Every finding on record at Mcintosh Care and Rehabilitation Center

Based on observations, record review and interviews, the facility failed to ensure one (#88) of three residents reviewed for accidents received adequate supervision out of 38 sample residents. Resident #88 was admitted on [DATE] with diagnoses cerebral infarction (stroke), acute respiratory failure, atrial fibrillation, pacemaker, osteoarthritis, obesity, hypertension and acute kidney failureOn 12/16/26, Resident #88 was being transported to an appointment in the facility's transportation van. Resident #88's wheelchair was not properly secured in the transportation van. During the transportation, Resident #88's wheelchair slipped and the resident hit her head on the van. The resident was transported to the emergency department (ED) and was admitted to the intensive care unit (ICU) for monitoring related to the sustained traumatic subdural hematoma (brain bleed) and Eliquis (blood thinner) use. Specifically, the facility failed to ensure Resident #88 was provided safe transportation. Findings include:Observations, record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 3/16/26 to 3/19/26, resulting in the deficiency being cited as past noncompliance with a correction date of 12/24/25. I. Incident on 12/16/25On 12/16/25 Resident #88 was being transported to a swallow study via the facility's transportation van. During the drive, Resident #88's wheelchair shifted, which caused her head to make contact with the interior of the van. The resident was transferred to the ED and was diagnosed with a subdural hematoma. II. Facility plan of correctionThe facility's plan of correction was provided by the director of nursing (DON) on 3/19/26 at 6:45 p.m. The plan revealed on 12/16/25 Resident #88 was not tied down, which caused the resident to hit her head during transportation. The plan revealed immediate actions that were implemented included: -Resident #88 was transferred to the hospital, observed overnight and returned to the facility on [DATE].-The resident was interviewed and mental health services were offered. -The hospital records were reviewed, the new recommendations and physician's orders were implemented. -Van driver #1 was suspended on 12/16/25 pending the investigation.-Additional residents were interviewed on 12/17/25 regarding safety concerns while being transported in the van. The plan revealed performance expectations included:-Total compliance with wheelchair and securement procedures.-Adherance to all transportation safety policies.-Safe driving practices. -Proper documentation/reporting of incidents. -Review of the facility's performance and adherence to the plan in the monthly quality assurance improvement plant (QAPI) meetings.The plan revealed the audit and monitoring plan included:-The DON would complete weekly audits for 12 consecutive weeks. The plan documented the plan of action included:-The driver was terminated.-The van was taken out of commission. -The van was taken to a third party vendor to be checked for safety concerns. -All transportation was outsourced to outside sources.-A new van driver would be hired. The new van driver would have complete training and safety competencies prior to starting.The transportation safety education was completed with staff from 12/17/25 to 12/24/25.On 12/24/25, staff members were provided additional education and required to demonstrate competency in properly and safely securing a resident in a wheelchair when using the facility's transportation van.The plan stated the compliance date was 12/17/25. -However, review of the plan revealed education and return demonstrations by staff for properly and safely securing a resident in a wheelchair for van transportation were not completed until 12/24/25.III. Resident #88A. Resident statusResident #88, age [AGE], was admitted on [DATE], discharged to the hospital on [DATE], readmitted on [DATE] and discharged home on 1/2/26. According to the January 2026 computerized physician's orders (CPO), diagnoses included cerebral infarction (stroke), acute respiratory failure, atrial fibrillation, pacemaker, osteoarthritis, obesity, hypertension and acute kidney failure.The 1/5/26 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. The resident need set-up assistance with transfers.B. Record review1. Care planThe anticoagulant care plan, initiated on 11/14/25, revealed the resident was on anticoagulant therapy related to atrial fibrillation. Pertinent interventions included, administering medications per physician's orders, monitoring for signs and symptoms of bleeding and monitoring for signs of complications.The ADL care plan, initiated on 11/13/26, revealed the resident had an ADL self care performance deficit related to weakness, stroke, malnutrition and medication side effects. Pertinent interventions included providing therapy as ordered, encouraging the resident to participate to the fullest extent possible with each interaction, encouraging the resident to use her call bell for assistance and monitoring and reporting any changes to the physician. The brain injury care plan, initiated 12/18/26, revealed the resident had an alteration in neurological status related to a head injury and subdural hematoma. Pertinent interventions included giving medications as ordered, monitoring the resident and obtaining laboratory and diagnostics as ordered. 2. Progress notesThe 12/17/25 nursing progress note documented at 1:51 p.m. revealed Resident #88 returned to the facility at approximately 1:00 p.m. and was assisted to her room. The resident was chatting with the nurse regarding eating solid food and eating ice cream. The resident said she was glad to be back at the facility. The resident requested to have ice cream. The note documented the resident's husband arrived at the facility. The resident had a bruise to the right shoulder. The 12/19/25 physician's progress note documented the medical director reviewed the recent hospital records. The note documented it appeared that she may have sustained a very small 3 millimeter (mm) hemorrhage brain bleed as a result of the incident in the transport vehicle. The note documented because there was a lack of neurological signs/symptoms it was impossible to definitely say the two events were linked. 3. Hospital reportThe 12/16/25 hospital documentation revealed in pertinent part, the resident was admitted with a traumatic subdural hematoma. The resident arrived at the facility after she experienced a head injury during transportation to a swallow test when her wheelchair was not properly secured. When the transportation vehicle came to a sudden stop she hit her head on the window. The resident was brought to the emergency department for workup because she was on Eliquis related to atrial fibrillation and a recent stroke. A computed tomography (CT) scan was completed and revealed a 3 mm subdural hematoma in the midline area of the brain. The resident was admitted to the intensive care unit (ICU) for monitoring related to the resident's use of Eliquis. The resident was started on Keppra 750 milligrams (mg) twice a day for one week for seizure prophylaxis in relation to the subdural hematoma. 4. Facility investigation the 12/16/26 incidentThe 12/16/25 facility investigation was provided by the DON on 3/18/26 at 2:45 p.m. The investigation revealed the following timeline:On 12/16/26 Resident #88 was being transported to a swallow study appointment on 12/16/26. At 11:16 a.m. Resident #88 was assisted into the transportation bus. At 11:50 a.m. Resident #88's wheelchair shifted, causing her head to make contact with the interior of the van. The transport staff assessed the resident and advised that the resident received a medical evaluation at the ED. At 12:20 p.m. the assistant director of nursing (ADON), the DON and the nursing home administrator (NHA) directed van driver #1 to take Resident #88 to the hospital for evaluation. At 1:20 p.m. Resident #88 arrived at the hospital. At 2:00 p.m. a CT scan was completed and revealed a 3 mm subdural hematoma.At 2:51 p.m. Resident #88 was admitted to the ICU for observation.At 6:00 p.m. a second CT scan was completed and showed no changes in the subdural hematoma. On 12/17/25 the van was taken out of commission. On 12/17/25 the resident returned to the facility.On 12/17/25 van driver #1 was terminated.On 12/17/25 the facility began to implement a process improvement plan (PIP). On 12/19/25 Resident #88 was seen by her primary care physician and remained at baseline. The investigation included an interview with van driver #1, dated 12/17/25. The interview was conducted by the clinical resource and the life safety resource. The interview documented van driver #1 said he parked the van in front of the facility, so the lift was on the sidewalk and as flat as possible. He said the resident was anxious while he was assisting her onto the lift, so he was explaining the safety measures he was taking. He said he used the lift to assist the resident into the van. He said while he was using the lift, he tied the resident down correctly. He said once as the resident was in the van, he locked the wheelchair brakes, secured the back of the wheelchair and placed the seatbelt and shoulder strap across the resident to secure the resident. Van driver #1 said he did not place the straps on the front of the wheelchair. Van driver #1 said he knew it was part of the procedure to secure the front straps. The interview documented van driver #1 said he made several turns and there were no concerns. He said he then heard a noise and Resident #88 screamed out. Van driver #1 said the resident was still sitting in her wheelchair with the foot pedals in place. The resident's wheelchair was in the same position and her head was approximately 12 inches from the lift gate. Van driver #1 said the resident reported she hit the back of her head on the window. Van driver #1 said he checked the resident's head and there were no signs of injury. The resident reported she was not dizzy, nauseated, or experiencing pain. Van driver #1 told the resident she needed to go to the ER. The interview documented the resident said she wanted to go to her appointment, so van driver #1 took her to the appointment. Van driver #1 said he then tied the front wheels down and then transported the resident to the appointment. Van driver #1 said after the appointment that was at the hospital, he assisted the resident to the ER. IV. Staff interviewsThe DON and the NHA were interviewed together on 3/29/26. The DON said van driver #1 called the facility when Resident #88 slipped from her wheelchair on 12/16/25. The DON said she told van driver #1 that Resident #88 needed to go to the ER. The DON said Resident #88 and her spouse declined to go to the ER and insisted on her going to her swallow study appointment. The DON said after the swallow study, the resident was transferred to the ER.

Based on observations and interviews, the facility failed to ensure that all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards for one of the two medication carts. Specifically, the facility failed to ensure there were no loose pills in the medication cart. Findings include:I. Facility policy and procedureThe Medication Storage policy, dated 3/18/26, was received from the director of nursing (DON) on 3/18/26 at 8:42 p.m. It revealed in pertinent part, Medication carts should be kept clean and organized. Dropped, loose, refused, or unused medications should not be placed in the red biohazard/sharps containers, in the trash, or put down the drain per (State) regulations or taped back into prescription cards. These medications should be placed in the drug buster. Medications and biologicals are stored properly, following the manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe, effective drug administration.II. ObservationsOn 3/17/26 at 11:15 a.m., the three hundred north medication cart was observed with licensed practical nurse (LPN) #2. The following was observed:There were 40 loose medications at the bottom of the medication cart drawer. LPN #2 was able to identify some of the medications, which included: fluoxetine (antidepressant), losartan (used to treat high blood pressure), methocarbamol (muscle relaxant), potassium chloride, and a multivitamin. III. Staff interviewsLPN #2 was interviewed on 3/17/26 at 11:40 a.m. LPN #2 said the risk of having a loose medication would be that the nurse could pick it up, and it could be the wrong medication. LPN #2 said giving the wrong medication would result in a medication error. LPN #2 said the nurses were responsible for cleaning the medication cart on their assigned shift. The DON was interviewed on 3/17/26 at 12:10 p.m. The DON said the charge nurse was responsible for cleaning the medication cart once a month. The DON said the nurse assigned to the medication cart was responsible for cleaning the cart on their shift. The DON said that the expectation was that the nurse should clean during the medication pass, and if a pill pops out into the drawer, they should retrieve it.

Based on observation and interviews, the facility failed to provide a clean, comfortable and homelike environment for resident rooms on two of four units. Specifically, the facility failed to provide clean linen hand towels and washcloths on a daily basis. Findings include:I. Facility policy and procedureThe Safe and Homelike Environment policy and procedure, reviewed January 2026, was provided by the nursing home administrator (NHA) on 3/19/26 at 1:13 p.m. It read in pertinent part, The facility will create and maintain, to the extent possible, a homelike environment that de-emphasizes the institutional character of the setting. The facility will provide and maintain bed and bath linens that are clean and in good condition.II. ObservationsAn initial tour was conducted on 3/16/26 from 8:30 a.m. to 9:30 a.m. The following was observed:Resident rooms #306, #318, #406, #407, #410, #412 did not have linen towels or washcloths in the rooms.A tour was conducted on 3/17/26 from 8:00 to 8:15 a.m. and the following was observed:Resident rooms #306, #318, #406, #407, #410 and #412, did not have linen towels or washcloths in the rooms. There was one linen closet used for all the units. The linen closet was observed by two surveyors on 3/17/26 at 11:00 a.m. The linen closet contained two hand towels and 20 washcloths, 30 white bath towels.The linen closet was observed on 3/19/26 at 12:30 p.m. There were numerous linen towels and washcloths, bath towels and blue bath towels.III. Resident interviewsThe resident who resided in room [ROOM NUMBER] was interviewed on 3/17/26 at 8:35 a.m. She said she rarely had linen towels or washcloths. She said if she had the towels and washcloths she would be more likely to wash herself up. She said there were paper towels in her room, but she said the paper towels were not really for cleaning up. She said it would be nice to have the linen towels.The resident who resided in room [ROOM NUMBER] was interviewed on 3/17/26 at 3:30 p.m. She said she had to ask for clean towels and washcloths and most times she did not receive them. She said this was very frustrating for her to have to ask and still not receive them on a daily basis. The resident said she was independent and did not want to use paper towels to dry her hands or face. The resident who resided room [ROOM NUMBER] was interviewed on 3/18/26 at 11:00 a.m. during the resident council group meeting. She said she used paper towels because her dirty towels were not picked up and changed for clean towels so she had to use the same dirty towel to wash up. She would like to have clean towels. The resident who resided in room [ROOM NUMBER] was interviewed on 3/18/26 at 11:00 a.m. during the resident council group meeting. She said she had to ask for linen towels and washcloths and still did not receive them. She said she should not have to ask for clean linens. She said it was very frustrating to have to ask and not receive clean towels. The resident who resided in room [ROOM NUMBER] was interviewed 3/19/26 at 9:00 a.m. She said she was not offered linen washcloths or towels in the evening to wash her face or hands. The resident said she did not use her bathroom because she does not get out of bed. She said it would be nice to have the towels available in order to clean herself up. She said she liked to feel clean and washing her face and hands at night would help with that. IV. Staff interviewsCertified nurse aide (CNA) #1 was interviewed 3/17/26 at 11:00 a.m. CNA #1 said the clean linen closet was stocked by the laundry department daily. She said hand towels and washcloths were passed out daily. She said this was usually done by the night shift but it was everybody's responsibility to make sure the residents had towels. CNA #2 was interviewed on 3/18/26 at 12:00 p.m. She said hand towels and washcloths should be passed out to each room daily. She said the night shift usually stocks the rooms but all shifts were responsible for providing clean towels to the rooms. CNA #2 said the resident assistants used to stock the rooms but that position had been cut. She said the CNAs were now responsible for the resident assistants responsibilities, which included stocking the linens in the rooms. CNA #9 was interviewed on 3/18/26 at 2:40 p.m. CNA #9 said the CNAs should be providing the linen towels. She said during her shift she will take the towels into the rooms so residents can wash their hands and face and remove them the same evening. She said she did not stock them overnight and she was not aware of who passed them out during the day.The housekeeping supervisor was interviewed on 3/19/26 at 12:30 p.m. The housekeeping supervisor said the laundry department was responsible for stocking the clean linen closet. The housekeeping supervisor said there were no linens stored in the laundry room. She said she recently, during the survey, put several hand towels and washcloths in circulation from their supply inventory. She said she was told the linens were running low. The director of nursing (DON) was interviewed on 3/19/26 at approximately 1:00 p.m. The DON said towels were passed out by the CNAs. She said the night shift should be auditing if the residents' rooms have clean linens. The DON said every resident should have their own hand towel and washcloth and should not have to ask for towels and washcloths. She said dirty linen should be removed and replaced by clean linens daily and as needed.

Based on observations and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.Specifically, the facility failed to ensure the laundry area and three soiled utility rooms were free from multiple environmental concerns. Findings include:I. ObservationsOn 3/17/26 at 11:15 a.m., the soiled utility room (in the laundry area) and the laundry were observed with the laundry aid. The solid utility room had a deep, large area of multiple layers of floor linoleum tile, cut out with eight tiles missing. There was a pile of dirt and debris along the base tiles behind the entrance door. The sheetrock was torn along the walls. There were areas of torn sheet rock without texture or paint.The laundry aide said that the lint traps were cleaned every two hours. There was dust built up behind the dryer near the vent pipe. There was peeling sheetrock outside the dirty utility room along the wall. There were missing cover-base tiles, approximately three feet.There was torn linoleum on the floor near the stand-alone washer. There was a hole in the wall, approx three by three inches, on the wall with a stand-alone washer. There was chipped paint outside the dirty utility room. There was a missing transition strip with five chipped floor tiles.On 3/19/26 at 12:28 p.m. The above concerns remained. The three-by-three-inch hole had been repaired).On 3/19/26 at 12:37 p.m. the north soiled utility room was observed with the housekeeping supervisor.There was sheet rock damage above the hopper (basin used to collect waste). The room had three cracked floor tiles under the hopper and four cracked floor tiles under the bins.On 3/19/26 at 12:45 p.m., the south soiled utility room had a loose metal heater cover and nine missing wall tiles at the door. II. Staff interviewsThe housekeeping supervisor was interviewed on 3/19/26 at 3:45 p.m. She said she had not placed any work orders to have anything corrected before the survey. She said it was the responsibility of the staff to place a work order to get items fixed and/or replaced. The maintenance supervisor was interviewed on 3/19/26 at 4:10 p.m. he said that the flooring was ordered to be replaced, but would start in the more visible areas. He said he filled the hole in the laundry room, which was damaged. The maintenance supervisor said the above issues were a problem. He said it was a safety concern if a staff member tripped and fell.

Based on observations, record review and interviews, the facility failed to ensure meals were served according to the resident's preferences on three of four units.Specifically, the facility failed to provide menus to residents in order for the residents to choose their meals and honor food preferences. Findings include:I. Facility policy and procedureThe Dietary Services for Food Preferences policy and procedure, reviewed January 2026, was provided by the nursing home administrator (NHA) on 3/19/26 at 1:13 p.m. It read in pertinent part: Food preferences, allergies and intolerances should be noted on the dietary ticket, also note cultural, ethnic, and religious preferences resident requests. Record of these preferences, allergies and intolerances on the resident's tray card and note in care plan/Kardex (staff directive tool) or electronic medical record (EMR). Preferences to be updated as notified. It is important that these preferences, allergies, and intolerances be honored on the service line and that appropriate substitutions are made when there is a dislike. Nursing staff/designee is responsible for obtaining meal orders and noting meal orders on tray tickets. Nursing staff/designee should take care to follow food preferences, allergies and intolerances when assisting residents with filling out meal tickets.II. ObservationDuring a continuous observation of the service line on 3/16/26, beginning at 12:15 p.m. and ending at 1:15 p.m. the following was observed:-A resident's meal ticket indicated the resident disliked pasta, the resident was served the main meal which was a pasta dish.-A resident's meal ticket indicated the resident disliked salad,the resident was served a green salad.-A resident's meal ticket indicated the resident disliked lasagna, marinara and rose sauce, she was served the main meal of pasta in red sauce. III. Resident interviews and observationsResident #45 was interviewed on 3/16/26 at 9:30 a.m. Resident #45 said she did not see the menu and said you get what she get.you get. She said she was frustrated the system changed and nobody came around to take her order. She said and she was supposed to eat what was given to her. She said she would preferred to make her own choices. Resident #41 was interviewed on 3/16/26 at 10:00 a.m. Resident #41 said she never knew what she was going to receive for her meals. She said there used to be a resident assistant who took meal orders. She said now that the position was eliminated the certified nurse aides (CNA) were supposed to take orders. She said it did not happen consistently. She said she had dislikes and allergies such as pork, fish and thyme that continued to be served to her because she was given the regular menu. Resident #41 said she told the CNAs she did not like pork but it continued to be served consistently on her breakfast tray. She said if she was given the choice she would choose food that she liked and would eat. Resident #29 was interviewed on 3/16/26 at 10:40 a.m. Resident #29 said since the resident assistantRA position was gone, the CNAs did not come around daily to take orders. She said she will received the main menu item and a lot of the time it had items she would not chose so she did not eat it.Resident #29 was interviewed again on 3/17/26 at 3:30 p.m. Resident #29 said she did not eat her lunch from the previous day (the pasta with what looked like red sauce) because it looked too much like lasagna which she told the staff she did not like to eat. She said she would not have ordered the meal if she was given the option. Resident #41 was interviewed again on 3/19/26 at 9:00 a.m. Her breakfast meal was served during this time with pieces of pork sausage. She said she has told the CNAs, who pass the trays, she did not like pork items. She said however, she continued to receive pork items frequently. She said it has been frustrating not choosing her meals and she became upset especially if she was served a meal she would not have ordered. She said she would often send the tray back because it was not what she would have ordered. III. Resident group interviewSix residents (#6, #17, #24, #25, #48, #68) were identified as alert and oriented by facility and assessment were interviewed 3/18/26 at 11:00 a.m. Four of the six residents frequently attended the resident council meetings. The residents were in agreement since the resident assistant's position had been eliminated, the process of taking meal orders had not been consistent. Residents #6, #24, and #48 said they did not always know what they were going to be served for meals because they did not always choose. Resident #68 said he went to the nurses' station and got the menu himself to fill out in order to receive what he liked. He said the staff did not take his order. Resident #48 said she was allergic to many things and she was always served sandwiches. She said she was tired of the sandwiches and felt stuck with them because that was what was chosen for her. She would like to see the menu so she can choose for herself. Resident #24 said since there was no longer a resident assistant she did not know when she would choose her meals. The resident assistant came every day and now she could choose a couple of times a week. Resident #24 said the meal just came and she would not know what has been ordered for her. She said this was frustrating not to choose her meals. Resident #6 said he often received items on his tray that he did not like. He said he did not drink milk, but got it every morning. He said he told the CNAs when they delivered the tray but he continued to receive the milk. He said he did not fill out menus consistently since the resident assistant position was eliminated and CNAs did not consistently come and take meal orders. He said if he had the choice he would not choose milk every morning. IV. Record reviewThe resident council meeting minutes, dated 1/28/26, revealed the residents in attendance voiced concerns with the meal tickets. -The minutes did not specify what specific concerns the residents had with the meal tickets. The resident council meeting minutes, dated 2/25/26, revealed the residents were advised by the dietary manager (DM) the kitchen was looking into a better meal ticket system since the resident aides were no longer in the building. -However, there was no documentation indicating the facility provided follow up regarding the potential new system. The food council meeting minutes, dated 3/4/26, revealed the residents in attendance complained they were not always getting a choice of their meal. A dietary performance improvement plan (PIP), dated 3/1/26, was provided by the NHA on 3/19/26 at 1:38 p.m. The PIP read in pertinent part, The PIP identified residents' meal orders were not taken by the staff on a regular basis. The items to address were identified as educating residents who were capable of taking their own orders and turning in their tickets, identifying residents who regularly dined in the dining room and educating staff on residents who will need their meal orders taken. The correction action plan identified residents into four categories; residents who needed their meal orders taken, residents who were capable of taking their own orders and turning them in, residents who regularly received the main meal, and residents who dined in the dining room and were able to request an alternate.-The PIP did not address how residents were categorized.-The PIP did not address how residents who were categorized as regularly receiving the main meal would be able to choose their own meals. Resident #41 and Resident #45, who were categorized as regularly receiving the main meal, were two residents who said they did not get options for meals. The plan was to educate residents of the new change and ensure they were comfortable with the new process. For residents who were identified as capable of taking their own orders and turning the tickets in; the DM would provide the residents their meal tickets a week in advance. The residents were then responsible to turn in their tickets to a staff member the day before the meal was served. -The PIP did not address what meal was provided for the residents who were identified as responsible for their own order if their ticket was not turned in timely. For residents that were identified as dining in the dining room; they will be educated that their orders will no longer be taken and the resident would need to notify staff, when they arrive in the dining room, if they choose an alternate meal. The residents also need to notify staff if they will not be dining in the dining room and request either the main meal or an alternate. The dietary manager will also post a week at a glance menu at the nurses' station. -The PIP did not address how residents who dine in the dining room and have a cognitive impairment were given choices during meals because the resident was now responsible for notifying staff if they want the alternate meal when they arrive at the dining room. -The PIP did not address how the residents who were identified on the always regular menu and who did not dine in the dining room were provided with meal options. The dietary aide would ask specific residents for their meal preference the day before and determine whether they would like a room tray or will be eating in the dining room.The goal date for the action plan was 3/20/26. -However, observations and resident interviews during the survey revealed there were ongoing issues with the residents not being able to make their own choices regarding the foods they received at meals (see observations and interviews above).V. Staff interviewsCNA #2 was interviewed on 3/18/26 at 12:00 p.m. CNA #2 said the night shift should be taking the residents' orders for the next day. She said she was not sure how it worked on the night shift. She said since there were no longer resident aides the CNAs had to take over those duties and taking meal orders was one of the duties. The regional dietary resource was interviewed on 3/19/26 at 11:32 a.m. The regional dietary resource said the facility was going through a transition with taking orders. The regional dietary resource said a resident aide used to take the resident orders the day before. The regional dietary resource said there was no longer a resident aide and now the CNAs were supposed to be taking the menu orders the day before. The regional dietary resource said the staff member taking the order should provide a description of the meal, ask about alternative items and turn in the meal ticket. The regional dietary resource said if a resident told a CNA or another staff member of their dislikes this information should be communicated to the dietary staff in order to make changes to their meal ticket. The regional dietary resource said the dietitian met with the residents on admission then quarterly and as needed to review likes and dislikes. She said a PIP was initiated that identified and addressed meal order issues.

Based on record review and interviews, the facility failed to honor resident choices for four (#17, #29, #41, #77) of 12 residents reviewed out of 38 sample residents. Specifically, the facility failed to ensure Resident #17, Resident #29, Resident #41 and Resident #77 received showers consistently according to the resident's choices and plan of care. Findings include:I. Facility policy and procedureThe Resident Showers policy, revised April 2025, was provided by the nursing home administrator (NHA) on 3/19/26 at 11:23 a.m. The policy read in pertinent part: It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current stands of practice. Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. Partial baths may be given between regular shower schedules as per facility policy.II. Resident #17A. Resident statusResident #17, age [AGE], was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included unspecified dementia without behavioral disturbance.The 4/20/26 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of eight out of 15. She required set-up assistance with activities of daily living (ADL) and supervision to touching assistance with showers. The MDS assessment did not document the resident was resistant to care. B. Record reviewThe ADL care plan, initiated 5/25/25 and revised 5/27/25, revealed the resident had an ADL self care performance deficit. Pertinent interventions included, set-up to supervised assistance with bathing/showering and as necessary. The resident preferred to shower in her room.-Review of the resident's comprehensive care plan did not reveal documentation indicating the resident was resistant to care.Resident #17's point of care (POC) response history for the bathing task revealed Resident #17 preferred showers on Monday and Thursday during the evening shift.Review of Resident #17's POC bathing task documentation from 2/19/26 through 3/16/26 revealed the resident refused all showers.The CNA shower/bath documentation revealed the following:The 2/19/26 CNA shower/bath documentation form documented Resident #17 refused. The reason for refusal was Resident #17 said it was too cold. The 2/23/26 CNA shower/bath documentation form documented Resident #17 refused. The reason for refusal was Resident #17 said she did not want to. The 2/26/26 CNA shower/bath documentation form documented Resident #17 refused. There was no reason documented for the refusal. The 3/2/26 CNA shower/bath documentation form documented Resident #17 refused. The reason for refusal was Resident #17 said her schedule was full. The 3/5/26 CNA shower/bath documentation form documented Resident #17 refused. The reason for refusal was the hot water was out before dinner and Resident #17 refused after dinner. The 3/9/26 CNA shower/bath documentation form documented Resident #17 refused. The reason for refusal was Resident #17 said not today, maybe next time. The 3/12/26 CNA shower/bath documentation form documented Resident #17 refused. The reason for refusal was Resident #17 said it was too cold. The 3/16/26 CNA shower/bath documentation form documented Resident #17 refused. The reason for refusal was Resident #17 said it was too late. A progress note, dated 3/2/26 at 4:40 p.m., documented Resident #17 was offered a shower through the day but she refused stating she did not create time for it. -There was no documentation that the resident had been provided showers or bed baths on other days.-There was no documentation that the resident was approached at different times or other interventions were attempted.III. Resident #29A. Resident statusResident #29, age less than 65, was admitted on [DATE]. According to the March 2026 CPO, diagnoses include multiple sclerosis (MS) and weakness.The 12/10/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was set-up assistance for ADLs including showers. The MDS assessment did not document the resident was resistant to care. B. Resident interviewResident #29 was interviewed on 3/17/26 at 3:10 p.m. Resident #29 said she was not receiving showers as often as she should. She said she was not asked regularly and this was very upsetting to her because she gets scabs on her scalp if she did not use her shampoo on a regular basis. She said she got angry because the scabs could be prevented if she used the shampoo regularly. She said she would not refuse showers. C. Record reviewThe March 2026 CPO documented ketoconazole external shampoo 1 percent (%) applied to scalp topically every 24 hours as needed for psoriasis (skin rashes). The ADL care plan, initiated 9/27/24 and revised 9/30/24, revealed the resident had an ADL self care performance deficit related to MS. Pertinent interventions included resident required one to two staff members to assist with bathing and she required one to two staff members' participation with personal hygiene and oral care, Resident #29's POC response history for the bathing task revealed Resident #29 preferred showers on Monday, Wednesday and Friday during the evening shift.Review of Resident #29's POC bathing task documentation from 2/27/26 to 3/16/26 documented the resident did not consistently receive showers on the preferred days.Review of Resident #29's POC documentation from 2/27/26 to 3/16/26 documented the resident received showers on 2/27/26, 3/4/26, 3/13/26 and 3/16/26. The resident received four showers out of nine opportunities. -However the POC response history for the bathing task documented a shower was provided on 3/4/26. There was a CNA shower/bath documentation, dated 3/4/26, signed by the CNA and nurse documenting the resident refused a shower that day. -CNA shower/bath documentation forms were requested for Resident 29 for this time period and were not provided.IV. Resident #41A. Resident statusResident #41, age less than 65, was admitted on [DATE]. According to the March 2026 CPO, diagnosis included morbid obesity.The 2/20/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was dependent on staff for showers and lower body dressing. She was substantial to maximal assistance for upper body dressing and setup assistance for oral hygiene and eating. The MDS assessment did not document the resident was resistant to care. B. Resident interviewResident #17 was interviewed on 3/19/26 at 8:53 a.m. Resident #17 said she did not receive her showers. She said she was not offered bed baths if she was not feeling up to getting out of bed. Resident #17 said she would accept a bed bath when she did not feel well enough to get out of bed. She said not getting showers made her feel forgotten and disgusting. She said she was not a dirty person and not showering regularly makes her feel dirty. C. Record reviewThe ADL care plan, initiated 9/1/24 and revised 1/20/25, revealed the resident had a self care performance deficit related to limited mobility. Pertinent interventions included, providing a sponge bath when a full bath or shower cannot be tolerated, and Resident #41 preferred to shower two times per week. Resident #41's POC bathing task revealed Resident #41 preferred showers on Wednesday and Sunday during the evening shift. Review of Resident #41's POC bathing task documentation from 2/25/26 to 3/18/26 revealed the resident did not consistently receive showers on her preferred days.Review of Resident #41's POC documentation from 2/25/26 to 3/18/26 revealed the resident received a shower on 2/25/26. The resident received one shower out of seven opportunities. The 3/11/26 CNA shower/bath documentation form documented Resident #41 refused. The reason for the refusal was the resident was not feeling good. A progress note, dated 3/4/26 at 10:07 p.m. documented Resident #41 switched her shower to the next day.-However there was no documentation the resident was offered or provided a shower or bed bath on 3/5/26. V. Resident #77A. Resident statusResident #77, age greater than 65, was admitted on [DATE]. According to the March 2026 CPO, diagnoses included vascular dementia without behavioral disturbance, and need for assistance with personal care.The 1/6/26 MDS assessment revealed the resident was cognitively impaired with a BIMS score of four out of 15. She required setup assistance for ADLs and partial to moderate assistance for showers.The MDS assessment did not indicate the resident was resistant to care.B. Record reviewThe ADL care plan, initiated 10/21/24 and revised 10/29/24, documented the resident had an ADL self care performance deficit. Interventions included, the resident preferred showers on Tuesdays and Thursdays and a bed bath on Saturday during the evening shift, and she required staff participation with bathing.Resident #77's POC for the bathing task revealed Resident #77's preferred showers on Tuesdays and Fridays during the day shift.Review of Resident #77's POC bathing task documentation from 2/17/26 to 3/17/26 documented the resident did not consistently receive showers on the preferred days.Review of Resident #77's POC documentation from 2/17/26 to 3/17/26 revealed the resident received a shower on 3/17/26. The resident received one shower out of nine opportunities. -However, her care plan documented the resident preferred two showers a week and a bed bath once a week. There were four bed bath opportunities missed and a total of 13 missed bathing opportunities.The 2/17/26 CNA shower/bath documentation form documented the resident refused. No reason was provided. There was no nurse signature.The 3/6/26 CNA shower/bath documentation form documented the resident refused. The reason was the resident did not want one. The documentation was not signed by the nurse and signed by the CNA on 3/18/26 (during survey).The 3/13/26 CNA shower/bath documentation form documented the resident refused. No reason was documented. VI. Staff interviewsCNA #1 was interviewed on 3/17/26 at 11:00 a.m. CNA #1 said CNAs provided the showers for their residents. CNA #1 said there was a shower aide but the shower aide did not work everyday. CNA #1 said there was a shower schedule kept at the nurses' station. She said if a resident refused their shower they were asked to sign a form stating they refused. CNA #8 was interviewed on 3/19/26 at 12:49 p.m CNA #8 said if a resident refused their shower the CNA should be going back and offering at least three times. CNA #8 said if the resident continued to refuse the CNA would notify the nurse and the nurse would approach the resident and have the resident sign the refusal shower/bath documentation form. CNA #8 said if the resident refused a shower then a bed bath should be offered. CNA #7 was interviewed on 3/19/26 at 1:25 p.m. CNA #7 said the CNAs were responsible for providing showers to their residents. CNA #7 said if a resident refused the CNA would tell the nurse and the nurse would check with the resident and have the resident sign a refusal form. CNA #7 said if a resident asked to have a shower at a different time, the information was passed on to the next shift. CNA #7 said the staff tried to accommodate the residents' preferences. She said if the not applicable was marked on the POC under the shower/documentation it may be the shower was triggered for a day which was not a preferred day. The director of nursing (DON) was interviewed 3/19/27 at approximately 1:00 p.m. The DON said residents were typically scheduled for two showers a week. The DON said if a resident requested more than the facility attempted to accommodate the request. The DON said the CNAs were responsible for the showers on their shifts. The DON said if a resident refused the CNA was expected to make accommodations for the resident for example, a different time or offer a bed bath. The DON said the CNA was to check with the resident at least three times about bathing. The DON said if the resident continued to refuse the CNA notified the nurse and the nurse would also talk to the resident and have the resident sign the shower/bath documentation form. The DON said the shower/bath documentation form stated the reason for the refusal and both the CNA and nurse were to sign along with the resident. The DON said the not applicable on the task screen should not be marked. She said it may have been marked because a shower triggered on a nonscheduled shower day and the CNA marked not applicable. She said if not applicable was marked a shower was not provided.

Based on record review and interviews, the facility failed to properly store, prepare, distribute and serve food in accordance with professional standards for food service safety.Specifically, the facility failed to ensure the facility's one dishwashing room was maintained and repaired in a timely manner. Findings include:I. Professional referenceAccording to the Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 3/26/26. The regulations revealed in pertinent part, physical facilities should be maintained in good repair. Physical facilities should be cleaned as often as necessary to keep them clean. Intake and exhaust air ducts should be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. (Chapter 6)II. Facility policy and procedureThe Safe and Homelike Environment policy, revised 10/1/24, was provided by the nursing home administrator (NHA) on 3/19/26 at 4:45 p.m. The policy revealed the facility would provide housekeeping and maintenance services as necessary to maintain a sanitary, orderly and comfortable environment. The staff were to report any unresolved environmental concerns to the NHA. III. Environmental tourAn environmental tour of the facility's dish washing room was conducted on 3/17/26 at 7:30 a.m. There was chipped paint on the wall at the entrance to the room. The air vent exterior metal cover contained black debris and lint. One wall was not completely painted. The exhaust vent over the dish washing machine had areas of black debris. The ceiling pipes were dusty. There was torn floor laminate (composite material) approximately four feet in length at the juncture of the floor and wall, under the sink near the dish washing machine. The baseboard was separated (pulled away from the wall) almost the entire length of the wall under the sink. The left corner of the room at the entrance door was dirty (uncleaned surface) and had various amounts of debris scattered on the floor. IV. Staff observations and interviewsThe NHA conducted an environmental review of the dish washing room with the surveyor on 3/19/26 at 7:21 a.m. The NHA observed the above listed concerns. The NHA said he was not aware of these issues. The registered dietitian (RD) conducted an environmental review of the dish washing room with the surveyor on 3/19/26 at 7:35 a.m. The RD observed the above listed concerns. The RD said she had not put in any work orders for these concerns.

Based on record review and interviews, the facility failed to maintain accurate medical records for advance directives on each resident for one (#29) of six residents reviewed out of 38 sample residents. Specially, the facility failed to ensure Resident #29's medical orders for scope of treatment (MOST) form corresponded with the computerized physician orders (CPO) for no cardiopulmonary resuscitation (CPR). Findings include:I. Facility policy and procedureThe Advanced Directive and Associated Documentation policy and procedure, reviewed [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 1:13 p.m. It read in pertinent part, It is the policy of this facility that a resident's choice about advance directives will be recognized and respected. Advance care planning will occur periodically (at least quarterly, annually and on the change of condition) to review the advance directive and/or preferences regarding treatment options with the resident or their representative to ensure that they are still the wishes of the resident. Such reviews will be made during the assessment process and recorded in the medical record. The resident may modify or cancel the advance directive decision at any time; changes or revocation of a directive must be submitted to the facility, in writing and immediate action must be taken to implement desired changes.II. Resident #29A. Resident statusResident #29, age less than 65, was admitted [DATE]. According to the [DATE] CPO, the diagnoses included multiple sclerosis (MS), gastro-esophageal reflux disease (GERD), bipolar disorder, muscle weakness and chronic pain. The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. B. Record review and observationObservation on [DATE] during the initial tour 8:30 a.m. revealed a green dot next to Resident #29's door name tag.Observation on [DATE] at 3:15 p.m. revealed a green dot next to Resident #29's door name tag.Resident #29's MOST form located in the advance directive binder at the nurses' station and uploaded into the electronic medical record (EMR) revealed it was signed and dated [DATE] by the resident. It was signed and dated by the nurse practitioner (NP) on [DATE]. The MOST form indicated, no CPR with selective treatment which included intravenous (IV) antibiotics and fluids, do not intubate and to avoid intensive care. The [DATE] CPO revealed a physician's order that Resident #29's code status was to receive CPR, ordered [DATE].-The CPO did not correspond with the directive on the MOST form, after the resident made a change in [DATE], six months prior. The care plan review document, dated [DATE], revealed the care conference was attended by Resident #29, her emergency contact, social services, a licensed practical nurse (LPN) and the medical provider. The care plan review document indicated Resident #29's advance directive was CPR.-However, Resident #29's MOST form was updated in [DATE], three months prior, to indicate she did not want CPR. C. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on [DATE] at approximately 1:30 p.m. She said in case of an emergency she looked at a resident's EMR for the resident's code status. LPN #2 said the hard copy of the advanced directive was kept in a binder located at the nurses' station labeled advanced directive binder. She said if the resident was transferred to the hospital she would make a copy of the advance directive located in the binder. LPN #2 said there was also a green dot on the resident's door name tag, located outside the room, to indicate if the resident was a full code. The director of nursing (DON) and regional nurse consultant were interviewed on [DATE] at 3:02 p.m. The DON said there was an advanced directive binder at the nurses' station where the MOST forms were kept. The DON said the advance directive forms should match the resident's CPO. The DON said a change in a resident's advanced directive was discussed during the interdisciplinary team's (IDT) morning meeting or during change of shift report. The DON said the expectation was that the nurse who received the new order would discontinue the old order and initiate the new order in the CPO. The DON said the new form was scanned into the resident's EMR and added to the advanced directive binder. The DON said the advance directives were reviewed at least quarterly during the care conferences. The DON said monthly audits were completed to compare the advanced directive binder to the CPO. The DON confirmed the green dots on the door name tags indicated that resident was a full code. The DON was interviewed again on [DATE] at 8:15 a.m. She said she spoke with Resident #29 on [DATE] during the survey who confirmed her wish for no CPR. The DON said the order was changed in the EMR.

Based on record review and interviews, the facility failed to ensure resident rights were promoted and dignity was maintained for one (#1) of three residents out of five sample residents. Specifically, the facility failed to ensure Resident #1's care was provided in a dignified and respectful manner by certified nurse aide (CNA) #1. Findings include: I. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included epilepsy (seizure disorder), bipolar disorder (mental disorder that causes unusual shifts in behaviors), low back pain and muscle weakness. The 9/12/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent on one staff member's assistance with toileting hygiene. She required substantial/maximal assistance for putting on/taking off footwear. She required partial/moderate assistance for bathing, upper/lower body dressing and personal hygiene. The MDS assessment indicated the resident did not have any behavioral symptoms or rejection of care during the review period. B. Resident interview Resident #1 was interviewed on 11/25/24 at 3:05 p.m. Resident #1 said that certified nurse aide (CNA) #1 was rough with her, for example, when turning her during her incontinence care she rolled her too quickly, made her do her activities of daily living (ADL) tasks in a hurry, and was impatient with her when she was unable to move as quickly as CNA #1 wanted her too. Resident #1 said she could not move as quickly as CNA #1 wanted her to because she was in a wheelchair and could not walk. Resident #1 felt that the way CNA #1 treated her was rude. Resident #1 said CNA #1 made her feel terrible, she could not stand it and it made her feel helpless. Resident #1 said CNA #1 was a sour apple and she wanted her banned from taking care of her and wanted her fired. Resident #1 said this happened a few weeks ago in October 2024 but she could not recall the exact day. Resident #1 said she could not recall whom she told about the incident but that CNA #1 has not worked with her since. C. Record review The behavior care plan, initiated on 10/29/24 revealed the resident had the potential for a mood/behavior problem related to her diagnosis of bipolar disorder. Interventions included anticipating and meeting the residents needs, approaching the resident in a calm manner, assisting the resident in developing more appropriate methods of coping and interacting, encouraging the resident to express feelings appropriately, explaining all procedures to the resident before starting and allowing her to adjust to changes, discussing the resident's behavior if reasonable, explaining/reinforcing why the resident's behavior was inappropriate and/or unacceptable, intervening as necessary to protect the rights and safety of others, approaching/speaking in a calm manner, diverting the resident's attention, removing the resident from the situation and taking her to an alternate location as needed observing the resident for side effects and adverse reactions of psychoactive medications and a program of activities that was of interest and accommodates the residents status. -The care plan was updated on 10/29/24 to include a potential for a mood/behavior problem related to bipolar diagnosis. The 10/30/24 nurse note revealed that administration met with Resident #1 that day (10/30/24) regarding the concern of the call lights and working with CNA #1. Resident #1 reported feeling safe and had no issues with any of the CNA's. The statement was completed with a nurse and human resources staff member. The 10/31/24 nurse note revealed the nurse and the MDS coordinator (MDSC) interviewed Resident #1 regarding her care at night and the call lights. Resident #1 was laying in bed, resting and reported she had no concerns and was okay with working with all of the CNAs. Resident #1 reported she felt safe and all needs were met regularly. The 11/3/24 psychosocial monitoring note revealed the resident was monitored for signs and symptoms of increased tearfulness, increase in isolation, or other changes every shift for three days. No increase in isolation or refusals of care that shift. D. Facility investigation The nursing home administrator (NHA) provided a facility investigation report regarding Resident #1's care on 11/25/24 at 4:37 p.m. The 10/31/24 facility investigation revealed the facility had a report of a conflict/concern between Resident #1 and CNA #1 the night prior (10/29/24). The unit manager (UM) #1 reported CNA #1 was moved to the front hall per the director of nursing's (DON) direction due to the concern between Resident #1 and CNA #1. UM #1 reported that CNA #1 had completed a pass off shift report and would be supervised until she exited the facility. The event description read that the compliance officer for the company called to notify the DON that there were two anonymous calls to the compliance line reporting neglect in the manner on part of CNA #1 refusing to answer specific residents'call lights. CNA #1 completed a pass off report for the oncoming shift with staff supervision, and exited the building. CNA #1 was suspended pending a full investigation by the facility. The report revealed the concern between Resident #1 and CNA #1 had not been witnessed. Resident #1 was assessed and interviewed the morning of 10/31/24. Resident #1 reported no issues, call lights were good and she was okay to work with CNA #1 and felt safe within the facility. Results of the interview with CNA #1 revealed she answered call lights appropriately and had not had issues with Resident #1 in the past. The facility interviewed other residents in the facility who reported no issues with CNA #1 and stated call lights were answered and they had no concerns or complaints. Nurses who were interviewed as part of the investigation reported CNA #1 could present as lazy, however, they had not seen any behaviors or neglect of residents by CNA #1, such as ignoring call lights, and they felt comfortable working with CNA #1. One nurse reported she preferred to work with CNA #1 as she was a hard worker and a team player. The facility found the allegation of neglect to be unsubstantiated. The facility actions included monitoring Resident #1's treatment regimen for any psychosocial changes or needs. Clinical staff was provided regarding the importance of answering call lights timely to ensure resident needs were met. Education was completed with the staff regarding kindness. CNA #1 received education on her approach and how she was perceived by other staff members and was allowed to return to work. II. Staff interviews CNA #2 was interviewed on 11/25/24 at 3:17 p.m. CNA #2 said that sometime in October 2024 Resident #1 had asked him how to report care concerns about something that had happened a few days before. CNA #2 said he told her he would contact the DON since it was after 9:00 p.m. CNA #2 said he called the DON and she said she had already spoken to the nurse on the back hall because Resident #1 had directly reported the concern to the nurse. CNA #2 said Resident #1 had told him she needed to report CNA #1, but she did not tell him the particulars of what happened. CNA #1 was interviewed on 11/25/24 at 4:05 p.m. via telephone. CNA #1 said she knew about the situation (allegations) but she said she did not know why Resident #1 felt that way about her caring for her. CNA #1 said Resident #1 was not following any orders when she was trying to provide care for her. CNA #1 said Resident #1 had gotten into a mood all day (on the day of the concern), did not feel like doing anything and was incontinent that day because she was not moving. The DON was interviewed on 11/25/24 at 3:47p.m. The DON said on 10/29/24 she got a phone call from CNA #2 regarding Resident #1 being upset with CNA #1. The DON said it was her understanding that the resident was upset with CNA #1 for how she acted during the resident's incontinence care. The DON said she called and talked to CNA #1 and CNA #1 said it was more about her trying to get the resident to roll over with her incontinence care. The DON said she called UM#1 and told her to move CNA #1 to a different hall because Resident #1 was irritated at her. The next morning, 10/30/24, the NHA interviewed the resident and there were no concerns. The DON said the next day, on 10/31/24, she received a phone call from the facility's internal compliance hotline stating that a neglect allegation had been called in for Resident #1 related to Resident #1 not wanting to be changed. The DON said the trigger word of neglect had been used in the compliance line report, so she immediately reported to the State Agency, CNA #1 was suspended and she began an investigation. The DON said she began education with CNA #1 about her approach and the importance of answering call lights. The DON said CNA #1 had not worked with Resident #1 since that date. The NHA was interviewed on 11/25/24 at 4:48 p.m. The NHA said from what he was told, it had sounded like Resident #1 was not getting care from CNA #1 but when he spoke with Resident #1 on 10/30/24, it was a different story and she had no concerns. The NHA said when he asked Resident #1 if the staff had ever neglected her care, she said no, they did a good job. He said he also asked Resident #1 if she had trouble getting her call light answered in a timely manner and Resident #1 said sometimes but not lately. The NHA said he also asked the resident when the staff answered her call light, did they assist her with what she needed and Resident #1 answered yes. The NHA said the DON had told Resident #1 that CNA #1 would not be working with her anymore. III. Facility follow-up On 11/27/24 at 4:28 p.m. the DON provided the following information via email revealing she and the NHA had completed further investigation into Resident #1's concerns. The NHA interviewed Resident #1 on 11/25/24 at approximately 6:00 p.m. Resident #1 was asked about if she felt safe and if she had any issues with any CNA's at the facility. Resident #1 said she had an issue with CNA #1, who was rough and rude. Resident #1 reported the situation had happened awhile ago and said she knew that she would not be working with CNA #1 any longer and felt safe with CNA #1 in the building if she was not working with her. When asked, Resident #1 was unable to detail the time or what she meant by rough. Resident #1 did not appear distressed when discussing the incident, however psychosocial support and validation of her feelings was offered. Education was provided to CNA #1 on 11/25/24. The education revealed when she was approaching residents and providing care, CNA #1 was to make sure that she talked through each step with the resident and offered residents help with each task that she was completing. If a resident refused care, she was to ensure she asked what she could do to help, what the resident needed and how CNA #1 and the resident could work together. CNA #1 was reminded it was important to make the residents feel comfortable in their home and ensure that staff were not being perceived as pushy or infringing on their rights.

Based on observations and staff interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public in two of three units. Specifically, the facility failed to: -Keep space heaters in areas deemed safe; -Maintain comfortable room temperature; -Remove exposed wires when equipment was removed; -Keep ceiling panels closed in residential areas; -Maintain flooring condition without tripping hazards in the dining area, and, -Keep emergency water sprinklers uncovered. Findings include: I. Maintain comfortable temperature and space heater On 2/12/24 at 11:30 a.m. room [ROOM NUMBER] had a black tall heater positioned between dressed and bedside commode. The resident in room [ROOM NUMBER] was interviewed on 2/12/24 at 11:14 a.m. She said it was cold every day. room [ROOM NUMBER] was observed on 2/12/24 at 1:23 p.m. There was a tall space heater in the semi-private room that was placed in the middle of the room. It was next to the privacy curtain that separated the two residents who resided in room [ROOM NUMBER]. He said his room was kept warm because his roommate wanted it warm and the space heater was used to keep it warm. The resident's representative in room [ROOM NUMBER] was interviewed on 2/12/24 at 2:36 p.m. She said the lobby was cold. The representative liked to be in the lobby to watch the birds. The representative said the facility provided lap blankets but the resident forgot to use the blanket. The resident told her representative that her room was sometimes too hot because her roommate wanted it warm and the space heater was on to keep her roommate warm. On 2/15/24 at 11:51 a.m. room [ROOM NUMBER] was entered with registered nurse (RN) #2 during medication administration. The resident was bundled up in several blankets laying in bed. She was wearing a warm coat with a hood. The temperature on the thermometer read 17.3 Celsius (63.14 Fahrenheit). RN #2 stated it was the only thermometer that had temperature recorded in Celsius. She said the resident preferred her room at cooler temperatures. The resident stated she was ok with the current temperature since her family brought her warm clothes. At 12:06 p.m. room [ROOM NUMBER] was reading 64 F. The resident was dressed in a long sleeve shirt and sweater. He said he understood the heater was not working and said he liked lower temperatures and was ok with the current temperature. The approved space heater map was provided by the nursing home administrator (NHA) on 2/14/24 at 11:27 a.m. It revealed rooms #205, #206 and #208 were not rooms that were approved to have space heaters in the room. II. Environmental observations On 2/12/24 at 11:30 a.m. the following observations were made on the hallway 300 and 400. -In hallway 300, a large air duct, eight to twelve inches in diameter, was coming out of the wall. The inside of the duct was black to gray and it was blowing warm air into the hallway. -The electric panel between rooms #314 and #315 had exposed wire of unknown origin sticking out of the wall; -In hallway 400, open ceiling tiles were observed throughout the hallway; -The main dining room had an area of four to five feet of cracked floors creating a tripping hazard; and, -The fire sprinkle at the end of the dining room was covered in bubble wrap and secured with tape all around. III. Staff interviews The maintenance director was interviewed on 2/13/24 at 10:30 a.m. He said the facility was currently relying on two portable generators due to the failure of the boiler. He said large open ducts were built into the walls to force the warm air into the building on the unit 200 and 300. He said space heaters were used in the areas where the temperature fell below the comfortable level. He said the facility was using infrared space heaters that were deemed safe. He said every room was equipped with a thermometer and every two hours certified nurse aides (CNAs) were recording room temperature on the log at the nurses station. He said all staff in the building received verbal education on the safety maintenance of space heaters. He said the front of the space heater should not be obstructed by any items and only safe infrared space heaters were allowed to be used. He said his understanding was that current heating means were covered under the waiver that the facility obtained in order to keep residents warm until the better options became available. He said ceiling panels were open to ensure air circulation to prevent the plumbing pipes from freezing in the attic. He was not sure why a non-infrared space heater was located in room [ROOM NUMBER]. He said it should be removed. He said unequal flooring in the dining room was a result of construction work that was done a long time ago. He said he was acquiring bids from different companies for the restoration of the floor area in the dining room. He said the fire sprinkles should never be covered. He said he would review all fire sprinkles to ensure they were uncovered. Licensed practical nurse (LPN) #1 was interviewed on 2/13/24 at 2:14 p.m. LPN #1 said space heaters were in the resident's rooms when it was cold outside. The regional corporate maintenance director (RCMD) was interviewed on 2/13/24 at 4:03 p.m. He said the space heaters used in the facility ensured the space heater could not tip over. The space heater could not block the door to the resident's room or to the resident's bathroom. The space heater had to be three feet away from any objects, it could not be near anything combustible, and the space heater had to be plugged directly into the wall electricity outlet. The NHA and regional clinical resource (RCR) #1 and #2 were interviewed on 2/14/24 at 10:01 a.m. RCR #1 said all space heaters were removed from residents' rooms except for infrared wood space heaters. RCR #1 said the space heaters were removed based on what the RCMD mentioned as the criteria that was not followed for having them. RN #1 was interviewed 2/14/24 at 2:45 p.m. She said space heaters were used in the facility since the heating system stopped working. She said her responsibility as a nurse was to make sure heaters did not have anything on top of them and room temperature was appropriate. She said every room had a thermometer mounted near the call light cable and it was the CNA's responsibility was to monitor the temperatures every two hours to ensure a comfortable temperature in the room. RN #2 was interviewed on 2/14/24 at 2:55 p.m. She said CNAs were supposed to monitor temperatures in the room every two hours and document it on the log. CNA #3 was interviewed on 2/15/24 at 3:40 p.m. She said the temperature in the room was recorded every two hours and put on the log. The maintenance director was interviewed again on 2/15/24 at 4:23 p.m. He said he removed the bubble wrap from the sprinkle on 2/13/24 and educated all staff on keeping fire sprinkles unobstructed and uncovered. He said the wire in the hallway 300 was covered by a thermostat that it was originally connected to, but removed from it previously for unknown reason. He said all non-infrared space heaters were removed from the rooms and hallways. The NHA was interviewed on 2/15/24 at 4:45 p.m. She said her understanding of the situation was that all current heating means were covered under the waiver that the facility had in place. She said she was not aware that space heaters were not covered under the waiver. She said since it was brought to her attention, all space heaters were removed from residents rooms and residents were relocated to the hallways that were able to maintain comfortable temperatures. She said multiple efforts were made to resolve the heating situation in the building and they were reviewing several bids from qualifying companies. She said due to the age of the building and plumbing problems, the restoration of the boiler was very unlikely. She said the facility was looking into installing packaged terminal air condition units in every room but it would require additional work on the electrical cables inside and outside the building. She said the plan was to resolve the situation prior to the next winter season and keep all residents safe and comfortable until then. 48112

Based on record review and interviews, the facility failed to have a registered nurse (RN) scheduled eight hours consecutively a day for seven days a week. Specifically, the facility failed to have an RN on duty for eight consecutive hours on a consistent basis from 11/1/23 to 2/5/24. Findings include: I. Record review Review of the nursing schedule from 11/1/23 to 2/5/24 revealed the following: -In November 2023, the facility did not have an RN on duty for eight consecutive hours on seven days during the month; -In December 2023, the facility did not have an RN on duty for eight consecutive hours on seven days during the month; -In January 2024, the facility did not have an RN on duty for eight consecutive hours on four days during the month; and, -In February 2024, from 2/1/24 to 2/5/24, the facility did not have an RN on duty for eight consecutive hours for one day. II. Staff interview The director of nursing (DON) was interviewed on 2/15/24 at approximately 10:20 a.m. The DON said it had been a challenge to hire RNs to fill their vacant positions therefore the facility had been utilizing agency staffing. She said the facility currently had one RN position open for the night shift. The DON said the facility occasionally utilized the RN state waiver when there was no RN in the building for the entire 24 hours a day. -However, an RN was required in the building for eight consecutive hours a day, seven days a week. The DON said licensed practical nurses were to contact the on-call RN for any emergencies that required an RN in the building. The nursing home administrator (NHA) and the RNC were interviewed on 2/15/24 at approximately 11:05 a.m. The NHA said her understanding was that the RN waiver covered the days there was no RN in the building.

Based on observations and interviews, the facility failed to ensure medications were stored in accordance with accepted professional standards for two of two medication refrigerators. Specifically, the facility failed to: -Ensure controlled medications were in a locked storage container that was permanently secured to the refrigerator; and, -Ensure all medications were stored under two separate locking devices. Findings include: I. Facility policy and procedure The Narcotic Storage policy and procedure, with no revision date, was provided by the nursing home administrator on 2/15/24. It read in pertinent part, To provide adequate and effective control of all narcotics and other controlled substances. All controlled medications will be kept under two separate locking devices to reduce the accessibility and increase security of controlled substances. II. Observations On 2/14/24 at 12:35 p.m. the medication refrigerator on the 200 unit in the medication room was observed with licensed practical nurse (LPN) #2. There was one controlled medication locked box in the refrigerator not permanently affixed to the refrigerator and it contained unopened liquid Ativan (a benzodiazepine and a schedule IV controlled substance used to treat anxiety) and another open liquid Ativan was on the refrigerator door shelf (not in locked box). On 2/15/24 at 11:34 a.m. the medication room on the 300 unit was inspected in the presence of registered nurse (RN) #2. The medication room was locked, however the height of the wall to the medication room was ending at the top of the door frame, creating a gap of approximately three by four feet wide between the door frame and the ceiling. The gap compromised the security of the room and created the possibility of access to the room without a key. The controlled medication locked box in the refrigerator was not permanently affixed to the refrigerator. The box was dented in many areas and contained approximately one inch hole on the top cover. There were no controlled medications in the box. III. Staff interviews LPN #2 was interviewed on 2/14/24 at 12:45 p.m. He said he did not know why one controlled medication was in the secured box and the other controlled medication was not. He said he was not aware that the controlled medication box in the refrigerator should be permanently affixed to the refrigerator. He said he understood that anyone with access to the refrigerator could just take the box of controlled medications out of the refrigerator. RN #2 was interviewed on 2/15/24 at 11:34 a.m. She said the medication room was unusual as it did have an opening above the door which would allow access to the room without a key. She said she was not aware that the controlled medication box in the refrigerator should be permanently affixed to the refrigerator. She said she had not used the box before and did not know what was in it and why it had a hole on the top. The director of nursing (DON) was interviewed on 2/15/24 at 4:30 p.m. The DON said she was not aware of the requirement that the controlled medication boxes should be permanently affixed to the refrigerators. She said she did not know that the controlled medication box on the 300 unit had a hole. She said the medication room on the 300 hallway will be re-evaluated for medication storage due to an opening above the door that was compromising its security.

Based on observations and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections in two out of four units. Specifically, the facility failed to follow proper personal protective equipment (PPE) procedures when entering resident rooms in isolation. Findings include: I. Professional reference According to the Center for Disease Control and Prevention (CDC) Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19 (6/3/2020), retrieved on 2/20/24 from https://www.cdc.gov/coronavirus/2019-ncov/downloads/communication/print-resources/A_FS_HCP_COVID19_PPE_card.pdf PPE must be donned correctly before entering the patient area (e.g., isolation room, unit if cohorting). PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas. PPE should not be adjusted (e.g., retying gown, adjusting respirator/face mask) during patient care. PPE must be removed slowly and deliberately in a sequence that prevents self-contamination. A step-by-step process should be developed and used during training and patient care. II. Observations On 2/12/24 at 11:30 a.m. housekeeper (HK) #1 was polishing floor in room [ROOM NUMBER], the sign on the door read, Enhanced precautions. Everyone entering this room must wear: N95 respirator, gloves, gown and eye protection. The resident was on isolation COVID-19. HK #1 was wearing a surgical mask. He did not wear a N95 respirator, gown or gloves. After he completed polishing floor in room [ROOM NUMBER], he moved to room [ROOM NUMBER], who was not on isolation wearing the same surgical mask. On 2/13/24 at 10:15 a.m. certified nurse aide (CNA) #2 was entered room [ROOM NUMBER]. The sign on the door read, Enhanced precautions. Everyone entering this room must wear: N95 respirator, gloves, gown and eye protection. The resident was on isolation for COVID-19. CNA #2 donned gown, gloves and goggles, however she did not switch her surgical mask with a N95 respirator prior to entering the room. At 12:15 p.m. CNA#2 entered room [ROOM NUMBER] again. She donned a gown, gloves and goggles, but she did not switch her surgical mask with a N95 respirator prior to entering the room. On 2/14/24 at 11:35 a.m. registered nurse (RN) #1 was entered room [ROOM NUMBER]. RN #1 donned the required PPE and entered the room. At 11:45 a.m., after she completed medication administration to the resident, she walked to the door and removed her PPE by removing her goggles first and placed them on an isolation cart outside the room, she removed her N95 respirator, gloves and gown. RN #1 failed to remove her PPE in the correct order (see the director of nursing interview below.) She left the room and left the goggles on the isolation cart without disinfecting it. IV. Staff interviews The director of nursing was interviewed on 12/15/24 at 4:37 p.m. She said rooms #211 and #305 were in isolation due to COVID-19 positive residents. She said all staff entering these rooms must follow isolation precautions listed on the sign on the door. She said CNA #2 should have worn respirator N95 prior to entering the isolation room. RN #1 did not follow proper steps of removing her PPE. She should have removed her gloves first, then gown. The respirator and goggles should be removed outside of the isolation room. The googles must be disinfected and only then placed on the clean isolation cart. She said polishing the floors should be postponed until the end of isolation precautions. The DON said she would provide education to nursing staff and housekeeping staff on proper use of PPE.

Based on record review and interviews, the facility failed to provide services under currently accepted professional standards. Specifically, the facility failed to ensure registered nurse (RN) #3 followed accepted professional standards for keeping controlled medications in a locked medication cart on 12/9/23 and 1/1724. Findings include: I. Facility policy and procedure The Controlled Substances policy, revised November 2022, was received from the nursing home administrator (NHA) on 2/14/24 at 3:26 p.m. The policy documented in pertinent part, The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Controlled substances were separately locked in permanently affixed compartments, except when using single unit package drug distribution system in which the quantity stored is minimal, and a missing dose could be readily detected. All keys to controlled substance containers are on a single key ring that is different from any other keys. II. Record review and interviews A review of the facility investigation on 12/9/23, registered nurse (RN) #3 left a controlled medication cart unlocked with medication keys at unit 200. Upon returning to the station, the RN discovered there were 17 tablets of oxycodone 5 milligrams (mg) missing from the cart. The facility investigated the incident, reported it to the appropriate agencies and educated RN #3 on proper storage of medications. On 1/17/24 RN #3 left the medication cart keys and two blister cards of controlled medication on top of the medication cart and left the station to assist a resident. Upon return to the cart, the RN discovered that 30 tablets of clonazepam 0.5 (mg) and 29 tablets of hydromorphone/acetaminophen 5/325 (mg) were missing from the place he left them. The facility investigated the incident, reported it to the appropriate agencies and educated RN #3 again on proper storage of medications. A license verification check on 2/13/24 at 2:00 p.m. revealed RN #3 had a public disciplinary action for forging the medical director's signature for prescription medication for himself in another state on 7/27/06. RN #3 had a history of alcohol and drug abuse in another state. III. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 2/15/24 at 2:30 p.m. LPN #2 said the controlled medication cart should be locked at all times and the keys properly kept. LPN #2 said leaving medication keys around might result in unauthorized personnel having access to controlled medication which could lead to missing medication. RN #2 was interviewed on 2/15/23 at 2:45 p.m. She said medication keys should be properly secured to prevent unauthorized persons from gaining access to narcotic drugs. The RN said lots of bad things could happen when controlled medication keys were not properly maintained. She said the negative outcomes such as missing medications, overdose and even death. The director of nursing (DON) was interviewed on 2/15/24 at 3:38 p.m. She said controlled medication keys were to be properly secured at all times by an authorized licensed staff. The DON said controlled medications were to be double locked. She said RN #3 on 12/9/23 and 1/17/24 failed to properly secure the medication cart which led to missing medication. The DON said the facility was aware of RN #3's past public disciplinary action on his license. IV. Facility follow up On 2/15/24 at 4:30 p.m. the nursing home administrator (NHA) provided a performance improvement project (PIP) for medication cart security. The PIP was initiated on 12/9/23 the day of the first reported incident, however, the same RN #3 left the medication keys and controlled medication on the cart on 1/17/24 which led to 29 tablets of hydromorphone/acetaminophen 5/325 and 30 tablets 0.5mg of clonazepam tablet missing.

Based on observations, record review and interviews, the facility failed to provide food that accommodated resident preferences for one (#45) of two residents out of 19 sample residents. Specifically, the facility failed to offer food choices according to resident preferences for Resident #45. Findings include: I. Facility policy The Resident Food Preferences policy, revised September 2017, was provided by the dietary manager (DM) on 2/15/24 at 1:40 p.m. It revealed in pertinent part, the dining services director will interview the resident or resident representative to complete a food preference interview within 48 hours of admission. The purpose of identifying individual preferences for dining locations and meal times. Food allergies, food intolerance, food dislikes and food and fluid preferences will be entered into the resident profile in the menu management software system. The individual tray assembly ticket will identify all food items appropriate for the resident based on diet order, allergies, intolerances and preferences. II. Resident representative interview The resident's representative was interviewed on 2/12/24 at 2:34 p.m. She said the resident reported there was not enough German food and the facility did not cook the way she cooked. The representative said she loved mashed potatoes and the resident told the representative that the facility did not have mashed potatoes. III. Resident #45 A. Resident status Resident #45, age 89, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included dementia, cerebral infarction (stroke), type two diabetes, chronic kidney disease, arthritis and cataracts. The 11/24/23 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of six out of 15. She required partial assistance with dressing, toileting and personal hygiene. She had an impairment on one side of her upper and lower extremities and required a wheelchair. B. Record review The nutrition care plan, revised on 2/12/24, revealed to offer Resident #45's preferred food. -The care plan did not reveal the resident's likes and dislikes. The quarterly dietary assessments for May 2023, August 2023 and November 2023 were reviewed. -The assessments did not reveal the resident's likes and dislikes. The May 2022 initial nutrition assessment revealed resident liked sweets, mashed potatoes and veggies. She disliked rice and corn. The multidisciplinary care conference summary revealed the resident's representative attended the meeting. The July 2023 dietary summary said she was not fond of all food but had a few favorites. She used to be a great cook. The November 2023 dietary summary documented she used to love to cook and likes German food. -The February 2024 dietary summary did not reveal the resident's preferences. IV. Observation On 2/14/24 at 12:06 p.m. the resident's lunch preparation was observed. The meal ticket revealed she requested potato chips. The cook and the dietary manager said the resident could not have the potato chips because her diet was dysphagia (difficulty swallowing). The cook did not replace the potato chips with an alternative. V. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 2/15/24 at 2:07 p.m. She was responsible for completing the resident's meal ticket on behalf of the resident. She said there was a binder had alternatives to reference if the resident did not want the main meal. She said she knew Resident #45 did not like green vegetables, loved fruits and any kind of meat. She knew when potatoes were instant. The DM was interviewed on 2/15/24 at 12:50 p.m. He said he was responsible to obtain the resident's food preference within 48 hours after admission. He documented the preferences on a Food Preference form. He said they did not use this form in 2022. The DM was not employed in 2022 to answer why the form was not used. The DM said Resident #45 did not like rice and corn. He did not know that she liked potatoes. He said he did not have the form for Resident #45. He said if a resident had dysphagia and requested potato chips, he could offer mashed potatoes. Mashed potatoes was a side dish that was offered at lunch and dinner. He said the resident recently changed to the dysphagia diet. He said yesterday was the first time she asked for potato chips on her new diet. VI. Facility follow up The DM provided a food preferences assessment on 2/15/24 at 1:40 p.m. It revealed it was completed on 2/15/24. The resident said chocolate was her number one favorite food. She did not know her least favorite foods. The nursing home administrator (NHA) provided a written statement by a registered nurse (RN) on 2/19/24 at 2:48 p.m. It revealed that the RN asked the resident if she wanted mashed potatoes instead of potato chips. The resident declined mashed potatoes.

Based on record review, observations, and interviews, the facility failed to manage pain in a manner consistent with professional standards of practice for one (#4) of three residents reviewed for pain out of 12 sample residents. Specifically, the facility failed to: -Ensure documentation for Resident #4's acceptable level of pain goal was documented consistently in the pain assessments, care plan and physician orders; and, -Ensure Resident #4's pain was managed appropriately and consistently to meet the resident's stated level of acceptable pain. Findings include: I. Facility policy and procedure The Pain Management policy, dated 5/3/23, was provided by the quality mentor (QM) on 1/8/23 at 3:04 p.m. The policy read in pertinent part, Pain is subjective and is what the resident says it is, existing when and where the resident says it does. Purpose: To accurately assess and achieve pain control. This does not necessarily mean the resident is pain free. Acceptable (tolerable) pain control is defined by the resident. All residents will be evaluated for pain by utilizing a pain evaluation tool. The pain evaluation will be completed upon admission, readmission, quarterly, and with any significant change in condition. The pain evaluation includes the following: location(s), quality, intensity, associated symptoms, precipitating, aggravating and relieving factors, chronology, pattern (frequency, onset and duration of pain), medication regimen and other treatment modalities used for pain management and their degree of effectiveness. Around the clock (ATC) dosing for continuous pain, whether it be chronic or acute, is the key to effective pain management. II. Resident status Resident #4, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included low back pain, restless legs syndrome, depression, abnormal posture and liver cell carcinoma (liver cancer). The 11/28/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. He had functional limitations in range of motion for the upper and lower extremities on one side and required moderate assistance with toileting hygiene, personal hygiene and bed mobility. He required maximal assistance for all transfers. The resident had an active diagnosis of cancer and was on hospice services. The resident experienced frequent pain which occasionally interfered with his sleep and day-to-day activities. The resident rated the intensity of his pain as a 7 on a pain scale of 1-10, with 0 being no pain and 10 being the worst pain imaginable. The resident received scheduled and as needed (PRN) medications for pain and received non-medication interventions for pain. III. Resident interview Resident #4 was interviewed on 1/4/24 at 3:00 p.m. He said he had chronic back pain. He said his pain level was at a 6 out of 10. He said he felt that his pain could be managed better than it was currently. He said he could use pain medication more often than it was currently scheduled. Resident #4 said he would like his pain level to be below a 4 out of 10. IV. Record review Review of Resident #4's pain care plan, initiated 8/13/21 and revised 7/25/23, revealed the resident had chronic pain related to a past CVA (stroke), generalized body pain and knee and joint pain. The resident was able to make his pain needs known and report pain appropriately. Pertinent interventions included anticipating the resident's need for pain relief, evaluating the effectiveness of pain interventions, including the alleviation of symptoms and providing non-pharmacological pain interventions. According to the care plan, Resident #4 preferred to have his pain controlled by pain medications and often refused non-pharmacological interventions. The care plan further documented Resident #4 reported a pain level of 4 to 5 out of 10 as an acceptable level of pain for him. -However, the resident's acceptable pain level documented on the care plan was not consistent with the acceptable pain level documented in the resident's physician orders or pain evaluations (see below). -Additionally, the pain level documented in the care plan was not consistent with the resident's acceptable pain level stated in his interview (see resident interview above). Review of the January 2024 CPO revealed the following physician orders for pain management: Pregabalin capsule 150 milligrams (mg). Give one capsule by mouth two times a day for pain. The order date was 11/17/23. Baclofen oral tablet mg. Give 5 mg by mouth two times a day for muscle spasm. The order date was 12/4/23. Morphine sulfate (concentrate) oral solution 20 mg/milliliter (ml). Give 0.25 ml by mouth every three hours as needed for shortness of breath, pain. The order date was 11/17/23. Oxycodone HCl oral tablet 5 mg. Give one tablet by mouth every six hours as needed (PRN) for chronic pain. The order date was 11/17/23. This order was discontinued due to an order change on 1/4/24. Oxycodone HCl oral tablet 5 mg. Give one tablet orally as needed for back pain twice daily. The order date was 1/4/24. Oxycodone HCl oral tablet 5 mg. Give two tablets orally as needed for back pain PRN in the morning and evening. The order date was 1/4/24. Non-pharmacological interventions for PRN pain: (1) Repositioning; (2) Quiet environment/dim light; (3) Cold compress; (4) Relaxation; (5) Music (6) Massage; (7) Gentle range of motion (ROM); (8) Medication; (9) Other every shift. The order date was 12/24/23. Monitor pain every shift using 0-10 pain scale. The resident's acceptable level of pain is 1-3/10 every shift. The order date was 12/24/23. Review of Resident #4's most recent pain evaluations revealed the following: -On 11/19/23, the pain evaluation documented Resident #4's acceptable level of pain was 0-3; and, -On 12/17/23, the pain evaluation documented Resident #4's acceptable level of pain was 0-3. Review of Resident #4's December 2023 and January 2024 medication administration records (MAR) revealed the following: On 12/1/23 at 10:12 a.m., Resident #4 was administered Oxycodone 5 mg for a pain level of 7 out of 10. -The pain medication was documented as effective, however the resident's follow up pain level, documented at 2:04 p.m. was a 5, which was still above the resident's stated acceptable pain level of 0-3. -No further PRN pain medications were administered until 12/1/23 at 7:16 p.m. despite the follow up pain level remaining above the resident's stated acceptable level of pain. On 12/5/23 at 7:51 a.m., Resident #4 was administered Morphine 0.25 ml for a pain level of 7 out of 10. -The pain medication effectiveness was documented as unknown and there was no follow up level of pain documented. -No further PRN pain medications were administered despite the follow up pain level remaining above the resident's stated acceptable level of pain. On 12/17/23 at 10:30 a.m., Resident #4 was administered Morphine 0.25 ml for a pain level of 7 out of 10. -The pain medication was documented as effective, however the resident's follow up pain level, documented at 11:40 a.m. was a 4, which was still above the resident's stated acceptable pain level of 0-3. -No further PRN pain medications were administered despite the follow up pain level remaining above the resident's stated acceptable level of pain. On 12/27/23 at 11:08 a.m., Resident #4 was administered Morphine 0.25 ml for a pain level of 8 out of 10. -The pain medication was documented as effective, however the resident's follow up pain level, documented at 12:15 p.m. was a 5, which was still above the resident's stated acceptable pain level of 0-3. -Despite the follow up pain level remaining above the resident's stated acceptable level of pain, no further PRN pain medications were administered until 3:13 p.m. when the resident stated his pain level was again at an 8 out of 10. On 12/28/23 at 1:36 a.m., Resident #4's pain level was documented as a 6 out of 10. -There was no documentation to indicate any PRN pain medication was administered at that time. On 12/28/23 at 11:25 a.m., Resident #4 was administered Oxycodone 5 mg for a pain level of 7 out of 10. -The pain medication was documented as effective, however the resident's follow up pain level, documented at 12:12 p.m. was a 5, which was still above the resident's stated acceptable pain level of 0-3. -No further PRN pain medications were administered despite the follow up pain level remaining above the resident's stated acceptable level of pain. On 1/1/24 at 10:40 a.m., Resident #4's pain level was documented as a 5 out of 10. -Despite the resident's pain level being above the resident's stated acceptable level of pain, no PRN pain medication was administered until 3:46 p.m. when the resident stated his pain level was at a 7 out of 10. On 1/2/24 at 10:12 a.m., Resident #4 was administered Morphine 0.25 ml for a pain level of 7 out of 10. -The pain medication was documented as effective, however the resident's follow up pain level, documented at 12:18 p.m. was a 5, which was still above the resident's stated acceptable pain level of 0-3. -Despite the follow up pain level remaining above the resident's stated acceptable level of pain, no further PRN pain medications were administered until 4:12 p.m. when the resident stated his pain level was again at a 7 out of 10. On 1/4/24 at 11:36 a.m., Resident #4 was administered Morphine 0.25 ml for a pain level of 8 out of 10. -The pain medication was documented as effective, however the resident's follow up pain level, documented at 12:28 p.m. was a 6, which was still above the resident's stated acceptable pain level of 0-3. -No further PRN pain medications were administered despite the follow up pain level remaining above the resident's stated acceptable level of pain. On 1/6/24 at 10:54 a.m., Resident #4 was administered Morphine 0.25 ml for a pain level of 7 out of 10. -The pain medication was documented as effective, however the resident's follow up pain level, documented at 12:14 p.m. was a 5, which was still above the resident's stated acceptable pain level of 0-3. -Despite the follow up pain level remaining above the resident's stated acceptable level of pain, no further PRN pain medications were administered until 3:59 p.m. when the resident stated his pain level was again at a 7 out of 10. On 1/7/24 at 10:51 a.m., Resident #4 was administered Morphine 0.25 ml for a pain level of 7 out of 10. -The pain medication was documented as effective, however the resident's follow up pain level, documented at 12:39 p.m. was a 5, which was still above the resident's stated acceptable pain level of 0-3. -Despite the follow up pain level remaining above the resident's stated acceptable level of pain, no further PRN pain medications were administered until 4:47 p.m. when the resident stated his pain level was again at a 7 out of 10. V. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 1/8/24 at 12:38 p.m. LPN #1 said residents had a pain evaluation conducted on admission and quarterly. She said residents were asked what their acceptable level of pain was during the evaluation and the acceptable level of pain was care planned and should match the pain evaluation. LPN #1 said residents' pain levels were assessed each shift and with each PRN pain medication administered. She said the goal for pain management was to keep the resident's pain level at or below their stated acceptable pain level. LPN #1 said pain levels were documented at the time a PRN medication was given. She said nurses were to go back within an hour and reassess the resident's pain to see if the pain medication had been effective. She said if a resident's pain level was still above their stated acceptable pain level upon reassessment she would offer the resident another type of pain medication. She said if the resident did not have another pain medication she would call the physician to see about obtaining an order for something else for pain. LPN #1 said if a resident stated their pain level was still higher than their acceptable level of pain but they did not want further pain medication she would document in the medication administration notes that more pain medication was offered and the resident declined. LPN #2 was interviewed on 1/8/24 at 12:58 p.m. LPN #2 said residents were assessed for pain every shift. He said all residents were assessed at least quarterly for pain, which included finding out what each resident's acceptable level of pain was. He said the resident's acceptable level of pain was documented on the care plan and as part of the physician's order for pain assessment every shift. He said the acceptable level of pain should be consistent with the pain assessment, care plan, and physician's order. LPN #2 said if a resident's pain level was above their stated acceptable level of pain he would see if they had PRN pain medications to administer. He said he would administer a PRN pain medication and go back and reassess the resident's pain in an hour. He said if the resident's pain level remained above their stated acceptable level of pain he would offer them a different type of pain medication if the resident had another pain medication to offer. LPN #2 said if the resident did not have any other pain medications he would call the physician to obtain an order for another pain medication. He said the pain management goal for all residents was to keep their pain levels at or below their stated acceptable level of pain. The director of nursing (DON) and quality mentor (QM) #2 were interviewed together on 1/8/24 at 1:16 p.m. The DON said when residents were admitted to the facility, a baseline pain assessment was completed. She said the assessment asked multiple questions about the resident's pain, including their acceptable level of pain. She said residents were also assessed for pain weekly, quarterly and every shift. She said residents were asked what their pain level was when PRN pain medications were administered and nurses were to go back and reassess the resident for the effectiveness of the pain medication. The DON said Resident #4 preferred to manage his pain with medication instead of non-pharmacological pain interventions. She said the resident had several pain medication administrations where the resident's pain level remained above his stated acceptable level of pain, however, she said Resident #4 was capable and competent enough to ask for further pain medication if he was not comfortable. The DON said she would assume the resident declined further pain medication on the dates that no further pain medication was given and the pain level remained above his acceptable level of pain. She said the resident would have told the nurse he did not need any further pain medication. The DON said the nurse did not need to document anything further as the pain medication had already been documented as effective, which was evidenced by the pain level being lower than when the pain medication was initially administered. VI. Facility follow-up On 1/8/24 at 2:20 p.m., the DON and QM #2 were interviewed again. The DON stated they had just talked to Resident #4 and he was now stating his acceptable level of pain was 7 to 8 out of 10. She said he told them he did not want any further scheduled pain medications and that he wanted to continue to ask for medications when he needed them. -However, the facility did not follow up with Resident #4 regarding his pain medications and levels of pain until the concern with pain management was brought to their attention during the survey.

Based on interviews, record review, and facility policy review, the facility failed to provide adequate supervision and assistance to prevent accidents for 2 (Resident #122 and Resident #224) of 4 sampled residents reviewed for falls/accidents. Specifically, the facility assessed Resident #122 to be at high risk for falls upon admission but did not develop interventions to prevent falls, and on 6/8/2022 (five days after admission to the facility) Resident #122 fell and sustained a [CONDITION(S)]. Additionally, the facility assessed Resident #224 to require the assistance of two staff for transfers; however, an incident report revealed the resident sustained an injury to the knee during a transfer with the assistance of only one staff person. Findings included: 1. Review of the facility's Fall Prevention Program, dated 2021, revealed, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The nurse will indicate on the (specify location) the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. High risk protocols included to indicate fall risk on care plan and provide interventions that address unique risk factors measured by the risk of assessment tool, medications, psychological, cognitive status, or recent change in functional status. When any resident experiences a fall, the facility will assess the resident, complete a post-fall assessment, complete an incident report, notify physician and family, review the resident's care plan, and update as indicated, document all assessments and actions, and obtain witness statements in the case of injury. Review of an Admission Record revealed the facility admitted Resident #122 on 06/03/2022 with diagnoses that included [CONDITION(S)], dementia, depression, hypertension (high blood pressure), and urinary tract infection ([CONDITION(S)]). The Admission Record further revealed the facility readmitted Resident #122 on 06/11/2022 with a diagnosis of fracture of the right femur (upper part of the leg) and then discharged the resident on 06/22/2022. Review of an admission Minimum Data (MDS), dated [DATE], revealed Resident #122 had a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating the resident was severely cognitively impaired. The MDS indicated the resident ambulated using a walker with the supervision of one-person. According to the MDS assessment, Resident #122 had a fall with major injury since admission. Review of a Morse Fall Scale, dated 06/03/2022, revealed Resident #122 had a score of 70, indicating a high risk for falling. Review of a Baseline Care Plan and Summary, dated 06/05/2022, revealed Resident #122 was at high risk for falls, used no safety devices, and was cognitively impaired. There were no interventions in place to prevent falls. Review of Progress Notes, dated 06/08/2022 at 9:30 p.m., revealed registered nurse (RN) #3 assessed Resident #122, who complained of right hip pain. RN #3 assigned certified nurse aide (CNA) #4 and CNA #5 to stay with Resident #122 while RN #3 notified the physician and power of attorney (POA). Resident #122 was then sent to the emergency room for evaluation of a possible hip fracture. Further review of the Progress Notes revealed a nurse's note dated 06/09/2022 that indicated Resident #122 was admitted to the hospital with a fractured right hip. Review of a Witnessed Fall incident report, dated 06/08/2022, revealed Resident #122 fell in the hallway and the fall was witnessed by a CNA. The report indicated the resident was continually reminded to use their walker, but frequently forgot and left it in their room. The report indicated that RN #3 assessed Resident #122, who complained of right hip pain and was sent out to the emergency room for evaluation of a possible hip fracture. The report further indicated the predisposing physiological factors included confusion, gait imbalance, impaired memory, and weakness. Review of a Hospital Transfer Form, dated 06/08/2022, revealed Resident #122 was transferred to the hospital following a fall. The form indicated the resident was at high fall risk and their usual mental and cognitive function included being alert, disoriented, and unable to follow simple instructions. During an interview on 11/15/2022 at 6:12 a.m., RN #1 stated she remembered Resident #122 was at high risk for falls and she kept Resident #122 near the nurses' station to prevent the resident from getting up on their own. During an interview on 11/15/2022 at 9:42 a.m., RN #2 stated Resident #122 was a high fall risk due to [CONDITION(S)] and had an unsteady gait. RN #2 stated that Resident #122 felt they could ambulate without assistance, but the resident needed to use a walker. During an interview on 11/16/2022 at 12:32 p.m., RN #3 stated Resident #122 had a witnessed fall in the hallway on 06/08/2022 around 9:00 p.m Per RN #3, Resident #122 was a high fall risk, and staff continuously reminded Resident #122 to use the walker for ambulation because the resident did not have the capacity to remember. During an interview on 11/16/2022 at 12:51 p.m., CNA #4 stated Resident #122 was a high fall risk and did not remember to use their walker when ambulating. During an interview on 11/16/2022 at 12:59 p.m., CNA #1 stated Resident #122 was a high fall risk due to [CONDITION(S)] and impaired balance. She stated she witnessed Resident #122's fall in the hallway. The resident was ambulating without the walker and immediately complained of hip pain after the fall. CNA #1 stated RN #3 assessed Resident #122 following the fall and notified the family, and the resident was then sent out to the hospital. During an interview on 11/16/2022 at 2:24 p.m., the Director of Nursing (DON) stated there were no fall interventions in place on Resident #122's baseline care plan when the resident fell and fractured their hip. During a follow-up interview with the DON on 11/17/2022 at 9:12 a.m., the DON stated she expected fall interventions to be in place on the baseline care plan for a resident that was at high risk for falls. The DON further stated Resident #122 ambulated well with a walker but did not remember to use it or their call light for assistance. During an interview on 11/17/2022 at 10:19 a.m., the Administrator stated management reviewed resident falls, but that process was not well documented. The Administrator further stated reminding a cognitively impaired resident to use their walker or their call light was not an appropriate intervention to prevent a fall for a high-risk resident. Any interventions in place should be a part of the baseline care plan because staff referred to it to see what should be in place for each resident. 2. Review of an undated facility policy titled, Accidents and Supervision, revealed, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. A review of the Admission Record for Resident #224 revealed the facility admitted Resident #224 on 10/24/2022, with diagnoses including acute and chronic [CONDITION(S)], essential (primary) hypertension, depression, type 2 diabetes, and dysphagia. A review of an admission Minimum Data Set (MDS) assessment, dated 10/31/2022, revealed Resident #224 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, and indicated the resident was cognitively intact. The resident required extensive assistance of two or more people with bed mobility and was totally dependent on two or more people with transfers and toilet use. Review of a care plan, dated as initiated 10/27/2022, revealed Resident #224 had a self-care performance deficit with activities of daily living (ADLs) and required assistance with care needs. The interventions indicated the resident required extensive assistance of two staff with bathing/showering and bed mobility and required a sit-to-stand lift (mechanical lift) and two-staff assistance with transfers. Review of an incident report, dated 10/31/2022 at 1:36 p.m. and completed by the Assistant Director of Nursing (ADON), revealed Resident #224's family member reported that something happened to the resident and that the resident could provide the details. The report indicated Resident #224 reported that a certified nurse aide (CNA) turned Resident #224's chair, bumping the resident's leg and then during a transfer in the bathroom, twisted the resident's knee. The report indicated that the immediate action taken was nursing staff assessed the resident's right leg and knee and no visible injuries were noted. Staff offered to contact the provider to get an x-ray, but the resident felt this was not necessary at that time. The report section labeled, Other info indicated the resident needed a sit-to-stand lift for all transfers and that the resident bumped their leg on the wheelchair. During an interview on 11/16/2022 at 11:56 a.m., the Director of Nursing (DON) revealed CNA #6 was the staff member involved in the transfer of Resident #224 that was reported on 10/31/2022. During an interview on 11/16/2022 at 12:44 p.m., CNA #6 revealed she had not worked at the facility in weeks and could not remember the last day she did work. CNA #6 stated she was not sure if she worked on 10/30/2022 or 10/31/2022. CNA #6 indicated this was the first time she had heard about an incident involving Resident #224 suffering a knee injury during a transfer. CNA #6 stated no one from the facility had contacted her or asked her about the incident. CNA #6 indicated she was not familiar with Resident #224. During an interview on 11/16/2022 at 1:15 p.m., the Assistant Director of Nursing (ADON) revealed Resident #224's family member was talking to a nurse and mentioned that Resident #224 wanted to talk to the ADON about transfers. The ADON stated Resident #224 told her staff bumped the resident's knee during a transfer in the bathroom and it was painful, and the resident's knee was bumped again in the bathroom when staff were transferring the resident off the toilet. The ADON stated Resident #224 did not know the staff's name but described the staff as a tall African American with long braids. The ADON stated the incident was reported to her on 10/31/2022 and that she contacted the physician, completed an incident report (risk management), and offered to have an x-ray of the resident's knee completed. The ADON stated Licensed Practical Nurse (LPN) #5 was the nurse at the time she spoke with Resident #224 about the incident. The ADON indicated she had no other involvement and stated no one ever spoke with her regarding the incident after she reported it. During an interview on 11/17/2022 at 8:35 a.m., CNA #3 revealed staff got reports from oncoming shifts and could also refer to the Kardex to know what type of assistance a resident required. CNA #3 stated Resident #224 required the assistance of two staff and a sit-to-stand lift with transfers. CNA #3 stated all of Resident #224's care, including transfers and bathing, required two staff to assist. CNA #3 stated one staff needed to assist getting the resident into the shower chair and the second staff assisted, but both staff should be present to get the resident back into the resident's room. CNA #3 stated Resident #224 had always required two staff to assist. CNA #3 stated Resident #224 did complain about their knees hurting and CNA #3 had reported that to nursing staff. CNA #3 stated it would not be safe for only one staff to transfer a resident who utilized a sit-to-stand lift and that staff were not allowed to have only one staff assisting with a sit-to-stand or a Hoyer lift. CNA #3 stated it was not safe to utilize the mechanical lifts with only one staff, and if staff did that they would be fired. CNA #3 stated staff should not attempt to transfer a resident with a sit-to-stand lift by themselves and should wait until they had a second staff to assist. During an interview on 11/17/2022 at 8:50 a.m., CNA #7 revealed staff could refer to the Kardex or ask therapy about the type of assistance a resident required. CNA #7 stated a sit-to-stand lift and Hoyer lift both required two staff to assist and that performing a mechanical lift transfer with only one staff would put both the resident and staff at risk. CNA #7 stated Resident #224 required a sit-to-stand lift with two staff assisting and that the resident had always required the assistance of two staff. During an interview on 11/17/2022 at 9:12 a.m., the DON revealed any mechanical lift transfer required two staff to assist, and if staff broke that rule, they were in trouble. The DON stated she knew the incident with Resident #224 involved CNA #6 based on the resident's description. The DON indicated she did not have any involvement with investigating the incident. She stated the ADON interviewed CNA #6, but the DON was not present during the interview and did not know if CNA #6 provided a statement. The DON stated she did not know why the facility never identified that Resident #224's incident occurred during an improper transfer and why that was never addressed. The DON stated there was only one staff involved during the transfer and there should have been two. During an interview on 11/17/2022 at 10:18 a.m., the Administrator revealed Resident #224 required two staff members to assist during transfers for the safety of both the resident and the staff member. The Administrator stated it was never identified before the survey that an improper transfer had occurred with Resident #224, since no investigation was completed.

Based on interviews, record reviews, and facility policy review, it was determined the facility failed to investigate for possible abuse or neglect related to a resident's allegation of rough handling and pain during transfers performed by a facility certified nursing assistant for 1 (Resident #224) of 3 sampled residents reviewed for abuse. Findings included: Review of a facility policy titled, Abuse, Neglect and Exploitation, revised October 2022, revealed, A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g. [for example], not tampering or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. Review of an Admission Record revealed Resident #224 had diagnoses including acute and chronic respiratory failure, hypertension (high blood pressure), depression, and type 2 diabetes. Review of an admission Minimum Data Set (MDS), dated [DATE], revealed Resident #224 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS indicated the resident required extensive assistance of two or more people with bed mobility and was totally dependent on the assistance of two or more people with transfer and toilet use. Review of a care plan, dated as initiated 10/27/2022, revealed Resident #224 had a self-care performance deficit with activities of daily living (ADLs) and required assistance with care needs. The interventions indicated the resident was totally dependent on two staff for toilet use and required a sit-to-stand (mechanical) lift and two-staff assistance with transfers. Review of an incident report, dated 10/31/2022 at 1:36 PM and completed by the Assistant Director of Nursing (ADON), revealed Resident #224's family member reported that on Sunday [10/30/2022] something happened to the resident and that the resident could describe what happened. The report indicated Resident #224 reported that a CNA turned the resident's chair and bumped the resident's leg, then took the resident to the bathroom and twisted the resident's knee during a transfer. The resident stated, I can't bend my knee, so she [the CNA] pushed my stiff leg down. The report indicated the resident did not specify which knee, but the family member pointed to the resident's right knee. The report revealed the ADON assessed the resident and that the resident denied pain currently but stated the pain intensity at the time of the incident was two on a scale of zero to 10 (with zero indicating no pain and 10 indicating the most severe pain). The report indicated the ADON offered to contact the physician and ask for an order for an x-ray but the resident did not think this was necessary. There was no evidence the resident's allegation was investigated. During an interview on 11/16/2022 at 11:30 AM, the Administrator indicated the CNA identified as being the one who transferred the resident was CNA #5. During an interview on 11/16/2022 at 11:39 AM with CNA #5 revealed she was not aware of any incident involving Resident #224 and was not familiar with Resident #224 or the resident's care. CNA #5 stated no one ever said anything to her or interviewed her about a transfer that resulted in an injury to Resident #224. CNA #5 stated neither the Social Services Director (SSD), nor the Assistant Director of Nursing (ADON) ever spoke to her about any incident involving Resident #224. CNA #5 stated this was the first time she had heard anything about any incident. During an interview on 11/16/2022 at 11:56 AM, the Director of Nursing (DON) stated there had been a mistake and that CNA #6 was the one involved in the transfer reported by Resident #224. During an interview on 11/16/2022 at 12:02 PM, the SSD revealed she was notified by the ADON that Resident #224 had some concerns with care by a CNA. The SSD stated she spoke with Resident #224 and the resident's family member. The SSD stated the resident reported that during a transfer, the CNA was rough with the resident's leg, and it caused some pain to the resident. The SSD stated she never spoke with the CNA about the allegations or concerns. The SSD stated she notified the Administrator and the Director of Nursing (DON) but did not recall the date she notified them. She reviewed her notebook and showed the surveyor an entry dated 10/31/2022. The SSD stated this was her only involvement in the incident. During an interview on 11/17/2022 at 9:12 AM, the DON revealed if there was an allegation that involved a staff member, the staff member would be suspended pending an investigation. The DON stated any mechanical lift, such as a sit-to-stand or Hoyer lift, required two staff to assist, and if staff broke that rule, they were in big trouble. The DON stated she felt if staff did an improper/unsafe transfer that resulted in any injury to a resident, that should have been investigated. The DON stated she did not know why Resident #224's allegation not investigated. She stated she did not know why the facility never identified that Resident #224's injury occurred during an improper transfer and why that was never addressed. The DON stated there was only one staff involved during the transfer and there should have been two. During an interview on 11/17/2022 at 10:18 AM, the Administrator acknowledged Resident #224 required two staff members to assist during transfers, for the safety of both the resident and the staff member. The Administrator stated she would consider an improper resident transfer something that needed to be investigated; however, she acknowledged she did not investigate the incident with Resident #224 since the resident did not feel the incident was intentional. The Administrator revealed it was never identified prior to the survey that an improper transfer occurred, since no investigation was completed.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure that before residents were allowed to self-administer medications, the interdisciplinary team (IDT) conducted an assessment to determine if self-administration was clinically appropriate and safe for 2 (Resident #56 and Resident #37) of 6 sampled residents reviewed for medication self-administration. Findings included: Review of an undated facility policy titled, Resident Self-Administration of Medication, revealed, A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. The policy also indicated the IDT should consider, e. The resident's comprehension of instructions for the medications they are taking, including the dose, timing, and signs of side effects, and when to report to facility staff. Additionally, the policy indicated, 13. The care plan must reflect resident self-administration and storage arrangements for such medications. 1. Review of an Admission Record revealed Resident #56 had diagnoses including type 2 diabetes mellitus, anxiety, depression, hyperlipidemia (high level of fats in the blood), and hypertension (high blood pressure). Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #56 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Observation on 11/14/2022 at 10:00 AM revealed Resident #56 lying in bed. There were four medication cups containing 13 pills on the shelf over the bed. During an interview at this time, Resident #56 stated the four medication cups contained their morning medications, which consisted of Tylenol, oxycodone (narcotic pain medication), Flexeril (muscle relaxer), lisinopril (blood pressure medication), a multivitamin, Vitamin B12, fish oil, metformin (diabetes medication), antidepressants, an antianxiety medication, and amlodipine (blood pressure medication). Resident #56 indicated the nurse left the medications in the resident's room, about an hour ago. The resident stated the nurses did not normally leave medications in the room. Resident #56 indicated they would take the medications later that morning. Review of a care plan, dated 08/16/2022, revealed Resident #56 kept creams and ointments at bedside and was safe to self-administer them. Interventions included to assess Resident #56 quarterly and as needed (prn) to ensure safety to keep certain creams and ointments at the bedside. There was no care plan for self-administration of oral medications. Review of a November 2022 Medication Administration Record (MAR) revealed Resident #56 received the following medications in the morning: - amlodipine besylate tablet five milligrams (mg) by mouth (po) one time a day (QD) for hypertension, started on 10/08/2022. - cyanocobalamin tablet (Vitamin B12) 1000 micrograms (mcg), one tablet po QD for fatigue, started on 08/17/2022. - escitalopram oxalate (antidepressant) tablet 20 mg, one tablet po in the morning for depression, started on 08/17/2022. - lisinopril tablet 20 mg po in the morning for hypertension, started on 08/17/2022. - multivitamin, one tablet po QD for prevention, started on 08/17/2022. - Omega-3 fish oil capsule, 1000 mg po QD for prevention, started on 08/17/2022. - buspirone hydrochloride (anti-anxiety medication) tablet 10 mg po twice daily (BID) for anxiety, started on 09/11/2022. - metformin hydrochloride (HCL) tablet, 1000 mg po BID for type 2 diabetes mellitus, started on 08/17/2022. - acetaminophen extra strength tablet (Tylenol) 500 mg, two tablets po every eight hours (Q8H) prn for mild pain or headache, started on 08/18/2022. - cyclobenzaprine HCL tablet (Flexeril) 10 mg po Q8H prn for muscle spasms, started on 08/17/2022. - oxycodone HCL tablet, five mg po every four hours (Q4H) prn for breakthrough pain, started on 08/17/2022. During an interview on 11/15/2022 at 3:31 PM, Licensed Practical Nurse (LPN) #2 stated she was written up on 11/14/2022 for leaving the medications in Resident #56's room. Per LPN #2, Resident #56 preferred their medications to be split up into different cups so pictures could be taken of each pill, and this was very time consuming. LPN #2 indicated she did not wait for Resident #56 to swallow the medications before she left to move onto other residents. LPN #2 stated she had no good reason for leaving the medications in Resident #56's room and that she normally did not do that. During an interview on 11/16/2022 at 9:33 AM, LPN #3 stated Resident #56 could be safe to self-administer medications, but the LPN did not think Resident #56 would take them at the ordered time if approved to self-administer. LPN #3 indicated she had left pills in Resident #56's room in the past and had come back an hour or so later and Resident #56 still had not taken the medications. Per LPN #3, it would be difficult for Resident #56 to self-administer the medications because the resident liked to sleep a lot and might not be awake when medications should be taken. During an interview on 11/16/2022 at 12:09 PM, the Physician stated he was not aware of Resident #56 having pills left at the bedside. The Physician indicated he was not aware of any residents self-administering medications in the facility, and he had concerns with medications being left in resident rooms. The Physician stated the nurses should not leave medications in resident rooms and that he expected staff to follow the facility's policy on medication self-administration. During an interview on 11/17/2022 at 9:55 AM, the Director of Nursing (DON) stated nurses should never leave pills at a resident's bedside. She indicated staff needed to complete a medication self-administration assessment to ensure a resident could identify the medication and knew when to take it for their own safety. Staff would then contact the physician to get an order for self-administration and update the resident's care plan. The DON revealed there were no residents in the facility who were approved for self-administration. During an interview on 11/17/2022 at 10:50 AM, the Administrator stated she expected the nurse to observe Resident #56 taking medications before the nurse left the room and to notify the DON if a resident refused to take the medications in front of the nurse. The Administrator indicated medications should not be left at a resident's bedside unless the resident had been properly assessed and had an order for medication self-administration. 22445 2. Review of an Admission Record revealed Resident #37 had diagnoses that included respiratory failure with hypoxia and dependence on supplemental oxygen. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS did not indicate the resident exhibited any behavioral symptoms and indicated the resident required supervision with activities of daily living (ADLs). Observations in Resident #37's room on 11/14/2022 at 10:50 AM revealed one container of Ayr saline nasal gel (a medication used to treat dry or irritated nasal passages) on the resident's overbed table and one container of the nasal gel on the bedside table. Observations made from outside the door to Resident #37's room on 11/15/2022 at 11:52 AM revealed Resident #37 was out of the room, and the two containers of nasal gel were visible from the doorway, one container on the bedside table and one container on the overbed table. Review of a care plan, dated as last reviewed 09/29/2022, revealed no interventions related to self-administration of medication. Review of the physician's orders in Resident #37's electronic medical record revealed the resident had no current order for Ayr nasal gel. During an interview on 11/16/2022 at 9:56 AM, Licensed Practical Nurse (LPN) #4, who was assigned to care for Resident #37, stated she did not have any assigned residents who self-administered medications. The LPN added that before a resident could self-administer medications, an assessment had to be completed to determine if the resident was safe to do so. LPN #4 stated this included prescription medications and over-the-counter medications. The LPN added that staff needed to find out if the resident knew what the medication was for, if the resident knew how to administer the medication and how often to administer the medication, and how to safely keep the medication. The LPN stated leaving a medication at the bedside was not considered safe. During an interview on 11/16/2022 at 12:11 PM, Resident #37's primary care physician (PCP) stated he was unaware of any resident self-administering medication in the facility, adding that in the past, nursing staff had been resistant to any resident self-administering medications. The PCP indicated he expected to be notified of any resident who wanted to self-administer medications but had not received any such notifications. The PCP stated Resident #37 was able to self-administer the nasal medication and he was unaware the order for the medication had been discontinued. The PCP stated he had no issues with Resident #37 self-administering the nasal medication but expected the facility to follow their policy. During an observation on 11/16/2022 at 1:00 PM, Resident #37 was in bed, asleep. From the resident's doorway, the nasal medication was observed sitting on the overbed table. Due to the privacy curtain being pulled, the bedside table was not visible from the doorway. During a follow-up interview with LPN #4 on 11/16/2022 at 1:12 PM, the LPN stated she was aware Resident #37 had medication at the bedside. The LPN stated that during her orientation, she was told by the nurse who oriented her that Resident #37 was allowed to keep the nasal medication at the bedside due to behaviors of aggression. The nurse stated she was not sure if the resident had been assessed for self-administration, had been educated to use the medication, or had been care planned to use the medication independently. At this time, LPN #4 reviewed the electronic medical record for Resident #37 and found no assessment, education, or care plan for Resident #37's self-administration of the nasal medication. During an interview on 11/16/2022 at 1:24 PM, the Assistant Director of Nursing (ADON) named one resident in the facility who self-administered medication, and that was not Resident #37. The ADON stated that prior to any resident being allowed to self-administer medications, the facility obtained a physician's order to self-administer and to keep medications at the bedside. The ADON added a resident would be assessed to ensure the resident knew what the medication was for, how often to administer the medication, and if the resident was physically able to self-administer. The ADON stated any medication kept in a resident's room had to be kept in a locked box, education had to be provided to the resident, and the resident's medication self-administration would be care planned. The ADON stated behaviors exhibited by Resident #37 would not validate the resident's ability to self-administer a medication. The ADON stated she was unable to remember any self-administration assessments completed for Resident #37. During an interview on 11/16/2022 at 3:14 PM, the Director of Nursing (DON) stated she expected no medications to be left at the bedside by nurses. The DON stated if a resident wanted to self-administer medications, there were steps to first be taken, including an assessment to determine physical ability to self-administer and knowledge about the effects and side effects of the medication. The DON added she expected medication self-administration to be care planned and added that an order for self-administration would be obtained from the resident's physician. She stated she expected any nurse observing medication at a resident's bedside to follow the facility policy, which was that no medication was left at the bedside without an assessment. During an interview on 11/17/2022 at 10:42 AM, the Administrator stated she expected no medications to be left at the bedside unless there had been an order received for self-administration. The Administrator added this was to provide resident safety by keeping medications from other residents and making sure residents were getting the medications they needed. The Administrator stated resident behaviors were not a reason for leaving medications at the bedside. She stated she expected the facility policy on self-administration to be followed.

Based on interviews, record reviews, and facility policy review, it was determined the facility failed to report an allegation of neglect or abuse to the state survey agency (SSA) related to a resident's report of rough handling and pain during transfers performed by a facility certified nursing assistant (CNA) for 1 (Resident #224) of 3 sampled residents reviewed for abuse/neglect. Findings included: Review of a facility policy titled, Abuse, Neglect and Exploitation, revised October 2022, revealed, Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. [for example], law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Review of an Admission Record revealed Resident #224 had diagnoses including acute and chronic respiratory failure, hypertension (high blood pressure), depression, and type 2 diabetes. Review of an admission Minimum Data Set (MDS), dated [DATE], revealed Resident #224 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS indicated the resident required extensive assistance of two or more people with bed mobility and was totally dependent on the assistance of two or more people with transfer and toilet use. Review of a care plan, dated as initiated 10/27/2022, revealed Resident #224 had a self-care performance deficit with activities of daily living (ADLs) and required assistance with care needs. The interventions indicated the resident was totally dependent on two staff for toilet use and required a sit-to-stand (mechanical) lift and two-staff assistance with transfers. Review of an incident report, dated 10/31/2022 at 1:36 PM and completed by the Assistant Director of Nursing (ADON), revealed Resident #224's family member reported that on Sunday [10/30/2022] something happened to the resident and that the resident could describe what happened. The report indicated Resident #224 reported that a CNA turned the resident's chair and bumped the resident's leg, then took the resident to the bathroom and twisted the resident's knee during a transfer. The resident stated, I can't bend my knee, so she [the CNA] pushed my stiff leg down. The report indicated the resident did not specify which knee, but the family member pointed to the resident's right knee. The report revealed the ADON assessed the resident and that the resident denied pain currently but stated the pain intensity at the time of the incident was two on a scale of zero to 10 (with zero indicating no pain and 10 indicating the most severe pain). The report indicated the ADON offered to contact the physician and ask for an order for an x-ray but the resident did not think this was necessary. Review of the facility's reportable log for October 2022 revealed no evidence this incident was reported to the SSA. During an interview on 11/16/2022 at 11:30 AM, the Administrator indicated the CNA identified as being the one who transferred the resident was CNA #5. During an interview on 11/16/2022 at 11:39 AM, CNA #5 revealed she was not aware of any incident involving Resident #224 and she was not familiar with the resident or the resident's care. CNA #5 stated this was the first time she had heard anything about an incident involving Resident #224. During an interview on 11/16/2022 at 11:56 AM, the Director of Nursing (DON) stated there had been a mistake and that CNA #6 was the one involved in the transfer reported by Resident #224. During an interview on 11/16/2022 at 12:02 PM, the Social Services Director (SSD) revealed she was notified by the ADON that Resident #224 had some concerns with care by a CNA. The SSD stated she spoke with Resident #224 and the resident's family member. The SSD stated the resident reported that during a transfer, the CNA was rough with the resident's leg, and it caused some pain to the resident. The SSD stated she never spoke with the CNA about the allegations or concerns. The SSD stated she notified the Administrator and the Director of Nursing (DON) but did not recall the date she notified them. She reviewed her notebook and showed the surveyor an entry dated 10/31/2022. The SSD stated this was her only involvement in the incident. On 11/16/2022 at 12:42 PM, the surveyor attempted to contact CNA #6 via telephone and left a voice mail requesting a return call. CNA #6 returned the call and stated she had not worked at the facility in weeks and could not remember if she worked on 10/30/2022 or 10/31/2022. She stated this was the first time she had heard about any incident involving a resident injuring their knee. The CNA also indicated she was not familiar with Resident #224. During an interview on 11/17/2022 at 9:12 AM, the DON stated that anything and everything should be reported and that staff did not decide if an incident was abuse. She indicated staff should report to the Administrator immediately, and an initial report would be made to the SSA within two hours. The DON stated she knew the involved staff member was CNA #6 based on the resident's description felt that if a staff did an improper/unsafe transfer that resulted in any injury to a resident, that would be reportable and should have been reported to the state survey agency. The DON stated she did not know why Resident #224's allegation was not reported. During an interview on 11/17/2022 at 10:18 AM, the Administrator stated staff should notify her of any concerns. The Administrator indicated she did not report the incident with Resident #224 because the resident did not feel the CNA intentionally hurt the resident, and the resident was not afraid of the CNA.

Based on observation, interviews, and record review, the facility failed to provide care and services necessary to prevent the formation of pressure ulcers, and the worsening of existing pressure ulcers for four (#11, #9, #6, and #7) of seven residents sampled for wounds out of 20 sampled residents. Specifically: -- The facility failed to prevent, assess and treat two pressure ulcers for resident #11, who had been assessed as being at risk for pressure ulcers. The facility failed to treat a pressure area to her upper left sacrum. Additionally, the facility failed to apply an ordered pressure relieving boot to her right heel. Within a week, the resident's heel was noted to be boggy, two weeks later, a wound was noted. This wound was assessed as unstageable during survey. -- The facility failed to implement preventive measures, and provide and document appropriate wound care for resident #9, who had been assessed as being at risk for skin breakdown. The resident acquired wounds on his right posterior heel, right ischium, left ischium, and upper back which were necrotic, some noted to have slough and or tissue injury. The resident also was observed with a deep tissue injury to his right plantar heel and a blister to his left distal foot. -- The facility failed to implement preventive measures, provide pressure ulcer interventions, or document weekly wound assessments for resident #6, who had been assessed as being at risk for skin breakdown. The resident developed a painful stage III ulcer to her right buttock. The ulcer was scheduled for a surgical procedure on 2/20/17. -- The facility failed to implement preventive measures, provide pressure ulcer interventions and treatments, or document weekly wound assessments for resident #7. The resident developed a painful stage III pressure ulcer to her left posterior calf, which was later determined to be unstageable due to necrotic tissue. The facility's failures related to pressure ulcer prevention and care presented a situation of immediate jeopardy that resulted in serious harm. The findings include: I: Immediate Jeopardy A. Findings Triggering Immediate Jeopardy Observation, record review, and interviews with staff, health professionals, and residents demonstrated the facility did not have an effective system in place to implement preventive measures for residents who had been assessed to be at risk for pressure ulcers. Nursing staff did not consistently complete weekly skin checks, and the skin checks did not always accurately describe the condition of the resident's skin. Treatments to improve the ulcers were not consistently implemented or monitored. The facility did not have weekly wound assessments completed, and wound assessments done by the wound physician did not include all the information needed to comprehensively assess the overall status and health of the wound. On 2/8/17 at 10:02 a.m., the facility provided a performance improvement plan (PIP), dated 2/7/17. The PIP included the following: -- A facility wide skin sweep to identify skin integrity concerns -- Weekly head to toe skin sheets being scheduled -- Nurse education related to triggering an SBAR, (situation, background, assessment and recommendations) and initiating treatment once a wound was identified -- The initiation of care plans for both pressure ulcers and non pressure ulcer wounds. -- Monitoring of identified wounds every 24 hours -- An audit of all residents with identified wounds to ensure policies and procedures were being followed appropriately. The PIP did not address gaps communication and in the implementation of preventive interventions, such as ensuring that high risk residents were repositioned, or that ordered pressure relief devices were in place. The facility's failures resulted in the acquisition of new pressure ulcers or worsening of existing pressure ulcers for residents #6, #7, #9, and #11, as well as an additional resident identified by the facility during their facility-wide skin checks. B. Imposition of Immediate Jeopardy On 2/8/17 at 5:21 p.m., the nursing home administrator (NHA), director of nursing (DON), consulting nursing home administrator (CNHA), were informed by the Colorado Department of Public Health and Environment (CDPHE) that the facility's failure to prevent the formation of avoidable advance stage pressure ulcers, infection of pressure ulcers, and the formation of multiple pressure ulcers, created a situation of immediate jeopardy for serious resident harm. C. Facility Response and Removal of Immediate Jeopardy On 2/9/17 at 11:16 a.m., the facility submitted the following plan (draft #6) to remove the immediate jeopardy. The plan read: I. 2/9/2017 To Whom It May Concern: Please consider the following abatement plan related to immediate jeopardy in F314. (The facility) respectfully presents the following abatement plan. -- Facility to conduct head to toe skin assessments on every resident to inspect for pressure ulcers. If an issue is identified, an SBAR will be completed, treatment orders will be obtained, preventative interventions will be implemented, and the care plan will be updated. This began on 2/7/17 and will be completed on 2/8/17. A registered nurse will complete the assessment. The Resident Care Management Director is responsible for updating the care plan of existing wounds and those and (sic) will be updated by 2/8/17. The Resident Care Management Director will be responsible for updating the care plan on an ongoing basis. -- The weekly pressure ulcer record will be updated by registered nurse manager. Existing wound pressure ulcer sheets will be in place by 2/9/17. If a new wound is identified, a registered nurse manager will be responsible for implementing a pressure ulcer record. -- All nurses will receive education that if a pressure ulcer is identified, an SBAR must be completed, the wound to be measured, appropriate notifications should be made, it will be placed on the 24 hour report, treatment orders will be obtained, preventative interventions will be implemented (i.e. heel floating, appropriate mattress, etc.), and a weekly pressure ulcer sheet will be implemented. This education will begin on 2/8/17 during the evening shift and will continue until all nurses have received education prior to working on the floor by the SDC or designee. The family will be notified within 24 hours. -- All pressure ulcers will have an order for [REDACTED]. -- If a wound is identified, the director of nursing will be immediately contacted via phone as the point person. The DON will then verify the pressure ulcer policy was followed. The DON will then ensure appropriate prevention equipment has been implemented or ordered. All pressure ulcers will be followed by the IDT (DON, SDC, ADON, Resident Care Management Director, RD, SSD) on a weekly basis. The wound orders will be reviewed for completeness and implementation on the MAR and/or TAR by the IDT. -- The unit managers of the North and the South unit will be the wound nurse. The DDCS will be responsible for training these wound nurses on procedures and expectation. This training will by (sic) 2/9/17. -- Any resident with a Braden score of twelve or below, identified as high risk, will have preventative interventions in place. The assigned nurse will be completing the Braden scale upon admission, quarterly, annually, and with significant change. The assigned nurse will put an intervention into place for anyone identified as high risk by the end of the shift and obtain orders as necessary. The registered nurse manager team will ensure the Braden was done as required and follow-up as necessary that appropriate interventions were implemented and orders are in place. -- Upon hire and during facility orientation, SDC or designee will train new licensed nurses on the procedures for pressure ulcers. Upon external nurses (due to agency use) working at facility, scheduler will notify SDC or designee so education can be completed with them prior to working their shift. If the SDC is not present, the DON will be responsible for the education. -- RCS staff will receive education on what to do when changes of skin condition occur and implementing CNA interventions such as repositioning. The SDC will be responsible for conducting the training, which will immediately begin on 2/9/17 during the 6:00 a.m. - 2:00 p.m. shift. RCSs will not be allowed to begin their shift until this training has occurred. For any agency CNAs, the scheduler is to notify the SDC so the training can begin prior to their working. On 2/9/16 at 11:45 a.m., the nursing home administrator (NHA) and consulting nursing home administrator (CNHA) were notified that the immediate jeopardy had been removed. However, based on observations, interviews, and record review, deficient practice remained at an H level (a pattern of actual harm). II. Facility Policies The pressure ulcer policy, as provided on 2/9/17 at 4:39 p.m. by the CNHA, indicated the following in pertinent part: -- Weekly skin checks should be completed and should note any changes in skin integrity and any breaks in the resident's skin, including ulcers. -- If a new skin concern was noted, a change of condition form was to be completed, and a new physician's orders [REDACTED]. -- The nurse was to be responsible for assuring treatment and interventions were in place, the care plan updated, and the appropriate skin documentation record (i.e. the Weekly Pressure Ulcer Record) initiated. -- Pressure ulcers were to be staged and measured weekly. III. Professional References According to the National Pressure Ulcer Advisory Panel (NPUAP), Prevention and treatment of [REDACTED]. -- Scheduled repositioning should be done to avoid individuals being in a position that places pressure on a vulnerable area for a long period of time. -- Heels should be placed in a position that eliminates pressure, referred to as floating the heels, by placing a cushion under the full back of the resident's calf. The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing: -- Positioning that places pressure on the pressure injury should be avoided. -- For heel ulcers, the heel should be floated. -- The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented. -- The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications. -- Signs of deterioration in the wound should be addressed immediately. -- The assessment should include: Location Category/stage Size Tissue types Color Periwound (the skin around the wound) condition Wound edges Any undermining or tunneling Exudate Odor National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of [REDACTED]. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014. From http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdf (2/17/2017). IV. Wound physician contract A copy of the facility's contract with its wound physician indicated the following in pertinent part: -- The facility was responsible for maintaining records of the wound care provided by the physician, and was responsible for assuring that documentation met the requirements of the state and federal regulations. -- The facility was responsible for coordinating the care provided by the physician, including scheduling appointments in a timely manner, and ensuring that services provided were consistent with the state and federal regulations. V. System Interviews Interviews with facility leadership, nursing staff, the facility's medical director and the wound physician revealed a breakdown in training and education provided to staff regarding the identification, reporting, assessment, and monitoring of wounds, as well as the implementation of wound treatments and preventive interventions. On 2/8/17 at 10:02 a.m., the director of nursing (DON), NHA, and the CNHA were interviewed. They said they had identified that progress notes related to wounds were not being done, or were in the wrong place. They said they had created the PIP (see above) to address these concerns. The DON said that the nurse managers were going to be responsible for conducting the assessments, and said they had initiated a sweep of the whole building to look for wounds. The DON said skin assessments should be conducted on shower days, and that any new concerns should be noted on an SBAR, and then an order should be obtained for the wound physician to see the resident. The NHA and DON confirmed that the PIP had been put into place on 2/7/17, after the initiation of the complaint investigation. They were not able to provide documentation to show the PIP had been created prior to the survey team initiating wound observations. Registered nurse (RN) #3 was interviewed on 2/8/17 at 10:45 a.m. She said she was the nurse responsible for overseeing wounds in the facility. She said she had been out for two weeks in early January, and since she had been back, she had been pulled to work the medication cart, and as a result, had only been able to go with the wound physician once. -The RN said the wound physician usually gave verbal notes at the end of his rounds, and sent written notes. She said she usually based her assessments of the wound notes, but she had not been able to get the assessments done because she had been pulled to work the cart so often. -Regarding updating the care plans, the RN said the system was not organized, and that really everyone should be updating the care plan, but there was not a point person to ensure that it got done. She said the facility did not have wound meetings to review active wounds. Licensed practical nurse (LPN) #1 was interviewed on 2/8/17 at 6:00 p.m. She said she had been at the facility for two and a half years. She said she had received some training about six months ago on reporting wounds she had observed and that aside from this training, she had not received wound training for more than a year and a half. RN #1 was interviewed on 2/8/17 at 6:05 p.m. She said she had worked at the facility for seven months. She said she had not worked in a long term care setting prior to her employment at the facility, but rather in an acute setting. -The RN said as a result, while she had been educated about wounds while obtaining her degree, she had not ever been in a setting where she was consistently expected to assess, stage, or treat wounds. She said she had not received any formal training about wounds at the facility, so she had been learning as she went. -The RN denied knowledge that any particular nurse was the facility wound nurse, and said all the staff worked with the wounds, but there was not any overall point person responsible for overseeing the assessment and treatment of [REDACTED]. The facility's medical director (MD) was interviewed on 2/9/17 at 4:25 p.m. He said the wound reports had not been available for his review at the previous QA (quality assurance) meeting, or afterword, although he had asked for them. -He said wound care had been a concern on a complaint survey during the summer, and that following that survey, the QA committee had initiated a wound program, but since then there had been at least two changes in administration, and the program had fallen through the cracks. -He said the facility had not informed him of the presence of multiple advanced wounds in the building, including those acquired by residents #11, #9, #6, or #7. The contracted wound physician was interviewed on 2/9/17 at 9:14 a.m. He said he was usually informed of new wounds on arrival at the facility, when he was given a list of residents to review. -The physician said when he visited, he would observe and assess the wound, provide debridement if it was indicated and able to be performed in house, and provide recommendations for treatment. He said he did not dress the wounds while onsite because he had multiple residents to see and not enough time. -The physician said there was not a consistent nurse in the building to accompany him on wound rounds. He said it had been RN #3 several months prior, then it was inconsistent, and then it had been whoever had been available. VI. Resident Failures A. Resident #11 Resident #11, age 79, was admitted to the facility on [DATE]. According to the computerized physician orders [REDACTED]. According to the minimum data set (MDS) assessment of 11/16/16, resident had moderate cognitive impairment with a brief interview for mental status (BIMS) of eight out of 15. The resident required extensive two person assistance with activities of daily living (ADLs). The resident was noted to be at risk for pressure ulcers. According to the care plan initiated 10/18/16, the resident had limited physical mobility deficit related to weakness and gait/balance deficit with a potential for pressure ulcer development. Record review: The therapy note dated 12/22/16 documented the goal for therapy was to improve bed mobility and preserve skin integrity. On 1/13/17, the following was ordered: Off-loading boot to right lower extremity (RLE) as tolerated for pressure relief. On 1/21/17, the shower sheet, created by a certified nurse aide (CNA) and reviewed by a nurse, documented the resident had a soft heel on the right foot. According to the 2/5/17 SBAR communication note, it documented the resident had a blister on her right heel and an open area to the top right side of her buttocks and should be seen by the wound doctor. Review of the CPOs, assessments and TAR on 2/8/17 revealed the resident was not prescribed a treatment for [REDACTED]. On 2/8/17, a list was presented by the DON of the residents to be seen by the wound doctor on 2/9/17. This list did not include the resident`s name. Observations: On 2/8/17 at 7:05 a.m. the resident was observed during morning care. CNA #2 assisted the resident with dressing and grooming. The CNA lifted the resident's right heel and asked the resident if her leg still hurt. A large dark area could be seen on the resident's right heel. The resident flinched as the CNA assisted the resident with her socks, and she said that it did hurt. When the resident was rolled to her right side a small wound on her left sacrum was visible. It appeared to be a pea sized opening with a healing periwound. The CNA said the resident's heel had fluid in it the other day but now it looked dry. The CNA said she was not sure when the resident acquired the wound on her sacrum, but they were applying a barrier cream. On 2/8/17 at 11:00 a.m. RN #3 was asked if she was aware of the resident's wounds. She said she was not aware the resident had a wound. She went to the resident's room and after observing the resident's heel, she said it looked like a pressure ulcer. She said she had not been made aware of the issue, and it should have been addressed immediately on discovery. An SBAR, notification to the family and physician, and treatment would be completed immediately. She said since the wound had a dry scab on it, she would have to call it unstageable if she were staging. She said the normal process was to get a boot and an air mattress for the resident. She said she was going to get an air mattress right away. Resident Interview: On 2/8/17 at 10:00 a.m. the resident was interviewed. She said she had both a boot and a brace for her foot. She said the boot was taken away but she did not know why. She said she did have a wound on her heel. Staff Interview: CNA #1 was interviewed on 2/8/17 at 9:00 a.m. She said she remembered it was 2/5/17 when they noticed the resident's right heel looked bad and told the nurse working on the hall immediately. The director of rehab was interviewed on 2/8/16 at 2:20 p.m. She said she was aware resident had a boot but she was did not know why the boot was not being worn anymore. On 2/8/17 at 2:32 p.m., she said when the order was given for the boot, she forgot to put it into the system including the care plan and the TAR, so it was missed. She said she just applied the boot and would ensure moving forward the order would be updated to appear on the care plan and the TAR. Facility follow up: After the facility was informed of the findings above on 2/8/17 at 11:00 a.m., the following observation and record review revealed: On 2/8/17 nursing progress note (created after observation at 11:00 a.m.) documented the resident`s medical power of attorney (MPOA) was called and notified of two skin issues identified and the plan of action. It documented the primary care physician`s (PCP) office recommended the resident should be seen by the wound doctor in the morning for both areas with sores. The care plan was to be updated to include the use of the boot to protect the right heel and barrier cream to the right buttock until the resident was seen by the wound doctor in the morning to determine what further action or orders were needed to promote healing. It documented the dietitian was called to review the resident's case to see what nutritional interventions were needed to promote wound healing. On 2/9/17 at 12:13 p.m. the resident was observed in bed in her room with no boot on her foot, and no air mattress on her bed. On 2/9/17 at 2:00 p.m. resident was in her room in her wheelchair with a boot on her right foot. The leg was elevated with the wheelchair leg extension. On 2/10/17 at 8:35 a.m. the resident was observed eating breakfast in the dining room. The resident had the boot on her right foot. Staff Interviews: On 2/9/17 at 9:30 a.m., the wound doctor was interviewed. He said prior to today, he was not notified the resident had any wounds. He said the wound on the upper right buttock was a stage 2 while the wound on the right heel was still unstageable as there was still some slough (necrosis) to be removed. On 2/9/17 at 2:11 p.m. RN #3 (wound care nurse) was interviewed. She said the normal process for skin checks and wound prevention was that residents were assigned to the nurses for skin checks weekly. Nurses were expected to do a thorough skin check for the residents assigned to them but the CNAs were also expected to report new skin conditions to nurses if any were found during showers or cares. The nurse was then expected to notify the unit manager or DON. The nurse was also expected to notify the primary care physician (PCP) and family, and obtain orders. The nurse was expected to do the SBAR, transcribe the orders and update the Kardex (CNA care plan) for the CNAs so they would know of the resident`s new skin condition and new orders such as repositioning and putting on boots. She said the wound nurse would then do a weekly wound check and dressing; she would then notify the wound doctor of any new concerns or improvement on the wounds. -She said the expected wound documentation would include the measurement, drainage, odor, color, and the nature of the wound surrounding (periwound). -She said she was not aware of any wounds on this resident. She said she had been gone for a couple of weeks and when she was back, she was assigned to other duties so no one informed her of these new wounds on resident #11. CNA #5 was interviewed on 2/9/17 at 3:50 p.m. She said if she found any skin issues on residents during showers, she would use the shower/bath skin check form and document it and would also report it to the nurse on duty. She said she first saw the skin issue on resident #11 sometime last week and she reported it to the nurse who came and looked at it. She said the area was soft and purplish and there was also another area on her sacrum on the right buttock that looked red. She said she did not know what happened after that. Wound doctor's evaluation: On 2/10/17 the wound doctor`s evaluation was provided. It documented the resident had a wound on her heel which was unstageable due to necrosis of the right posterior medial heel at least four days old. It documented there was moderate serous exudate and there was indication of pain associated with the wound. The wound on the right heel measured 4.5 cm x 5.5 cm x not measurable. The blister was fluid filled and thick adherent devitalized necrotic tissue was present. The wound on the right sacrum measured 1 cm x 0.9 cm x not measureable. The wound was not staged. B. Resident #9 Resident #9, age 64, was admitted to the facility on [DATE]. According to the CPOs, [DIAGNOSES REDACTED]. According to the 12/14/16 MDS assessment, the resident was cognitively intact as evidenced by BIMS score of 15 out of 15. He did exhibit some verbal behavior symptoms. Resident #9 admitted with a moderate risk for pressure development due to a [DIAGNOSES REDACTED]. The care plan, initiated 12/15/16 and revised 2/7/17, identified the resident had potential/actual skin issues related to [MEDICAL CONDITION]. Interventions included to notify MD of changes in the wound or emerging wounds, observe wound healing, prevalon boots to bilateral feet when the resident was in bed and up in a wheelchair, provide wound care/preventative skin care per order, weekly skin checks, and turn and reposition frequently to decrease pressure. Observation: On 2/10/17 at 2:05 p.m. the resident's dressing change was observed. The resident was cooperative prior to, during and after dressing change. The dressing change was provided by the facility unit manager and CNA #12 assisted. The resident remained very involved/engaged in wound care providing staff with positioning techniques for comfort during his treatment. The resident's wounds (right posterior heel, right ischium, left ischium, and upper back) were necrotic, some noted to have slough and or tissue injury. The resident also was observed with a deep tissue injury to his right plantar heel and a blister to his left distal foot. Record review: Record review revealed the resident was non-compliant with repositioning at times; however, there was no pertinent documentation provided that risk verses benefit was reviewed with the resident or preventative measures and treatment were timely put into place to prevent pressure ulcer development. The resident developed multiple pressure ulcers after admission. Skin assessments -The resident's skin assessment dated [DATE] identified that the resident's skin was intact. -The resident's skin assessment dated [DATE] identified that the resident had an existing abrasion to his coccyx. -The resident's skin assessment dated [DATE] identified that the resident had existing abrasions with no identification as to where on the body. -The skin assessment dated [DATE] identified the resident had existing skin tears and abrasions to the left upper back and right lower extremity. -The skin assessment dated [DATE] identified an abrasion to right lower leg, a skin tear to the upper/mid back, and pressure ulcers to the sacrum and coccyx. -The skin assessment dated [DATE] identified pressure ulcers to the sacrum and coccyx. -The skin assessment dated [DATE] identified existing non-pressure and pressure ulcers present; however, the assessment did not distinguish which areas were pressure or non-pressure. SBAR On 12/26/16 an SBAR was completed by RN #3. It identified a shear wound which correlated with a treatment order to the resident's right upper back; however, there was no mention of a coccyx or sacral wound. Progress notes from admission through 2/7/17 -The first mention of wounds was in the progress notes was a note dated 12/21/16 which read, in pertinent part, cleansed and changed bandage to wound on sacrum and resident refused to be turned. -The progress/nursing note dated 1/26/17 read in pertinent part, wound doctor in to assess wounds to left ischium (stage II), right ischium(unstageable), upper back (necrotic), right plantar heel (deep tissue injury) and right posterior heel (unstageble blood filled blister) per MD assessment. CPOs According to the CPOs reviewed from 12/26/16 through 2/9/17, there was an order for [REDACTED]. There also was an order for [REDACTED]. There were no treatment orders noted in the CPOs or on the medication administration record (MAR) or treatment administration record (TAR) related to right or left ischium wound or right heel wound prior to 1/26/17. Wound doctor evaluations Per the wound care doctor's evaluations on 1/26/17, 2/2/17 and 2/9/17, the evaluations identified wounds to the left ischium and upper back that worsened. The evaluation 1/26/17 noted the left ischium to be a stage II and the upper back to be healing. The evaluation 2/9/17 noted the left ischial wound to be unstageable due to necrosis and the upper back wound to be excised of necrotic tissue. Measurements of the wounds were obtained by the wound doctor on 2/9/17. The right plantar heel measured 0.5 cm x 1cm x not measurable in centimeters, intact (deep tissue injury). The right posterior heel measured 2 cm x 4.6 cm x not measurable in centimeters, (50% necrotic tissue, 10% granular tissue and 40% skin). The wound doctor preformed debridement of the wound in which he removed necrotic tissue. The right ischium (the bony protuberance of the upper hip and lower buttock) measured 5 cm x 4 cm x not measurable (70% necrotic tissue, 10% granular tissue, and 20% skin). The wound doctor performed debridement of the wound in which he removed necrotic tissue. The left ischium measured 2.8 cm x 4cm x not measurable, (30% necrotic tissue, 50% granular tissue and 20% skin). The wound was debrided by the wound doctor. The wound to the upper back measured 1.5 cm x 0.8 x not measurable, (25% necrotic tissue, 35% granular tissue, and 40% skin). The wound was debrided by the wound doctor. The left distal foot measured 1.1 cm x 1.8 cm x not measurable, (fluid filled blister stage II). Treatment was provided to all wounds per the wound doctor's recommendations. Weekly pressure ulcer record The weekly pressure ulcer record was updated during survey on 2/7/17. It identified wounds to the right heel, upper back, left ischium and right ischium as being in house acquired on 1/26/17. Staff interviews: CNA #7 was interviewed on 2/8/17 at 9:51 a.m. She said the typical routine of the resident in the morning included offering the resident plenty of fluids. Then she would warm the resident's shoulders with her hands and provide gentle range of motion to his bilateral upper extremities. This would be done prior to a position change or prior to getting the resident out of bed. She said that the resident would not let the staff turn him side to side; however, he would allow them to reposition him with pillows. RN #3 was interviewed on 2/8/17 at 11:04 a.m. She said that a preventative

Based on observations, record review and interview, the facility failed to identify issues about which quality assessment and assurance (QAA) activities were necessary, and develop and implement appropriate plans of action to correct identified quality deficiencies affecting facility residents. The facility's failure to identify through its QAA systemic issues in its management of residents at risk for pressure ulcers, including the lack of preventative measures for at risk residents, the lack of weekly skin checks, wound assessments and planned treatments and interventions, contributed a pattern of residents developing multiple, painful pressure ulcers. Cross-reference F 157, F 285, F 309, F 312, F 314, and F 516 The findings included: 1. History of noncompliance Review of the facility's regulatory record over approximately the last six months, which included a recertification survey (11/7/16) and two abbreviated surveys (8/11/16 and 2/15/17), revealed the facility failed to operate a QAA program to maintain compliance with regulatory requirements and prevent repeat deficiencies. The facility was cited with 17 deficiencies (excluding F520) during the abbreviated survey exiting 2/15/17, with one deficiency cited at an immediate jeopardy level for findings representative of a pattern with the potential for serious harm (F314K). F314K represents an increase in both the scope and severity of noncompliance found during an abbreviated survey in 8/11/16, when F314 was cited at a level of noncompliance that was isolated, actual harm. The findings on the 2/15/17 abbreviated survey revealed the failure of the facility to have an effective system in place to manage residents' risk for and development of pressure ulcers. -Observation, record review, and interviews with staff, health professionals, and residents demonstrated the facility did not have an effective system in place to implement preventive measures for residents who had been assessed to be at risk for pressure ulcers. Nursing staff did not consistently complete weekly skin checks, and the skin checks did not always accurately describe the condition of the resident's skin. -Treatments to improve the ulcers were not consistently implemented or monitored. The facility did not have weekly wound assessments completed, and wound assessments done by the wound physician did not include all the information needed to comprehensively assess the overall status and health of the wound. Other repeat citations over the past six months included: -F 157 - cited for failure to notify legal representatives of resident changes during both the recertification survey 11/7/16 and the abbreviated survey 2/15/17 at a D level, isolated potential for more than minimal harm -F285 - cited for failure to appropriately screen residents for mental illness during both the abbreviated surveys 8/11/16 and 2/15/17 at a D level, potential for more than minimal harm. -F 309 - cited for failure to provide residents necessary care and services during both the recertification survey 11/7/16 and the abbreviated survey 2/15/17 at a D level, isolated potential for more than minimal harm. -F 312 - cited for failure to provide timely assistance with activities of daily living (ADLs) during both abbreviated surveys 8/11/16 and 2/15/17 with findings at a pattern, E level, with the potential for more than minimal harm on 2/15/17. -F 516 - cited for failure to safeguard identifiable information on both abbreviated surveys 8/11/16 and 2/15/17 at an E level, a pattern with the potential for more than minimal harm. 2. Failures in QAA program - Lack of data to identify and evaluate system failures and lack of participation to develop and implement appropriate plans of action to correct identified quality deficiencies. The facility's medical director (MD) was interviewed on 2/9/17 at 4:25 p.m. -He said he participated in the QAA meetings, and said his role was to provide medical guidance on any concerns the facility was identifying. He said the meetings generally include a review of a number of reports, including skin care and pressure ulcers, but said at the recent QAA meetings, many of the reports had not been available. -The MD said the pressure ulcer reports generally included information about wound rates, conditions of each wound, and the status of the wound. He said the report could be used to identify trends in the development or worsening of wounds. However, he said he had not received pressure ulcer reports for the past several months, although he had asked for them. Review of the sign in sheet for the QAA meetings revealed the facility failed to ensure the presence of the director of nursing (DON) at the previous two QAA meetings. Specifically, review on 2/15/17 at 11:00 a.m. of the sign in sheet for the QAA meeting 11/30/16 revealed it did not include a signature from the interim DON. Review on 2/15/17 at 11:39 a.m. of the sign in sheet for the QAA meeting dated 12/21/16 revealed it, too, did not include a signature from the DON. No QAA meeting sign in sheets were available for 1/17 or 2/17. The nursing home administrator (NHA) and consulting nursing home administrator (CNHA) were interviewed on 2/15/17 at 10:49 a.m. -The NHA said the QAA committee was due to meet every other month, and the five people who always attended the meetings were herself, the medical director (MD), the director of nursing (DON), the dietary manager (DM), and social services director (SSD). However, the NHA confirmed after reviewing the sign in sheets for the 11/30 and 12/21/16 QAA meetings, that neither sign in sheet contained a signature to demonstrate the DON had attended the meetings. -The NHA said the committee reviewed a number of metrics to identify QAA concerns, including trending in the concern forms received and resident council minutes. Clinically, she said the council examined weight reports, bladder and bowel reports, unplanned discharges, falls reports, and 24-hour reports. She said the council also went over any surveys in the past year, including any abbreviated surveys. -In regard to identifying issues with respect to which quality assessment and assurance activities are necessary outside of the formal QAA meetings, she said the facility pulled clinical triggers, including pressure ulcers, every month. However, she was not able to say the last time the triggers had been pulled. She said the Resident Care Management Director (RCMD) was responsible for pulling the reports. -The NHA said the committee had not identified any concern with pressure ulcers prior to 2/7/17, when the 2/15/17 abbreviated survey began. -At 12:20 p.m., the NHA said she had not been able to find the last time the QA trigger reports had been pulled.

Based on observation, interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically: Record review and interviews with staff involved in pressure ulcer management revealed an ineffective system in implementing facility policy on pressure ulcers and in communicating information on residents' pressure ulcer status to promote healing, prevent infection and prevent further pressure ulcer development. These failures contributed a pattern of residents developing multiple, painful pressure ulcers. Cross Reference F 314 K; F 520 H The findings included: A. Current findings in area of quality of care - Failure to ensure facility policy was implemented to identify, prevent, asses and treat pressure ulcers for resident's #11, #9, #6 and #7. 1. Facility Policy The facility pressure ulcer policy, as provided on 2/9/17 at 4:39 p.m. by the Consultant Nursing Home Administrator (CNHA), read in pertinent part: -- Weekly skin checks should be completed and should note any changes in skin integrity and any breaks in the resident's skin, including ulcers. -- If a new skin concern is noted, a change of condition form is to be completed, and a new physician's orders [REDACTED]. -- The nurse was to be responsible for assuring treatment and interventions were in place, the care plan updated, and the appropriate skin documentation record (i.e. the Weekly Pressure Ulcer Record) initiated. -- Pressure ulcers were to be staged and measured weekly. 2. Cross reference F314K. Facility administration failed to timely and comprehensively identify, assess, prevent the development of and treat pressure ulcers. These failures created an immediate jeopardy situation that resulted in serious harm. -Observation, record review, and interviews with staff, health professionals, and residents demonstrated the facility did not have an effective system in place to implement preventive measures for residents who had been assessed to be at risk for pressure ulcers. Nursing staff did not consistently complete weekly skin checks, and the skin checks did not always accurately describe the condition of the resident's skin. -Treatments to improve the ulcers were not consistently implemented or monitored. The facility did not have weekly wound assessments completed, and wound assessments done by the wound physician did not include all the information needed to comprehensively assess the overall status and health of the wound. 3. Record review and interviews with staff involved in pressure ulcer management revealed an ineffective system in implementing facility policy (above) and in communicating information on residents' pressure ulcer status in order to promote healing, prevent infection and prevent further pressure ulcer development. -Resident #11 developed an unstageable wound on her heel. According to the 2/5/17 SBAR (situation, background, assessment and recommendation) communication note, the resident had a blister on her right heel and should be seen by the wound doctor. However, review of the computerized physician orders [REDACTED]. On 2/8/17 at 11:00 a.m. Registered Nurse (RN) #3, the facility wound nurse, said she was not aware the resident had a wound. She said she had not been made aware of the issue, and it should have been addressed immediately on discovery. On 2/8/17, a list was presented by the director of nursing (DON) of the residents to be seen by the wound doctor on 2/9/17. This list did not include the resident #11. -Resident #9 developed multiple ulcers after admission. Record review revealed that although there had been an order for [REDACTED].#3, the wound nurse, was interviewed on 2/9/17 at 9:55 a.m. She said she was not notified by staff that the resident had multiple pressure wounds to the left and right ischium and right heel. She thought the resident's wounds should have been assessed sooner; however, it was overlooked as she was off during that week. -Resident #6 developed a painful ulcer on her right buttock which became infected. On 2/8/17 at 9:47 a.m. RN #3, the wound nurse, was interviewed. She said she was out on medical leave for the first couple of weeks in January, then when she came back the facility put her on a medication cart. She said she had not done wound rounds for the past two weeks since her return because she could not do them and be the unit nurse at the same time. She said prior to her being out on medical leave, if a wound was discovered, they would notify the nurse so she could assess the wound and refer it to the wound physician. To her knowledge, if they had enough staff, she would be performing wound nurse duties. -Resident #7 developed a painful ulcer on her left posterior calf. On 2/9/17 at 3:13 p.m. the resident was interviewed. She thought they did not do the wound care as often as they were supposed to. The facility's failure to identify its systemic issues in its management of residents at risk for pressure ulcers, including the lack of preventative measures for at risk residents, the lack of weekly skin checks, wound assessments and planned treatments and interventions, contributed a pattern of residents developing multiple, painful pressure ulcers. B. Past findings in the area of quality of care - Failure to address issues previously identified in pressure ulcer management. Review of facility compliance history revealed the facility was cited for noncompliance in the same regulatory area, F314, in the last six months. Specifically, on 8/11/16, during an abbreviated survey, the facility was cited at F314 at a G harm level for failing to identify, assess, prevent and treat a pressure ulcer. Current findings under F314 at K level represented an increase level of noncompliance in both scope and severity. C. Cross reference F520. Interview and record review revealed the facility's quality assessment and assurance (QAA) committee had not identified the systemic issues in its management of residents at risk for pressure ulcers, including the lack of preventative measures for at risk residents, the lack of weekly skin checks, wound assessments and planned treatments prior to initiation of the abbreviated survey 2/7/17. D. Interviews The facility's medical director was interviewed on 2/9/17 at 4:25 p.m. He said the building had experienced frequent turnover in administration positions, and as a result, it had been difficult to get systems implemented. -The MD said he would expect to be notified of an existing immediate jeopardy in the building so he could assist with the abatement plan. He said he had heard the day before that the concerns in wound care could rise to an immediate jeopardy level, but stated that the administration had not notified him when the immediate jeopardy was called, or asked him for guidance in the abatement process. -The MD said that several months ago, the facility had been actively working on a performance improvement related to wounds. However, he said the program had stopped when the individual who had been the director of nursing (DON) at the time left. He said he had attempted to get it started again, but he had ultimately not been successful at getting the reports he needed to do so. The nursing home administrator (NHA) and consulting nursing home administrator (CNHA) were interviewed on 2/15/17 at 10:49 a.m. -The NHA said she had been officially listed as the administrator in the building beginning 12/28/16, but had been acting as the administrator for two months earlier under another NHA as she waited for her provisional license. She said the DON had started in early January, 2017. -The NHA acknowledged that the facility had missed a scheduled QA meeting in January, and said this was because the leadership staff had been pulled to the floor. She confirmed by observation that the sign in sheets for 11/30 and 12/21/16 failed to include the DON's signature. She said she was responsible for assuring that each member of the QA meeting was present and signed in.

Based on observations, resident interviews, family interviews, staff interviews, and record review, the facility failed to ensure sufficient nursing staffing to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident as determined by resident assessment and individual care plans for facility residents, including residents #2, #5, #6, #7, #9, #11, #13, #14, and #16. The facility's failure to ensure sufficient nursing staffing contributed to decline in the residents' quality of care, as evidenced by residents acquiring multiple pressure ulcers, and experiencing incontinence, untimely medication administration, and missed showers. Cross reference F312E, F314K, and F333D The findings included: I. Residents' Need for Nursing and Related Services According to the Census and Conditions report, signed by the director of nurses (DON) on 2/8/17, the resident census was 103. The following care needs were enumerated: -33 residents required assist of one to two staff for bathing and 20 residents were dependent for bathing. -23 residents required assist of one to two staff for dressing and one resident was dependent for dressing. -25 residents required assist of one to two staff for transfers and two residents were dependent for transfers. -60 residents required assist of one to two staff for toilet use and two residents were dependent for toilet use. -4 residents required assist of one to two staff for eating and ten residents were dependent for eating. -65 residents were occasionally or frequently incontinent of bladder. -65 residents were on a urinary toileting program. -22 residents were occasionally or frequently incontinent of bowel. -22 residents were on a bowel toileting program. -1 resident was bedfast all or most of the time and 75 residents were in a chair all or most of the time. -47 residents ambulated with assistance or an assistance device. -15 residents had contractures and 7 of the 15 residents with contractures developed the contractures after admission to the facility. -7 residents had pressure ulcers. None of the residents with a pressure ulcer had pressure ulcers present on admission to the facility. -94 residents were receiving preventative skin care. -67 residents had documented signs and symptoms of depression. -41 residents had dementia-related diagnoses. -50 residents had behavioral healthcare needs. -56 residents were on psychoactive medications including 18 residents on antipsychotic medications. -73 residents were on a pain management program. -35 residents were receiving rehabilitation services. -5 residents had significant, unplanned weight loss. II. Failure to Meet Residents' Need for Nursing and Related Services A. F312E - Failure to provide residents their showers as scheduled. B. F314K - Failure to provide care and services necessary to prevent the formation of pressure ulcers, and the worsening of existing pressure ulcers. Record review and interviews with staff involved in pressure ulcer management revealed an ineffective system in implementing facility policy on pressure ulcers and in communicating information on residents' pressure ulcer status to promote healing, prevent infection and prevent further pressure ulcer development. These failures contributed a pattern of residents developing multiple, painful pressure ulcers. C. F333D - Failure to administer medications on time. III. Interviews Interviews with residents, family and staff revealed insufficient staff to meet residents' needs. Residents reported delays of over an hour in call light response, bowel/bladder accidents due to long waits for help, and problems receiving showers. Staff reported an inability to complete their duties, resulting in undetected pressure ulcers (see F314), missed showers (see F312) and untimely medication administration (see F333). A. Resident Interviews Resident #5 was interviewed on 2/7/1:30 pm. The resident said staff was working short all the time, and call lights at times take 1 hour and 30 minutes. She said specifically that the night of 2/6/17, CNA #14 told her she was working short and was the only one working in the building. A group interview was conducted on 2/8/17 at 11:00 a.m. -Resident #13 said she has had to wait two to four hours for her call light to be answered. She said that was not showered as often as she would like. -Resident #16 said that whenever she used her call light, staff usually took 30 to 45 minutes to help her. -Resident #17 said she has had accidents because she has had to wait too long for help to the restroom. - Resident #14 said he was showered once a week and this was brought up to staff last year and had not improved. He said the facility had always had problems with showers. -Resident #20 was interviewed on 2/7/17 at 2:41 p.m. The resident said that the call light did not always get answered timely, but eventually it did get answered. B. Family Interviews Resident #2's interested party was interviewed on 2/8/17 at 3:13 p.m. She said the resident had not received a shower during all of the last week. She said the aides told her this was because they were short-staffed. C. Staff Interviews -Licensed Practical Nurse (LPN) #3 was interviewed on 2/7/17 at 3:29 p.m. The LPN said that the nurses work eight hour shifts; however, a replacement did not always come and then they had to work the next shift. The LPN said that she did not receive a lunch or dinner break as there was not enough time to complete the work load. -LPN #6 was interviewed on 2/7/17 at 11:10 p.m. The LPN said that she was the charge nurse for the north station and that she had two CNAs that were working with her. She said that the other LPN #8 was going home soon as she had been working since 2:00 p.m. -LPN #2 was interviewed on 2/8/17 at 10:26 a.m. She said residents were supposed to be showered several times per week. She said resident #8 was supposed to receive a shower every Monday, Wednesday and Friday. She said showers did not always happen on their scheduled days and usually happened twice per week instead of three times per week due to inadequate staffing. -LPN #1 was interviewed on 2/9/17 at approximately 3:00 p.m. The LPN said that they never had five CNAs as they had scheduled today. She said that they always have two CNAs on the evening shift, one for 300 and one for 400 hall. -LPN #8 interviewed with LPN #1 above, agreed with LPN #1 and said that they struggle during meals to pass trays, and to answer call lights, as there is only one CNA left on the floor during meal times. -A CNA was interviewed on 2/7/17 (time not posted due to anonymity). The CNA said the staffing ratios were not good. She said that she had to care for as many as 30 residents on a given shift. The CNA said that the licensed nurses attempt to help, but that it was not enough. The CNA said the staffing shortage had been going on for a while. The CNA further said that s/he wanted to do a good job, but that felt that s/he did not do a good job as s/he had no time to complete all tasks. -CNA #14 was interviewed on 2/7/17 11:30 p.m. She said that she had worked part of the night alone on 2/6/17. She said they usually they had four CNAs in the building, but last night (2/6/17) one agency CNA said she was only on the schedule until 2:00 a.m. because she needed to be at her next job and another agency CNA had an emergency and had to leave at 2 a.m., leaving one CNA on North and one CNA on South. The staffing sheets were reviewed and showed that on the night shift of 2/6/17, CNA #14 was the only CNA working on the South unit. -CNA #7 was interviewed on 2/8/17 at 9:47 a.m. The CNA said that she worked the 200 unit and the unit usually had two CNAs; however, it was difficult to get everything done, along with showers. She said that she had five showers to give today and was not sure if she wanted to get them done. -CNA #5 was interviewed on 2/8/17 at 10:18 a.m. The CNA said that they do not get a break, as there were not enough CNAs on the floor. -CNA #13 was interviewed on 2/10/17 at 2:00 p.m. The CNA said that there was not enough staff and that showers were skipped as there was not enough time to complete the showers. -CNA #10 was interviewed on 2/10/17 at 2:00 p.m., she said that they were working short of help consistently. -Registered nurse (RN) #3 was interviewed on 2/8/17 at 10:45 a.m. She said she was the nurse responsible for overseeing wounds in the facility. She said she had been out for two weeks in early January, and since she had been back, she had been pulled to work the medication cart, and as a result, had only been able to go with the wound physician once. The RN said the wound physician usually gave verbal notes at the end of his rounds, and sent written notes. She said she usually based her assessments on the wound notes, but she had not been able to get the assessments done because she had been pulled to work the cart so often. IV. Staffing Structure - Planned and Actual A. According to the daily schedule, the staffing structure was as follows: 1. Day shift 6:00 a.m. to 2:00 p.m. -100 hall one CNA -200 hall two CNAs -300 hall two CNAs -400 hall two CNAs One licensed nurse at each station 2. Evening shift 2:00 p.m. to 10:00 p.m. -100 hall one CNA -200 hall two CNAs -300 hall two CNAs -400 hall two CNAs One licensed nurse at each station 3. Night shift 10:00 p.m. to 6:30 a.m. -100 hall one CNA -200 hall one CNA -300 hall one CNA -400 hall one CNA One licensed nurse for 200, 300 and 400 hall B. Staff Interviews and Review of Staffing Sheets See staffing interviews above regarding staffing that differed from the daily staffing schedule and reported lack of replacements at end of shift, lack of breaks, fewer staff working than the number of staff on the daily staffing schedule. A review of the staffing sheets from 1/25/17 through 2/8/17 revealed the facility regularly had staff work through their lunch break. -LPN #8 worked through her lunch break ten times out of two weeks worked -CNA #18 worked through her lunch break six times out of seven shifts -CNA #14 worked through her lunch break four times out of five shifts. -CNA #2 worked through her lunch break five times out of 13 shifts. -CNA #15 worked through his lunch break ten times out of 11 shifts. -CNA #5 worked through her lunch eight times out of ten shifts. -CAN #16 worked through her lunch seven times out of twelve shifts -CNA #17 worked through her lunch three times out of eight shifts. -LPN #3 worked through her lunch twelve times out of 13 shifts The scheduler was interviewed on 2/9/17 at approximately 2:00 p.m. She said agency staff is used to fill in the vacant slots. She confirmed that not all shifts were always filled, as sometimes they were unable to find a replacement. The scheduler said that 2/6/17, she was aware the night shift worked with one CNA on the North and South units. She said that the shifts were not filled when the agency staff had to leave the facility. The NHA was interviewed on 2/10/17 at 10:38 a.m. The NHA confirmed that staffing has been a challenge. -She said she had directed the licensed nurses to call her directly if they were not going to be working their shift and then she would attempt to find a replacement. The process had worked as the NHA said that call offs had lessened. She said when a CNA calls in sick, the charge nurse is responsible to find a replacement. The NHA said that the facility used an agency which provided RNs, LPNs and CNAs. She said the scheduler would inform her that an agency staff member would be scheduled. -She further stated a staffing engagement coordinator was hired approximately three weeks ago. She said that the purpose of the coordinator was to set up interviews and follow the individual through the hiring process into orientation. She said the position is too new to evaluate at this time.

Based on observations, resident interviews, family interviews, staff interviews, and record review, the facility failed to ensure sufficient nursing staffing to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident as determined by resident assessment and individual care plans for 10 (residents #3, #4, #5, #6, #7, #8, #9, #10, #11, and #13) of 13 sample residents. Specifically, the facility's failure to consistently provide adequate nursing staff resulting in delayed toileting assistance, delayed call light response times, inadequate supervision for wandering residents, inadequate supervision for fall-prone residents, inadequate assistance with positioning/repositioning, inadequate cleanliness for resident equipment, and inadequate nursing documentation. The findings included: Cross reference F241 dignity for failure to timely assist resident #4 with meals. Cross reference F253 housekeeping and maintenance services for failure of night nursing staff to clean the sit-to-stand lift. Cross reference F312 ADL (activities of daily living) care for dependent residents for resident #5 for grooming assistance and #13 for failure to provide timely assistance with incontinence cares. Cross reference F314 treatment and services to prevent/heal pressure ulcers for residents #6, #7 and #11 for failure related to the prevention and healing of advance stage and multiple pressure ulcers developed in the facility. Cross reference F323 accident free environment/necessary supervision for residents #3 and #9 related to resistant falls with injury. Cross reference F327 hydration for failure to consistently offer fluids to resident #4 and to pass fresh water to residents on the south station. I. Resident Status According to the Census and Conditions report, signed by the minimum data set coordinator (MDS) on 8/5/16, the resident census was 102. The following care needs were enumerated: -25 residents required assist of one to two staff for bathing and 26 residents were dependent for bathing. Three residents were independent for bathing. The facility did not account assistance needs for 48 residents. -92 residents required assist of one to two staff for dressing and one resident was dependent for dressing. -82 residents required assist of one to two staff for transfers and nine residents were dependent for transfers. -88 residents required assist of one to two staff for toilet use and five residents were dependent for toilet use. -84 residents required assist of one to two staff for eating and two residents were dependent for eating. -52 residents were occasionally or frequently incontinent of bladder. -One resident was on a urinary toileting program. -22 residents were occasionally or frequently incontinent of bowel. -Zero residents were on a bowel toileting program. -Three residents were bed fast all or most of the time, nine residents were in a chair all or most of the time and six residents independently ambulated. -54 residents ambulated with assistance or an assistance device. -34 residents had contractures. -Four residents had pressure ulcers. One of the residents with pressure ulcer had pressure ulcers present on admission to the facility. -102 residents were receiving preventative skin care. -13 residents had documented signs and symptoms of depression. -18 residents had dementia-related diagnoses. -41 residents had behavioral healthcare needs. -54 residents were on psychoactive medications including 16 residents on antipsychotic medications. -74 residents were on a pain management program. -45 residents were receiving rehabilitation services. -Nine residents had significant, unplanned weight loss. Observations and Interviews: A. Actual Staffing The north unit nursing staff was observed on 8/4/16 at 7:02 p.m. and 7:37 p.m. Licensed Practical Nurse (LPN) #7 was observed preparing medications for the 400 hall. LPN #1 was observed at the 400 hall medication cart. LPN #7 said there were three certified nurse aides (CNAs) being shared with the 300/400 halls. LPN #7said she performed medication, treatment, documentation, and charge duties for the 27 residents on the 400 hall. LPN #7 said she was the only nurse on the north station and LPN #1 was helping out until someone could come in. The south unit nursing staff was observed on 8/4/16 at 7:25 p.m. LPN #1 was observed preparing medications for resident's on the 100 hall. Registered nurse (RN) #6 was preparing medications for the residents on the 200 hall. RN #6 said the facility currently had one RN and two LPNs for 102 residents. The RN said the facility tried to have four nurses on the evening shift. The LPN said she believed there were currently six CNAs on duty. Staffing was observed 8/7/16 at 9:10 p.m. The RN #1, RN #2, staff development coordinator (SDC) and the division trainer (DT) were the nurses on duty. RN #2 said she did not really have time to talk because she was about to assume responsibility for the 400 hall cart as she would be the only nurse on the 300/400 halls overnight. RN #2 said there are supposed to be two nurses for that work load overnight. RN #2 had been on duty since 6:00 p.m. and would be working a 12 hours shift. CNA #21 was interviewed on 8/7/16 at 10:10 p.m. The CNA reported having to provide CNA care for 31 residents that day. The CNA said in the last several months it was typical to work short on scheduled shifts. The CNA said one concern about working short was the inability to monitor high risk residents, like resident #9, who fell a lot. The CNA reported being concerned about the night shift because there was one nurse for 55 to 60 residents on the north hall. The CNA said the residents of that unit were very active at night and there needed to be two nurses. CNA #20 was interviewed on 8/7/16 at 10:16 p.m. The CNA reported working in the building for a long time. The CNA said the North unit required two nurses overnight but was staffed with one that night. The CNA said it was common to be short both CNAs and nurses. The CNA reported being the only CNA for 27 residents for the overnight shift. The CNA said there were a lot of residents that were awake at night and that the staff schedule did not consider this. The CNA said answering call lights was the top priority and that there was a lot of call light activity overnight. The CNA said that even though she wanted to get rounds completed on residents every two hours, it was not possible. The CNA said there were nights when getting one repositioned and brief change for residents completed was a struggle. The CNA said night shift side duties like cleaning wheelchairs and restocking did not get done because of lack of staff. RN #4 was observed to be alone on the south unit on 8/7/16 at 10:30 p.m. The RN said there were only going to be two nurses for 102 residents overnight when they were supposed to have three. The RN said it was difficult to meet resident needs with insufficient staff. LPN #4 was interviewed on 8/8/16 at 9:20 a.m. The LPN said she was short one CNA for the unit that day. The LPN said working with one CNA for 30 or more residents was impossible. The LPN said bathing would not get done. The LPN expressed concerns about not being able to adequately monitor resident #9 and #3 due to lack of CNA assistance. The south unit was observed on 8/10/16 at 5:55 a.m. One nurse and one CNA were present on the unit. RN #3 said she worked the night shift with one CNA and herself to care for 50 residents. The RN said with the number of residents up at night, that this was not safe. The RN said working with one nurse and one CNA was not uncommon on the south (100/200 halls) unit. B. Call Light Wait Resident #7 placed her call light on 8/8/16 at 3:25 p.m. The resident stated that she wanted to get up from bed. CNA #19, who was pushing a vital signs kit around the hall, went into the resident's room at 3:29 and turned off the call light. The CNA exited the room and continued down the hall, entering to obtain vital signs from another resident. The resident's call light was observed to turn back on at 3:30 p.m. At 3:33 p.m. CNA #8 entered the resident's room, turned off the call light and exited the room. The resident's call light was turned back on at 3:35 p.m. CNA #8 turned the call light off at 3:42. At 4:10 p.m. the resident's call light was observed to be back on and the resident remained in bed. CNA #19 and CNA #17 entered the resident's room at 4:16 p.m. with a lift to assist the resident from bed. This represented a 49 minute wait for the resident to receive assistance initially requested at 3:25 p.m. Resident Interviews: Resident #12 was interviewed on 8/5/16 at 8:46 a.m. The resident requested to speak about his concerns at the facility. The resident states, This place is a dump. They leave these senior citizens, they leave them alone. They fall and get hurt. They are short handed. Someone should help these people. Resident #13 was interviewed on 8/5/16 at 9:49 a.m. The resident said her pain medication was late and was often late. The resident said the facility was short of nurses and nurse aides. The resident reported going without bathing for a month due to staffing shortages. The resident said the short staffing caused her to receive late/cold meals because she received a room tray. The resident said she was glad she had her faculties because she could remind staff of important health concerns, like not having a bowel movement. Family Interviews: A family member that regularly visited the facility was interviewed on 8/5/16 at 8:19 a.m. The family member said the facility did not have enough staff to meet resident needs. The family member reported that she had observed confused residents off facility grounds and had to get staff to bring them back. The family member said resident's to do not get grooming assistance because of insufficient staffing. The family member said residents do not receive fresh water to drink because of insufficient staffing. The family member said she is always worried about what is happening to her loved one when she is not present. The family member said she reported her concerns about staffing to the nursing home administrator (NHA) but she felt nothing was being done. A second family member was interviewed by telephone on 8/5/16 at 8:48 a.m. The family member said there is insufficient staff to meet resident needs. The family member said she learned the facility was often one nurse short at night. The family member said she was concerned that they staff the facility currently had was going to burn out or make mistakes because they work short and are made to work double shifts. The family member said she was concerned her mother's unit often had one CNA for 45 to 50 residents overnight. The family member said when she visits her mom; it is not uncommon to find her mom soaked. The family said her mother does not get bathing as scheduled, waits long times for assistance, and never has access to fresh water because of the short staffing. Staff Interviews: The assistant director of nursing (ADON) was interviewed on 8/5/16 at 8:00 a.m. The ADON said he was hired to be a unit manager/ADON a couple of months ago. The ADON said staffing at the facility was insufficient. The ADON said both nurses and nurse aides were short staffed. The ADON said the staffing was worse on the weekend. The ADON said he always ended up working the cart. The ADON said oversight of floor nurses and care coordination responsibilities of the ADON/unit manager position do not get done because of the requirement to be working on the floor. The ADON said the short staffing caused necessary care to not be rendered. The ADON said his biggest concerns were lack of cares related to pressure ulcers and residents that fall. The ADON said he was not sure he could continue working at the facility because he worried about putting his license at risk. (The ADON resigned effective immediately during survey and was not observed after 8/5/16.) RN #6 was interviewed on 8/5/16 at 10:22 a.m. The RN said the facility had not had unit managers in eons. The RN said that when nurses are hired for the ADON/unit manager positions they end up working the floor instead of serving in a nurse leader roll. The RN said that the nurses needed the oversight of an ADON/unit manager. The RN said the floor nurses usually have 25 to 30 residents for whom they provide all medication, treatment, order change, assessment and documentation duties. A staff member (staff #3) requesting anonymity was interviewed 8/5/16 at 2:23 p.m. The staff reported insufficient staffing. The staff member said the 200 hall had more than 30 residents but often had one CNA to care for all of them on the evening shift. The staff said there were many residents that required close monitoring due to health concerns that could not be adequately monitored with present staffing. According to the staff, resident #14 was a brittle diabetic that was found unconscious after missing a meal. The staff said the meal might not have been missed if enough staff were present in the building. According to the staff member resident #9 needed one-to-one monitoring when awake and a walking program to prevent falls. The staff member said recently CNAs had gone two weeks without providing showers to residents. The staff member said someone called corporate about missed bathing so now the facility is trying to ensure bathing but other tasks are being missed instead. CNA #4 was interviewed on 8/5/16 at 3:15 p.m. The CNA said the 200 hall had 32 residents and eight of them required mechanical lifts for transfers. The CNA said it was not uncommon to be left to work alone on the evening shift on the 200 hall, which was overwhelming. The CNA said it was not possible to provide all expected/necessary services alone on the evening shift A staff member (staff #4) requesting anonymity was interviewed on 8/8/16 at 9:25 a.m. The staff member said that when there is a call off or a vacant shift after one's scheduled shift nurses are made to stay over. The staff member said being made to stay over was not acceptable because it was not safe. The staff member said it was not uncommon to have to work whole extra shift, unplanned, which was mentally and physically fatiguing. The staff expressed worry about errors in care due to fatigue. The staff member expressed concern with not being able to provide friendly and personable service when worked to the point of fatigue. The health information coordinator (HIC) was interviewed on 8/8/16 at 3:12 p.m. The HIC said she was also a CNA. The HIC said she usually worked the floor as a CNA 20 or more hours weekly. The HIC said working the floor as a CNA meant she did not get her HIC duties done. The HIC said she was behind with processing records. Record Review: A. Actual Staff Schedule On 6/1/16 the 100 hall was without a CNA from 6:00 a.m. until 10:00 a.m. on the day shift and the 400 hall was short one CNA for two hours on the evening shift. On 6/2/16 the 400 hall was without a nurse on the evening shift. On 6/4/16 the 300 hall was without a CNA on the night shift. On 6/5/16 the 300 hall was without a CNA on the night shift. On 6/8/16 the 400 hall was short one CNA for the day shift. On 6/10/16 the 400 hall was short a CNA for two hours on the evening shift. On 6/11/16 the 400 hall was short a CNA on the day shift; the restorative aide called off; the 400 hall was without a nurse after 6:00p.m.; and the night shift was short one nurse. On 6/12/16 the 300 hall was short a CNA on the day shift. On 6/13/16 the 400 hall was short a CNA on the evening shift. On 6/14/16 the 200 hall was short a CNA on the evening shift. On 6/16/16 the 400 hall was short a CNA on the day shift. On 6/17/16 the 200 hall was short a CNA for two hours on the day shift, the 400 hall was short a CNA for the evening shift, and the 100 hall was without a nurse for the evening shift. On 6/18/16 the 400 hall was short a CNA on the day shift; the 100 hall had no CNA for the evening shift; the 200 hall was short a CNA for an hour and forty five minutes on the evening shift; and the 400 hall was short a CNA for four hours on the evening shift. On 6/19/16 the 400 hall was short a CNA on the day shift and the 100 hall was without a nurse on the evening shift. On 6/22/16 the 100 hall was without a nurse on the day shift; the 300 hall was without a nurse on the evening shift; and the 100 hall was without a CNA on the night shift. On 6/24/16 the 200 hall was short one CNA on the day shift. On 6/25/16 the 400 hall was without a nurse on the night shift and the 300 hall was without a CNA for four hours on the night shift. On 6/26/16 the 400 hall was without a nurse on the night shift and the 300 hall was without a CNA for four hours on the night shift. On 6/27/16 the 400 hall was short one CNA on the day and evening shifts and the 200 hall was short one CNA on the evening shift. On 6/28/16 the 100 hall was short a CNA on the day shift and the 200 hall was short a CNA on the night shift. On 6/29/16 the 200 hall was short one CNA on the night shift. On 6/30/16 the 400 hall was without a nurse on the evening shift and the 200 hall was without a CNA for four hours on the night shift. On 7/2/16 the 200 hall was short one CNA on the evening shift; the 400 hall was short a CNA for two hours on the evening shift; and the 400 hall was short a CNA for four hours on the night shift. On 7/3/16 the 200 hall was short a CNA for four hours on the day shift; the 400 hall was short one CNA on the day shift; and the 200 hall was short a CNA for four hours on the evening shift. On 7/4/16 the 300 hall was short one CNA for four hours on the evening shift; the 400 hall was without a nurse on the evening shift; the 200 hall had no CNA for the night shift; the 300 hall had one CNA for four hours on the night shift; and the 400 hall had no nurse for the night shift. On 7/5/16 the 200 hall was short a CNA on the day shift. On 7/6/16 the 400 hall did not have a nurse for the night shift. On 7/7/16 the 400 hall was short a CNA on the day shift and the 300 hall did not have a nurse for the overnight shift. On 7/8/16 the 200 hall was short a CNA for four hours on the day shift; the 300 hall was short a CNA for two hours on the evening shift; the 100 hall had no CNA for the night shift; and the 400 hall did not have a nurse for the overnight shift. On 7/9/16 the 200 hall was short one CNA for the day shift and the 400 hall did not have a nurse for the overnight shift. On 7/10/16 the 300 hall was short one CNA for the day shift; the 300 hall had no nurse for the day shift; the 200 hall was short one CNA for the evening shift; the 400 hall was short one CNA for the evening shift; and the 400 hall had no nurse for the overnight shift. On 7/11/16 the 200 hall was short one CNA for four hours on the day shift and the 200 hall was short one CNA on the evening shift. On 7/12/16 the 200 hall was short one CNA on the evening shift; the 400 hall had one light duty CNA only instead of two fully functional CNAs on the evening shift; the 100 hall was without a CNA on the overnight shift; and the 400 hall was without a nurse on the overnight shift. On 7/13/16 the 400 hall was without a nurse on the overnight shift. On 7/14/16 the 200 hall was short one CNA on the evening shift; the 400 hall was short one CNA for four hours on the evening shift and the 100 hall was without a CNA for the night shift. On 7/15/16 the 300 hall was without a nurse on the overnight shift. On 7/16/16 the 100 hall was without a CNA for two hours on the evening shift; the 300 hall was short one CNA for four hours on the evening shift; and the 200 hall was without a nurse on the overnight shift. On 7/18/16 the 100 hall did not have CNA for the evening shift. On 7/19/16 the 300 hall did not have a nurse for the overnight shift and the 400 hall was short a CNA on the evening shift. On 7/20/16 the 400 hall was short one CNA for the day shift; the 200 hall was without a nurse on the evening shift for one hour and forty-five minutes; and the 300 hall had no nurse for the evening shift. On 7/21/19 the 400 hall was short one CNA for the day shift; the 400 hall was short one CNA for the evening shift; the 100 hall had no nurse for four hours on the evening shift. On 7/22/16 the 400 hall did not have a CNA on the overnight shift. On 7/23/16 the 300 hall was short one CNA on the day shift; the 200 hall was short one CNA for four hours on the evening shift; the 400 hall was short one CNA for four hours on the evening shift; and the 400 hall did not have a nurse on the overnight shift. On 7/24/16 the 200 hall was short one CNA on the day shift; the 300 hall was short one CNA on the day shift; the 200 hall was short one CNA on the evening shift; the 300 hall was short one CNA for four hours on the evening shift; the 400 hall was short one CNA for four hours on the evening shift; and the 300 hall was without a nurse on the overnight shift. On 7/25/16 the 300 hall was short one CNA on the day shift; the 100 hall was short one CNA for four hours on the evening shift; the 200 hall was short one CNA for four hours on the evening shift; the 400 hall was short one CNA for two hours on the evening shift. On 7/26/16 the 100 hall was without a nurse for four hours on the evening shift. On 7/27/16 the 200 hall was short one CNA for four hours on the evening shift. On 7/31/16 the 200 hall was short one CNA for five hours; the 400 hall was short one CNA on the day shift; the 200 hall was short one CNA on the evening shift; the 300 hall was short one CNA for four hours on the evening shift; the 400 hall was short one CNA for four hours on the evening shift; and the 300 hall was without a nurse for four hours on the evening shift. On 8/1/16 the 200 hall was without a CNA on the night shift. On 8/2/16 the 300 hall was short one CNA on the evening shift. On 8/3/16 the 300 hall was short one CNA on the evening shift and the 100 hall was without a CNA on the overnight shift. On 8/4/16 the 300 hall was short one CNA on the evening shift and the 400 hall was short one CNA on the evening shift. On 8/5/16 the 400 hall was short one CNA on the evening shift and the 200 hall was without a nurse for four hours. On 8/6/16 the 200 hall was short one CNA for four hours on the evening shift and the 400 hall was without a nurse on the overnight shift. On 8/7/16 the 400 hall was short one CNA for four hours on the day shift; the 400 hall was without a nurse for four hours on the evening shift; and the 300 hall had not nurse on the overnight shift. On 8/8/16 the 200 hall was short one CNA on the evening shift. On 8/9/16 the 100 hall was without a CNA on the overnight shift. B. Resident Council Minutes The 5/3/16 resident council minutes showed multiple residents had concerns with bathing. Nursing was not in attendance for the resident council meeting. The 6/7/16 resident council minutes showed multiple residents had concerns with call light wait times, bathing frequency, and toileting assistance. One resident complained about not receiving medications. Nursing and administration were not in attendance of the meeting. The 7/5/16 resident council minutes showed the director of nursing (former director of nursing) had given notice. One family member complained about resident grooming not being provided. Multiple residents complained about not getting bathing. Residents expressed concerns about call light response. Additional Interviews: The staff scheduler was interviewed on 8/9/16 at 3:55 p.m. The scheduler reported she was a CNA and had worked in the building off and on for six years. The scheduler said she tried her best to fill all shifts; however the facility did not have enough current staff to complete the schedule. The scheduler reported being short of both nurses and CNAs. The scheduler said she knew cares did not get delivered when staff worked short and she tried to avoid this by asking staff to stay over and by filling in herself. The scheduler stated the interim director of nursing (IDON) was currently picking up a number of shifts to help fill holes in the schedule for nurses. The scheduler said ideally she would like at least three CNAs for the day and evening shifts on the south nurses station (100/200 halls) and five CNAs on the north station (300/400 halls) for the day and evening shift. The scheduler said she was working with corporate on getting more staff for the building by placing ads on job sites. The scheduler reported she was working on a job fair to help recruit was well. The IDON was interviewed on 8/9/16 at 4:15 p.m. The IDON said she was working on a medication cart that evening shift. The IDON said she became the IDON when the former DON left sometime in 7/16. The IDON agreed the facility was short of nursing staff. The interim assistant director of nursing (IADON) and the regional clinical resource (RCR) were interviewed on 8/10/16 at 10:24 a.m. The RCR stated it was not acceptable for a resident to wait more than 40 minutes to have their request to get up from bed honored.

Based on observations, interviews, and record review 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, prevent infection and prevent new sores from developing for three (residents #6, #7 and #11) of three sample residents. Specifically the facility failed to: -Thoroughly assess, timely consult the physician, obtain orders, develop interventions and render treatments for pressure ulcers developed at the facility for resident #6. The facility's failure contributed to the resident developing three unstageable pressure ulcers and one stage two pressure ulcer. -Thoroughly assess, track and consistently treat a pressure ulcer developed at the facility by resident #7. The facility's failures contributed to the resident's pressure ulcer becoming a stage three pressure ulcer. -Thoroughly assess, monitor and treat a stage four pressure ulcer with which resident #11 was admitted . The findings included: 1. Resident #6 Resident Status: Resident #6, age [AGE] years, was admitted to the facility on [DATE]. According to the ,[DATE] computerized physician's orders [REDACTED]. The resident discharged from the facility to the hospital on [DATE]. The [DATE] admission minimum data set (MDS) assessment stated the resident was cognitively intact with a brief interview for mental status score of 13 of 15. The resident did not have a life expectancy of less than six months to live. The resident did not have behaviors and did not exhibit rejection of care. The resident required extensive assistance from two staff for bed mobility, transfers, and toilet use. The MDS showed the resident had four stage one or higher pressure ulcers that were not present on admission to the facility. Three pressure ulcers were unstageable and one pressure ulcer was classified as a stage two. The resident had pressure relieving devices to the bed and chair and was on a turning/positioning schedule. The resident was receiving physical and occupational therapy. The resident had one physician order [REDACTED]. A care plan initiated [DATE] said the resident had potential/actual skin issues related to a surgical site and pressure ulcer. The goal was to keep the resident's skin intact without signs of breakdown through the next review. The second goal was that the wounds would show signs of healing through the next review. The approaches were: -Notify physician of changes in wound or emerging wounds. -Observe wound healing. -Provide wound care/prevention per orders. -Weekly skin check per facility protocol. Family Interview: Interviews with the resident's wife were conducted by telephone on [DATE] at 6:30 p.m., and on [DATE] at 4:45 p.m. The resident's wife said the resident went to the facility to recover from a surgical repair of the left hip. The resident's wife said the resident developed a very serious wound to the coccyx while at the facility. According to the resident's wife, the resident was left in bed, was not repositioned due to pain and did not get out of bed due to pain. The resident's wife said she learned about the coccyx wound when the resident went to the hospital on [DATE]. According to the resident's wife, the wound was very serious and contributed to the resident being transferred from the local hospital to a hospital in Denver for care. The resident's wife said the resident experienced significant pain from the coccyx wound. According to the wife, the facility did not provide wound treatments to the resident during his stay. The resident's wife said she felt the facility did not give good care because they were always short of help. Staff Interviews: The physical therapist (PT) that assisted with the resident's care was interviewed on [DATE] at 8:10 a.m. The PT said the resident's pain caused the resident to have some therapy sessions from bed. When the resident was adequately treated for [REDACTED]. The PT said the resident developed a coccyx wound at the facility. The PT said that therapy was not involved with treating the resident's wound. The PT said the resident should have been on an air mattress. Licensed practical nurse (LPN) #3 was interviewed on [DATE] at 10:58 p.m. The LPN said she took care of the resident during his stay at the facility. The LPN said she remembered the resident had a wound on his coccyx that was pretty bad. The LPN said she thought a wound on the coccyx was present on his arrival to the facility. The LPN said if the wound was present on admission, it would be on the initial nursing assessment. Certified nurse aide (CNA) #7 and #13 were interviewed on [DATE] at 11:23 a. m. The CNAs both recalled the resident being in a lot of pain when he arrived, which limited his willingness to move in bed. Both CNAs reported the resident was incontinent of bowel and bladder at times. Both CNAs remember the resident received an air mattress toward the end of his stay but had been on a regular mattress prior to that. CNA #13 said she remembered seeing a dressing on the resident's coccyx and recalled telling the nurse that it needed to be changed after a shower. CNA #13 said she never saw the wound without a dressing on it. CNA #13 asked for a follow-up interview on [DATE] at 12:25 p.m. The CNA said she remembered the wife asking her to give the resident a shower on the second day of his stay due to an episode of incontinence. The CNA said she saw a dressing on the coccyx at that time. The CNA said the dressing was thick and shiny; the kind that can stay on for days. The CNA said she remembered thinking that dressing was not from the facility but was probably from the hospital. Record Review: A review of the resident's records revealed the resident was first identified to have a pressure area to the sacral/coccyx region on [DATE]. The record review revealed the first attempt to address the wound came four days later on [DATE] when a consult with the wound physician, a turning schedule, and an air mattress were all ordered. By the time the wound physician initiated care on [DATE], the resident had developed two more unstageable wounds (both on the left foot) and a stage two pressure ulcer to the right buttock. The records showed the facility failed to timely respond to an identified skin condition. Additionally, once the wound was identified and orders for treatment received, those orders were not transmitted to the medication or treatment administration record. This meant the nursing staff did not know to provide wound care to the resident via the electronic medication/treatment administration system. The medical orders scope of treatment (MOST) form showed the resident wanted CPR, full medical treatment and artificial nutrition on a short term basis only. A review [DATE] hospital disposition paperwork showed the resident had a surgical repair to the right hip. The resident was weight bearing as tolerated, on anticoagulants, and needed to follow-up with physicians in one to two weeks. The discharge paperwork did not show the resident had a pressure wound or was receiving treatment for [REDACTED]. The [DATE] Braden Scale for Predicting Pressure Sore Risk showed the resident was at high risk for pressure ulcers with a score of 11. There was not an initial skin assessment in the electronic health record (EHR) or paper chart. The initial nursing assessment was not conducted nor was an entry for a daily skilled charting. A review of daily skilled charting from [DATE] through [DATE] revealed the following documentation about the resident's skin: -[DATE] Nothing was documented about the resident's skin except the surgical site to the right hip. -There was not a daily skilled entry for [DATE]. -[DATE] Coccyx pressure was documented in the skin section. For the coccyx pressure ulcer, there was no wound measurement, no description of the wound bed, surrounding tissue, wound edges, drainage, or any other pertinent information about a newly identified wound. The form said there were no changes in the resident's skin integrity. -[DATE] Coccyx pressure was documented on the skin section of the form. No information about wound size, wound appearance or other pertinent information was present. -[DATE] Coccyx pressure was documented on the skin section of the form. No information about wound size, wound appearance or other pertinent information was present. -[DATE] Coccyx pressure was documented on the skin section of the form. No information about wound size, wound appearance or other pertinent information was present. -[DATE] The skin section did not demonstrate the presence of any skin injury. -[DATE] Coccyx wound and pressure to the left heel were documented in the skin section of the form. No information about wound size, wound appearance or other pertinent information was present for either wound. The form showed there was no change in the skin integrity of the resident's wound. A review of nurse's notes from [DATE] through on [DATE] revealed no measurements, assessments or other documentation of the resident's coccyx or heel pressure wounds. Additionally, no situation background assessment recommendation (SBAR) was found for the wounds to the coccyx or heel during the [DATE] to [DATE] time frame. The [DATE] nutrition assessment identified the presence of a surgical wound. The nutrition assessment did not identify the presence of a pressure wound to any portion of the resident's body. A [DATE] at 3:30 a.m. telephone order included the following instructions: -(Wound doctor) to evaluate and treat wound. -Turn side to side frequently. -Air mattress. A [DATE] Head-to-Toe Skin Check form showed the resident had the following injuries: -Stage two pressure ulcer to the right buttock measuring 0.6 cm x 0.2 cm. -Unstageable pressure ulcer to the left heel measuring 2.3 cm x 0.7 cm. -Unstageable pressure ulcer to the left fifth toe measuring 1.4 cm x 0.8 cm -Unstageable pressure ulcer to the sacral area measuring 6.0 cm x 6.7 cm. The sacral wound was noted to be 30% skin, 20% necrosis, 10% granulation, and 40% granulation. No other documentation about wound bed, surrounding tissue, drainage, and odor were present for the other wounds noted on the skin check. On initial review of the clinical record, wound physician information was not present. (See interview below about the facility not obtaining wound documentation until [DATE].) A [DATE] wound care specialist initial evaluation said: -The resident had an unstageable deep tissue injury to the left heel of greater than one day in duration. The wound measured 2.3 cm x 0.7 cm x un-measureable depth. The wound doctor recommended skin prep, an air boot and off-loading to treat the wound. -The resident had an unstageable to the left fifth plantar toe of greater than one day in duration. The wound measured 1.4 cm x 0.8 cm x un-measureable depth. The wound doctor recommended skin prep, an air boot and off-loading t treat the wound. -The resident had an unstageable pressure wound to the mid-sacrum of greater than one day in duration. The wound was unstageable due to necrosis. The wound measured 6.0 cm x 6.7 cm x un-measureable depth. The wound bed was 20% thick, adherent necrotic tissue, 10% yellow necrotic tissue, 40% granulation tissue, and 30% skin. The wound had moderate serous exudate. The physician recommended a daily dressing change, a group 2 mattress, limited sitting to 60 minutes, wound offloading, and positioning per facility protocol. -The resident had a stage two pressure ulcer to the right buttock. The wound was greater than six days in duration. The wound measured 0.6 cm x 0.2 cm x not measureable. The wound had light serous drainage. The physician recommended foam dressing once daily and was needed. Additional recommendations were a group 2 mattress, limited sitting to 60 minutes, wound offloading, and positioning per facility protocol. A [DATE] at 2:51 p.m. telephone order said, Per (wound doctor) wound care to sacral wound and right buttock using skin prep to peri wound area, apply Santyl, then apply calcium alginate cut to size, and cover with foam dressing, change daily. A [DATE] at 2:49 p.m. telephone order said, Per (wound doctor) skin prep to left heel and left forth toe plantar aspect twice daily. A review of the ,[DATE] medication administration record (MAR) revealed no order for wound treatments from [DATE] through discharge on [DATE]. The [DATE] telephone orders were not inclusive of the wound doctor's recommendations to use an air boot on the resident's left foot, off-load the resident's left foot, and limit sitting to 60 minutes. These recommendations were also absent from the care plan. A review of the ,[DATE] treatment administration record (TAR) revealed no order for wound treatments from [DATE] through discharge on [DATE]. The [DATE] physician admission visit showed the resident's skin, on inspection, was without significant [MEDICAL CONDITION], rashes or suspicious tumefactions. A [DATE] nurse's progress note said, This nurse observed stage II to coccyx area, 6.0 cm x 6.0 cm x 1.4 cm, with wadded up duoderm (hydrogel type) dressing on it. Removed, cleansed area, patted dry gently and reapplied duoderm dressing to site. The physician facility discharge summary, dated [DATE], stated the resident was discharged to the hospital for a [MEDICAL CONDITIONS]. The summary did not reference the three unstageable pressure ulcers or the stage two to the buttocks that were present on discharge from the facility. Physician Interview: The primary physician for the resident was interviewed on [DATE] at 9:39 am. The physician said he learned the resident was not really his after he completed the review. The physician said he did not actually visualize the resident's skin on the date of his initial physician visit. The physician reviewed a little note book where he kept his visit notes. The physician said he had not been informed of the resident's pressure wounds. Wound Nurse Interview: The minimum data set (MDS) coordinator #1 was identified by the interim director of nursing (IDON) as the nurse responsible for completing wound rounds each week. MDS coordinator #1 was interviewed on [DATE] at 4:20 p. m. MDS coordinator #1 said she was part time and worked 30 hours weekly. The MDS coordinator said she began assisting with wound rounds in ,[DATE]. The MDS coordinator said that when a wound was first identified that staff should assess the wound. After assessing and forming a plan, the physician should be contacted for orders on how to treat the wound. A telephone order is written and linked to the TAR. If an order is not linked to the TAR, the MDS coordinator said it will not be present on the TAR and nurses will not know to do it. The MDS coordinator said nurses should also create and SBAR for new wounds and should put the new wounds on the 24 hour report. The MDS coordinator reviewed the resident's clinical record. The MDS coordinator said the resident's wound was initially identified on [DATE] in the daily skilled nurse's notes. The MDS coordinator agreed no wound assessment was generated at the time the wound was identified. The MDS coordinator said she was unable to find an SBAR or any orders related to the wound when it was first identified. The MDS coordinator said the first order related to the wound was generated on [DATE]. The MDS coordinator reviewed nursing notes and said the only note about the wound of any substance was generated on [DATE]. The MDS coordinator said a depth of 1.4 cm did not seem like a stage two wound to her. The MDS coordinator said she did participate in wound rounds with the wound doctor for this resident on [DATE]. The MDS coordinator said she recalled writing the orders for the wound treatment. The MDS coordinator reviewed the TAR and MAR and said neither the MAR or TAR evidenced any wound treatment for [REDACTED]. The MDS coordinator agreed that the resident had a delay in wound assessment, initiation of wound interventions, and did not receive planned wound treatments as ordered during his stay. Regional Clinical Resource Interview: The regional clinical resource (RCR) was interviewed on [DATE] at 11:14 a.m. The RCR stated the facility created a performance improvement plan on [DATE] related to wounds. The RCR said she identified concerns related to wound physician information, weekly skin assessments, and rounding. The RCR said the facility was in the process of obtaining the wound doctor notes for all residents. (It was unclear why the notes were not obtained sooner if they were identified as being missing for all wound residents on [DATE].) According to the RCR, the wound doctor's notes were available within 24 hours of the wound doctor visit; however no one knew how to retrieve them from the records portal and thus they were not being obtained and placed in the chart. The RCR's performance improvement plan did not address concerns related missed treatments, residents sent out for wound care, and failures to timely intervene with newly identified wounds. 2. Resident #7 Resident #7, age [AGE] years, was admitted to the facility on [DATE]. According to the ,[DATE] computerized physician's orders [REDACTED]. The [DATE] admission minimum data set (MDS) assessment said the resident was cognitively intact as evidenced by a brief interview for mental status score of 15 of 15. The resident did not have behaviors or reject care during the MDS assessment period. The resident was totally dependent on two staff for transfers. The resident required extensive assistance from two staff for bed mobility, toileting and dressing. The resident was always incontinent of bowel and bladder. The resident did not have any pressure ulcers on admission to the facility and did not have any pressure ulcers at the time of the assessment. The resident had a pressure relieving device to the bed, wheelchair and was on a turning schedule. The pressure ulcer care plan initiated on [DATE] said the resident had pressure ulcers to her right buttock and left foot. The goal was for the resident's pressure areas to show signs of healing and remain free of infection through the next review. Approaches included: -Administer medications as ordered. -Administer treatments as ordered and observe for effectiveness. -Assess/record/observe wound healing. Weekly measure length, width, depth where possible. -Complete and document weekly body checks. -Refer to interdisciplinary team as needed. Observations: The resident was observed being transferred from wheel chair to bed on [DATE] at 1:56 p.m. Certified nurse aide (CNA) #13 and #6 were providing the transfer assistance. The resident's wheelchair was too small for her and provided little room for repositioning. The resident was transferred using a mechanical sit-to-stand lift. The CNA said the resident was encouraged to lay down each afternoon. The CNAs did not state awareness of turning or positioning schedule. As the resident was raised up in the lift and positioned in bed, the resident was observed to have redness to the back of the right leg that was about two inches wide and 14 inches long. The redness was observed with licensed practical nurse (LPN) #8. The LPN said the redness was blanchable and was probably from the wheelchair cushion. The resident was observed on [DATE] at 1:50 p.m. being transferred to bed with a sit-to-stand lift by CNA #11 and CNA #6. The daughter was also present for the transfer. The resident was observed to fit tightly in the wheelchair. According to the daughter, the resident owned the wheelchair, but had gained more than 20 pounds, making the wheelchair too small. CNA #6 reported noticing the wheelchair's snug fit. The CNA reported putting in a ticket that morning for therapy to assess the resident's wheelchair. A dressing change was observed on [DATE] at 2:20 p.m. LPN #8 performed the dressing change. The LPN removed the dressing to the buttock. The wound was cleaned. The wound measured 0.5 cm length x 0.4 cm width x 0.7 cm depth. The LPN said slough was present in the wound bed and estimated the wound bed was 25% granulation tissue. The LPN said the wound edges were clean and the peri wound skin was pink. The LPN completed the dressing changed and repositioned the resident on her back. The dressing to the foot was not observed as it was changed every three days and had been changed the previous day. Resident Interview: The resident was interviewed on [DATE] at 3:14 p.m. The resident said the wound on her bottom happened while at the facility. The resident said the wound did hurt at times. The resident said she had wound care to her foot and her bottom. According to the resident the wound care to her bottom was not provided daily. The resident was unsure how often she was supposed to get wound care to her heel, but she knew it was less than daily. Family Interview: The resident's daughter was interviewed on [DATE] at 1:30 p.m. The daughter said the resident was prone to heel wounds and was first admitted to a facility related to an infected heel wound that formed at home. The daughter said she heard the resident had a wound on her buttocks but did not know if it was getting better or worse. The daughter said the facility implemented an air mattress after the resident developed the buttock wound. Staff Interviews: The assistant director of nursing (ADON) was interviewed on [DATE] at 8:00 a.m. The ADON said he was hired to be the ADON for the north unit (where the resident lived). The ADON said staffing was a problem at the facility. According to the ADON, instead of coordinating care and supporting the nurses with completing assessments and orders, he worked the cart. The ADON said because he worked the cart, things were missed. The ADON said pressure ulcer care was a concern for him due to staffing. LPN #8 was interviewed on [DATE] at 2:10 p.m. The LPN said the resident had pressure wounds on her left heel and right buttock. The nurse said the heel ulcer was improving but the buttock ulcer was not. A nurse, requesting anonymity, who often worked the north unit where the resident resided, was interviewed on [DATE] at 9:25 p.m. The nurse said it was very difficult to give care and meet resident needs due to staffing shortages. The nurse said cares were missed because staff had to prioritize. The nurse said assessments were not always completed, but that she did try to get weekly skin checks done. LPN #8 was re-interviewed on [DATE] at 11:04 a.m. The LPN said that all wound documentation was in the electronic health record (EHR) except the physician information which was in the chart. The LPN said staff does weekly skin checks to identify skin issues. The LPN said all residents have Braden scales (pressure ulcer risk assessment) completed weekly for four weeks at admission. The LPN said the admitting nurse would document wound present at admission on the initial admission assessment. The LPN said wound notes might be on the weekly skin check form or nurses notes, but she was not sure because she did not participate in them. The LPN was asked to review the paper chart and EHR for evidence of wound documentation. The LPN said none of the wound doctor information was present in the chart. The LPN was not able to locate wound measurements. The LPN was not sure how staff would know wound status from week to week without measurements and information about the wound being documented. The LPN said the resident did not refuse cares and was generally good about allowing repositioning and treatments. Record Review: Record review showed the resident did not have pressure ulcers present on admission. Pressure areas were first identified to the right buttock and left heel on [DATE]. Though the resident had pressure areas, treatments were not provided as ordered. The clinical record did not contain any wound assessments until they were entered by the staff development coordinator (SDC) on [DATE], so from [DATE] through [DATE], the facility direct care nurses were without access to the resident's complete wound information. A. Staffing Shortage Summary A review of nursing staffing revealed the facility was short at least one scheduled nursing staff member for at least some portion of one shift on the hall where the resident resided 20 times from [DATE] through [DATE]. The building was short at least one nursing staff member on any unit 35 times from [DATE] through [DATE]. B. Resident Wound Formation and Tracking The [DATE] Initial Nursing Assessment showed the resident had excoriation to the buttocks but no pressure wounds. No wound was documented on the left heel. The [DATE] Braden Scale for Predicting Pressure Ulcer Risk showed the resident was at risk for pressure ulcers as evidenced by a score of 16. The [DATE] initial nursing plan of care said resident had potential for pressure ulcers related to incontinence. The goal was for skin to remain intact. The approaches were to provide preventive care; skin checks weekly; notify physician of changes; and turn and reposition frequently. The [DATE] Braden showed the resident was not at risk for pressure ulcers. The [DATE] Head-to-Toe Skin Check showed the resident did not have any skin injuries. A [DATE] at 5:51 p.m. nurse's note showed the resident was seen by the wound doctor. The wound doctor debrided a foot wound to the left mid-foot and the unstageable pressure ulcer to the right buttocks. A situation background assessment recommendation (SBAR) for [DATE] said the resident had developed and unstageable pressure ulcer to the right buttocks. The buttock wound measured 0.8 cm x 0.9 am x unstageable. The second area was noted to be a stage one pressure area to the left plantar that measured 0.9 cm x1.0 cm. The ,[DATE] TAR had the following orders for the unstageable pressure area on the right buttock: - Per (wound doctor) for unstageable wound right buttock, cleanse wound with wound cleanser, skin prep to peri wound, Santyl calcium alginate cut to fit, cover with foam one time daily. The order was initiated on [DATE] and was discontinued on [DATE]. The order was completed on [DATE] only. -Per (wound doctor) for unstageable wound right buttock, cleanse wound with wound cleanser, skin prep to peri wound, Santyl calcium alginate cut to fit, cover with foam daily every evening shift. This order was initiated on [DATE] and discontinued on [DATE]. The TAR showed the order was not completed on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. A [DATE] weekly skin assessment document showed the resident had worsening to the pressure ulcer on the right buttock. The wound now measured 1.2 cm x 1.0 cm by unstageable. New shearing injury was noted to the left buttock. The left foot wound was classified as trauma and was considered to be improved. The physician recommended implementing an air mattress. The [DATE] and [DATE] weekly Head-to-Toe skin check noted existing pressure areas to the left buttock (it was actually the right buttock) and the left foot. No measurements or descriptions assessing the wound were present in either skin check. The [DATE] Monthly Nursing Summary did not show the resident had a pressure ulcer. The [DATE] weekly Head-to-Toe skin check showed the resident had existing pressure areas to the right buttock and left foot. The ,[DATE] TAR showed the resident did not receive dressing change treatments to her right buttock on [DATE] and [DATE]. The facility did not furnish the wound doctor progress notes for review, though all provider progress notes were requested in writing on [DATE] at 11:45 a.m. Wound Nurse Interview: MDS coordinator #1 was interviewed on [DATE] at 4:20 p. m. The MDS coordinator said she accompanied the wound doctor on rounds weekly and was designated as the wound nurse for that reason. Treatments to wound were completed by the floor nurses according to the MDS coordinator. The MDS coordinator reviewed the resident's clinical record and said the resident developed a stage three pressure ulcer to the right buttock while a resident at the facility. The MDS coordinator agreed the resident did not have a care plan developed to address the pressure ulcer on the buttocks once it was formed. The MDS coordinator said she would put one in place right away. The MDS coordinator reviewed the electronic and paper records for the resident. The MDS coordinator said she did not know the wound doctor documentation was not present in the clinical record. The MDS coordinator said she had not been consistently entering wound round information in the resident's clinical chart because the wound doctor information should have been present and should have contained the pertinent information. The MDS coordinator reviewed the resident's TAR for resident. The MDS coordinator acknowledged the resident missed several wound treatments to the buttocks in ,[DATE] and continued to miss treatments in ,[DATE]. The MDS coordinator said the wounds were discussed at times in the morning meeting. The MDS coordinator said floor nurses did not attend the morning meeting. The MDS coordinator said the facility would benefit from a regular wound huddle. Summary: Staffing shortages, delayed assessment of the resident's wheelchair, missed treatments and failure to timely document the resident's skin conditions contributed to the formation of and potentially delayed healing of the resident's stage three pressure ulcer to the right buttock. 3. Resident #11 Resident Status: Resident #11, age less than [AGE] years, was admitted to the facility on [DATE]. The resident discharged from the facility on [DATE]. According to the ,[DATE] computerized physician's orders [REDACTED]. The resident did not have a minimum data set (MDS) assessment completed for review. The wound care plan initiated on [DATE] said the resident had potential for skin issues related to a pressure sore. The goal was for the resident to show signs of healing with decreased wound area and overall size through the next review. Approaches included: -Notify physician of changes in wound or emerging wounds. -Observe wound healing. -Provide wound care/preventative skin care per orders. -Skin checks weekly per facility protocol, document findings. Resident Interview: The resident was interviewed on [DATE] at 10:15 a.m. The resident said he developed the wound from a fall where he passed out and was on the ground for a long time. The resident said the wound was treated in the hospital prior to admission to the facility. The wound treatments included some surgical interventions and a diverting [MEDICAL CONDITION] to help with healing due to the location of the wound. The resident said he was supposed to get his wound dressed two times daily, but that the dressing changes were missed at times. The resident said no one at the facility had every measured his wound that he could recall. The resident said his wound was mea

Based on observations, interviews, and record review the facility failed to ensure adequate supervision and safety to devices related to fall prevention for two (residents #3 and #9) of three sample residents and for wandering for two (resident #8 and resident #10) of three sample residents. Specifically, the facility failed to: -Thoroughly investigate falls for residents #3 and #9. -Provide necessary supervision and resident centered approaches to mitigate fall risk. -Consistently ensure placement of Wanderguard device for resident #10. -Provide necessary supervision to redirect residents from exiting the building for residents #8 and #10. -Accurately assess elopement risk. The facility's failures resulted in resident #3 and #9 experiencing multiple falls, including a fall that required sutures and a trip to the emergency department. The facility's failures resulted in residents #8 and #10 wandering from the building. The findings included: 1. Falls A. Resident #3 Resident Status: Resident #3, age [AGE] years, was admitted to the facility on [DATE]. According to the 8/16 computerized physician's orders [REDACTED]. The 7/1/16 admission minimum data set (MDS) assessment showed the resident had severe cognitive impairment as evidenced by a brief interview for mental status score of zero of 15. The resident had no behaviors that impacted the self or others; did not reject cares; and wandered without exit seeking on one to three days of the observation period. The resident required extensive assistance from one staff for bed mobility, transfers, dressing, toilet use and personal hygiene. The resident required limited assistance for walking in room; locomotion on and off the unit; and eating. The resident was unsteady and only able to stabilize with human assistance when moving from seated to standing position; walking; turning around to face the opposite direction; moving on and off the toilet; and with surface-to-surface transfers. The resident was frequently incontinent of bladder and was always incontinent of bowel. The resident had falls in the one month and the two to six month periods before admission to the facility. The resident had not experienced a fracture related to falls. The resident had one fall with injury at the facility prior to the MDS evaluation period. The fall safety care plan, initiated on 7/13/16 and last updated on 8/10/16, said the resident had a potential/actual safety and/or fall risk related to falls, history of falls and dementia. The goal was for the resident to be free from falls or related injury through the next review. Approaches were: -Educate resident to call for assistance and encourage the resident to wait for assistance. Educate staff to anticipate the resident's needs. (added on 7/26/16) -Educate staff to ensure the halls were free and clean of clutter (added on 7/26/16) -Follow facility protocol for fall prevention. (added on 7/13/16) -Initiate safety checks as indicated. (added on 7/13/16) -Low bed with floor pad in place while in bed. (added on 8/10/16) -Offer non-skid socks. (added on 8/10/16) The actual fall since admission care plan, initiated on 7/11/16, said the resident had an actual fall since admission to the facility. The resident had an unsteady gait and was independently mobile in a wheelchair. The goal was for the resident to resume usual activities without further incident through the next review date. The approaches were: -Anticipate needs and monitor for environmental changes. (added on 7/11/16) -Anticipate resident assistance needs. (added on 7/21/16) -Fall prevention program. (added on 7/11/16) -Invite and assist to activities of interest and watch for signs of enjoyment. (added on 7/21/16) -Place frequently needed items in reach. (added on 7/11/16) -Resident has had an actual fall since admission, continue to have her independently mobile in wheelchair. (added on 7/21/16) Other Resident Interviews: Resident #12 approached requesting an interview on 8/5/16 at 8:46 a.m. The resident said, They leave these senior citizens, they leave them alone. They fall and get hurt. They are short handed. We just had a lady here fall. Someone should help these people. Resident #17, who shared a room with the resident, was interviewed on 8/5/16 at 11:23 a.m. According to resident #17, the resident had a fall a lot. Resident #17 said her roommate did not have a good memory and got up from bed on her own when she should wait for help. Observations: Cross reference to F253 for observations of hallway clutter on 8/4/16, 8/5/16, and 8/8/16 and interview with the director of rehabilitation on 8/8/16 confirming the presence of clutter in the hallways. The resident was observed on 8/5/16 at 7:38 a.m. in the hallway. The resident's hair was uncombed and was sticking up in back. The resident had a skin tear with steri-strips in place on the right hand. There was a skin tear on the left forearm and another skin tear with steri-strips on the left thumb. The resident had an old yellow and red bruise under the left eye. The call light was on in the resident's room on 8/5/16 at 3:24 p.m. The resident was observed to stand from bed and self-transfer to the wheelchair. The resident exited the room. The resident was observed to self-transfer from bed to her wheelchair on 8/10/16 at 2:21 p.m. The resident did not have her glasses on. She did not turn the call light on to request assistance prior to transfer. The resident was observed to exit the room and propel down the hall in her wheelchair in the direction of the activity area and dining room. The fall mat was present, the bed was not in the lowest position. The resident was observed to return to her room on 8/10/16 at 2:39 p.m. The resident stood from her chair and began straightening her bedding. No staff was in the area. An outside visitor that identified as the resident's friend entered the room to visit the resident. Staff interviews: The assistant director of nursing (ADON) was interviewed on 8/5/16 at 8:00 a.m. with a follow-up interview on 8/5/16 at 10:52 a.m. The ADON said the facility had a staffing problem with both nurses and CNAs. According to the ADON the facility had numerous falls that were impacted by the lack of staffing. The ADON said he was concerned about the resident because she had multiple falls with injury. The ADON said he could not think of any intervention put into place to help the resident be safer. The ADON said the resident lacked impulse control and was unable to make safe decisions. Restorative certified nurse aide (RCNA) #2 was interviewed on 8/9/16 at 11:18 a.m. The RCNA said the resident was on a restorative nursing program for 15 minutes daily. The RCNA said the program included walking and use of the stationary bike. The RCNA said the resident was very wobbly on her feet, particularly when tired. The RCNA said the resident's balance also seemed to be worse when there were a lot of people around. Certified nurse aide (CNA) #14 was interviewed on 8/10/16 at 6:05 a.m. The CNA reported working as the only CNA on the south unit overnight. The CNA said she and registered nurse (RN) #3 were the only staff on the hall the 100/200 halls overnight. The CNA said the resident had experienced falls with injury on the night shift. The CNA said many residents on the unit were awake at night so it was difficult to keep an eye on everyone, even when not working alone. RN #2 was interviewed on 8/10/16 at 2:36 p.m. The RN said the resident was alert but not oriented to time or person. The RN said the resident was not able to understand or retain instructions. The RN said the resident had multiple falls during her stay at the facility. The RN said the resident had a fall that required a trip to the hospital and stitches. Record Review The 6/28/16 history and physical said the resident was admitted to the facility with a history of falls, aphasia, dementia and recent hospital visits for a small post-fall subarachnoid hemorrhage. Prior to admission on 6/28/16 the resident experienced a fall from the toilet in the bathroom while her daughter turned her back briefly. The assessment plan was to determine why the resident was falling. Fall risk assessments completed on 6/24/16, 6/30/16, 8/1/16, and 8/8/16 showed the resident to be at high risk for falls. A situation, background, assessment, recommendation (SBAR) communication form dated 6/30/16 at 8:00 a.m. said the resident had an unwitnessed fall in her room. The resident was found scooting towards the door of her room on her bottom. A 0.5 cm skin tear was present on the back of the head. The wound was cleaned and treated with a steri-strip. The resident was wearing non-skid socks; her bed was in low position; the room was adequately lit; no spills present; the call light was in reach; and the fall mat was in place. A 6/30/16 at 10:50 p.m. nursing note said the resident was on follow-up for a fall that morning. The resident had a new skin tear to the back of the head. No other documentation about the fall was present in nursing notes. The 6/30/16 fall investigation, signed on 7/11/16 by social services, recapitulated the 6/30/16 SBAR note. The investigation identified the activity at the time of the fall as unknown. The resident had been in bed prior to the fall. The section describing contributing conditions to the fall (e.g., unsteady gait, history of halls, recent admission) was not completed. The recommendation from the investigation was to encourage the resident to call for help; anticipate the resident's needs; continue to monitor that recommendations were in place; and continue to work with therapy. A 7/22/16 at 6:26 p.m. SBAR documented the resident had a fall in her room. The resident was found sitting on the floor on her buttocks. There was a small abrasion to the right eyebrow from the resident's eye glasses. The resident was assisted to the wheelchair. The 7/22/16 at 6:38 p.m. fall investigation said the resident had an unwitnessed fall in her room. The resident was in bed prior to the fall. The resident was predisposed to falls related to unsteady gait, history of falls, cognitive deficit, and vision deficit. The resident had shoes on at the time of the fall. No environmental factors like spills contributed to the fall. The resident did not take medications that contributed to the falls. The investigation recommended that the resident be encouraged to call for assistance and to educate staff to anticipate the resident's needs. A 7/23/16 at 1:38 p.m. a note documented the resident was on incident follow-up for an unwitnessed fall with injury. The note stated the skin tear above the resident's right eyebrow was well approximated with no drainage. Nurse's notes dated 7/24/16 at 3:06 a.m. and 9:54 a.m. the resident had a fall with laceration above the left eyebrow. The resident returned from the hospital with wound care instructions related to the sutured laceration on the forehead. A 7/24/16 at 6:20 a.m. SBAR said the resident had a fall with laceration above the left eye and skin tear to the left forearm. The form said the resident appeared to lack safety awareness and impulse control. An order was obtained to send the resident to the emergency department for evaluation and treatment. A 7/24/16 hospital discharge instruction stated the resident was seen in the emergency department for a 4 cm laceration to the forehead. Instructions directed that sutures be removed in eight to ten days. A 7/24/16 at 5:35 p.m. fall investigation said the resident fell out of her chair on to the ground by the nurse's station. The reason for the fall was unknown. The resident was wearing socks and not shoes at the time of the fall. The recommendation was to place anti-roll breaks on the wheelchair and to educate staff to keep the halls free from clutter. A 7/25/16 nurse practitioner progress note did not reference the resident's trip to the emergency department on 7/24/16. The 7/27/16 nurse practitioner progress note showed the resident had bruising and a sutured laceration around the left orbital. A skin tear was noted to the left forearm. No recommendations or discussion of resident falls was present in the notes. An 8/1/16 at 6:10 a.m. SBAR said the resident had a witnessed fall while transferring from bed to wheelchair. The resident fell to her knees and caught her hand on the bed. The resident sustained [REDACTED]. A fall investigation was not provided for review for the 8/1/16 fall. The 8/2/16 nurse practitioner progress note said the left eye brow laceration was well approximated. The resident continued to have bruising to the left side of her face. No falls were documented since the 7/24/16 fall. The 8/4/16 nurse practitioner progress note said the resident had not had a fall since 7/24/16. The note stated the goal was to have no falls for five days while the resident completed therapy services. The 8/8/16 at 7:31 a.m. SBAR said the resident had an unwitnessed fall in her bedroom. The resident was found sitting on her buttocks next to the bed. Two skin tears to the right arm and one skin tear to the right hand were noted. The nurse completing the SBAR attributed the fall to a lack of safety awareness. An 8/8/16 at 7:45 a.m. nurse's note documented the resident had an unwitnessed fall in her room. The resident was found sitting on her bottom next to her bed. The resident sustained [REDACTED]. The wounds were cleaned and steri-strips placed. The 8/8/16 at 7:46 a.m. fall investigation recapitulated information the 8/8/16 at 7:45 SBAR. The activity at the time of the fall was unknown. The predisposing factor for fall was marked as history of falls, only. The resident was wearing socks and not shoes at the time of the fall. The recommendation was to place a fall mat next to the bed. (This intervention had been in place according to the 6/30/16 SBAR.) It was also recommended to keep the resident's bed in the lowest position. The 8/8/16 at 9:30 p.m. SBAR documented the resident had a fall that was witnessed by the resident's roommate. The resident was attempting to self-transfer from bed to the wheelchair when she sat on the floor and then lay down. The 8/8/16 at 9:30 p.m. fall investigation documented the resident had a witnessed fall in her room. The resident was in bed and was attempting to self-transfer. The section on predisposing diseases was not completed on the investigations. The resident was noted to have a history of falls and an unsteady gait. The resident was wearing socks at the time of the fall. No environmental factors were determined to contribute to the fall (e.g., spills, lighting). The investigation recommended placing a floor mat, ensuring the bed was in the low position, and offering non-skid socks. The facility was short one CNA on the hall where the resident lived on the day shift when the resident fell during the day shift on 7/24/16. The facility was short one CNA on the hall where the resident lived on the evening shift when the resident fell [DATE] during the evening shift. Additional Interview: The interim assistant director of nursing (IADON), staff development coordinator (SDC) and the regional clinical resource (RCR) were interviewed on 8/11/16 at 10:24 a.m. The interview revealed: -The floor nurse was responsible for starting the fall investigation. The interdisciplinary team would meet and then complete the form within 72 hours. -No additional investigation documentation was generated apart from the SBAR, nurse's notes and the investigation form. -The goal of the investigation was to select appropriate interventions. -The IADON said the fall was on 7/24/16 was a different from the other falls because it was a fall from the wheelchair in the hall. - The IADON, SDC, and RCR were unable to demonstrate where the facility evaluated aspects of each fall for commonality, like time of day, location, unmet needs like being wet/soiled or needing to toilet. -The resident had severe cognitive impairment and was unable to communicate what she was doing at the time of the falls. They agreed that recommendations like, remind to call for assistance, might not be realistic for the resident. -The resident experienced multiple falls with injury including transfer to the hospital for sutures of a laceration to the forehead. -Other than placing a fall mat no other steps were taken to minimize the residents potential injury from falls. B. Resident #9 Resident #9, age less than [AGE] years, was admitted to the facility on [DATE]. According to the 8/16 computerized physician's orders [REDACTED]. The 7/21/16 significant change minimum data set (MDS) assessment showed the resident had severe cognitive impairment as evidence by a brief interview for mental status score of zero of 15. The resident had verbal behaviors and wandering without exit seeking on one to three of the days of the MDS observation period. The resident required extensive assistance from two staff for bed mobility. The resident required extensive assistance from one staff for transfers, dressing, eating, toileting and personal hygiene. The resident required supervision and set-up for walking in his room. The resident required supervision from one staff to walk in the corridor and for locomotion off the unit. The resident was unsteady and only able to stabilize with human assistance when moving from seated to standing position; walking; turning around to face the opposite direction; moving on and off the toilet; and with surface-to-surface transfers. The resident was frequently incontinent of bowel and bladder. The resident had two or more falls without injury and two or more falls with injury since the prior MDS comprehensive assessment. The history of falls care plan, initiated on 4/2/16 and last updated on 8/1/16, said the resident was known to kneel or stretch out on the fall mat next to the bed. The goal was for the resident to reposition himself with or without staff assistance for his own comfort or safety. Pertinent approaches included: -Check frequently and assist with repositioning. -Encourage to call for assistance, participate in restorative program, and use wheelchair as tolerated. -Encourage staff to get meals as soon as he arrived in the dining room. -Ensure that resident had proper footwear in place when ambulating and transferring. -Encourage resident to wear gait belt. -Resident to wear safety helmet as tolerated to prevent injury. The potential/actual safety and/or fall risk care plan, initiated on 4/5/16 and last updated on 7/5/16, said the resident was at risk for falls related to poor safety awareness. The goal was to be free of major injury through the next review. The approaches were: -Encourage to call for assistance to use wheelchair when out of bed. -The resident had a history of [REDACTED]. -Ensure proper footwear for ambulation. -Follow fall prevention protocol. -Initiate safety checks as indicated. -Observe frequently during increased wandering to ensure safety. -Anti-rollback to wheelchair to prevent falls. Observations: The resident was observed on 8/5/16 at 11:04 a.m. The resident had a helmet on along with a gait belt. The resident walked from an unobserved location, up to the south nurse's station. The resident stated, I have a prairie dog in my diaper. Registered nurse (RN) #6 was observed to assist the resident to his room. The RN was heard to tell the resident to use the call light when he finished in the bathroom as she exited the room. The resident was observed on 8/5/16 at 11:09 a.m. The call light above the resident's door was turned on was blinking indicating the bathroom call light was on. After less than 60 seconds of call light illumination and sounding, the resident was observed to walk out of his room with his pants around his knees, calling for help. The resident was assisted back into his room by staff at 11:12 a.m. The resident was observed continuously on 8/5/16 at 3:31 p.m. until 8/5/16 at 3:50 p.m. The resident was observed to exit the wheelchair and bed on his own multiple times. Certified nurse aide (CNA) #10 was stationed near the resident. Each time the resident stood from his bed he was offered a walk, which he accepted once. Each time the resident attempted to exit the chair, the CNA offered to lay him down. The resident was put in bed twice during this time. Each time the resident was placed in bed the CNA asked the resident to use the call light for help. Within minutes of being put in bed, each time the resident emerged from bed under his own power while either calling for assistance and/or after turning on the call light. Multiple call lights on the south unit were observed to turn on during this time. CNA #4 was observed to respond to the call lights as CNA #10 monitored the resident. CNA said #10 she was basically providing one-to-one supervision of the resident because he fell so much. The resident was observed on 8/8/16 at 2:01 p.m. The resident stood from his wheelchair while in the hall. Licensed practical nurse (LPN) #4 was heard to direct the resident to sit back down. The resident complied. The resident was observed on 8/8/16 at 2:06 p.m. The resident stood from his wheelchair. LPN #4 directed him to sit back down and he complied. The resident was observed sleeping in his wheelchair in the hall by the nurse's station on 8/9/16 at 7:21 a.m. His helmet was on but the gait belt was not. The resident was observed to stand from his chair and be directed to sit back down by LPN #4 on 8/9/16 at 7:27 a.m. The resident was observed sitting in his wheelchair in the dining room on 8/9/16 at 8:01 a.m. His helmet was on but the gait belt was not on. The resident was observed sleeping in the hall by the nurse's station on 8/9/16 at 9:24 a.m. His helmet was in place but no gait belt was in place. The resident was observed in the hallway on 8/11/16 at 9:31 a.m. The resident was standing up from the wheelchair. The resident was asked to sit back down by CNA #15 and the resident complied. Staff Interviews: The assistant director of nursing (ADON) was interviewed on 8/5/16 at 10:52 a.m. The ADON said the resident had multiple falls with injuries and he was concerned that the facility could not keep the resident safe. According to the ADON the resident would stand up repeatedly, as often as 60 times a shift. The ADON said in his opinion, the resident needed one-to-one monitoring while awake but that was impossible because the facility was so short staffed. The ADON said he also felt the resident would benefit from an extensive walking program to help decrease the urge to stand all the time; however the ADON felt no staff was available to help meet that need. The ADON said the resident had cognitive impairment and lacked impulse control. CNA #1 was interviewed on 8/5/16 at 2:23 p.m. The CNA said the resident was very difficult to manage due to falls. The CNA said she felt the only way to keep him safe was to have a 1:1 program. The CNA said the resident fell that morning. The CNA expressed additional concern about the resident, noting that it was not uncommon for there to be one CNA for 24 residents on the evening shift on the hall where the resident resided. LPN # 4 was interviewed on 8/8/16 at 9:20 a.m. The LPN said the resident was very difficult to manage related to falls. The LPN said she worried the resident was going to be seriously hurt from a fall. The LPN said she had told leadership about her concerns for the resident and the response was to get the resident a helmet. The LPN said she once counted 90 times that she and others redirected the resident to sit back down during a shift. The LPN said she felt the resident required one to one supervision and a walking program that was more than just a few minutes a day, but staffing problems prevented that. The LPN expressed worry about the resident because there was only one CNA working the day shift on the resident's hall that day. CNA #21 was interviewed on 8/7/16 at 10:10 a.m. The CNA said the facility was short on staff, nurses and CNAs, regularly. The CNA reported the staff shortage impacted monitoring of fall residents. The CNA said the resident was known to fall a lot and required close supervision. Record Review: A review of the resident's clinical record revealed he had one fall risk assessment. It was completed on 3/19/16 and showed the resident to be high risk for falls with a score of 18. No additional fall risk assessments were completed. A 5/10/16 at 3:35 p.m. situation background assessment response (SBAR) showed the resident was lowered to the floor while walking in the hall during therapy. No fall investigation was conducted for the fall on 5/10/16. A 5/12/16 at 5:49 a.m. SBAR showed the resident rolled from bed and hit his head on the register causing a reddened area. The 5/12/16 fall investigation recommended ensuring safety devices were in place. A 5/23/16 at 9:52 a.m. SBAR showed the resident had an unwitnessed fall in the morning. The resident was found lying across the bathroom entrance. The fall was without injury. The 5/23/16 fall investigation recommended reminding the resident to ask for assistance and to use his wheelchair when out of bed. The resident was found by the bathroom. A 5/28/16 at 5:45 p.m. SBAR showed the resident had an unwitnessed fall in the hall by the activity room while ambulating alone. The resident was uninjured. No fall investigation was provided for review related to the fall on 5/28/16. A 6/18/16 at 10:49 a.m. SBAR showed the resident had an unwitnessed fall in his room that resulted in a 3 cm x 3 cm goose egg on the back of the head. The 6/18/16 fall investigation recommended encouraging the resident to ask for assistance and encouraging the resident to allow staff to walk with him. The resident was noted to be on a restorative program. A 7/2/16 at 6:59 p.m. nurse's note said the resident fell while standing up in the dining room. The resident wobbled then stepped back and fell over a chair. The resident hit the back of his head. The 7/2/16 fall investigation recommended use of proper footwear and educating the staff on safety awareness and anticipating the resident's needs. A 7/17/16 at 12:52 p.m. nurse's note stated the resident was found belly up on the floor at 11:00 p.m. The resident was had some pain to the left arm. He was assisted back to bed. No fall investigation was provided for the fall on 7/17/16. A 7/19/16 at 1:14 p.m. SBAR said the resident a witnessed fall while walking on the 100 hall without assistance. The resident lost balance falling forward toward the left side. The resident was sent to the hospital for x-ray related to right shoulder and face pain. The 7/19/16 in the first fall on 7/19/16 was reviewed. The fall investigation was for the first fall where the resident fell while walking in the hall. The recommendation was for the resident to have stand-by assist when walking and to have lab work ordered by the physician A 7/19/16 at 11:00 p.m. SBAR said the resident was found on his back by the bed. The resident said he just woke up there. The 7/20/16 fall investigation into the second fall on 7/19/16 recommended the resident have labs ordered related to a fluctuation in temperature. A 7/20/16 at 1:48 p.m. SBAR said the resident had an unwitnessed fall in his room with a laceration above the left eyebrow. The laceration was treated with normal saline. The 7/20/16 fall investigation for the 7/20/16 fall did not make recommendations for the resident's safety. The investigation noted the resident's lab work and x-ray came back negative. A 7/22/16 at 3:49 p.m. SBAR said the resident had two falls that day. The first fall was witnessed and in the dining room with no injuries. The second fall was unwitnessed in his room. A laceration was noted on above the left eye. The resident was sent to the hospital for an evaluation, sutures were not required. The 7/22/16 fall investigation recommended that staff provide the resident's meal right away when he arrived in the dining room. No recommendations were made related to the fall in his room. A 7/24/16 at 9:15 a.m. SBAR said the resident was found sitting on his buttocks on the floor in the doorway of his room. No injuries were identified. The 7/24/16 fall investigation had no recommendations. A 7/27/16 at 4:19 p.m. nurse's note said the resident had an unwitnessed fall in the hallway and sustained a deep laceration over the left eye. A 7/27/16 at 10:32 p.m. nurse's note said the resident returned from the hospital via ambulance at 7:30 p.m. The resident had received sutures to the left eyebrow. The 7/27/16 fall investigation recommended the resident be encouraged to wait for assistance and to call for help before transferring. A 7/29/16 at 9:11 a.m. SBAR said the resident tipped over backwards in his wheelchair during a witnessed fall. The resident did not hit his head. The 7/29/16 fall investigation recommended the resident have anti-tipper devices applied to his wheelchair. A review of the record related to falls and the fall investigations showed the resident did not receive resident-specific recommendations to abate falls as evidenced by recommendations to remind the resident to ask for assistance. The facility's failure to thoroughly and consistently investigate falls resulted in the resident continuing to experience falls including falls with injury that required trips to the hospital for sutures. Additional Interview: The interim assistant director of nursing (IADON), staff development coordinator (SDC) and the regional clinical resource (RCR) were interviewed on 8/11/16 at 10:24 a.m. The interview revealed: -The resident did have numerous falls at the facility, including falls with injury. -The resident was cognitively impaired, but they felt reminders were an acceptable recommendation for the resident to promote safety because the resident did call out for help a times and did turn on the call light at times. -The resident had not had a fall since 7/29/16. -A new intervention of using a helmet and a gait belt had been implemented. 2. WanderGuard Facility standards According to the Elopement Management Practice Guidelines, dated 8/2012, provided by the NHA, all residents upon admission will be assessed for elopement. For residents identified to be at risk for elopement, appropriate interventions are developed and implemented per the plan of care. The placement of the signaling device (WanderGuard) must be checked by nurse, and documented on Treatment Administration Record (TAR) every shift. Following an elopement/elopement attempt a plan of corrections, review of plan of care, and appropriate interventions will be initiated with each event. A. Resident #10 Resident Status Resident #10, age 98, was admitted on [DATE] and readmitted on [DATE]. According to the 8/16 computerized physician orders [REDACTED]. According to the 5/25/16 minimum data set (MDS)

Based on record review and staff interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practical physical well being for three ( #43, #23 and #53) of 32 sampled residents. Specifically: --The facility failed to honor a resident #43's advance directive to receive CPR (cardiopulmonary resuscitation) which resulted in death; --The facility failed to monitor the thrill and bruit for resident #53. --The facility failed to report blood sugars outside of parameters to the physician as ordered for resident #23. The findings include: A. Facility policy The facility's policy titled Death of a Resident last revised ,[DATE], read in pertinent part: Procedure -When the resident's spontaneous respiratory and circulation functions have ceased and the resident is Do Not Resuscitate status, or CPR attempts have been exhausted, an evaluation is made. This begins the process of pronouncing the death of the resident. -When a resident is found to be without heartbeat or respirations, the nurse on duty identifies the code status. If the resident is Full Code status, CPR is started and emergency 911 services are activated; If the resident is Do Not Resuscitate status, the following procedures are followed if permitted by the states laws. The nurse on duty contacts the attending physician/NP/PA and communicates the clinical information. Documentation -The nurse documents in the Nurse's notes: absence of audible/palpable blood pressure, absence of audible/palpable heartbeat, absence of respirations, absence of papillary response to light, general observations, such as degree of cyanosis or pallor, skin temperature (warm or cool), stiffness or pooling of blood in the extremities, and any other pertinent information leading to the determination of death. B. Resident Status Resident #43, age 59, was admitted initially 0n [DATE] and was readmitted into the facility on [DATE]. According to the face sheet, the [DIAGNOSES REDACTED]. According to the admission minimum data sets (MDS) assessment dated [DATE], the resident was alert and the hearing was adequate. Had a clear speech and vision was impaired but was able to read with corrective lenses. The resident's Brief interview for Mental Status (BIMS) score was 8 out of 15 which indicated the resident cognition was moderately impaired. The MDS assessment revealed the resident had some behaviors as evidenced by rejection of care that occurred 1 to 3 days. The resident required one to two physical assist with transfers and toileting. Resident expired [DATE]. Record Review The resident's closed medical record contained a MOST form (Medical Orders for Scope of Treatment) was signed by the resident and the physician in charge on [DATE]. The form indicated the resident would like to be resuscitated/CPR (cardiopulmonary resuscitation). The social service note dated [DATE] documented, .resident was admitted to facility [DATE]. He is full CPR and able to make his needs known . remains long term care and will attend [MEDICAL TREATMENT] 3 times weekly as able . The Physician's Orders dated [DATE] through [DATE] reviewed and revealed the resident's COR STATUS: FULL CODE (request CPR). Treatment Administration Record (TARs) TARs dated [DATE] - [DATE] reviewed and revealed the resident's Advanced Directive as Full code which indicated resident requested CPR. The [DATE] Nursing Admission Data Collection revealed the resident was alert and oriented to person, place and time. The resident's cognition was intact and the resident spoke English and was able to communicate his needs. The resident # 43 required oxygen. The resident was admitted with an AV Shunt to left upper arm and the bruit /thrill were present. According to the care conference note dated [DATE], the note was reviewed and revealed in pertinent part; the resident was a full CPR (cardiopulmonary resuscitation) and able to make his needs known. He attended [MEDICAL TREATMENT] three times a week, and there were no concerns at this time. The nurses note (NN ) dated [DATE] documented, Resident went to [MEDICAL TREATMENT]. VS ,[DATE], 98, 96.5, 16, SPO2 95% RA. Resident is in constant pain. Limited movement with his arms. [MEDICATION NAME] given at HS. No difficulty taking medications. Thrill and brut good. Call light within reach. Will continue to monitor. C. Failure to provide CPR as directed on the MOST form. The NN with the date of [DATE] documented, RCS (resident care specialist/CNA) gave resident fresh water at 0305 (3:00 a.m.) At 0315 (3:15 a.m.). RCS noticed resident was not breathing and was cool to the touch. This nurse and the nurse from 300 hall went to assess resident. Attempted to take his pulse found none. Called RN into room who assessed resident and listened for his heart beat she stated that we did not need to perform CPR since we did not see him take his last breath. Nurse from 300 hall asked if crash cart should be brought in and again RN stated no it was not needed because no one saw him take his last breath. Called 911 paramedics arrived at 0320 (3:20 a.m.) and ran a heart monitor which showed no activity. The police came in also and interviewed all staff. Called (name of primary physician) at 0325 he pronounced the death at 0315 (3:15 a.m.) . The RN #4 who was involved with the incident on [DATE] was interviewed via phone on [DATE] at approximately 4:00 p.m. The RN #4 stated while she was the only RN in the building at the time and was working on another station. The LPN # 5 in charge of the resident # 43 came over and stated that the resident was unresponsive. The RN stated that she had never met resident #43. The RN stated when she saw the resident he was cold and he had changed grey color and cold. She stated that the CNA #2 found him and stated he saw the resident within an hour but was not sure what time between 1:00 a.m. and 4:00 a.m. The CNA told her that he had just talked to the resident and had offered him some water. The RN stated that she listened for breath sounds and another LPN was on the phone with dispatch because the resident was a full code and blue. The RN said, the LPN #5 had told us she did not get permission to do CPR. However, CPR was not started. When the paramedics arrived they were informed the resident was found unresponsive and that CPR had not been started. The resident was hooked up on heart monitor but could not register the heartbeat and the fire department left. At the completion of the interview the RN stated that she did not initiate CPR as she was not aware that CPR needed to be started, as she and the other two nurses thought that 911 had to be called and instructed to start CPR. The RN stated that after the incident the director of nurses explained to the her and the other two nurses that CPR needed to be initiated immediately and that permission from 911 did not need to be obtained. The RN #4 stated that she did not receive any other training on CPR after that night. D. Staff Interviews: The director of nursing (DON) was interviewed on [DATE] at 11:20 a. m. The DON stated the resident's Cor Status should be on the MOST Form, face sheet and on the physician's orders. The DON stated, if a resident was Full Code (Yes to CPR) and the resident was found unresponsive, she would expect the nurse in charge to start CPR immediately. The licensed practical nurse (LPN) #3 was interviewed on [DATE] at 1: 00 p.m. The LPN #3 stated each resident had a signed and completed MOST form. The MOST form was their advanced directive on their wishes for CPR. The LPN #3 stated that the social worker and nursing updated the MOST Form for any changes. The LPN said, nurses usually go over the MOST Form with the family and the resident. The LPN stated, if a resident was found unresponsive, she would immediately start CPR. The LPN #3 stated if the resident was a DNR, I will still start CPR until I found out about the resident COR Status. The registered nurse (RN) #2 was interviewed on [DATE] at 1:05 p.m. The RN #2 stated that she was aware of residents COR status by referring to the MOST form and also the 24 hour report sheet. She showed a copy of the report form and in the far left column under all the resident's room numbers it lists FULL or DNR. If she were to find an unresponsive resident she would try to find out the COR status. If she did not know, she would start CPR and she would have a staff member go look for the MOST form. If the resident was DNR, she would stop the CPR. If the resident was known to be Full code or the MOST form indicated it, she would have staff call 911. She would have another nurse or staff obtain the crash cart. LPN #2 was interviewed on [DATE] at 1:55 p.m. The LPN stated the residents core status was found on the front inside flap of the chart and if she was not able to find it there, she would check on the electronic charting system. She said if she found a resident not breathing and no pulse, she would start CPR and send someone to call 911. The staff development coordinator (SDC) was interviewed on [DATE] at 4:40 p.m. The SDC stated that she did not have any in-service on CPR. The SDC stated that after the [DATE] incident she did remember an informal huddle discussing CPR. However, nothing formalized. The in-service tracking book was reviewed and found no in-service including CPR. The SDC stated that when licensed nurses were hired they were required to be CPR certified. The DON was interviewed on [DATE] at approximately 5:30 p.m. The DON stated that she was doing in-services with every licensed nurse to inform of the policy in regards to both CPR and if the resident was a DNR. 2. [MEDICAL TREATMENT] A. Facility Policy: The [MEDICAL TREATMENT], Care of Residents policy dated [DATE] documented .6. Upon return from [MEDICAL TREATMENT], the nurse will check for thrill and bruit twice during the first eight hours after the resident returned. The nurse will assess the condition of the access site for bleeding, redness, tenderness or swelling. If any of these conditions are noted, contact physician and document findings . B. Resident Status Resident #53, age 50, admitted to the facility on [DATE]. According to the computerized physician orders [DIAGNOSES REDACTED]. According to the [DATE] Minimum Data Set (MDS) the resident was independent in his decision making. He was independent in his bed mobility, transfers, dressing, toilet use and personal hygiene. C. Record Review Review of the physicians orders dated [DATE] documented the resident may go to [MEDICAL TREATMENT] on Monday, Wednesday and Friday. The orders documented: --Check [MEDICAL TREATMENT] site every morning and at bedtime; --Vital signs pre [MEDICAL TREATMENT] one time a day every Monday, Wednesday and Friday; and --Vital signs post [MEDICAL TREATMENT] one time a day every Monday, Wednesday and Friday. The CPO failed to show a physician order monitor the bruit and thrill. The care plan dated [DATE] identified the resident received [MEDICAL TREATMENT] related to [MEDICAL CONDITION], Approaches: After returning from [MEDICAL TREATMENT], check for thrill and bruit two times per shift on day resident returned (Monday, Wednesday and Friday). A review of the resident's Medication Administration Record [REDACTED]. The nursing progress notes from [DATE] to current revealed no documentation by a nurse monitoring the shunt for bruit and thrill. D. Interview --On [DATE] at 1:20 p.m. the director of nursing (DON) stated she did not know the bruit and thrill were not on the MAR's. She further stated the nursing staff should have been following the policy. She stated that a performance improvement plan on [DATE] and [MEDICAL TREATMENT] residents were one of them. --On [DATE] at 2:15 p.m., the DON stated the performance plan identified on [DATE] was to be completed/resolved by the end of this week She further stated that an order to add thrill and bruit to the MAR indicated [REDACTED]. 3. Blood sugars A. Facility Policy Review of the facility policy for Diabetic Management dated [DATE] documented .Assessment; Upon admission the interdisciplinary team evaluates the diabetic resident and implements a plan of care to ensure; orders are received and are accurate related to blood glucose monitoring and anti-diabetic agents. Blood glucose orders should include parameters to follow and when to notify the physician. Routine Care; Blood glucose measurements are taken per the physician order. Results outside of ordered parameters are communicated to the physician immediately . B. Resident Status Resident #23, age 44, was admitted to the facility on [DATE]. According to the ,[DATE] computerized physician orders [DIAGNOSES REDACTED]. According to the resident's annual MDS dated [DATE] the resident was independent in her decision making. She was independent in her bed mobility, transfers, toilet use, dressing and personal hygiene. C. Record Review According to the ,[DATE] CPO the resident had an order for [REDACTED]. --180 - 199 =3 units --200 - 249 = 5 units --250 - 299 = 9 units -- 300 - 349 = 12 units --350 - 400 = 14 units --401 - 500 = 15 units The ,[DATE] CPO also had orders for [MEDICATION NAME] Flex Pen injector 20 units to be administered subcutaneous in the morning with the associated [DIAGNOSES REDACTED]. Blood sugar check were to be checked before meals and at bedtime related to diabetes type II. The physician order ([DATE]) further documented to notify physician if blood sugar was less than100 or greater than 400. Review of the resident ' s blood sugars revealed the resident ' s blood sugars results were out of the parameters and the physician was not notified as ordered. The results were as follows: --[DATE] 458 at 8:00 p.m.; --[DATE] 61 at 11:00 a.m.; --[DATE] 402 at 5:00 p.m.; --[DATE] 500 at 8:00 p.m.; --[DATE] was 600 at 5:00 p.m.; and --[DATE] was 468 at 7:00 a.m. D. Interview The DON was interviewed on [DATE] 5:24 p.m. The DON stated that she would clarify the blood sugar reporting parameters with the physician. The DON was interviewed a second time on [DATE] at 9:23 a.m. The DON stated she started an in-service to educate staff on calling the physician and documentation for blood sugars that were out of the parameters ordered by the physician. The DON also stated the physician was contacted and did not want the parameters changed.

Based on record review and staff interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (#2) of seven sample residents. Specifically, the facility failed to clarify and adequately address all behaviors and related symptoms. The findings include: a. Resident Status Resident #2 Resident #2 was a [AGE] year old admitted to the facility on [DATE] and was discovered by the local fire department and admitted to the hospital on [DATE] after wandering away from the facility. According to his face sheet the resident's [DIAGNOSES REDACTED]. The resident had malignant neoplasm of the prostate ([MEDICAL CONDITION]) noted on his face sheet; however, a lab and physician's statement dated [DATE] noted the resident did not have [MEDICAL CONDITION]. The resident was admitted to the facility receiving hospice services for the main [DIAGNOSES REDACTED]. According to the most recent minimum data set (MDS) assessment dated [DATE], the resident was noted as cognitively intact, with no behaviors of wandering. He was noted as having one instance of a behavior of rejecting care during the observation period. He was noted as cognitively intact scoring 15 out of 15 on his brief interview for mental status (BIMS). His nutritional therapy review dated [DATE] noted he had dysphagia (difficulty swallowing). An MDS monitoring tool indicated the resident was observed from [DATE]-[DATE] and had one verbal symptom directed towards others on [DATE], but no other symptoms, including wandering. The admission physician's orders [REDACTED]. (Roxinol) (pain medication) ,[DATE] mg every two hours prn for pain. The March computerized physician's orders [REDACTED]. A long term care eligibility assessment conducted on [DATE] and provided to the facility prior to the resident's admission, revealed the resident exhibited inappropriate behaviors that put himself, or others at risk. He needed more than verbal redirection to interrupt inappropriate behaviors. The evaluation documented the resident had cognitive impairment, impaired judgment, medication management, memory impairment, short term memory loss, and self neglect. He was noted as having a mini mental exam and scoring 17 with significant impairment in orientation to time and circumstances. The evaluation summarized that the resident had a substantial history of behavior concerns and had a significant cognitive decline. b. Record review A facility admission physician progress notes [REDACTED]. The physician noted,"Patient's judgment and insight are grossly impaired." A subsequent physician progress notes [REDACTED]. The same psychiatric issues were noted as in the [DATE] note, as well as the statement that mild dementia was present. A final physician's progress note was documented on [DATE] with no new issues noted. A [DATE] psychiatric evaluation report indicated the resident was reporting constant pain of moderate intensity, and had [MEDICAL CONDITION], significant anxiety, and difficulty sleeping. As a result, the psychiatrist revealed a plan to discontinue the resident's use of Trazadone and [MEDICATION NAME], begin [MEDICATION NAME] (anti psychotic) to control the resident's anxiety, [MEDICAL CONDITION] and difficulty sleeping, and switch from [MEDICATION NAME] to [MEDICATION NAME] (antidepressant) to address the resident's depression. The psychiatric evaluation was ordered on [DATE] and performed the same day on [DATE]; however, the facility did not receive the report until it was later requested on [DATE] (ten days after the resident's death). A telephone order dated [DATE] noted the resident was "okay for a psych eval (evaluation)." There was no telephone order to discontinue or change the [MEDICATION NAME] to a tablet form. Care plan review revealed the resident had a care plan for the use of psychoactive medications including [MEDICATION NAME], Trazadone, [MEDICATION NAME], and [MEDICATION NAME]. The care plan documented the medications were for anxiety and depression. Approaches were to review the medication, observe for side effects and report to the physician and hospice if side effects were observed. A care plan initiated [DATE] was noted for depression. Approaches included encouraging the resident and staff to be alert to events or situations that precipitated episodes of restlessness or anxiety, and psych services as able. There was no care plan to address the resident's anxiety or behaviors specifically. Review of the Nursing notes revealed: -Review of nursing notes from [DATE] (admission note) to discharge ([DATE]) revealed the resident did not have noted anxiety until [DATE]. The note written at 11:00 p.m. detailed, "Very anxious-pacing the hallway, placing phone calls, expressing concerns about money, "I am broke." Overheard on the phone trying to sell a gun. "All I have is a dollar." Medicated x's 2 (twice) with [MEDICATION NAME] (anti-anxiety medication) slightly effective." -On [DATE] at 1:00 a.m. a note read,"Resident is increasing in needs and requests. Supportive care given." -On [DATE] at 10:00 p.m., a nurse documented, "Pt (patient) anxious and confused. Pacing from his room to med cart repeatedly. [MEDICATION NAME] 1 ml given SL (sublingually) at 1800 (6:00 p.m.) followed by routine meds. Pt promptly had emesis (vomiting) of copious, thick, white mucus. At 1900 (7:00 p.m.) Roxinol (pain medication) 1 ml given SL followed again by emesis of mucus. Pt increased anxiety at 2130 (9:30 p.m.). Call placed to hospice nurse, (nurse's name) who suggested giving [MEDICATION NAME] 2 ml SL at 2200 (10:00 p.m.) which has been given at this time. Next shift to continue monitor." -On [DATE] a note was written in past tense spanning form 1:00 a.m. to 4:00 a.m. The following was documented: "0100 (1:00 a.m.) Resident noted wandering near room. Cont(inue) to be confused. Snack offered. Declined. Taking fluids fair. (nurse signature) 0300 (3:00 a.m.) Resident noted to not be in room. Was in recliner at 0205 (2:05 a.m.) and 0230 (2:30 a.m.) when RCS (resident care specialist) and this writer did room checks. Upon noting resident not in room check was done to all rooms in hall. Nurses and RCS notified on north. All staff started room to room search continue check x 20 min. Then notified DON (director of nursing) while continued to check around building. RCS also drove vehicle around neighborhood. 0330 (3:30 a.m.) Notified the local police dept (department) and resident's sister of situation. All staff remain looking in building and around nursing home grounds. DON stated would be coming to assist with looking. Cont.(Continued on next page). 0400 (4:00 a.m.) RCS who was looking in neighborhood stopped at (local hospital). To check resident had been located (approximately) 2 blocks away from facility and was taken to (hospital). Nurse (name) requested face sheet and paperwork send to ER (emergency room ). Advance directives and med list also faxed to hospital. 0400 (4:00 a.m.) Resident sister and (local police) made aware of resident's location. DON notified." Review of the hospice notes (not included in the resident's closed record but obtained on [DATE] after requested) revealed the following: -On [DATE] the resident complained of chest pain. The facility was instructed to administer Roxinol and [MEDICATION NAME] and call for continued pain, problems or questions. -On [DATE] the hospice social worker documented the resident was confused asking, "Is this where I am staying?" -On [DATE] the hospice social worker documented the resident asked again if he was staying at the facility. The resident reported to her that he was worn out from a short walk down the hall to the nurse's station. -On [DATE] the hospice chaplain documented the resident was having increased anxiety in the afternoon. The previous day he was reported as getting into a "shouting match" with his sister in the front lobby (received verbal report from social services manager (SSM)). -On [DATE] the hospice social worker documented a meeting with the SSM, team registered nurse (RN), and team companion. It was noted the resident was not sleeping well at night, and was having increased agitation in the afternoons, some involving his sister, but also some agitated behaviors were being demonstrated other times of the day. The SSM reported they had requested a psych evaluation that day for questionable competency per the sister's request. -On [DATE] nursing triage noted the resident's sister called hospice wanting to speak with the team regarding her concerns with her brother's condition. -On [DATE] at 4:00 p.m., the hospice nurse documented that she returned the sister's call and the sister reported the resident had a lot of increased agitation. She stated that at her visit he was yelling and she said he was even aggressive to the nurses at the station. She reported the psychologist had assessed the resident but she was asking for collaboration with hospice and the facility to see what could be done for the resident. The hospice nurse commented in her note that she had spoken to the facility SSM and it was reported that the resident became agitated when the sister visited, but he called down after the sister left. The nurse documented that she validated to the sister that a visit would be made to coordinate with the facility to see if medications could be looked at to help with the resident's agitation. -On [DATE] at 4:40 p.m., it was documented the resident called and requested contact from the team social worker. The call was forwarded to the team: no response was noted. -On [DATE] at 9:15 p.m., the hospice nurse documented that she spoke to the nurse (RN #2) about the patient and suggested to give [MEDICATION NAME] 2 mg for nausea, vomiting, and increased agitation. The facility nurse stated the patient was spitting up mucus after she have him his scheduled mediations. The patient was also reported as being agitated and pacing back and forth to the nursing station. Hospice offered a nursing visit to the facility; however, RN #2 declined the visit. The facility nurse indicated she would administer the [MEDICATION NAME] and call the hospice nurse back if it was not effective. -On [DATE] at 9:35 p.m., hospice noted that the facility nurse (RN #2) called back and stated they only had the injectable [MEDICATION NAME], but they could get the liquid in about two hours. Hospice suggested to give the resident 2 mg of [MEDICATION NAME] at 10:00 p.m., and reorder the liquid [MEDICATION NAME], and administer it upon delivery. The facility nurse stated she would call back if she needed further support. -There were no further hospice notes. c. Failure to clarify and adequately address all behaviors and related symptoms The facility failed to clarify the presence of new and increased signs of anxiety, and [MEDICAL CONDITION]. The facility failed to develop and implement approaches to support the resident when anxiety/agitation and/or [MEDICAL CONDITION] were present. The facility failed to maintain tracking of physical aggression and verbal outbursts when the resident was care planned for psychoactive medications and depression with the approaches to monitor changes in behavior including restlessness and anxiety. Record Review: The initial social services evaluation dated [DATE] noted no concerns, and did not include information pertaining to resident behavioral symptoms. Review of the social service progress notes from admission to discharge did not reveal any concerns of increased agitation, outbursts, aggression or anxiety. Only after the resident eloped on [DATE] and was transferred to another facility, did the SSM note at 11:00 a.m., "SS was made aware that (resident) was at (hospital) and then was going to go to (inpatient hospice facility) due to increase in agitation and restlessness. There are no concerns at this time. Sister remains supportive and involved in care. SS will call to monitor and follow up as needed." Further review of physician, nursing and social services assessments and progress notes completed between [DATE] and [DATE], did not reveal additional information pertaining to resident behaviors and did not include or describe the presence of [MEDICAL CONDITION], aggression or increased confusion. Behavior Tracking Behavior tracking was not completed ,[DATE] and ,[DATE] for verbal outbursts, pacing, or aggression. Disruptive/yelling out and striking out behaviors were not monitored. Behaviors specifically noted for prn [MEDICATION NAME], and Trazadone were not noted or monitored. Medication administration records (MARs) -Trazadone was noted as refused from admission to the 17th of February, accepted on ,[DATE], refused on the 19th and 20th, accepted on ,[DATE], refused on ,[DATE]-,[DATE], accepted on ,[DATE]-,[DATE] and ,[DATE] and ,[DATE]. Refusals were only documented on the back of the MAR indicated [REDACTED]. -Hours of sleep were noted as monitored from [DATE] through [DATE]. From [DATE] to [DATE], the resident was only noted as sleeping a maximum of 2 hours in 24 hours. He was noted as sleeping a total of 15 hours from [DATE]-[DATE]; however, there was no documented notification to the physician or hospice that the resident was refusing his Trazadone or sleeping so little. -Review of the MARs revealed the resident was never given a dose of his prn [MEDICATION NAME] tab or liquid during his stay at the facility. -Review of the MARs revealed the resident was given prn [MEDICATION NAME] 13 times from admission to discharge ([DATE], [DATE] at 2:45 a.m. and 8:30 p.m., [DATE], [DATE] at 4:00 p.m. and 8:00 p.m., [DATE] at 2:30 a.m. and 2:15 p.m., [DATE], [DATE] at 4:00 p.m. and 8:00 p.m., [DATE] at 2:15 p.m. and 7:30 p.m., and [DATE] at 1:30 a.m. and 10:00 p.m.). The effectiveness was only noted four times (twice on [DATE], once on [DATE] and once on [DATE] at 3:00 a.m. when it was noted to be helpful with restlessness). d. Interviews -An interview was attempted with the nurse present and on duty the night the resident had eloped. The facility was able to identify the nurse (RN #2) from the signature on the notes from [DATE]-[DATE]. The RN was not on duty during any of the onsite visits; however, a call was made to her home and a voicemail requesting an interview was left. The nurse did not return the call and subsequent attempts to contact the nurse were unsuccessful. -An interview with the DON, nursing home administrator (NHA) and clinical nurse consultant (CNC) on [DATE] at 9:05 a.m. regarding the resident's elopement revealed they had no indication that he was an elopement risk and he demonstrated no behaviors. -On [DATE] at 8:37 p.m., a nurse who worked with the resident in the evening shift for the last two weeks of his stay (RN #1) was called. She had been on shift from 2:00 p.m. through 10:00 p.m. on [DATE]. The nurse stated that the resident was always anxious and confused. On [DATE] the facility had called the hospice on call nurse and ordered a medication to assist the resident (liquid [MEDICATION NAME]), but they did not administer the medication as it was not available and had to be ordered from a pharmacy. She stated that the resident was a smoker and it was important to the resident to smoke. She stated they did not initiate any additional interventions for the resident's increased agitation and anxiety as they were waiting for his medication to be delivered. The RN on the night shift (RN #2) was aware of the situation and trying to help out by ordering the medication. She worked the next day and found out that the resident had eloped. She discovered they had never administered the liquid [MEDICATION NAME] because it did not arrive until 6:00 a.m. on [DATE]. She stated they did not have an active order for liquid [MEDICATION NAME] for the resident before that night. -On [DATE] at 11:44 p.m., CNA #2, present at the facility on [DATE] during the night shift, was interviewed. She stated that she remembered resident #2 walking back and forth from the desk to his room. CNA #4 had notified her that she had not seen the resident for an hour and that was when they started looking for the resident. Once they confirmed the resident was not in the facility, they started looking in the community, but she had stayed at the facility to attend to the residents. She stated she did not hear an alarm, but alarms would go off all the time because they had a wander guard system. -On [DATE] at 12:16 a.m., CNA #4 was interviewed. She stated that she was the only CNA on the hall that night which was normal. On [DATE] she remembered the resident was in his recliner watching television when she came on shift at 10:00 p.m. At 11:00 p.m. he wanted a shot gun to go hunting because he was watching a hunting show on television. Before midnight she saw him in his chair when they did rounds. At 2:00 a.m. when they did second rounds, he was still there. She stated the resident was not a smoker, but they thought that he had left through the smoking door. She stated the resident had not been seen for a maximum of 45 minutes when they noted that he was gone. -On [DATE] at 5:22 p.m., the DON was interviewed regarding [MEDICATION NAME] for resident #2. She stated the nurse in the evening on [DATE] had said the resident had increased mucus and was even coughing up his liquid [MEDICATION NAME]. The hospice nurse was called and recommended liquid [MEDICATION NAME], which they ordered STAT from the pharmacy. It did not arrive until 6:00 a.m. the next morning so the resident did not receive the medication. She stated the nurse did not document this but had reported it to the DON. -On [DATE] at 4:58 p.m., the SSM was interviewed. She stated the resident had shown increased anxiety in the evenings and he would perseverate on issues. The resident would do things like call his sister 25 times in one evening. She stated that he was easily redirected. She stated that hospice was aware of his increased anxiety and was "on top of it." Based on the resident's anxiety, she was aware that he was angry with his sister. She had met with the hospice on [DATE] and they had decided to request a psych evaluation. She stated that usually after the order was written, they would have the psychiatrist come to the facility and he would give recommendations to the nursing staff which they would relay to the physician. She stated that she would be responsible for updating care plans to reflect behavioral interventions and behavioral medications. -On [DATE] at 9:30 a.m., an interview with the psychiatrist (that completed the psychiatric evaluation) revealed it usually takes five to seven days to get the report out; however, he stated, there had been no request from the facility for the report until [DATE], ten days after the resident had expired. -An interview with the local pharmacy on [DATE] at 2:10 p.m. revealed the facility had received 120 cc of liquid [MEDICATION NAME] on [DATE] from the original order dated [DATE]. On [DATE] the pharmacy had an electronic order submitted from the facility at 9:00 p.m., then an additional order was called in at 9:45 p.m. -An interview with the resident's sister on [DATE] at 2:00 p.m. revealed she had been concerned that the facility and hospice were not addressing her brother's increased agitation and behavioral issues. She stated he was having a very hard time and was having a major mental decline. She stated he would yell and become aggressive, but the facility did not seem to do anything. She had reported that it was very important for him to take his Trazadone in the past. She had not been informed that he was consistently not taking his Trazadone. The night that he eloped, she had called the facility and expressed her concerns.

Based on observations, record reviews, and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for residents, including one of seven sample residents (#2). Specifically, the facility failed to: -Ensure appropriate interventions were implemented and followed to prevent an actual elopement for resident #2 and potential elopement for other residents of the facility. The facility did not react to a gate alarm sounding, resulting in resident #2 not being discovered as missing for a period of time in the cold, contributing to his death three days later. The findings include: Record review and interview revealed resident #2, who was agitated, ambulatory, and who was deemed to have non Alzheimer's dementia, anxiety, and impaired decision making skills was seen ambulating up and down the hall that exited to the smoking area on [DATE] during the evening and night shift. The resident was not medicated as ordered, or further monitored above regular rounds observations. He was noted as, "wandering near room," at 1:00 a.m. He then exited the facility at approximately 2:00 a.m. on [DATE] via the side door to the smoking area, then out the alarmed wooden gate. The side door was equipped with an elopement alarm (Wander guard), which would sound if a resident wearing a special device exited, and the wooden gate was armed with an alarm, which sounded until the gate was in the closed and latched position. No staff member noted hearing the gate alarm sound. Once the wooden gate was exited, the gate would have latched and the resident would not be able to regain access to the facility without staff inside letting him in. An immediate search was not conducted outside to ensure a resident had not eloped. The resident was discovered missing at approximately 3:00 a.m. on [DATE], after a routine "bed check." Although the resident was seen ambulating near the side door and the gate alarm sounded, a resident head count was not done, and after the resident was discovered missing, the interior of the facility was searched initially by facility staff. When the resident was not found after 20 minutes from the time he was noted missing, the search was expanded outside. The local fire department had received an emergency call at 2:31 a.m. that a male was knocking on a window at the back of an apartment building. They arrived at the scene at 2:41 a.m. and found resident #2 frozen to the ground on the ice, suffering from an altered mental status and hypothermia. Once the resident was noted as missing at 3:00 a.m. after 20 minutes of searching the facility, a staff member noted as the certified nurse aid (CNA) #4, assigned to care for resident #2 that night, was sent out to search the community in her car. At approximately 4:00 a.m., the CNA went to the local emergency room where she identified resident #2. The resident had not been determined as an elopement risk; however, the facility took no action or increased vigilance when the resident was seen wandering with increased agitation. The facility used the gate alarm as a precaution to prevent residents from leaving undetected, but failed to respond to the alarm when it sounded. Once found, the resident did not regain consciousness, was admitted to an inpatient hospice, and died on [DATE]. The county coroner ruled the resident's death an accident. 2. Facility policy The facility policy titled 'Resident Elopement' dated ,[DATE], read in pertinent part: "Wander/Elopement Alarm Activation 1. If an employee hears a door alarm, he or she should; a. Immediately go to the site off the alarm; b. If a resident is observed attempting to elope, follow the steps outlined below for Attempted Elopement; c. If no resident is found to be exiting the facility, the employee should i. Exit the facility, walk around the building, and ensure that the resident has not already exited the facility; important: Be sure to search locked rooms and in stairwells. ii. Notify the Director of Nursing and the Administrator immediately; and iii. Complete a head count to ensure that all residents are accounted for. Missing Resident 1. Should an employee discover that a resident is missing from the facility, he or she should: a. Determine if the resident is out on an authorized leave or pass. If not; b. Notify the Administrator and the Director of Nursing services; c. Make a thorough search of the building(s) and premises. If the resident is not located; 2. The Administrator, Director of Nursing, or a designee will; a. Notify the resident's legal representative; b. Notify the attending physician; c. Notify the Sheriff and Police Department; d. Notify the state agency, if required; e. If necessary, notify volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.); f. Provide search teams with resident identifying information; and g. Make an extensive search of the surrounding area." 3. Resident #2 Resident #2 was a [AGE] year old admitted to the facility on [DATE]. He was discovered by the local fire department after wandering away from the facility. He was admitted to the hospital on [DATE]. According to his face sheet the resident's [DIAGNOSES REDACTED]. The resident had malignant neoplasm of the prostate ([DIAGNOSES REDACTED]) noted on his face sheet; however, a lab and physician's statement dated [DATE], noted the resident did not have [DIAGNOSES REDACTED]. According to the most recent minimum data set (MDS) assessment dated [DATE] the resident was noted as cognitively intact, with no behaviors of wandering. Review of the resident care plan revealed there was no indication of interventions for increased confusion or wandering. a. Record review Nursing notes: -Review of nursing notes from [DATE] (admission note) to discharge ([DATE]) revealed the resident did not have noted anxiety until [DATE]. The note written at 11:00 p.m. detailed, "Very anxious- pacing the hallway, placing phone calls, expressing concerns about money, "I am broke." Overheard on the phone trying to sell a gun. "All I have is a dollar". Medicated x's 2 (twice) with Ativan (anti-anxiety medication) slightly effective." -On [DATE] at 1:00 a.m., a note read, "Resident is increasing in needs and requests. Supportive care given." -On [DATE] at 10:00 p.m., a nurse documented, "Pt (patient) anxious and confused. Pacing from his room to med cart repeatedly. Ativan 1 ml given SL (sublingually) at 1800 (6:00 p.m.) followed by routine meds. Pt promptly had emesis (vomiting) of copious, thick, white mucus. At 1900 (7:00 p.m.) Roxinol (pain medication) 1 ml given SL followed again by emesis of mucus. Pt increased anxiety at 2130 (9:30 p.m.). Call placed to hospice nurse, (nurse's name) who suggested giving Ativan 2 ml SL at 2200 (10:00 p.m.) which has been given at this time. Next shift to continue monitor." -On [DATE] a note was written in past tense spanning form 1:00 a.m. to 4:00 a.m. The following was documented: "0100 (1:00 a.m.) Resident noted wandering near room. Cont(inue) to be confused. Snack offered. Declined. Taking fluids fair. (nurse signature) 0300 (3:00 a.m.) Resident noted to not be in room. Was in recliner at 0205 (2:05 a.m.) and 0230 (2:30 a.m.) when RCS (resident care specialist) and this writer did room checks. Upon noting resident not in room check was done to all rooms in hall. Nurses and RCS notified on north. All staff started room to room search continue check x 20 min. Then notified DON (director of nursing) while continued to check around building. RCS also drove vehicle around neighborhood. 0330 (3:30 a.m.) Notified local police dept (department) and resident's sister of situation. All staff remain looking in building and around nursing home grounds. DON stated would be coming to assist with looking. Cont..(Continued on next page). 0400 (4:00 a.m.) RCS who was looking in neighborhood stopped at (local hospital). To check resident had been located (approximately) 2 blocks away from facility and was taken to (hospital). Nurse (name) requested face sheet and paperwork send to ER (emergency room ). Advance directives and med list also faxed to hospital. 0400 (4:00 a.m.) Resident sister and (local police) made aware of resident's location. DON notified." Hospice notes obtained on [DATE] and not available in the resident chart initially revealed: -On [DATE] the chaplain noted the resident was concerned about the smokers' club. -A care conference was conducted with the facility team, the hospice nurse and social worker to discuss resident needs. Social Services notes revealed: -On [DATE] the facility team met for a care conference. There were no concerns noted at that time. -On [DATE] the resident had declined a room change. -On [DATE] the resident had eloped and was going to an inpatient hospice. -There were no social service notes indicating the resident was having increased behaviors, needs, wandering, or distress. There was also no reference to a psychological evaluation obtained at the facility on [DATE]. Review of the local fire department medical incident report revealed the fire department had received a call at 2:31 a.m. on [DATE], which indicated a male was knocking on the window of an apartment building and was then lying on the ground: he was shaking. The caller did not know who it was and said he looked elderly. Upon arrival at 2:41 a.m., they found a man lying on the ice. The man was noted as being very cold, pale and unable to speak. The resident was hypothermic and had an altered mental status. Hospital records dated [DATE] at 2:59 a.m. noted the resident was admitted with hypothermia and altered mental status. The patient was found frozen to the ground with an unknown down time, was combative and moaning at arrival and had a core temp of 31 C/ 87.8 F (regular body temperature is 98.6 F and 37 C). b. Observations On [DATE] at 2:00 p.m., the smoking area was observed. Resident #2's former room was located down the hall from the egress. The door had a crash bar and wander guard attached. When the door was opened, it did not alarm or sound. The gate was checked and it did not have any alarm or alert device attached. The gate was easily opened from the inside, making no sound. On [DATE] at 11:00 p.m., the outside of the wooden gated smoking area was observed. The gate could not be opened from the outside, and was high and could not be scaled. There was no doorbell or notification system to alert the facility of needing assistance on the outside of the gate. On [DATE] at 11:56 p.m., a resident came out of room #103 and ambulated to the smoking area egress. He started asking when it was time for a cigarette and began standing at the door. CNA #4 came out of another resident's room and asked the resident to move away from the door because he would set the alarm off. c. Interviews -An interview was attempted with the nurse present and on duty the night the resident had eloped. The facility was able to identify the nurse (RN #2) form the signature on the notes from [DATE]-[DATE]. The RN was not on duty during any of the onsite visits; however, a call was made to her home and a voicemail requesting an interview was left. The nurse did not return the call and subsequent attempts to contact the nurse were unsuccessful. -An interview with the DON, nursing home administrator (NHA) and clinical nurse consultant (CNC) on [DATE] at 9:05 a.m. regarding the resident's elopement revealed they had created a timeline, which included that the resident was seen at 1:00 a.m., 2:05 a.m., and 2:30 a.m. At 3:00 a.m. the resident was noted as not in his room and room checks were initiated for 20 minutes, then they notified the DON and sent CNA #4 out to search the neighborhood. At 3:30 a.m. the police and sister were notified of the resident being missing, and at 4:00 a.m., CNA #4 stopped at the ER and found the resident. The resident was admitted to the ER at 2:57 a.m. The resident was found about two blocks away, and he had not been determined as an elopement risk. They determined in their investigation that the resident had left through the smoking gate through the 100 hall. The resident did not have a wander guard so the door would not alarm. The gate did have an alarming system that alarmed while it was opened but would stop once it was closed again. Since then they had installed a door timer that would make the door sound is residents used it to egress after 11:00 p.m. They were unsure, but thought it possible to get back through the gate after one had exited. The night of the elopement no one had heard the gate alarm: when they tested it, it only alarmed for a matter of seconds. The NHA stated that per the hospice report, the cause of death was [DIAGNOSES REDACTED] and the resident was not hypothermic. -On [DATE] at 8:37 p.m., RN #1 was called. She had been on shift from 2:00 p.m. through 10:00 p.m. on [DATE]. The nurse stated the resident was always anxious and confused. The night in question the resident had been medicated but had vomited and she suspected the resident did not retain much of the medication he was given. They had called the hospice and ordered a medication to assist the resident, but they did not administer the medication as it was not available and had to be ordered from a pharmacy. She stated the resident was a smoker and it was important to the resident to smoke. She stated they did not initiate any additional interventions for the resident as they were waiting for his medication to be delivered. The RN on the night shift (RN #2) was aware of the situation and trying to help out by ordering the medication. -On [DATE] at 11:44 p.m., CNA #2, present at the facility on [DATE] during the night shift, was interviewed. She stated she remembered resident #2 walking back and forth from the desk to his room. CNA #4 had notified her that she had not seen the resident for an hour and that was when they started looking for the resident. Once they confirmed the resident was not in the facility, they started looking in the community, but she had stayed at the facility to attend to the residents. She stated she did not hear an alarm, but alarms would go off all the time because they had a wander guard system. -On [DATE] at 12:16 a.m., CNA #4 was interviewed. She stated she was the only CNA on the hall that night which was normal. On the night in question, she remembered the resident was in his recliner watching television when she came on shift at 10:00 p.m. At 11:00 p.m. he wanted a shot gun to go hunting because he was watching a hunting show on television. Before midnight she saw him in his chair when they did rounds. At 2:00 a.m. when they did second rounds he was still there. She stated the resident was not a smoker, but they thought he had left through the smoking door. When they were investigating the door, she and another CNA had tested the alarm and it did not sound when she opened the door, but did sound when the second CNA tested the door. She stated the resident had not been seen for a maximum of 45 minutes when they noted that he was gone. She stated the nurse and CNAs did not do rounds together, and that night the nurse had not done rounds with her. When the resident was missing, they checked all of the rooms and then she went out and drove around. She received a call asking her to go to the hospital, where she found the resident as a John Doe in the emergency room .

Based on record review and interview, the facility failed to have evidence an incident of alleged sexual abuse involving one of 37 sample residents (#96) was thoroughly investigated and that steps were taken to protect resident #96 during the investigation. Specifically: Resident #96 reported on 5/9/13 that she had been sexually abused in mid-April by a night male licensed practical nurse (LPN). Interview with the resident revealed she had seen the LPN since the incident, was fearful of him, and blocked her door at night with a trashcan "in case he comes in." -The facility failed to have evidence the resident's allegation was thoroughly investigated after it was reported 5/9/13. -The facility failed to protect the resident during the investigation. The facility concluded its investigation of the resident's allegation 5/13/13. The LPN worked 5/9/13, 5/13/13 and 5/14/13. He was suspended 5/15/13. The findings include: I. Facility Expectations A. Abuse and Neglect Prohibition The facility's abuse and neglect prohibition policy last revised in June 2012 revealed in pertinent part: "--Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property. --Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. --Residents, families, and staff will be able to report concerns, incidents, and concerns without fear of retribution. --Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect, injuries of unknown origin, or misappropriation of resident property is at risk for occurring. --The facility will conduct an investigation of any alleged abuse/neglect, injuries of unknown origin, or misappropriation of properly in accordance with state law. Any employee alleged to be involved in an instance of abuse and/or neglect will be suspended immediately and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated. --The facility will protect residents from harm during the investigation." B. General Investigation Guidelines The facility's general investigation guidelines policy, last revised in June 2012, documented: "Investigations should be conducted immediately after an incident, event, or allegation of improper conduct or non-compliance is reported. Investigations should be thorough, accurate, and fact based. Investigation findings should be well documented, concise, and understandable ..." II. Allegation of Abuse A. A complaint was filed with the Health Department on 5/13/13 regarding an allegation of sexual abuse involving resident #96 on 5/9/13 by a male LPN. The complaint investigation was conducted 5/15/13 - 5/16/13. B. Resident #96 According to the face sheet, resident #96 was a [AGE] year-old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident resided on the 300 hall of the facility which was adjacent to the 400 hall. The Minimum Data Set (MDS), dated [DATE], showed the resident was cognitively intact, scoring 13 out of 15 possible points on the brief interview of mental status (BIMS). She had exhibited verbal behavior toward others x 1, and inattention/disorganized thinking that comes and goes. She was not coded with [MEDICAL CONDITIONS] or hallucinations. The resident required extensive assistance with bed mobility and toilet use. Review of Pressure Ulcer Records revealed the resident had a Stage IV pressure ulcer on her sacrum, identified on admission. There were orders for dressing changes daily and as needed (PRN). Care plan review revealed plans for activities of daily living, pressure ulcer, and behavior. (1) The care plan for "behavior" was dated 10/26/12. It read the resident had "possible dementia", depression, [MEDICAL CONDITION] and was taking [MEDICATION NAME] (anticonvulsant) and [MEDICATION NAME] (antipsychotic) on admission. Approaches included: --Re-orientation PRN (as needed) --Encourage resident to participate in ADLs PRN --Provide verbal cues, task segmentation with simple directions PRN --Remove from environment PRN --Request feedback to ensure understanding of communication --Stand in line of vision and make eye contact --Avoid activities that over stimulate resident --SS visits as needed --Have female care givers (added 5/9/13) --Psych visits if needed (The resident was seeing mental health biweekly) (2) The care plan for activities of daily living (ADLs), dated 10/20/12, showed the resident required limited to extensive assistance with activities of daily living. Approaches included in pertinent part: Allow individual adequate time to complete tasks; provide cueing with tasks as needed; ensure effective pain management prior to ADL activities. -A 2/21/13 note added to the care plan documented, "Res(ident) often refuses showers as scheduled. 2/12 and 2/19 - offered and refused x 3. Res refuses dressing change at times." -A 5/9/13 note added to the care plan documented, "No male caregivers." (3) The care plan for pressure ulcers, dated 10/29/12, showed the resident was admitted with a stage IV sacral pressure ulcer. Approaches included in pertinent part "pressure ulcer treatment as ordered." Review of resident #96's comprehensive care plan and review of progress notes back to April 2013, revealed no documentation the resident exhibited problems of [MEDICAL CONDITION], hallucinations or made false accusations. C. Allegation of Sexual Abuse 5/9/13 and Resident Report of Feeling Fearful 1. Record Review a. A 5/9/13 mental health clinical progress note, documented by the resident's psychiatrist revealed in pertinent part: -"(Resident) has remained psychiatrically stable ... (Resident) reported that last month she was touched in a sexual manner by a male nurse. - ...Engaged easily; mentation clear of psychotic features ...This writer prepared to end session when (resident), without preamble, described a male nurse coming to her room to do a wound care/dressing change about a month ago, accompanied by a male staff which client noted as unusual as female staff has been/is apparently always present given the location of the ulcer at base of client's spine. (Resident) stated that he spread her cheeks then slipped his finger into her vagina. (Resident) reported this in a direct manner with steady eye contact and a sad affect. -This writer's immediate response was to ask if (resident) had reported this to (the facility) staff and when client stated "No" this writer informed her that this writer would have to report it and (resident) was agreeable to this stating that she had been waiting for this writer to come tell someone. With (resident's) permission, this writer left the room and located the client's nurse and discretely informed her that client had just told this writer of having been touched inappropriately by a male staff member ... -(Resident) and this writer then joined by unit manager (UM) took some limited information (name of staff, approximate date of incident). (UM) stated she would next be informing relevant staff to carry the investigation forward. In response to this writer's queries, (UM) stated that (resident) would not receive any future care from (the male nurse) ...(UM) then left..." b. Review of the nursing progress note, dated 5/9/13, read in pertinent part: -At 1:00 p.m. - "Res(ident) psychologist requested to speak with this nurse at appox(imately) 10:30 a.m. Resident reports that she was assaulted by a male nurse sometime last month. Resident reporting that male nurse was changing her dressing and he "put his finger in my vagina." Res states incident occurred on the night shift - DON (director of nursing) and admin(istrator) notified immediately of resident report, investigation initiated. Admin contacted police, police interview with res completed. Msg (message) left for res sister/guardian to contact this nurse. Call placed to (nurse practitioner). Res up in w/c, out to smoke, interacting with staff and other residents per usual." -At 9:15 p.m. - "Assessment done of vaginal/peri area d/t complaint from above note. Resident cooperative/pleasant. No noted bruising, redness, or lacerations of area noted ... Will cont(inue) to monitor." c. The social service progress notes dated 5/19/13 read in pertinent part: Per NUM (North Unit Manager) res reported to psych that a male nurse assaulted her mid April 2013. Please see nurses note dated this date. Per NUM an investigation was in place. SS will visit and assist as needed. 2. Resident Interview On 5/16/13 at 12:40 p.m., the resident was observed in her room. She was seated in her wheelchair near her bed. The resident was alert and oriented and responded appropriately to questions. The resident stated she had been touched inappropriately by a male licensed practical nurse (LPN) during the night shift about two weeks ago. She said, "I have a wound on my lower back. He walked in with a male CNA (certified nurse aide) and after my treatment was done, he spread my cheeks and put his finger in my vagina. I'm scared and I can't stand him. He has flirted with me in the past and I told him he was married and I didn't want a married man." The resident said she has seen the LPN since the incident occurred and said, "He stares at me and makes me uncomfortable." The resident stated she was fearful the male LPN would return to her room at night and rape her. She said, "I block my door with a trashcan at night in case he comes in." The resident stated she did not report the incident to facility staff immediately because, "They blow me off." She said she waited until her psychiatrist came to visit to report it. "They (the facility staff) act like nothing happened." III. Failures in Facility Response to Resident's Allegation of Abuse A. Facility Investigation - Failure to Thoroughly Investigate Resident #96's Allegation of Abuse 1. Facility Investigation The facility's investigation was reviewed on 5/15/13 at approximately 2:00 p.m. The investigation summary documented in pertinent part: -"Date of Incident: Sometime mid-April -Time of Incident: Night time -Date Investigation Initiated: 5/9/13 -Brief Description of Incident: Res states when (male LPN) was changing her dressing "He spread my cheeks apart and looked at my rectum. Then her put his finger in my vagina." Resident also states that (male CNA) was in the room. "He usually brings a female with him." The investigation showed nine residents were interviewed. Although the questions the residents were asked were unclear from the investigation document, responses were: "No problem," "I think it's fine," "I'm not sure I even remember all of them," "I don't remember having any problems," "No problems," "The nurses are great," "Everything is just fine," "They're doing good," and "It's better, no problems with staff." The investigation also showed three staff members' interviews were documented. Although the questions the staff members were asked were unclear from the investigation document, responses were: -Licensed nurse #1: "Never had (male LPN named in allegation) help, would not ask another male - would only ask female." -Licensed nurse #2: "Would only ask female. Res does not like men providing tx (treatment)." -Male CNA named in allegation: "Been a long time since I took care of her - probably 3-4 months. Only time I go in her room is to get her w/c (wheelchair) to wash. The only time I ever went with (male LPN named in allegation) to help change the dressing was right after she first got here. Maybe 2-3 times with (male LPN), that's it." According to the nursing home administrator (NHA) interviewed on 5/15/13 at 4:50 p.m., (see below), the facility investigation of the resident's allegation concluded on 5/13/13. 2. Staff Interviews Regarding Facility Investigation On 5/15/13 at approximately 4:50 p.m., the unit manager (UM), nursing home administrator (NHA), and social service director (SSD) were interviewed. a. The UM stated (on 5/9/13) the mental health counselor had gone to the LPN working on the floor about the resident's allegation of abuse. The LPN then passed the information onto her and she interviewed the resident. -The UM stated, "(Resident #96) said that a male nurse had come to the room to do a dressing change and with a male CNA, spread her cheeks, and slid his finger into her vagina." The UM said the resident is alert and oriented and is very aware of staff members' appearance and names. -The UM continued, "We then initiated our investigation. That nurse and that CNA would not take care of her at all and no male caregivers. We also notified the nurse practitioner." The UM confirmed nine (female) residents were interviewed (facility census was 92) who resided in the facility on the 300 hall. -The UM then said she went through the schedule and saw that (the male LPN) had not been assigned to resident #96's hall (300 hall) "in months." Rather, the male LPN had been assigned to the 400 hall, which is right next to the 300 hall. -The UM said she also talked with two male licensed nurses who said resident #96 did not like working with men. The male nurses stated they had female nurses come and do the resident's dressing changes. b. The NHA said she called the police on 5/9/13 and the police took a statement from the resident. The NHA stated that, based on the other resident interviews and that (the male LPN) had not been assigned to work on the resident's hallway and had not signed off on any treatments, the allegation was not substantiated. She said the police did not find anything in their investigation either. 3. Failures in Facility Response a. Review of the facility investigation revealed no evidence the male LPN identified in the resident's allegation was interviewed by the UM, the NHA, or the Director of Nurses (DON). See facility investigation above, including three staff members' responses, but not a written response by the male LPN identified in the resident's allegation. See interview above; the UM stated she talked with two male nurses, but she did not state this included the male LPN identified in the resident's allegation. b. Review of the facility investigation revealed neither the NHA nor the DON interviewed resident #96 during the investigation. On 5/16/13 at 1:02 p.m., the DON said she was not involved in the initial investigation of the resident's allegation; she said it was conducted by the unit manager and NHA. She said she had not yet talked with the resident about her allegation and was not aware of her fear of the male LPN. The DON stated the male LPN had not worked on the 300 hallway, but acknowledged the 300 and 400 hallways were on the same unit. On 5/16/13 at approximately 2:00 p.m., the NHA said she had not talked with resident #96 about her allegation. She said, "I thought the DON did." The NHA said she was not aware the resident was in fear of the male LPN. c. Review of the facility investigation and interview with the UM revealed the resident interviews completed were not comprehensive. Specifically: The UM, during the interview, on 5/15/13 beginning at 4:50 p.m., talked with residents who would give a reliable interview. She said the nine residents interviewed were not specifically asked about the male LPN and if he had ever been inappropriate with them. She said she asked residents, "How are things going? How have things been the last several weeks? Are there any problems with the night shift?" The SSD, present during this interview, on 5/15/13 beginning at 4:50 p.m., stated it would have been "okay" to ask residents if they had ever been touch inappropriately. (The SSD was not involved in the facility investigation.) The UM further stated that of the nine residents interviewed, three did not require assistance with toileting or have dressing changes in the perineal area and one of the nine residents only sometimes required assistance with toileting. The UM stated she had not received training on how to conduct sexual abuse allegation investigation. B. Resident Protection Review of the resident #96's care plan revealed that on 5/9/13, the resident's care plan was updated to read that cares were to be provided by female staff only. And, see above; the unit manager said that on 5/9/13, the male LPN and male CNA were not to take care of resident #96 "at all and no male caregivers." However, interview and review of the staffing schedule revealed the male LPN was not suspended pending the outcome of the facility's investigation. Specifically: 1. On 5/15/13, in an interview beginning at 4:50 p.m., the NHA stated the male LPN named in the allegation was allowed to work the evening shift on the date the allegation was made (5/9/13) from 6:00 p.m. to 6:00 a.m. He had not been suspended. 2. On 5/16/13 at 2:31 p.m., the DON provided a schedule showing the male LPN worked the night shift (6:00 p.m. - 6:00 a.m.) on the 400 hallways on 5/9/13, 5/13/13, and 5/14/13. When asked if the male LPN was provided additional supervision pending the conclusion of the investigation, she said the other nurse on the unit worked closely with him, but additional supervision was not provided. 3. See 5/16/13 resident interview above; the resident said she had seen the LPN since the incident occurred and he stares at her and she was fearful he would return to her room at night. IV. Facility Follow-up A. On 5/15/13 at 5:20 p.m., the DON stated the facility had reopened the investigation and suspended the male LPN and male CNA named in the allegation. B. On 5/16/13 at 2:52 p.m., the NHA was interviewed. She stated, in pertinent part, that she had just interviewed the resident. She stated, "She said that she's afraid (of the male LPN) at night and puts her trashcan by the door. She went on to start talking about three other times she'd been raped ... I don't know if that's valid or not. She said she feels the unit manager doesn't listen to her." The NHA said she'd had encounters where the resident complained about someone stealing her clothes, underwear, and jewelry. However, the NHA acknowledged the resident had been consistent in her interviews regarding the abuse allegation. C. On 5/16/13 at approximately 4:00 p.m., the DON stated the male LPN would be transferred to another facility and would not be allowed to work another shift at the facility.

Based on observation, record review and interview, the facility failed to ensure an environment remained as free of accident hazards as possible; and each resident received adequate supervision and assistance devices to prevent accidents for one (#11) out of 16 sample residents. Specifically, fall interventions were ineffective in preventing a fall resulting in a fracture. After the fracture, new fall interventions were not implemented to prevent recurrence. The findings include: Resident #11 According to the face sheet, the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The annual Minimum Data Set, dated dated [DATE], showed the resident was unable to complete the Brief Interview of Mental Status (BIMS) and her long-term memory and short-term memory was impaired. The resident required extensive assistance with bed mobility, transfers, locomotion, and eating. She required total assistance with dressing and toilet use. The fall care plan, last revised on 2/14/12 showed the resident was at risk for falls related to a recent fall, history of previous falls, balance problem with standing, balance problem with walking, utilizes assistive devices, and osteoporosis. Approaches included: --Encourage resident to ask for assistance. --Ensure that resident has proper footwear as indicated and accepted. --Orient resident to room/environment. --Provide assistive devices as indicated and accepted. --Place call light within reach. --Observe for potential patterns of falls to identify possible causes. --Offer/assist to toilet frequently and as accepted. --Place frequently used items within reach. --Observe for potential medication related causes. --Lay resident down after meals if resident allows. The care plan showed the resident fell on : --9/21/12: Increased after supper monitoring. --12/4/12: PT to reassess w/c positioning when equipment available. --12/4/12 Staff to monitor positioning in w/c (wheelchair) FALLING STAR. --12/13/12: Slid out of w/c. a. Resident Observations The resident's room was observed at 11:36 a.m. on 1/24/13, she was not in bed and a fall mat was down on the floor. The resident was observed in the dining room on 1/24/13 at 11:50 p.m. The resident was seated in a wheelchair and was receiving feeding assistance. Her left ankle was in a hard boot. Although the care plan called for the resident to be laid down after meals, she was observed in her room seated in her wheelchair following lunch on 1/24/13. Her wheelchair was placed on top of a fall mat next to the resident's bed. On 1/24/13 At 1:50 p.m., the resident remained in her room seated in her wheelchair. On 1/24/13 at 2:31 p.m., the resident remained in her room seated in her wheelchair. On 2/1/13 at 8:55 a.m., the resident was observed sleeping in front of the north nurses station while seated in her wheelchair. She was observed to be wearing regular socks not non-slip. No documentation was located showing the resident refused to lie down after meals. b. Record Review The January 2013 physician orders [REDACTED]. According to the 10/1/12 fall risk assessment, the resident was at high risk for falls. The resident's falls were reviewed back to September 2012. --9/21/12 fall The interdisciplinary post fall review dated 9/24/12 showed the resident fell on [DATE] at 8:30 p.m. Description: Resident found on floor of bedroom lying on (L)eft side in fetal position. States "I fell and hit my head." No injuries noted. Did assessment once resident in bed. VS WNL. Resident refused BP and temp check. Resident states, "I'm fine, I'm fine." Will continue to monitor and do neuro checks." Summary of IDT (interdisciplinary team): Last fall 3/12, low bed and floor mat in place. Staff to increase monitoring after supper - offer to go to bed earlier. The progress notes were reviewed and showed the IDT reviewed this fall on the following dates: --9/25/12: "IDT review of res(ident) fall 9/21/12. Staff to increase after supper monitoring for need to go to bed. Care plan up to date." --10/10/12: "IDT review of resident fall 9/21/12. All interventions remain in place. Res has had no further falls. Care plan up to date." --12/4/12 fall The interdisciplinary post fall review, dated 12/5/12, documented the resident fell on [DATE] at 11:30 a.m. "Description of fall: Resident slid out of w/c (wheelchair), half way sitting between w/c and furniture. Assisted to sit all the way on the floor, noted small bump to L side of her head, no other injuries ...Resident hit her head on the furniture by TV." Intervention recommendations: PT (physical therapy) to reassess w/c positioning when new equipment available. Staff to monitor positioning in w/c." The progress notes were reviewed and showed the IDT reviewed this fall on the following dates: --12/7/12: "IDT review of resident fall 12/4/12. Res has recently completed PT for w/c positioning. PT to reassess when new equipment available. Staff to cont(inute) to monitor positioning frequently. Care plan up to date." The physical therapy notes were reviewed and showed the resident received physical therapy from 10/18/12 - 12/3/12, to address the resident's sliding forward in her wheelchair. After the resident was discontinued from therapy on 12/3/12, she was not reassessed after falling out of her wheelchair on 12/4/12. The December 2012 physician orders [REDACTED]. --12/13/12 fall The IDT post fall review dated 12/14/12 showed the resident fell on [DATE] at 10:35 a.m. "Description of fall: Called to recreation room, observed res lying on floor in front of w/c on R(ight) side. Per recreation volunteer, res slid out of w/c, did not hit head. Res assisted back to w/c, WNL (within normal limits) for this resident. No apparent injury." Summary of IDT: Resident slid out of w/c on buttock, then back. Tibia L(eft) fx (fracture) noted. PCP orders keep LE (lower extremities) elevated ... Intervention recommendations: Pull tab alarm to wheelchair. The resident's 12/13/12 nursing progress notes were reviewed and showed in their entirety: --12/13/12 (12:00 noon): "New orders noted. Placed call to (x-ray company) to request x-rays." --12/13/12 (5:40 p.m.): "Noted results from L ankle x-ray results. Placed call to (physician's) office ..." --12/13/12 (1:20 p.m.): "Placed call to (daughter) to inform of x-ray of L ankle and results. Will let her know when we found out what he wants to do." The 12/13/12 x-ray results documented the resident had an acute left tibia fracture. A 12/19/12 physician's progress note documented, "Pt (patient) has undisplaced fracture of distal tibia. Have reviewed x-ray ...given pt's age and non-wt (weight) bearing status, we feel simple immobilization with walking boot x 1 month is appropriate. Boot may be removed at night." c. Staff Interviews --On 1/24/13 at 3:35 p.m., a licensed practical nurse (LPN) who responded to the resident's fall on 12/13/12 was interviewed. She said, "They called for a nurse into the activity room and (a registered nurse) and I went. I assessed her and helped her back up into her wheelchair." After reviewing the post fall review for 12/13/12, the LPN was asked if the resident's range of motion was assessed or if a head-to-toe assessment was completed following the fall. She replied, "I documented she was within normal limits, although I didn't write I checked her range of motion. I don't remember if her socks were removed to look at her ankles." She added, "Her doctor was in that same day and she started complaining about her left ankle hurting after the fall." --On 1/24/13 at 3:47 p.m., the LPN who was assigned to work with the resident on 12/13/12 stated, "She fell in the activity room. After lunch sometime, someone who works here came up to me and said she was complaining of pain. I looked at the ankle and she grimaced, it was a little bit swollen. Her doctor was here and decided to x-ray." I didn't make a note regarding that time. The LPN stated she did not document the resident complaining of pain to her ankle or her observation of it swelling. --On 1/24/13 at 4:01 p.m., the therapy director (TD) stated the resident was discharged from physical therapy on 12/3/12. She said, "It's a very difficult case. She tended to scoot and slide out of her chair and that was her preferred posture. If you could see her getting in an activity she would just slouch down and she couldn't reposition herself." When asked what interventions were implemented while the resident was on therapy caseload, she said, "I believe they did a drop seat. It's basically a seat that hangs and it drops it down so her feet would drop down and she could push herself up." The TD stated she did not know a reassessment by physical therapy was recommended following the 12/4/12 fall. She said, "It would be up to the nurse to request it from the physician." --On 1/24/13 at 4:36 p.m., the nursing home administrator (NHA) stated she expected the resident to be laid down after meals, unless she refused. She stated if the resident was refusing to lie down, it should be documented by nursing staff. When asked about interventions following the 12/4/12 fall, the NHA stated, the resident was going to be reassessed by therapy after a new wheelchair had arrived. She said, "I think I ordered her a new wheelchair. It hasn't come in yet but it's a hemi high-back reclining chair. The other intervention was to monitor her wheelchair positioning." The NHA was asked to provide an invoice showing this chair was ordered, but by the end of abbreviated survey, this information was not provided. The NHA acknowledged the resident slid out of her wheelchair on 12/13/12 while in an activity. The only new intervention implemented following the 12/13/12 fall where the resident suffered a fracture, was a pull tab alarm. The NHA said, "It was decided not to use it. I don't know that it was ever put into place because she was on bed rest for a while after the fracture." Therefore, the NHA acknowledged no interventions were implemented for the resident.

2 Based on observation, record review and interview, the facility failed to ensure an environment remained as free of accident hazards as possible; and each resident received adequate supervision and assistance devices to prevent accidents for one (#11) out of 16 sample residents. Specifically, fall interventions were ineffective in preventing a fall resulting in a fracture. After the fracture, new fall interventions were not implemented to prevent recurrence. The findings include: Resident #11 According to the face sheet, the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The annual Minimum Data Set, dated dated [DATE], showed the resident was unable to complete the Brief Interview of Mental Status (BIMS) and her long-term memory and short-term memory was impaired. The resident required extensive assistance with bed mobility, transfers, locomotion, and eating. She required total assistance with dressing and toilet use. The fall care plan, last revised on 2/14/12 showed the resident was at risk for falls related to a recent fall, history of previous falls, balance problem with standing, balance problem with walking, utilizes assistive devices, and osteoporosis. Approaches included: --Encourage resident to ask for assistance. --Ensure that resident has proper footwear as indicated and accepted. --Orient resident to room/environment. --Provide assistive devices as indicated and accepted. --Place call light within reach. --Observe for potential patterns of falls to identify possible causes. --Offer/assist to toilet frequently and as accepted. --Place frequently used items within reach. --Observe for potential medication related causes. --Lay resident down after meals if resident allows. The care plan showed the resident fell on : --9/21/12: Increased after supper monitoring. --12/4/12: PT to reassess w/c positioning when equipment available. --12/4/12 Staff to monitor positioning in w/c (wheelchair) FALLING STAR. --12/13/12: Slid out of w/c. a. Resident Observations The resident's room was observed at 11:36 a.m. on 1/24/13, she was not in bed and a fall mat was down on the floor. The resident was observed in the dining room on 1/24/13 at 11:50 p.m. The resident was seated in a wheelchair and was receiving feeding assistance. Her left ankle was in a hard boot. Although the care plan called for the resident to be laid down after meals, she was observed in her room seated in her wheelchair following lunch on 1/24/13. Her wheelchair was placed on top of a fall mat next to the resident's bed. On 1/24/13 At 1:50 p.m., the resident remained in her room seated in her wheelchair. On 1/24/13 at 2:31 p.m., the resident remained in her room seated in her wheelchair. On 2/1/13 at 8:55 a.m., the resident was observed sleeping in front of the north nurses station while seated in her wheelchair. She was observed to be wearing regular socks not non-slip. No documentation was located showing the resident refused to lie down after meals. b. Record Review The January 2013 physician orders [REDACTED]. According to the 10/1/12 fall risk assessment, the resident was at high risk for falls. The resident's falls were reviewed back to September 2012. --9/21/12 fall The interdisciplinary post fall review dated 9/24/12 showed the resident fell on [DATE] at 8:30 p.m. Description: Resident found on floor of bedroom lying on (L)eft side in fetal position. States I fell and hit my head. No injuries noted. Did assessment once resident in bed. VS WNL. Resident refused BP and temp check. Resident states, I'm fine, I'm fine. Will continue to monitor and do neuro checks. Summary of IDT (interdisciplinary team): Last fall 3/12, low bed and floor mat in place. Staff to increase monitoring after supper - offer to go to bed earlier. The progress notes were reviewed and showed the IDT reviewed this fall on the following dates: --9/25/12: IDT review of res(ident) fall 9/21/12. Staff to increase after supper monitoring for need to go to bed. Care plan up to date. --10/10/12: IDT review of resident fall 9/21/12. All interventions remain in place. Res has had no further falls. Care plan up to date. --12/4/12 fall The interdisciplinary post fall review, dated 12/5/12, documented the resident fell on [DATE] at 11:30 a.m. Description of fall: Resident slid out of w/c (wheelchair), half way sitting between w/c and furniture. Assisted to sit all the way on the floor, noted small bump to L side of her head, no other injuries .Resident hit her head on the furniture by TV. Intervention recommendations: PT (physical therapy) to reassess w/c positioning when new equipment available. Staff to monitor positioning in w/c. The progress notes were reviewed and showed the IDT reviewed this fall on the following dates: --12/7/12: IDT review of resident fall 12/4/12. Res has recently completed PT for w/c positioning. PT to reassess when new equipment available. Staff to cont(inute) to monitor positioning frequently. Care plan up to date. The physical therapy notes were reviewed and showed the resident received physical therapy from 10/18/12 - 12/3/12, to address the resident's sliding forward in her wheelchair. After the resident was discontinued from therapy on 12/3/12, she was not reassessed after falling out of her wheelchair on 12/4/12. The December 2012 physician orders [REDACTED]. --12/13/12 fall The IDT post fall review dated 12/14/12 showed the resident fell on [DATE] at 10:35 a.m. Description of fall: Called to recreation room, observed res lying on floor in front of w/c on R(ight) side. Per recreation volunteer, res slid out of w/c, did not hit head. Res assisted back to w/c, WNL (within normal limits) for this resident. No apparent injury. Summary of IDT: Resident slid out of w/c on buttock, then back. Tibia L(eft) fx (fracture) noted. PCP orders keep LE (lower extremities) elevated . Intervention recommendations: Pull tab alarm to wheelchair. The resident's 12/13/12 nursing progress notes were reviewed and showed in their entirety: --12/13/12 (12:00 noon): New orders noted. Placed call to (x-ray company) to request x-rays. --12/13/12 (5:40 p.m.): Noted results from L ankle x-ray results. Placed call to (physician's) office . --12/13/12 (1:20 p.m.): Placed call to (daughter) to inform of x-ray of L ankle and results. Will let her know when we found out what he wants to do. The 12/13/12 x-ray results documented the resident had an acute left tibia fracture. A 12/19/12 physician's progress note documented, Pt (patient) has undisplaced fracture of distal tibia. Have reviewed x-ray .given pt's age and non-wt (weight) bearing status, we feel simple immobilization with walking boot x 1 month is appropriate. Boot may be removed at night. c. Staff Interviews --On 1/24/13 at 3:35 p.m., a licensed practical nurse (LPN) who responded to the resident's fall on 12/13/12 was interviewed. She said, They called for a nurse into the activity room and (a registered nurse) and I went. I assessed her and helped her back up into her wheelchair. After reviewing the post fall review for 12/13/12, the LPN was asked if the resident's range of motion was assessed or if a head-to-toe assessment was completed following the fall. She replied, I documented she was within normal limits, although I didn't write I checked her range of motion. I don't remember if her socks were removed to look at her ankles. She added, Her doctor was in that same day and she started complaining about her left ankle hurting after the fall. --On 1/24/13 at 3:47 p.m., the LPN who was assigned to work with the resident on 12/13/12 stated, She fell in the activity room. After lunch sometime, someone who works here came up to me and said she was complaining of pain. I looked at the ankle and she grimaced, it was a little bit swollen. Her doctor was here and decided to x-ray. I didn't make a note regarding that time. The LPN stated she did not document the resident complaining of pain to her ankle or her observation of it swelling. --On 1/24/13 at 4:01 p.m., the therapy director (TD) stated the resident was discharged from physical therapy on 12/3/12. She said, It's a very difficult case. She tended to scoot and slide out of her chair and that was her preferred posture. If you could see her getting in an activity she would just slouch down and she couldn't reposition herself. When asked what interventions were implemented while the resident was on therapy caseload, she said, I believe they did a drop seat. It's basically a seat that hangs and it drops it down so her feet would drop down and she could push herself up. The TD stated she did not know a reassessment by physical therapy was recommended following the 12/4/12 fall. She said, It would be up to the nurse to request it from the physician. --On 1/24/13 at 4:36 p.m., the nursing home administrator (NHA) stated she expected the resident to be laid down after meals, unless she refused. She stated if the resident was refusing to lie down, it should be documented by nursing staff. When asked about interventions following the 12/4/12 fall, the NHA stated, the resident was going to be reassessed by therapy after a new wheelchair had arrived. She said, I think I ordered her a new wheelchair. It hasn't come in yet but it's a hemi high-back reclining chair. The other intervention was to monitor her wheelchair positioning. The NHA was asked to provide an invoice showing this chair was ordered, but by the end of abbreviated survey, this information was not provided. The NHA acknowledged the resident slid out of her wheelchair on 12/13/12 while in an activity. The only new intervention implemented following the 12/13/12 fall where the resident suffered a fracture, was a pull tab alarm. The NHA said, It was decided not to use it. I don't know that it was ever put into place because she was on bed rest for a while after the fracture. Therefore, the NHA acknowledged no interventions were implemented for the resident.

Based on observations, record review, resident and staff interviews, the facility failed to provide adequate supervision to prevent accidents for two of 11 sample residents (#2, #10). Specifically: A. The facility failed to ensure fall safety devices were in place for sample resident #2 on 2/24/11 when she fell . The resident had recently been readmitted to the facility from the hospital on [DATE] with a subdural hematoma subsequent to a fall ten days earlier at the facility. After the second fall on 2/24/11, the hospital records reported another subdural hematoma. The resident sustained [REDACTED]. The resident did not return to the facility. B. The facility failed to implement safety measures for sample resident #10 after she spilled hot cocoa on 4/6/11. The facility recommended staff place lids on the cups or put ice in the hot beverages but this did not occur. The findings include: I. Facility Expectations with falls and prevention: The Fall Management policy was reviewed in pertinent part, "The IDT (interdisciplinary team) will review all resident falls within 24-72 hours at the morning interdisciplinary team meeting to evaluate circumstances and probable cause for the fall...The IDT then modifies and implements a care plan and treatment approach to minimize repeat falls. The Care plan will be reviewed/revised as indicated. The care Kardexes are updated as appropriate...The Falling Star is a visual identifier/reminder program for staff to recognize and to be aware of residents determined to be at risk. Visual identifiers will assist the facility staff as well as family and visitors to identify those residents that are at risk for falls, and to respond accordingly when the resident demonstrates a behavior that may be associated with an impending fall. Placement on the falling star program - a. newly admitted residents, b. residents identified at risk, c. IDT determination...Each facility is responsible for implementing individualized interventions related to/for each resident's fall risks." A. According to the hospital reports, dated 2/14/11 and 2/24/11, the resident sustained [REDACTED]. The physician recommended observations at this point. The resident returned to the facility on [DATE]. The 2/24/11 discharge summary indicated the final [DIAGNOSES REDACTED]. Closed record review for sample resident #2, [AGE] years old, showed an admission date of [DATE]. According to the admission sheet, the medical [DIAGNOSES REDACTED]. 1. According to the 9/17/10 Minimum Data Set, the resident required supervision with Activities of Daily Living (ADLs) and had falls within the past 31-180 days. 2. The resident was identified at risk for falls and safety interventions were recommended: A 6/16/10 fall care plan (last reviewed on 12/13/10) showed the resident was at risk for falls and the following approaches were included (not all inclusive), "Physical Therapy 1/13/11, Occupational Therapy screen 2/11/11, eye exam list 2/11/11, call light within reach, falling star program 11/29/10, signs to lock brakes 11/29/10, lab work and x-rays 1/10/11, bladder wheel 1/13/11, tabs alarm to wheelchair and stationary chair 1/13/11, 1/31/11 place on bladder wheel and start bladder schedule, in-service staff on alarms, orthostatic blood pressure in evening and dining chair removed from dining table." On 12/12/10, the fall risk assessment showed a score of 12, indicating a high risk for falls. On 12/23/10, a care conference occurred and the team discussed falls, therapy involvement to improve ambulation, transfers and safety skills. Staff noted the resident was forgetful and required reminders and cues. A 2/19/11 fall care plan (developed after the resident's 2/14/11 fall - see below) showed the resident was at risk for falls related to recent fall, history of falls, balance problems, blood pressure changes, cerebral vascular accident, arthritis, psychotropic, subdural hematoma and anemia. Approaches included falling star program, encourage resident to ask for assist, ensure proper footwear, therapy evaluations, trough mattress, orientation to room, provide assistive devices, bed alarms, side mat, chair alarm, hi-low bed, place call light within reach, observe for potential patterns of falls, toileting plan, signs to lock brakes and orthostatic blood pressures in evenings. A 2/19/11 toileting plan showed the resident was at high risk for falls trying to take self to toilet. Staff was directed to check the resident during the night rounds and assist as needed. On 2/21/11, a care conference occurred and the team discussed falls, therapy recommendations, memory problems with regards to ADLS, room move to 200 hall, balance and safety. The resident care cardex worksheet (used by certified nurse aides/CNAs to direct resident care) showed the following safety interventions, "high/low bed, trough mattress, tabs alarm to wheelchair, bed and stationary chair, falling star and floor pad." 3. The resident's history included multiple falls with injury while she resided in the facility. Notifications, post fall investigations and neurological checks were completed. Documentation about the falls was collected by nurse's notes, interdisciplinary post fall reviews and facility handwritten documents: --On 11/27/10 at 8 p.m., the resident fell during a self transfer as she did not lock the walker brakes. The resident sustained [REDACTED]. On 11/29/10, the Interdisciplinary review team (IDT) reviewed the fall and recommended the following interventions, falling star program, visual signs for the resident to lock her brakes and therapy screens. Physical Therapy was initiated and discontinued on 12/29/10 with a referral to restorative (see notes below as the restorative program was not completed per recommendation). --On 1/9/11 at 7:15 p.m., the resident fell during a self transfer as she again did not lock the walker brakes. The resident sustained [REDACTED]. The IDT reviewed the fall on 1/10/11 and requested tests to rule out infection. Lab work and x-rays were ordered and the physician ordered Levaquin for an upper respiratory infection. No further recommendations were made at this time and the resident continued on the falling star program. --On 1/13/11 at 8:30 p.m., the resident fell in her room and was found lying on floor in front of her chair. The resident sustained [REDACTED]. On 1/17/11, the IDT reviewed the fall and initiated safety alarms and a referral to Physical Therapy. The facility started a three day bladder wheel assessment. Physical Therapy evaluated the resident on 1/13/11 for weakness due to falls and an onset of pneumonia. A bladder wheel assessment was initiated on 1/18/11 and completed on 1/20/11. However, there was no indication the toileting care plan had been updated with a toileting plan after this assessment was completed. However, review of the care plans showed no reference to a toileting plan that was supposed to be initiated after the 1/13/11 fall. --On 1/28/11 at 1:00 a.m., the resident fell while getting out of bed and attempting to ambulate to the restroom. There was no indication the alarm was sounding to alert staff or that it was in place at the time of the fall. On 1/31/11, the IDT reviewed the fall and recommended the resident be placed on a toileting plan and continue the falling star program. Another 3-day bladder data collection tool was initiated on 2/1/11 through 2/3/11. On this document a hand-written notation was noted, "Remind/assist to toilet after dinner, at bedtime and during night rounds. All highlighted times, resident must be toileted." The highlighted times were 6 p.m., 8 p.m., 10 p.m., midnight and 2 a.m. --On 2/6/11 at 9 p.m., the resident fell in the bathroom while getting ready for bed (putting a gown on). There was no investigation/indication as to how the resident got to the restroom on her own given that alarms were to be in place to alert staff that she required assistance and no immediate IDT review of interventions necessary for maintaining the resident's safety. --On 2/10/11 at 11:45 am, four days after her fall on 2/6/11, the resident fell in the main dining room while attempting to transfer from the wheelchair into a regular chair. The resident sustained [REDACTED]. On 2/11/11, the IDT reviewed both the 2/6/11 fall and the 2/10/11 fall. With regard to the 2/6/11 fall, the IDT review revealed staff was unable to recall if alarm was sounding or in place. The IDT recommended an Occupational Therapy screen and an eye exam. With regard to 2/10/11, the tab alarm was not sounding. There was no indication if the wheelchair brakes were locked. X-rays were negative but the resident complained of increased neck pain which therapy addressed with modalities and range of motion. Seven staff members were in-serviced on 2/11/11 regarding this resident and ensuring alarms were in place and functioning. --On 2/14/11 at 5:30 a.m., three days later, the resident was found on the floor in her room. Staff reported the resident was found next to her roommate's bed lying on her back. Although there was no documentation, a staff member stated the alarm was sounding. The resident was confused and sustained skin tears with complaints of low back pain. The resident was hospitalized with a subdural hematoma. The resident returned to the facility on [DATE]. Physical Therapy was still working with the resident (1/13 - 2/14) and her functional status was at minimal assist. On 2/14/11, the IDT reviewed the fall and recommended reassessing the resident safety needs upon her return to the facility. The resident returned to the facility on [DATE]. Per the facility recommendations, on 2/19/11, further safety interventions were recommended: falling star (not new), bed alarm (not new), chair alarm, (not new) hi/low bed, fall mat, signs to lock brakes (not new) and a trough mattress. On 2/18/11, after a fall on 2/14/11 (see below), the fall risk assessment showed a score of 20, indicating a high risk for falls. On 2/21/11, a physician order [REDACTED]. Physical Therapy and Occupational Therapy re-evaluated the resident on 2/21/11 that showed the resident's functional mobility declined to moderate assist. 4. Fall 2/24/11 On 2/24/11, six days after returning to the facility following her hospitalization for a subdural hematoma on 2/14/11, staff heard the resident's alarm sounding at 12:20 a.m. The resident was observed on the floor next to her bed. There was no mat by the bedside and the bed was not in the lowest position. The resident sustained [REDACTED]. The resident was transported to the hospital and diagnosed with [REDACTED]. Review of nurses' notes prior to this fall revealed, in pertinent part: -On 2/23/11 at 6 p.m., the nurse documented, "bed and chair alarms in place, Alert and oriented to person only. Sitting in big chair. Denies pain, bruises to left forehead, left and right forearms and right inner knee healing some now. Need assistance for all ADLS and ambulation and transfers. Rounds made by this RN several times this shift to see if resident needed anything." -At 9:30 p.m., the nurse documented, "Alarm on bed intact with resident in bed. Call light within reach. No needs at this time. Is resting comfortable." -On 2/24/11 at 12:20 a.m., the nurse documented, "resident's alarm went off - resident found laying on floor. Nurse went to resident's room and found her laying back side on floor next to bed. Hand on right side of head - blood noted to area. Alert and responding to nurse Ax0x3. ROM (range of motion) WNL (within normal limits). Neurological checks WNL. C/o (complained of) pain to right side of head. Alarms going off in bed. Called daughter immediately wanted mother send to hospital. Called (name of physician) answering service stated (physician name) would return call. Will speak with DON (Director of Nursing) and send to (initials of hospital). Paperwork done called 911." After the resident's fall on 2/24/11, all staff received re-training on fall prevention and the falling star program. 5. Facility failures Review of the February 2011 treatment records indicated nursing staff initialed all safety devices were in place on 2/23/11 and the 10-6 shift on 2/24/11. However, see above documentation of the resident's fall on 2/24/11. All safety devices were not in place; the resident's bed was not in low position and a mat was not beside the bed. Review of the resident's care plan (see above) and facility recommendations after the resident's return 2/18/11 (see above), revealed no plan to increase supervision of the resident notwithstanding her repeated self-transfers. While the resident was on the falling star program, indicating increased supervision by staff during routine duties, the resident had been on such program since 11/10, and since that time had sustained numerous falls (see above). Moreover, on 2/24/11, documentation indicated the resident's door was closed, minimizing the effect of the falling star interventions to view the resident when passing the room. Review of therapy notes revealed that In December (12/30/10), therapy discontinued services with a referral to restorative exercise program for strengthening and range of motion. At the time of discharge, the resident was independent in the facility with the walker. In January 2011, the resident was seen on 12/31/10, 1/9/11 and 1/10/11. On 1/13/11, the resident was referred back to therapy due to falls and weakness. Thereafter, review of the records showed the resident only received restorative three times within a span of 13 days, not 6 times per week as ordered. 6. Staff interviews: On 3/23/11 at 4:21 a.m., one Resident Care Specialist (RCS) stated staff should ensure safety devices were in place. On 3/23/11 at 4:35 a.m., one Registered Nurse (RN) stated if a nurse checked and initialed the MAR/TAR, that indicated the safety devices were in place. On 3/23/11 at 7:03 p.m., one RCS stated information was passed on in report about safety devices and safety information could be located on the care cardex. On 3/24/11 at 6:13 a.m., the night RCS (working on night of 2/23/11 - 2/24/11 a.m.) stated she got report between 10 and 10:30 p.m. from off-going staff member that this resident was in bed and 'pottied'. The RCS recalled she would need to check this resident about midnight. The resident's door was shut per resident's request. Several call lights were going off that evening continuously, new admission with increased needs/requests and four other lights going off that night (all before midnight). In addition, one resident yelling in the hall and she got him milk. The RCS stated she heard the resident's alarm and responded around 12:15 a.m. The RCS stated the hall was hectic that night. Cross-reference F353; insufficient nursing staff. On 3/24/11 at 9:30 a.m., during a meeting with the Director of Nursing (DON), Nursing Home Administrator (NHA) and nurse consultant, the following comments were made: The DON stated the nurses were responsible to check and ensure safety devices were in place and working. The DON continued resident care specialists were responsible as well. The facility acknowledged the safety devices were not in place for this resident on 2/24/11. The DON stated that staff had been re-inserviced about fall prevention, the facility had initiated staff huddles for communication and had clarified nursing responsibilities. The DON stated the facility expected the nurses to visually check the resident to ensure safety devices are in place. The DON stated staff was expected to visually check residents every two hours at night. On 4/20/11 at 9:10 a.m., a meeting occurred with the DON, SDC (staff development coordinator) and staffing scheduler. The following comments were made and the facility's investigation was reviewed: -The SDC stated staff reported it was a busy night (2/23/11 - 2/24/11) and as soon as the night shift walked onto the floor, they were running. The call lights were going off and there were increased resident requests. The evening RCS was ill and was supposed to work through the night (but left at 10 p.m.). The South unit (halls 100 and 200) worked with two aides that evening (2-10). There were three aides scheduled to work the night shift (two aides from 10-6 and the third aide from 10p-2a) for the South unit. -The scheduler stated an extra aide was scheduled for four hours that evening to help out due to the current resident population on 200 hall. Through the facility's investigation, one RCS was running late that day for the evening shift (2-10) and did not get report from the previous shift (6a - 2p). One nurse for the 200 hall that was scheduled to work 6p - 6a was canceled from 6p - 10 pm, so the RN returned to work the 200 hall at 9:30 p.m. One RN worked the 200 hall 2-10 p.m. and another LPN worked the 200 hall from 6a - 6p. The nursing coverage decreased to one nurse on hall 200 from 6-10 p.m. -Through facility review of the treatment records, the 2-10 nurse initialed the treatment sheet indicating the safety devices were in place but this nurse did not see the resident in the bed. The RN (that was supposed to work 6p - 6a but ended up working 9:30 p.m. to 6 a.m.) initialed the resident's safety devices were in place but did not visually check the resident. -The facility investigation revealed the 2-10 p.m. RCS stated her last check of the resident was around 9:30 p.m. and alarms were in place. The fall mat and bed were not in place; the RCS was not aware they should be in place. The night RCS stated the evening RCS told her the resident had just been toileted and told her why the door was closed. Both the RCS and night nurse had not performed a resident check until the alarm sounded after midnight. (Cross-reference F353 insufficient nursing staff). II. Hot cocoa spill Sample resident #10, [AGE] years old, was admitted to the facility on [DATE]. According to the admission sheet, the medical [DIAGNOSES REDACTED]. 1. According to the 2/14/11 Minimum Data Set, the resident had severe cognitive impairment and required supervision/setup with meals. Review of the 12/10/10 ADL (Activities of Daily Living) care plan directed staff to assist as needed. 2. Medical record review revealed the resident spilled her hot cocoa: On 4/6/11 at 3:00 a.m., the nurse documented, "resident confused this shift early. Unsure of time, up and dressed. forgets to wait for assist..." -At 8:50 a.m., the nurse documented, "patient spilled hot chocolate on right leg this am, cleaned and dried and changed quickly. Small red mark noted on mid-thigh. No blistering noted - able to change and return to eat breakfast. denies pain...moderately forgetful and impulsive...Will continue to monitor and provide ongoing emotional support as indicated..." -At 1:00 p.m., the nurse documented, "increase lethargy noticed after lunch today. O2 sats (saturation levels) checked - lips looked cyanotic - O2 at 68% on 2 L - increase to 4L to get into 90s. Feeling better - looking better. Will continue to monitor closely." On 4/7/11 at 4:00 a.m., the nurse documented, "resting quietly, voicing no complaints. Right thigh red mark. No blisters noted after spilling hot chocolate of self." Review of physician orders [REDACTED]. 3. Review of the facility's investigation, dated 4/6/11, revealed the facility recommended lids to hot beverage cups as resident allows (states history of taking lids off). If resident refused lid, cool the beverage with ice. 4. Facility failure to implement safety recommendations Review of the care plan after the spill on 4/6/11 showed no revisions to address the hot cocoa spill or resident safety. Observations of the evening meal on 4/18/11 around 5:26 p.m. showed a dietary member started to take meal orders for supper. This resident called the dietary aide over from another table and requested a cup of coffee. The aide proceeded to the beverage cart and poured the resident a cup of coffee. The cup was placed in front of the resident without being allowed to cool, without a lid or piece of ice. The aide was neither heard to offer the resident a lid for the coffee nor was the resident heard to refuse such an offer. Review of the resident's diet card reflected no safety information to alert staff about offering lids or putting ice in hot beverages. 5. Staff interviews: On 4/19/11 at 4:13 p.m., the unit manager stated staff offered the resident lids but the resident was refusing. The evening observations were shared with the DON and unit manager. On 4/19/11 at 4:20 p.m., the dietary manager (DM) stated staff provides the resident lids and she takes them off. The DM stated the resident feeds herself and the department heads were aware of the issue. The hot water in the kitchen was checked and the temperature was 160 degrees. The DM said s/he would in-service staff about offering lids.

Based on observations, record review, and staff interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, for two (#9 and #13) of 21 sample residents. Specifically: -the facility failed to ensure resident #9 was properly assessed and received adequate nursing care after she experienced change in medical condition, which resulted in fall and fracture of her hip; and -the facility failed to follow physician's orders [REDACTED].#13. The findings include: I. Failure to Adequately Address a Change of Condition A. Facility Policy The facility policy, revised on 6/08, regarding changes in condition read in pertinent part: "assess and document changes in condition in an efficient and effective manor, provide assessment information to the physician, and provide clear comprehensive documentation...Changes in condition are communicated from shift to shift through the 24-hour report management system. Changes in resident status that affect the problem/goal or approach on his or her care plan are documented as revisions and communicated to the interdisciplinary caregivers." B. Resident Failure Sample resident #9, [AGE] years old, was admitted to the facility on [DATE]. The medical diagnoses, according to the face sheet, included [MEDICAL CONDITION] of legs, [MEDICAL CONDITION], urinary tract infection, muscular wasting and disuse atrophy, and difficulty in walking. The 6/23/10 admission Minimum Data Set (MDS) assessment documented the resident had no memory problems and was independent with her daily decision-making. The resident required extensive physical assistance of one person with all activities of daily living except eating. There were no behavior symptoms identified on the assessment. The Medicare MDS (60 days) assessment, dated 8/13/10, indicated overall improvement. The resident continued to work with a therapist and the goal was to return to the community soon. Her gait was still unsteady, but there was no history of falls. 1. Record Review: The nurses notes (NN) dated 9/10/10 revealed the resident was complaining of "feeling foggy" after she returned from a local hospital after CT (computed tomography) scan of her abdomen and pelvis at 1:30 p.m. to address her urinary tract infection [MEDICAL CONDITION]. The hospital physician ordered a new medication, [MEDICATION NAME], to treat the UTI. According to Mosby's Drug Reference, 2007, page 1013, a possible side effect of the medication was "hallucinations." A 9/10/10, 6:00 p.m. NN note read in pertinent part, "Resident hallucinating-seeing a dog lying on the bathroom floor, thinks there is a man in her bed." A 9/11/10, 4:00 a.m. NN documented, "the resident was confused last night and needed more assistance." A 9/11/10, 9:30 a.m. NN read in pertinent part, "No behavioral change this a.m., uses call light, will monitor." A 9/12/10, 5:30 a.m. NN read in pertinent part, "At this time resident turned on call light for assistance to bathroom ... Resident appears to be having hallucination at this time. She does however (seem to) be alert and aware of place but not time." A 9/12/10, 9:20 a.m. NN read in pertinent part, "alert, confused, patient looking around at floor,...states I'm tired of seeing things that aren't here, crying. Support given. Needs assist with ADLs and transfer, will self transfer. Gait weak and unsteady...on antibiotic without adverse effect. Continues to have frequent urination with burning at times." A 9/12/10, 9:30 p.m. NN documented, "Resident found on floor in bathroom doorway, lying on left side. Complained (of) hip/pelvic pain. MD (physician) called, ordered patient to be sent to hospital emergency room for evaluation." A 9/12/10, 11:45 p.m. NN revealed the resident had a broken left hip and was admitted to the local hospital. Future record review revealed the mental change of condition was not communicated on 24-hour reports and the social services department was not notified as indicated in facility policy (see above). The resident's confusion was not adequately addressed by staff to prevent accidents and provide support to the resident. 2. Staff Interviews: On 11/17/10 at 9:30 a.m., the south unit manager (UM) was interviewed regarding resident #9's change of condition and her fall. The UM confirmed additional assessment regarding her mental condition or specific needs were not documented in the nurses' notes for a period of 12 hours on the day of fall. She reviewed the certified nurse aide (CNA) documentation from that time period and stated there was no documentation that care was provided to the resident for an extensive period of time (over nine hours) on 9/12/10. She also verified there were no notes or assessments done by social services regarding resident's mental change. The UM stated the resident had improved with rehabilitation and would have, soon, been ready to be discharged home prior to the fall; however the [MEDICAL CONDITION] and the surgery had weakened her and the resident was not coping well with the prospect of residing at the facility long-term. During a meeting on 11/17/10 at 3:15, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were notified of the above findings. On 11/18/10 at 4:10 p.m., the Social Services Director was interviewed and stated she was not aware of the resident's hallucination episodes and changes in mentation. She stated she should have been notified as soon as possible so she could assess resident's mental status and revise the care plan. On 11/18/10 at 4:15 p.m., the DON stated the resident's change in condition (hallucinations and change in mentation) was not included in 24-hour reports from 9/10/10 through 9/12/10. The DON stated the nurses should have followed the facility policy (see above) and she agreed there was lack of documentation and proper assessment regarding resident's condition and her needs. The DON stated there should have been increased monitoring and frequent help with ADLs and transferring, especially when the resident exhibited frequent urination. 3. Resident Interview: On 11/17/10 at 12:05 p.m., resident #9 stated that she had never experienced hallucinations before her change of condition on 9/10/10 (see above). She stated she "started seeing things about three days before the fall." The resident stated she needed more help with transfers and walking because of her condition (UTI, frequent urination, and hallucinations); however, she was left alone for long periods of time. She stated she needed to go to bathroom, so she got up on her own and fell (on 9/12/10). The resident could not recall if she had activated her call light. The resident added that the [MEDICAL CONDITION] had limited her mobility and she was no longer motivated to get better because she learned she would not be able to return and function in her own home. II. Failure to Follow Physician's Diabetic Management Orders A. Facility Policy The facility's "Diabetic Management" policy, most recently revised 6/08 and received from the facility on 11/17/10, documented the following, in pertinent part: "Diabetic Management involves both preventative measures and treatment of [REDACTED]. ASSESSMENT Upon admission, the interdisciplinary team evaluates the diabetic resident and implements a plan of care to ensure: -orders are received and are accurate related to blood glucose monitoring and anti-diabetic agents. Blood glucose orders should include parameters to follow and when to notify the physician. -appropriate nutritional orders are in place (enteral, diet, supplements, snacks) -preventative skin care measures are in place ROUTINE CARE -Blood glucose measurements are taken per the physician order. Results outside of ordered parameters are communicated to the physician immediately. -Anti-diabetic agents (insulin or oral anti-diabetic agents) are administered per physician order [REDACTED]. -Residents are monitored for signs/symptoms of complications. ACUTE COMPLICATION MANAGEMENT [MEDICAL CONDITION] - High Blood Sugar Levels ... 4. Notify the physician of abnormal blood glucose test results and symptoms exhibited. 5. Follow physician's orders [REDACTED]. [DIAGNOSES REDACTED] - Low Blood Sugar Levels -perspiring or sweating excessively -weakness, dizziness or faintness -excessive hunger -blurred or impaired vision -trembling or tremors -headaches, light headedness -change in level of consciousness (lethargy or stupor) 1. If the resident is unconscious or vital signs are absent, give [MEDICATION NAME] 1 mg IM (one milligram intramuscular) and call 911... 2. Test the resident's blood glucose (BG) with a blood glucose-monitoring device. 3. If BG level is below 70 mg/dl (milligrams/deciliter), and the resident is presenting with signs/symptoms of [DIAGNOSES REDACTED] and can swallow, administer: -4 ounces of fruit juice, or -Administer three (3) 5-gm (gram) oral glucose tablets, or -If resident is tube fed, glucose gel into the [MEDICATION NAME] space and massage to increase adsorption (sic) 4. Reassess blood glucose level in 15 minutes. 5. If blood glucose level remains below 70 mg/dl, and symptoms continue to exist, but the resident can swallow or if tube fed, administer: -4 ounces juice, or -6 ounces milk, or -three (3) 5-gm glucose tablets, or -glucose gel into the [MEDICATION NAME] space and massage to increase absorption 6. Recheck blood glucose in 15 minutes. 7. Notify the physician of abnormal blood glucose test results, symptoms exhibited and interventions implemented. 8. If the resident rallies immediately and is able to swallow, follow up with one of the following foods if it is more than 30 minutes until the next meal. These are considered additional snacks and are not to be deducted from the next meal. -buttered toast or -one serving of crackers with peanut butter or cheese or -one serving of ice cream, or -one serving of milk 9. Stay with the resident to ensure all the food is eaten and the resident does not fall back to sleep. Feed the resident if he or she is disoriented or lethargic. 10. Repeat blood glucose level 15-30 minutes after food is consumed to ensure maintenance of acceptable range. DOCUMENTATION For acute complications, the clinical record should include the following information: -notification of physician and any new orders, -resident's signs and symptoms, -results of blood testing, -interventions initiated -resident's response to treatment, and -notification of responsible party ..." B. Resident Failure Sample resident #13, [AGE] years old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most current MDS assessment, with an Assessment Reference Date (ARD) of 10/22/10, documented the resident received a Brief Interview for Mental Status (BIMS) score of 11/15 and required the limited assistance of one staff member for most ADLs, including bed mobility, transfers, dressing, eating, and toileting. Per the MDS, the resident required the extensive assistance of one staff member for ADLs including ambulation and hygiene. The resident was able to understand others and be understood, per the MDS, although she only spoke and understood Spanish. 1. Record Review: Review of a care plan dated 10/22/10 documented a problem of "Resident has cognitive loss w/ (with) ST (short-term) memory deficit possibly due to dx (diagnosis) of Dementia, Depression and DM (diabetes mellitus). (Resident) is able to make choices re: (about) her daily routine." Record review of a Hypo/[MEDICAL CONDITION] care plan for resident #13, dated 10/18/10, documented the resident had the potential for [DIAGNOSES REDACTED] and [MEDICAL CONDITION] related to a [DIAGNOSES REDACTED]. were changed on 10/29/10 to "70-450." Associated approaches were documented as: -"Observe for signs and symptoms of hypo/hyper glycemia (sic), excessive thirst, frequent urination, clammy skin, confusion." -"Finger stick blood sugars as ordered" -"Sliding scale insulin as ordered" -"Diet as ordered" -"Monitor labs as ordered" -"Notify MD as indicated" Review of the 11/10 Computerized Physician order [REDACTED]. The order also documented the physician was to be notified if the finger-stick blood sugar (FSBS) was less than 70 or greater than 400. According to a 10/29/10 telephone order (TO), the upper limit on the FSBS parameter was raised to 450 before the physician was to be notified. Although the 11/10 CPOs had been signed by a nurse as being reviewed for accuracy on 10/30/10, the most current 10/29/10 order was not reflected on the CPOs. Review of the 11/10 Medication Administration Records (MARs), the FSBS parameters were less than 70 or greater than 300 from admission on 10/15/10 to 10/20/10, when the order changed as described above. The facility used a Blood Glucose Tracking/Sliding Scale Insulin Administration Record to document each FSBS, the time, the nurse's initials, and whether or not the physician was notified. The back of the Blood Glucose Tracking Record (BGTR) provided a space to document the time, FSBS, and actions taken for FSBS levels that required interventions. The bottom of the front of the BGTR read: "PLEASE NOTE: -If the blood glucose is ABOVE or BELOW the parameters the physician must be notified immediately and interventions implemented. -If the resident is UNRESPONSIVE, the nurse MUST proceed with 1 mg [MEDICATION NAME] IM, call 911 and the physician. -Document on the reverse, 15 minute follow-ups of blood glucose checks below parameter requiring intervention." Review of the 10/10 and 11/10 BGTRs and NN revealed the following: -On 10/17/10 at 7:00 a.m., the resident's FSBS was 38; the resident was given a snack of milkshake and oatmeal cookie. -On 10/17/10 at 7:30 a.m., the resident's FSBS was 30; a [MEDICATION NAME] injection was administered. -On 10/17/10 at 8:15 a.m., the resident's FSBS was 58; the resident was eating breakfast. -On 10/17/10 at 9:00 a.m., the resident's FSBS was 88. -On 10/20/10 at 7:00 a.m., the resident's FSBS was 67. Per the BGTR, the physician was notified. However, there was no evidence of any interventions for the FSBS below physician-ordered and facility protocol parameters. -On 11/13/10 at 7:00 a.m., the resident's FSBS was 58; orange juice was administered. -On 11/13/10 at 7:30 a.m., the resident's FSBS was 100. The facility failed to follow the Diabetic Management policy in the above-stated hypoglycemic episodes. The correct intervention on 10/17/10 was not administered (milkshake and cookies were not on the list of specific interventions), interventions were not continued until the FSBS was above 70 before the meal on 10/17/10, interventions were not administered on 10/20/10, and the FSBS was not re-checked every 15 minutes with additional interventions until the FSBS was at least 70. The DON was interviewed on 11/18/10 at 3:10 p.m. and acknowledged the correct interventions were not administered and/or documented for the above-stated hypoglycemic episodes. According to the DON, her expectation was that the physician orders [REDACTED].