider ordering a chest x-ray. On 4/11/11 documentation on the Fax read in part: Resident has elevated temperature, complaints of back hurting, continues to cough productive with clear sputum noted, sleeping in recliner one and one half weeks. (resident sleeping in chair and has multiple pressure wounds). 4. Wound Clinic Visits Review of the notes from the hospital wound clinic documented in part as follows: 3/7/11 wound #1 right calcaneus (heel), drainage serosanguineous, no odor, pressure ulcer unstageable due to eschar, length 2.0 cm width X 2.5 cm onset date 1/7/11, clinic start date 3/7/11. 3/7/11 wound #2 buttocks, drainage low serous, no odor, small area of denuded skin, see photo, wound bed 100% granular, onset date 1/7/11, clinic start date 3/7/11. On 3/25/11 Wound #1 right calcaneus (heel), drainage serosanguineous, mild odor, pressure ulcer , length 2.0 cm width X 1.5 cm depth 0.6 cm, wound bed 50% grandular and 50% slough, onset date 1/7/11, clinic start date 3/7/11. Wound #2 buttocks, drainage low serous, no odor, small area of denuded skin, see photo, wound bed 100% granular, onset date 1/7/11, clinic start date 3/7/11. On 3/29/11 Wound #1 right calcaneus (heel), drainage serosanguineous, mild odor, pressure ulcer, length 2.0 cm width X 1.5 cm depth 0.6 cm, wound bed 20% grandular and 80% slough, onset date 1/7/11, clinic start date 3/7/11. Wound #2 buttocks, drainage low serous, no odor, small area of denuded skin, see photo, wound bed 100% granular, onset date 1/7/11, clinic start date 3/7/11. On 4/5/11 Wound #1 right calcaneus (heel), drainage serosanguineous, mild odor, pressure ulcer, length 2.0 cm width X 1.5 cm depth 0.6 cm, wound bed 50% grandular and 50% slough, onset date 1/7/11, clinic start date 3/7/11. Wound #2 buttocks, drainage low serous, no odor, small area of denuded skin, see photo, wound bed 100% granular, onset date 1/7/11, clinic start date 3/7/11. Summary note wound appears to be healing with some slough removed with Dakins solution, no signs of infection. 4/12/11 Wound #1 right calcaneus (heel), drainage serosanguineous, mild odor, pressure ulcer, length 2.0 cm width X 1.5 cm depth 0.3 cm, wound bed 75% grandular and 25% slough, onset date 1/7/11, clinic start date 3/7/11. Wound #2 buttocks, no drainage, no odor, small area of denuded skin, see photo, wound bed 100% granular, onset date 1/7/11, clinic start date 3/7/11. Interviews On the evening of 5/2/11 the Director of Nursing (DON) was interviewed related to resident #47, her pressure ulcers and a fall. The surveyor requested to review the reports and investigation reports. The DON expressed that resident #47 was admitted with skin issues and a coccyx small open area, and a pressure ulcer on her left heel that had osteo[DIAGNOSES REDACTED] and was on intravenous antibiotics. She expressed the resident was placed on an air mattress on admission to the facility. She expressed the resident had been admitted to the hospital at the end of January, had a left above the knee amputation (AKA); and was readmitted to the facility with a plan to discharge back to a private home after improvements in her health. The DON expressed the resident had an open area on her upper right thigh, believed to have been caused from the Hoyer sling, possibly skin tear/pressure. The DON expressed the Occupational Therapist had made a visit to the [MEDICAL TREATMENT] center to assess any problems that might have caused pressure to the resident while sitting in the [MEDICAL TREATMENT] chair, three days every week, for up to 4 hours at a time. The DON expressed the facility did use the Hoyer lift and left the sling under the resident only on [MEDICAL TREATMENT] days. She stated the resident was not gotten up into the Hoyer sling until just a few minutes prior to the time she left for [MEDICAL TREATMENT]. On 5/3/11 at approximately 10:15 a.m., resident #47 was interviewed and expressed that she had a cough that had kept her awake at night, and so she had been sleeping in her roommate's recliner chair at nights to help the cough. She expressed the bed mattress on her bed was an air mattress that was very hard and uncomfortable to sleep on. She had requested a recliner for her side of the room, but was never provided with one. She stated she had a new air mattress on her bed now, and it was very comfortable to sleep on. On 5/3/11 at 12:15 p.m., the Occupational Therapist was interviewed and expressed she had visited the [MEDICAL TREATMENT] unit center three times. The first was to do assessment for pressure areas while sitting at the [MEDICAL TREATMENT] center, the other two times was to make observations, and provide education to the staff on the reduction of pressure, and the third was to provide education to the staff on the leg/foot Sage Boot. Observations On 5/3/11 at 10:30 a.m., the wound nurse and the staff nurse came into resident #47's room to provide wound care and dressing changes. The resident expressed it was okay with her for the surveyor to remain in the room and observe the wounds during the treatments and dressing changes. Three pressure areas were present: Wound #1 on the right heel, Wound #2 on the coccyx, and Wound #3 on the upper thigh. The nurse changed the dressing and applied treatments to the wounds. The surveyor asked the nurse and the wound nurse about the stage of each pressure ulcer. The nurses expressed that the coccyx wound and the right heel wound were unstageable due to slough, and one nurse expressed that she would not stage wound #3 on the right upper thigh (wound #3 was observed to be an open area, approximately 1 ? inches wide X 4 inches long, on the upper thigh just below the buttocks area possibly due to the position of the strap along the edges of the sling). Review of the incident/accident/investigation Review of the incident report related to the #3 wound documented that resident #47's right upper thigh wound was first observed by facility staff on 4/21/11. The incident report, dated 4/21/11, documented that the wound was on the right posterior thigh and measured 9.0 x 2.9 cm open area. The Occupational Therapist and the registered nurse were in the resident's room at the time. The RN expressed the wound was not there last week. The physician was notified and the certified nurse aides were educated on the importance of frequent repositioning of the resident. Occupational Therapy and Devices On 4/22/11 an upgraded air mattress (Trinova Model 7101) was placed on resident #47's bed, and a Sage Boot was obtained for her right foot/heel. Summary The facility failed to prevent additional pressure ulcers, did not have the resident on a turning schedule of 2 hours or more often that was done consistently and documented, did not have a documented every two hours that the resident's heel was floated, did not place the sage boot or the up graded air mattress on the bed until 4/22/11, did not provide a therapy device to keep pressure off the right heel (ie; sage boot) when she was admitted with a red area on the right heel, resident was sleeping in a chair at times even though she had coccyx ulcer. The wound on the back of her upper thigh was not on the wound sheet and was not on the care plan.