Every finding on record at Medallion Post Acute Rehabilitation

Based on observations, record review and interviews, the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.Specifically, the facility failed to:-Maintain residents' dignity and ensure call lights were answered timely; and,-Ensure residents were treated with dignity by staff during meal service.Findings include:I. Failed to maintain residents' dignity and ensure call lights were answered timelyA. Facility policy and procedureThe Call Light/Bell policy and procedure, revised May 2007, was received from the director of nursing (DON) on 6/17/26 at 11:02 a.m. It read in pertinent part, Procedures: Answer the light/bell within a reasonable time (approximately five minutes). Leave the resident comfortable. Place the call device within resident's reach before leaving the room. If the call light/bell is defective, immediately report this information to the unit supervisor.B. Resident and resident's representative interviewsResident #3 was interviewed on 6/10/26 at 9:37 a.m. Resident #3 said sometimes staff did not treat her with respect and dignity. Resident #3 said a few weeks ago she laid in her bed for an hour and a half waiting for a staff member to come and help her get cleaned up after being incontinent. Resident #3 said it often took half an hour for a staff member to come when she used her call light. Resident #3 said the staff's call light response times were worse at night and over the weekends. She said it did not seem like the facility was properly staffed. Resident #3 said she sometimes wondered why she even had a call light because the staff did not seem to respond to it and it made her feel worthless. Resident #3 said there were a lot of times where she had activated her call light and heard people outside her room talking and laughing but no staff members ever responded to her. Resident #3 said sometimes she would ask a certified nurse aide (CNA) to get a nurse's attention for her but no staff member would ever return to her room. Resident #3 said the nurses all told her to let them know if she needed anything, but Resident #3 said it felt like there was no point in telling them. Resident #3 said she felt like her concerns did not matter and the staff would not help. Resident #3 said the issues with call light response times had been going on for a while and were not getting any better. Resident #3 said she was frustrated because she often was left lying in her own feces, which she said she was not supposed to do because it was damaging to her skin. She said when she was left soiled for too long, her skin became itchy.Resident #9 was interviewed on 6/10/26 at 2:12 p.m. Resident #9 said she usually had to wait an hour for her call light to be answered. Resident #9 said she used her call light to get staff assistance to change her colostomy bag or to go to the bathroom. Resident #9 said she felt disgusted when the nursing staff took a long time to answer her call light. Resident #9 said it seemed like the facility had enough people working, but sometimes they were all standing in a group talking and laughing in the hallway. Resident #9 said she had started getting herself up from bed because she did not want to wait.Resident #51 was interviewed on 6/10/26 at 10:55 a.m. Resident #51 said she thought the facility was understaffed and the staff were very overworked and exhausted. Resident #51 said it took a very long time at certain times of the day for staff to answer her call light. Resident #51 said staff generally would not respond to her call light for 45 minutes. She said she was blind and could not walk so she needed a lot of help from the facility staff.Resident #52 was interviewed on 6/10/26 at 2:53 p.m. Resident #52 said any time she hit her call button, the staff would come in and turn it off, repeating this process several times. Resident #52 said when a staff member turned her call light off, an hour would go by before they returned. Resident #52 said she usually used her call light to request her pain pill, as she tried to stay on top of her pain to keep it managed. Resident #52 said she felt aggravated by the long call light response time. Resident #52 said she put her call light on at 5:15 p.m. the other day but did not get the medication she requested until 8:30 p.m.Resident #5 and his representative were interviewed together on 6/10/26 at 3:22 p.m. Resident #5's representative said it took the staff a while to come in when Resident #5 pressed his call light. Resident #5's representative said it often took the staff 15 to 20 minutes to answer the resident's call light, but it sometimes took 30 minutes or more.Resident #56 was interviewed on 6/10/26 at 3:28 p.m. Resident #56 said he sat in his bed for three hours the other night waiting for staff to answer his call light. He said he had activated his call light at 7:00 p.m. and no one came in until 10:00 p.m. Resident #56 said he used his call light to get assistance with getting his brief changed. Resident #56 said his roommate pushed his call light every five minutes so the staff thought when the call light activated it was just his roommate calling again. Resident #56 said he was angry when it took the staff so long to answer his call light.Resident #13 was interviewed on 6/10/26 at 2:02 p.m. Resident #13 said it sometimes took staff quite a while to get to her room when she had her call light on. Resident #13 said her roommate had her call light on for four hours the other night. She said the CNA kept coming in to turn her call light off so she kept having to turn it back on. Resident #13 said the facility's administration had told the residents to turn their call light back on if a staff member turned it off, and to keep turning their call light on until their request was complete.C. Resident group interviewSix residents (#43, #56, #1, #19, #23 and #27) who frequently attended the monthly resident council meetings and were identified as alert and oriented by facility and assessment were interviewed on 6/15/26 at 10:01 a.m. All residents in attendance said they had issues with their call lights not being answered timely. Resident #19 and Resident #23 said they both often waited 30 minutes or more for their call lights to be answered. Resident #56 said he had to wait three hours for his call light to be answered the other day. Resident #43 said he usually waited 15 to 20 minutes for his call light to be answered. Resident #56 and Resident #19 said they used their call lights to have their briefs changed. Resident #23 and Resident #1 both said they had heard staff laughing and talking in the hallways while they waited for their call lights to be answered. Resident #56, Resident #1 and Resident #19 said they had sometimes had issues with nursing staff answering their call light but thinking it was their roommate that needed help, helping their roommate and leaving without assisting them with what they needed. All residents in attendance said they felt frustrated having to wait long periods for their call lights to be answered.D. ObservationsOn 6/15/26 at 2:30 p.m. four call lights were activated and visible on the switchboard by the nurses' station. CNA #2 and an unidentified CNA were sitting in the charting area near the nurses' station. One of the CNAs was looking down and using her phone. CNA #3 and CNA #4 were standing near the nurses' station in the common area talking about their outfits. Two staff members approached CNA #3 and CNA #4 and requested their help with assisting residents.At 2:34 p.m. the unidentified CNA said she was not on her break period. The assistant director of nursing (ADON) approached CNA #2 and asked her to help her answer the call lights.E. Record reviewFacility grievances pertaining to call lights were provided by the nursing home administrator (NHA) on 6/11/26 at 3:07 p.m. and revealed the following:The facility received a total of 23 grievances, dated from 1/18/26 through 5/30/26, from residents, resident council meetings and frequent visitors of the facility regarding prolonged call light wait times. Review of these grievances revealed multiple residents reported waiting from 20 minutes to several hours for their call lights to be answered. Multiple residents reported experiencing extended call light wait times overnight. Resolutions to these grievances included staff education, initiating disciplinary actions for staff, and modification of residents' care plans to include their preferred time to get up in the morning or go to bed. All of the grievance forms documented the residents were satisfied with the solution and completed.-However, residents continued to report extended call light wait times throughout the survey process.Quality assessment and performance improvement (QAPI) committee meeting minutes, dated 5/12/26 at 9:00 a.m., revealed the interdisciplinary team (IDT) met to identify and discuss projects and trends within the facility, and reviewed nursing performance improvement plans (PIP). The minutes documented there was an active PIP for call lights. The minutes documented call light audits were being conducted and showed some times of day were busier. Staff were educated in anticipating residents' needs as well as ensuring there was nothing else the resident needed before the staff member left the room. The minutes documented it was mainly three individual residents who were saying they had issues with their call lights, and the staff were keeping in communication with them. The minutes documented the audits were continuing.Call light audits, dated 2/1/26 through 6/13/26, were received from the DON on 6/15/26 at 9:29 a.m. and revealed the following:The call light audits were conducted periodically for a few rooms each time and documented the room, the time the call light was turned on and the time the call light was answered. Call light audits, dated 2/2/26 through 2/19/26, revealed room [ROOM NUMBER] had ten call light audits conducted during the day shift (between 6:00 a.m. and 2:00 p.m.), five call light audits conducted during the evening shift (between 2:00 p.m. and 10:00 p.m.), and no call light audits conducted on the night shift (between 10:00 p.m. and 6:00 a.m.).On 2/16/26 a call light in room [ROOM NUMBER] was activated at 8:30 a.m. and answered at 8:47 a.m.Call light audits, dated 2/2/26 through 2/10/26, revealed room [ROOM NUMBER] had five call light audits conducted during the day shift, one call light audit conducted during the evening shift, and no call light audits conducted on the night shiftOn 2/13/26 a call light in room [ROOM NUMBER] was activated at 12:07 p.m. and answered at 12:28 p.m. On 2/13/26 a call light in room [ROOM NUMBER] was activated at 2:33 p.m. and answered at 2:52 p.m.A call light audit, dated 2/5/26, revealed room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER] each had one call light audit conducted during the day shift.Call light audits, dated 3/2/26 through 3/17/26, revealed room [ROOM NUMBER] had 15 call light audits conducted during the day shift, 12 call light audits conducted during the evening shift, and no call light audits conducted on the night shiftOn 3/13/26 a call light in room [ROOM NUMBER] was activated at 8:00 a.m. and answered at 8:20 a.m.Call light audits, dated 3/18/26 through 4/23/26, revealed room [ROOM NUMBER] had 40 call light audits conducted, one of which was performed during the night shift.On 6/9/26 the call light in room #S2 was activated at 8:20 a.m. and answered at 8:45 a.m.An undated call light log, conducted some time during the weekend of 6/12/26 through 6/14/26 per the DON, revealed a call light was activated in room #S9 at 12:54 a.m. and answered at 1:13 a.m.-No call light audits were conducted during the night shift from 2/2/26 through 5/31/26. -Call light audits were not consistently conducted for any rooms other than room [ROOM NUMBER] and room [ROOM NUMBER] from 2/2/26 through 5/31/26.-Several call lights on the audit log were not answered for 15 minutes or more.Resident council meeting minutes, dated March 2026, revealed residents attending the council meeting voiced concerns regarding staff prioritizing meal tickets and trays over resident care, waiting a long time in the morning to be assisted by staff with getting up and ready, and waiting a long time for their call lights to be answered in the evenings. Resolutions were listed for each concern and included staff education, investigation and resolution of the concern, and continuing call light audits and staff education, respectively.Resident council meeting minutes, dated April 2026, revealed residents attending the council meeting voiced concerns regarding staff turning off residents' call lights before their request was completed and CNAs not helping cover other hallways. The resolution listed for both concerns was staff education.Resident council meeting minutes, dated May 2026, revealed residents attending the council meeting voiced concerns regarding night shift staff not getting coverage when the staff went on break, and staff turning off residents' call lights before completing their request. The resolution listed for both concerns was staff education.-However, staff education was not effective, as residents continued to have multiple concerns regarding call light response times at the time of the survey (see resident interview above).F. Staff interviewsThe DON was interviewed on 6/15/26 at 9:29 a.m. The DON said the receptionist/central supply coordinator was the person who conducted call light audits during the day. The DON said the receptionist had worked during the evening shift for a few weeks to conduct call light audits at night when the administration had identified some concerns with the evening shift. The DON said she had appointed a lead CNA who worked nights, so she was the main person who conducted call light audits at night. The DON said the lead CNA position was created as an intervention for call light wait times, as the night shift staff became more relaxed when the administration team left.-However, review of the call light audits revealed only one night shift audit was documented on the audit log from 2/2/26 through 5/31/26 (see record review above). CNA #3 was interviewed on 6/16/26 at 8:35 am. CNA #3 said she felt like she could get all of her tasks done timely, but the workload was person-dependent. CNA #3 said if she came out of a resident's room and saw multiple call lights were activated, she would answer whichever call light she saw first.CNA #2 was interviewed on 6/16/26 at 8:44 a.m. CNA #2 said she was not sure how to tell which call light to answer first if she left a resident's room and saw multiple call lights were activated. CNA #2 said in that scenario, she would work her way down the hall and answer them in order, or use her judgement if she knew the residents and what they usually used their call light for.The DON was interviewed again on 6/16/26 at 10:44 a.m. The DON said it was the same residents who complained about call lights in each resident council meeting. The DON said when she spoke with those residents, they reported call light times had generally gotten better but there were one-off situations where their call lights took a longer time to be answered. The DON said there were situations where nursing staff would be attending to a resident who needed more assistance, which would delay them in answering other call lights, but residents generally reported their call light times were better. The DON said interventions the administration put in place to improve call light wait times included staff education, one-on-one education with specific staff members, initiating disciplinary action for staff members, shifting staffing positions to different areas, designating a shower aide in the evening shifts, creating the position of lead CNA and trying to identify a root cause. The DON said she was not able to determine a root cause for the long call light times because the call light concerns seemed to move from shift to shift and could not have a blanket answer for each instance. The DON said she was trying to [NAME] in on some of the nursing staff to improve the issue. The DON said she was consistently trying to come up with new solutions to the issue, which was why the facility had conducted call light audits here and there. The DON said she did not want to say one specific call light wait time was her expectation, but said she would want to analyze a call light wait time of 15 or 20 minutes to see what happened and why it took that amount of time for staff to answer.The DON said for call light audits, the receptionist would watch the call light alert board for the residents' rooms they identified from grievance forms and time the call light responses. The DON said she created the role of lead CNA to do the same process for rooms they had identified from grievance forms, and said the CNA would throw in other random rooms for the audit if they could. The DON said the nurses had been conducting the night shift call light audits and had been including CNAs into the audit workload as well. The DON said she had done call light audits sporadically whenever she received grievance forms. The DON said she and the ADON had come in on a few night shifts to perform call light audits but said the staff were more conscientious when they were in the building, so they did not accurately reflect what may have been happening, and the DON had not recorded or documented these audits. The DON said there were no documented call light audits completed by any members of the IDT.II. Failed to ensure residents were treated with dignity by staff during meal serviceA. Facility policy and procedureThe Dignity and Respect policy and procedure, revised February 2020, was received from the DON on 6/17/26 at 11:02 a.m. It read in pertinent part, The staff shall display respect for residents when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings.B. ObservationsDuring a continuous observation of the lunch meal service on 6/10/26, beginning at 11:41 a.m. and ending at 12:13 p.m., the following was observed:At 11:41 a.m. CNA #3 was standing at a dining table where Resident #44 and Resident #10 were seated. CNA #3 asked an unidentified dietary aide if he had the two feeder's meals coming up, and pointed at Resident #44 and Resident #10. -CNA #3 said this with a volume that was heard from the other end of the dining room and was within earshot of the other residents.C. Staff interviewsA social services support staff member, who was filling in for the social services director, was interviewed on 6/16/26 at 10:04 a.m. The social services support staff member said she would expect the facility staff to talk to residents with respect during meal service and talk to the residents themselves, rather than talking around them. The social services support staff member said it was not appropriate to refer to residents as feeders as it was an issue of dignity, and said she would not want to be called a feeder.The DON was interviewed on 6/16/26 at 10:44 a.m. The DON said facility staff should converse with the residents they were assisting with eating and should not refer to residents as feeders. The DON said being called a feeder would make her feel like she was not a part of everyone else.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in one of two medication carts and one of one medication storage room. Specifically, the facility failed to:Ensure medications were labeled with the date they were opened;-Ensure expired medications were disposed of; and, -Ensure there were no loose pills in the bottom of the medication cart's drawers.Findings include:I. Professional referenceThe United States Food and Drug Administration (USFDA) Don't Be Tempted to Use ExpiredMedicines (revised 10/31/24) was retrieved on 6/21/26 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It read in pertinent part, Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth, and subpotent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed, there is no guarantee that the medicine will be safe and effective. If your medicine has expired, do not use it.According to the manufacturer's recommendations for Latanoprost 0.005% ophthalmic solution, retrieved 7/21/26 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/020597s044lbl.pdf, Once a bottle is opened for use, it may be stored at room temperature up to 25 degrees Celsius (C)/77 degrees Fahrenheit (F) for six weeks.According to the manufacturer's recommendations for Flonase, retrieved on 6/21/26 from https://www.flonase.com/products/sensimist/faqs/,, Flonase Sensimist: A 60-spray bottle will last you two weeks and a 120-spray bottle will last you four weeks. Standard Flonase/Fluticasone Propionate is good for up to 60 days after opening. According to Health Direct Pharmacy Services (6/22/26), RX Guides: Select Medications with Shortened Expiration Dates., retrieved on 6/24/26 fromhttps://www.hdrxservices.com/rx-guides-select-medications-with-shortened-expiration-dates/ Ipratropium Albuterol three months after first actuation or when the device locks out.According to the manufacturer's recommendations for azelastine HCl ophthalmic solution 0.05%, retrieved on 6/24/26 from https://www.medicines.org.uk/emc/files/pil.11152.pdf, Once opened: Do not use this medicine if the bottle has been open for longer than 28 days. This medicine does not require any special storage conditions.II. Facility policy and procedureThe Medication storage policy, dated 10/1/23, was provided by the nursing home administrator (NHA) on 6/11/26 at 4:21 p.m. It revealed in pertinent part, All medications dispensed by the pharmacy are stored in the container with the pharmacy label. Outdated medications are immediately removed from inventory and disposed of in accordance with medication disposal procedures. Medication storage conditions are monitored every month by the consultant pharmacist. Multiple-dose ophthalmic products, once opened, require an expiration date that is shorter than the manufacturer's expiration date to ensure medication purity and potency. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a 'Date opened' sticker and enter the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating.III. ObservationsThe medication room was observed with the director of nursing (DON) on 6/11/26 at 11:29 p.m. The following item was found:-One bottle of latanoprost 0.005% eye drops which expired on 1/25/26.Medication cart one was observed with registered nurse (RN) #5 on 6/11/26 at 2:00 p.m. The following items were found:-One bottle of latanoprost ophthalmic solution 0.005 % was not labeled with the date it was opened; -One bottle of fluticasone propionate nasal suspension 50 microgram per actuation (mcg/act) was not labeled with the date it was opened; -One bottle of fluticasone propionate nasal suspension 50 mcg/act was not labeled with the date it was opened;-Ipratropium-Albuterol Inhalation Solution 0.5-2.5 mg/3ml inhaler was not labeled with the date it was opened;-One bottle of azelastine HCl ophthalmic solution 0.05% was not labeled with the date it was opened; and,-One bottle of fluticasone propionate nasal suspension was not labeled with a resident's name or the date it was opened. -There were 33 unidentified pills loose on the bottom of the medication cart's first and second drawers.IV. Staff interviewsRN #5 was interviewed on 6/11/26 at 2:20 p.m. RN#5 said the nurse who opens a medication should mark the open date and expiration date on the medication. He said each nurse on their shift should clean the medication carts. He said the night nurses should be checking for expiration dates and open dates on the medication. He said expiration dates should be clearly marked to prevent administration of expired medication. He said if medications were expired, the medication may not be effective. RN #5 said the pharmacy consultant completed monthly rounds to check medication expiration dates. The DON was interviewed on 6/11/26 at 3:29 p.m The DON said the night shift nurses had the task of checking the medication room and the medication carts for open dates and expiration dates on medications. She said all the nurses should clean the medication carts on their shift. The DON said the night shift nurses should discard expired medications according to the policy. She said the pharmacy consultant completed a monthly audit of the medication carts and medication room. The DON said expired medications may not be as effective.

Based on observations, record review and interviews, the facility failed to provide an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to: -Ensure the facility was kept free from mice, spiders and other insects; and,-Consistently follow recommendations from the pest control company to decrease the potential for mice, spiders and other insects to enter the facility.Findings include: I. Professional reference According to the Centers for Disease Control(CDC) Guidelines for Environmental Infection Control in Health-Care Facilities (revised July 2019), retrieved on 6/19/26 from https://www.cdc.gov/infection-control/media/pdfs/Guideline-Environmental-H.pdf,From a public health and hygiene perspective, pests should be eradicated from all indoor environments. Approaches to institutional pest management should focus on: eliminating food sources, indoor habitats, and other conditions that attract pests; excluding pests from entering the indoor environments; and applying pesticides as needed. Rodents can transmit viruses such as lymphocytic choriomeningitis, bacteria such as campylobacteriosis, leptospirosis, plague, salmonellosis, tularemia, yersiniosis, and fungi such as dermatophytosis. Spiders and mice are among the typical arthropod and vertebrate pest populations found in health-care facilities. Insects can serve as agents for the mechanical transmission of microorganisms or as active participants in the disease transmission process as vectors. Sealing windows helps to minimize insect intrusion. When windows need to be opened for ventilation, ensuring that screens are in good repair and closing doors to the outside can help with pest control. A pest-control specialist with appropriate credentials can provide a regular insect-control program that is tailored to the needs of the facility and uses approved chemicals and/or physical methods.II. Facility policy and procedure The Pest Control Program policy, dated January 2025 and revised 6/9/26, was received from the nursing home administrator (NHA) on 6/17/26 at 11:02 a.m. It read in pertinent part, The policy is to maintain an effective pest control program that eradicates and contains common household pests and rodents. The facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis. The facility will utilize a variety of methods in controlling certain seasonal pests. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations.III. Facility observations staff interviewOn 6/10/26 at 8:51 a.m. a tour of the kitchen was conducted. The door to the alleyway in the back of the kitchen was observed to be propped open and no staff members were walking in or out of the doorway.On 6/10/26 at 9:21 a.m. a gap was observed under the emergency exit door at the end of the [NAME] hallway, which exited to the outside of the facility. There was daylight visible through the gap.On 6/10/26 at 2:40 p.m. a spider was observed crawling on the floor in the middle of the hallway at the intersection of the Silverthorn and Aspen unit hallways. Resident #51 was walking with a member of the therapy staff. The therapy staff member crushed the spider with her shoe. Resident #51 told the therapy staff member that she had seen spiders in her room.On 6/10/26 at 3:22 p.m. a large spider was observed by the doorframe of the exit door at the eastern end of the [NAME] hallway.On 6/12/26 at 1:30 p.m. there were two mousetrap boxes observed on the floor at the end of the 100 hallway.On 6/16/26 at 11:53, following an initial interview (see interview below), the maintenance director went to Resident #3 and Resident #7's shared room. The maintenance director said that there were no spiders in that room. He said that there were sticky traps in the residents' room because when one resident requested a sticky trap, they were placed in every residents' room.Resident #7 said she did see spiders in their room.Resident #3 said she saw a centipede at night but she had not yet reported it. The maintenance director proceeded to remove the sticky traps that had been placed under each sink in Resident #3's room. He confirmed that the first sticky trap had one spider and mouse droppings on it and the second sticky trap had bugs and mouse droppings on it. The maintenance director said the sticky traps were changed out every Friday. He said he would spray for insects when the NHA asked him to spray. During the interview, a bug was observed walking across the floor. The maintenance director said the bug was a glow bug. IV. Resident interviews and observationsResident #51 was interviewed on 6/10/26 at 10:55 a.m. Resident #51 said she had spiders in her room and saw them every day. Resident #51 said she had previously had an ant issue in her room and the sanitary conditions of the facility left something to be desired. A glue trap was observed under Resident #51's sink. The glue trap had several spiders of varying sizes on it and a spider was observed walking across the resident's wall during the interview.Resident #27 was interviewed on 6/10/26 at 4:56 p.m. Resident #27 said he had seen a mouse in his room and the last time he had seen it was two days (6/8/26) ago, around 3:00 p.m., by the radiator. During the interview, several mouse droppings were observed by the window sill and under the sink. There was a mouse trap underneath the radiator and under the sink. Resident #27 said he did not like having a mouse in his room.Resident #7 was interviewed on 6/11/26 at 9:41 a.m. Resident #7 said she had seen a spider on her bed the other day and said she had seen several large spiders crawling under her bed and on her walls. During the interview, a glue trap was observed under the resident's sink. The glue trap contained several mouse droppings on it.Resident #48 was interviewed on 6/11/26 at 9:50 a.m. Resident #48 said she had mouse droppings in her room. She said she reported it to the facility staff. Resident #48 said she cleaned out her room and removed all food from her room to try to eliminate the mouse problem. Resident #25 was interviewed on 6/11/26 at 10:00 a.m. Resident #25 said she had seen mouse droppings in her room and she had cleaned out all her food from her room. She said she did not have any food in her drawers. Resident #25 said she hoped not to see any more mice because she did not like them.Resident #3 was interviewed on 6/11/26 at 10:18 a.m. Resident #3 said she had seen a bug parade on her floor this morning (6/11/26). She said she had seen several insects crawling along her floor.V. Resident group interviewSix residents (#43, #56, #1, #19, #23 and #27) who frequently attended the monthly resident council meetings and who were identified as alert and oriented by facility and assessment were interviewed on 6/15/26 at 10:01 a.m. Resident #19 and Resident #43 both reported seeing spiders in their rooms and both residents said they had been bitten by spiders in the facility recently.Resident #1 and Resident #19 said the facility had tons of mice. Resident #19 said the residents had been voicing their concerns about mice each month in resident council meetings since January 2026. Resident #19 said he had found several mice in his room and had seen mouse feces on his bed. He said the way the facility was trying to treat the mice problem was not working.Resident #27 said he saw mice running from resident room to resident room and down the facility's hallways.VI. Resident council meeting minutesReview of the facility's resident council meeting minutes, from December 2025 through May 2026 revealed the following:The 12/29/25 resident council meeting minutes documented there was a continued mouse problem and the facility would continue checking the traps and putting new traps down.The 1/15/26 resident council meeting minutes documented would continue to monitor mice in the building and the mouse traps. The minutes did not identify that the concern regarding the mouse problem had been resolved.The 2/19/26 resident council meeting minutes did not identify that the facility's mouse problem had been discussed at the meeting or that the concern regarding the mouse problem had been resolved. The March 2026 (no day specified) resident council meeting minutes documented there were no unresolved issues from the February 2026 resident council meeting. However, the meeting minutes additionally documented that maintenance would continue checking the mouse traps daily.The April 2026 (no day specified) resident council meeting minutes did not identify that the facility's mouse problem had been discussed at the meeting or that the concern regarding the mouse problem had been resolved.The 5/21/26 resident council meeting minutes documented that mouse traps in resident rooms had been observed to have mouse activity and the traps were checked daily.-Review of the resident council meeting minutes, from December 2025 through May 2026 did not identify that the facility was attempting to address the mouse problem in other ways besides placing and checking mouse traps.VII. Additional record reviewReview of pest control service invoices were provided by the facility for 1/13/26, 2/5/26, 3/6/26, 4/15/26, 5/8/26 and 6/1/26.The 4/25/26 pest control service invoice documented that the pest control company identified an area in the facility that had a door gap and a door that was open when it was not in use. The recommendation was for the facility to add/repair the door sweep (the plastic or rubber part that attaches to the bottom of the door). Additionally, the 4/15/26 pest control service invoice documented the pest control company identified a second area in the facility that had a door gap. The recommendation was for the facility to seal the gap.The 5/8/26 pest control service invoice documented the pest control company identified that the door to the dumpster area outside the facility had a door gap and was observed to be open when not in use. The service invoice documented the concern remained an open action issue from the April 2026 service visit. The recommendations were for the facility to add/repair the door sweep and keep the door closed. The service invoice documented that a resolution by the facility was needed.The 6/1/26 pest control service invoice documented the openings around the penetration points (entry points into the facility) remained an open action issue from the April 2026 visit and the status of the resolution was still pending.-However, observations during the survey revealed the door to the alleyway in the back of the kitchen was propped open when it was not in use and there was a gap under the emergency exit door at the end of the [NAME] hallway, which exited to the outside of the facility (see facility observations above).VIII. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 6/15/26 at 11:40 a.m. CNA #1 said he had seen a spider in the charting room. He said he killed it and disposed of it. CNA #1 said he did not report it. CNA #1 said he had heard discussions about mice being an issue in the facility from residents and other staff members. Housekeeper (HK) #1 was interviewed on 6/16/26 at 11:15 a.m. HK #1 said she had heard residents complain about mice. She said she attended the resident council meetings and had heard the residents' discussion of pests leaving droppings in the residents' rooms.The maintenance director was interviewed on 6/16/26 at 11:45 a.m. The maintenance director said the pest control company came to the facility monthly to address the issues with mice. He said he called the pest control company to come out more frequently when needed. He said he had requested two additional mousetrap boxes for the facility and said the facility had a total of six mousetrap boxes. He said he had requested that housekeeping frequently check the residents' rooms and floors after meals to sweep up and clean crumbs. The maintenance director said he had not seen any notes regarding doors being left open or other recommendations on the pest control invoices. The maintenance director said when he received invoices from the pest control company, he looked at what services were provided and what they cost. He said he must have missed the notes in the service invoices regarding the pest control company's recommendations (see record review above).

Based on record review and interviews, the facility failed to document resuscitation choices accurately in the medical record for two (#5 and #40) of 24 residents reviewed out of 41 sample residents. Specially, the facility failed to:-Ensure Resident #5's medical orders for scope of treatment (MOST) form matched the computerized physician orders (CPO) for cardiopulmonary resuscitation (CPR); and,-Ensure Resident #40's MOST form matched the CPO for no CPR.Findings include:I. Facility policy and procedureThe Advanced Directives policy and procedure, revised [DATE], was received from the director of nursing (DON) on [DATE] at 11:02 a.m. It read in pertinent part, Once the advanced directive or information regarding resident preferences regarding treatment options is received by the facility, it will be confirmed in the resident medical record and communicated to members of the care plan team. The facility will also notify the attending physician of advanced directives so that, if necessary, appropriate orders can be documented in the resident's medical record and plan of care.II. Resident #5A. Resident statusResident #5, age [AGE], was admitted on [DATE]. According to the [DATE] CPO, diagnoses included chronic obstructive pulmonary disease, chronic kidney disease, dementia and Alzheimer's disease. The [DATE] minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 10 out of 15. B. Resident's representative interviewResident #5's representative, who was the resident's power of attorney (POA) was interviewed on [DATE] at 2:24 p.m. The resident's representative said she was not sure if she had filled out any documentation regarding her wishes for Resident #5's code status (a set of medical orders directing what life-saving interventions a healthcare team should perform if a patient's heart or breathing stops) when he first admitted to the facility. The resident's representative said she would want Resident #5 to receive CPR at that moment because he was still strong, but said her decision would depend on what his condition was at the time of the event.C. Record reviewResident #5's MOST form, located in the advance directive binder at the nurses' station and uploaded into the resident's electronic medical record (EMR), revealed it was signed and dated on [DATE] by the resident's POA. The MOST form indicated the resident's/POA's wishes were for Resident #5 to receive CPR with full treatment, including intravenous (IV) antibiotics and fluids and intubation. -However, review of Resident #5's [DATE] CPO revealed a physician's order for do not attempt resuscitation (DNR), ordered [DATE] and signed by Resident #5's physician on [DATE].Another MOST form for Resident #5, dated [DATE], was uploaded to Resident #5's EMR on [DATE] (during the survey process). The MOST form was signed by Resident #5's POA on [DATE]. The MOST form indicated no CPR and comfort-focused treatment, which included relieving pain using medication and manual treatment of airway obstruction. The form documented the director of nursing (DON) had reviewed the form on [DATE] and no changes had been made.-However, a second MOST form had been created and uploaded on [DATE] which indicated Resident #5's POA did elect for the resident to receive CPR (see above). III. Resident #40A. Resident statusResident #40, age [AGE], was admitted on [DATE] and discharged to independent living on [DATE]. According to the [DATE] CPO, diagnoses included fracture of right tibia, type 2 diabetes and atherosclerotic heart disease (plaque build-up inside the arteries that supply blood to the heart).The [DATE] MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. B. Resident interviewResident #40 was interviewed on [DATE] at 10:28 a.m. Resident #40 said he had indicated on his admission paperwork that he did not want to receive CPR. Resident #40 said he had changed his decision a few days ago and elected to receive CPR without extreme measures.-However, a new MOST form was not completed for Resident #40 to reflect the update in his CPR elections (see record review below). -Additionally, Resident #40's EMR and [DATE] CPO did not reflect his CPR elections on admission (see record review below).C. Record reviewResident #40's MOST form, located in the advance directive binder at the nurses' station and uploaded into the resident's EMR, revealed it was signed and dated on [DATE] by the resident. The MOST form indicated the resident's wishes were for no CPR with comfort-focused treatment which included do not intubate and to avoid intensive care. Review of Resident #40's [DATE] CPO revealed the following physician's orders:CPR/Full code, ordered [DATE] and discontinued [DATE]; and,DNR/comfort measures, ordered [DATE] (during the survey process).-Resident #40's physician's order for code status was not updated to match what he elected on his [DATE] MOST form (DNR) until [DATE], during the survey process, and the day of the resident's discharge from the facility.IV. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on [DATE] at 2:49 p.m. LPN #1 said the charge nurse was the person responsible for going through all of the newly admitted residents' paperwork and uploading the information into their EMRs. He said the DON would follow up to ensure it was entered correctly. LPN #1 said the facility kept a physical copy of residents' MOST forms in a binder at the nurses' station. LPN #1 said in an emergency, he would generally check a resident's EMR for their code status information first because it was easier to access.Registered nurse (RN) #5, who also served as a charge nurse, was interviewed on [DATE] at 2:53 p.m. RN #5 said the medical records official was the person responsible for entering MOST form information for newly admitted residents. RN #5 said he would use the resident's EMR in an emergency to find their code status information and said he did not have to use the paper copy of the MOST form. RN #5 said if a resident wanted to change their code status, the staff would assist them in filling out a new MOST form. RN #5 retrieved the advanced directives binder from the nurses' station and found Resident #5's MOST form. He said the resident elected for a full code/CPR code status. RN #5 then found Resident #40's MOST form in the binder which he said documented the resident wanted no CPR and comfort care.-However, the MOST forms RN #5 found in the advanced directives binder did not match the physician's orders in the residents' EMRs (see above).The medical records official was interviewed on [DATE] at 3:07 p.m. The medical records official said the facility had recently changed how new admission paperwork was handled. The medical records official said the nursing staff went through the new admission paperwork with the residents and their families, and said the charge nurse now uploaded that information to the residents' EMRs. The medical records official said that documentation had previously come to her to be uploaded, but she had gotten too far behind in uploading it, and said the change in processes had happened the month prior ([DATE]). The medical records official said the nursing staff were the responsible parties for entering the physician's orders for whether the resident would receive CPR or was DNR in the resident's EMR. The DON was interviewed on [DATE] at 3:17 p.m. The DON said when a new resident was admitted to the facility, the charge nurse would take the resident their admission packet, including the MOST form, and go through the admission information with the resident. The DON said she and the assistant director of nursing (ADON) would then enter all of the resident's physician orders into their EMR. The DON said if a resident admitted with a MOST form, she would make sure those physician's orders for code status were entered into their EMR, and if any changes needed to be made to their existing MOST form, the physician's orders in their EMR would be changed. The DON said nursing staff should use the physical copy of the resident's MOST form in the case of an emergency to identify the resident's code status and treatment elections. The DON said the code status information in residents' EMRs should match their MOST form. -However, interviews with nursing staff revealed they did not look for the physical copies of residents' MOST forms in the event of an emergency, but relied on the information in the residents' EMRs.The DON said she had identified the discrepancies between Resident #5 and Resident #40's MOST forms and their EMRs that day ([DATE]) and said she was not sure what happened. The DON said if a resident wanted to change their code status, they would need to fill out a new MOST form. The DON said Resident #40 had just spoken with his physician the day prior ([DATE]) and may have reviewed his code status elections at that time.The regional nurse consultant was interviewed on [DATE] at approximately 5:15 p.m. The regional nurse consultant said she had found another MOST form for Resident #5 tucked away in the advanced directives binder, which she said was the most accurate form for the resident and matched what was in his EMR.-However, the MOST form, dated [DATE], had been filled out prior to the newer MOST form available in the advanced directives binder for Resident #5 (see record review above).RN #4 was interviewed on [DATE] at 10:34 a.m. RN #4 said in the event of an emergency, she would look for a resident's code status information in their EMR. RN #4 said she thought there were also physical copies of residents' MOST forms in a binder at the nurse's station, but said she would look at the resident's EMR first because it was faster.The DON was interviewed a second time on [DATE] at 10:44 a.m. The DON said Resident #5 had been admitted to the facility with an existing MOST form (the form dated [DATE]). The DON said the regional nurse consultant had found Resident #5's MOST form, and said it revealed the resident's code status was DNR. The DON said the MOST form originally in Resident #5's EMR was filled out by the resident himself, while the form dated [DATE] was filled out by the resident's POA. The DON said since Resident #5 had cognitive impairments, the facility needed to use the MOST form filled out by his POA. -However, both the [DATE] and the [DATE] MOST forms were filled out and signed by Resident #5's POA. -Additionally, the physical copy of the version of Resident #5's MOST form the DON said was correct ([DATE]) was not readily available in the advanced directives binder at the nurses' station for staff to use.V. Facility follow-upThe DON provided a copy of Resident #5's MOST form via email on [DATE] at 11:02 a.m., after the survey exit The MOST form, dated [DATE], revealed Resident #5's code status had been reviewed again on [DATE] without any changes. The MOST form indicated Resident #5's representative elected not to have the resident receive CPR.-However, an interview with Resident #5's representative on [DATE] revealed she did not recall reviewing Resident #5's code status and wanted the resident to receive CPR at that time (see representative's interview above).

Based on observations, record review and interviews, the facility failed to communicate effectively with the dialysis centers for one (#3) of two residents reviewed for dialysis out of 41 sample residents.Specifically, the facility failed to ensure pre- and post-dialysis assessments for Resident #3 were completed and documented per professional standards.Findings include:I. Facility policy and procedureThe Renal Dialysis, Care of Resident, Hemodialysis Access Site policy and procedure, revised December 2025, was received from the director of nursing (DON) on 6/17/26 at 11:02 a.m. It read in pertinent part, The facility licensed nurse will complete the baseline information, pre- and post-dialysis section of the nurses dialysis communication record. Dialysis center licensed nurses will complete the dialysis center section of the nurses dialysis communication record.II. Resident #3A. Resident statusResident #3, age [AGE], was admitted on [DATE]. According to the June 2026 computerized physicians orders (CPO), diagnoses included end stage renal disease (the irreversible loss of 85% to 90% of kidney function, where the kidneys can no longer support life), type 2 diabetes mellitus, chronic respiratory failure and seizures.The 4/24/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. The resident required setup or cleanup assistance for most activities of daily living (ADL). The assessment documented the resident was receiving dialysis.B. Resident interviewResident #3 was interviewed on 6/11/26 at 9:26 a.m. Resident #3 said she had a dialysis binder at the nurses' station and said the nursing staff were supposed to fill out information in the binder each time before she went to dialysis. Resident #3 said the facility's nursing staff had not filled out her binder when she went to dialysis the day prior (6/10/26). Resident #3 said she kept asking the nursing staff to fill out her binder before her dialysis appointments because it was supposed to be done. Resident #3 said there was only one nurse who filled out her dialysis binder consistently. Resident #3 said the nursing staff usually assessed her blood pressure prior to her dialysis appointments but said she did not think they assessed it afterwards.Resident #3 said she felt frustrated and did not know why she had to keep reminding the nurses when it was supposed to be done, as the dialysis center staff appreciated seeing it was filled out. Resident #3 said there was an instance in December 2025 where the nursing staff had not looked at the notice posted on her dialysis binder from the dialysis center which revealed her dialysis appointment time had been changed due to an upcoming holiday. Resident #3 said she was still able to attend her appointment because the outside transportation company had arrived to pick her up, but said she was late to her appointment because the nursing staff had not prepared her to go to the appointment. Resident #3 said she should not have to do the facility nursing staff's job for them.C. Record reviewThe dialysis care plan, revised 9/10/25, revealed Resident #3 needed dialysis to treat her end stage renal disease. Pertinent interventions included encouraging Resident #3 to go to her scheduled appointments on Mondays, Wednesdays and Fridays, checking the resident's arteriovenous fistula every day for bruit (low pitched whooshing sound heard with a stethoscope over a fistula indicating healthy blood flow through the vascular access site) or thrill (physical vibration or buzzing sensation felt with the fingertips over a vascular access site), and monitoring, documenting and reporting to the physician any signs of bleeding, hemorrhage, bacteremia or septic shock.Review of Resident #3's June 2026 CPO revealed the following physician's order:Send Resident #3 with dialysis communication form. If the form is not returned, call the dialysis center and ask for it to be faxed to the facility, ordered 10/17/25 and revised 6/10/26 at 10:22 a.m. (during the survey process).Review of Resident #3's dialysis communications forms, from 3/11/26 to 6/12/26, revealed the forms consisted of a pre-dialysis assessment section and a section which gave information and assessment results during the dialysis treatment.The pre-dialysis section was to be filled out by facility nursing staff and contained information about vital signs, weight, blood glucose level, assessment of the access site (the surgically created point on the body where blood was removed and returned during hemodialysis), the resident's diet, medications administered pre-dialysis, diet and time of last meal, and any meals sent with the resident to the dialysis center.The dialysis center section of the communication form was to be filled out by dialysis staff. The section consisted of the dialysis center name, nephrologist (specialized physician who diagnoses and treats kidney diseases), vital signs taken, condition of the access site, whether or not a bruit and trill were present, type of vascular access site, and notes about amount of food consumed during the dialysis procedure.Review of Resident #3's dialysis communication forms revealed the following:The pre-dialysis center information was not filled out in its entirety on 3/11/26.The dialysis center information section was not filled out and was blank or nearly blank on 4/8/26, 4/13/26 and 4/15/26.No dialysis communication form was provided, the pre-dialysis information was not filled out and the dialysis center wrote resident assessment information on a sticky note or blank piece of paper on 3/13/26, 3/16/26, 3/20/26, 3/23/26, and 6/10/26.-Review of Resident #3's electronic medical record (EMR) did not reveal documentation to indicate the dialysis center information, from 4/8/26 through 4/15/26, had been obtained or recorded by the facility.-Review of Resident #3's EMR did not reveal documentation to indicate Resident #3 was assessed or had her vital signs obtained consistently after dialysis, from 3/11/26 through 6/8/26.Review of Resident #3's June 2026 medication administration record (MAR), from 6/1/26 through 6/15/26, revealed the following:-Resident #3's vital signs were measured at 3:00 p.m. (pre-dialysis) and at 7:30 p.m. (post-dialysis) on 6/10/26, 6/12/26 and 6/15/26 and recorded in the order to send Resident #3 with her dialysis form. No other vital signs were recorded in the MAR before or after Resident #3's dialysis appointments from 6/1/26 through 6/8/26. III. Staff interviewsRegistered nurse (RN) #1 was interviewed on 6/16/26 at 9:54 a.m. RN #1 said Resident #3 went to her dialysis appointments on Mondays, Wednesdays and Fridays each week. RN #1 said she checked Resident #3's vital signs before and after her dialysis appointments and recorded them in her dialysis binder and in her EMR.RN #4 was interviewed on 6/16/26 at 10:34 a.m. RN #4 said residents receiving dialysis had a binder that was kept at the nurses' station. RN #4 said to prepare a resident to go to dialysis, she would make sure the resident was dressed and ready, get their face sheet and any medications, and assess the resident's vital signs. RN #4 said she would also assess the resident's vital signs when they returned from their dialysis appointments. RN #4 said she would document the resident's vital signs in their EMR. RN #4 said the nursing staff needed to obtain the resident's vital signs before and after their dialysis appointments to establish their baseline and to assess the resident's condition when they returned. The DON was interviewed on 6/16/26 at 10:44 a.m. The DON said there were dialysis communication sheets kept in the resident's dialysis binder. The DON said on dialysis days, there were orders in the resident's CPO to obtain vital signs before and after the dialysis appointment, monitor the shunt or fistula, and monitor pre- and post- dialysis weights. The DON said the nursing staff should record the resident's vital signs in the dialysis communication binder and in their MAR. The DON said she had noticed an issue with Resident #3's vital signs measurement order and had corrected it (on 6/10/26 during the survey process - see record review above). The DON said she expected the nursing staff to assess Resident #3's vital signs after she returned from dialysis to see how her body handled the dialysis appointment.

Based on observations, record review and interviews, the facility failed to ensure received routine dental care obtaining routine and 24-hour emergency dental care for one (#7) of three residents reviewed for ancillary services out of 41 sample residents. Specifically, the facility failed to provide dental services for Resident #7, who had been identified as having dental decay.Findings include:I. Facility policy and procedureThe Dental Services policy and procedure, revised November 2019, was received from the director of nursing (DON) on 6/17/26 at 11:02 a.m. It read in pertinent part, It is the policy of this facility, in accordance with residents' needs, to promptly assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. The facility will, if necessary or requested, assist the resident with making dental appointments and arranging transportation to and from the dental services location. All actions and information regarding dental services, including any delays related to obtaining dental services, will be documented in the resident's medical record.II. Resident #7A. Resident statusResident #7, age [AGE], was admitted on [DATE], discharged home on 3/20/26 and readmitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included cellulitis of the right lower limb, need for assistance with personal cares, epilepsy and adult failure to thrive.According to the 4/18/26 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required setup or cleanup assistance from staff for oral hygiene and required partial to maximal assistance from staff for most other activities of daily living (ADL).The assessment documented the resident had obvious or likely cavities or broken natural teeth.B. Resident interview and observationsResident #7 was interviewed on 6/11/26 at 9:41 a.m. Resident #7 said she had one tooth that felt tender. Resident #7 said she had seen the dental hygienist once but had not seen a dentist in a while. Resident #7 said she thought she should see a dentist.Resident #7 held the upper left side of her mouth as she spoke about her sore tooth. C. Record reviewThe dental care plan, revised 4/20/26, revealed Resident #7 had oral/dental health problems resulting from poor oral hygiene. Pertinent interventions included coordinating arrangements for dental care and providing transportation as needed, and monitoring and reporting to Resident #7's physician any signs of oral/dental problems needing attention, including pain or her teeth being missing, loose, broken, eroded or decayed.A dental hygiene treatment chart, dated 9/18/25, revealed Resident #7 was seen by the dental hygienist for an exam and prophylaxis. Resident #7 was documented to have complained of upper left and lower right quadrant mouth pain. Resident #7 had severe inflammation, high decay rate, heavy bleeding, plaque and calculus and poor oral hygiene. Resident #7 had possible decay for teeth #3, #14 and #18. The note documented Resident #7 needed extractions and recommended an appointment for scaling and root planing (a dental cleaning procedure used to treat gum disease).A dental visit note, dated 10/8/25, revealed Resident #7 was seen by a dentist for a comprehensive exam. Resident #7 had moderate plaque accumulation throughout her dentition and moderate to severe bone loss. Resident #7 was interested in extracting tooth #15 (a tooth on the upper left quadrant) at her next visit. The dentist documented tooth #15 was not able to be restored, and had a fluoride application applied to the cavity surfaces. The dentist documented Resident #7's recommended treatments included a hygienist visit and extraction of tooth #15. The dentist documented Resident #7 would have tooth #15 extracted at her next visit.-However, review of Resident #7's electronic medical record (EMR) did not reveal documentation to indicate any follow-up dental appointments to remove tooth #15 were scheduled.A social services note, dated 11/28/25 at 1:38 p.m., revealed Resident #7 was reviewed by the social services team. The note documented Resident #7 had last been seen for a dental exam on 10/8/25 and visited the dental hygienist on 9/18/25.-The note did not document any dental follow-up appointments were needed for Resident #7.A dental hygiene treatment chart, dated 12/9/25, revealed Resident #7 was seen by the dental hygienist for a scale and root planing. Resident #7 had severe inflammation, high decay rate, heavy bleeding, plaque and calculus and poor oral hygiene. Resident #7 had possible decay for tooth #15. The hygienist recommended Resident #7 have a visit for periodontal maintenance (a maintenance hygienist visit typically performed every three to four months to treat gum disease).-However, review of Resident #7's EMR did not reveal documentation to indicate any follow-up dental appointments were scheduled.A social services note, dated 2/26/26 at 3:30 p.m., revealed Resident #7 was reviewed by the social services team. The note documented Resident #7 had last been seen by the dentist on 12/9/25.-The note did not document any dental follow-up appointments were needed for Resident #7.A readmission assessment tool, dated 4/12/26 at 3:57 p.m., revealed Resident #7 was assessed by a member of the facility's nursing staff on admission. Resident #7's oral/dental status was not evaluated at the time.A social services progress note, dated 4/17/26 at 10:52 a.m., revealed Resident #7 was reviewed by the social services team. The note revealed Resident #7 did not have any immediate ancillary requests. A care plan review note, dated 4/17/26 at 3:10 p.m., revealed Resident #7 attended a care conference. The social services plan of care section of the review note revealed Resident #7 had last been seen for dental services on 12/9/25.-The note did not document any dental follow-up appointments were needed for Resident #7.A progress note, dated 5/22/26 at 1:59 p.m., revealed Resident #7 had obvious or likely cavities or broken natural teeth.Review of Resident #7's electronic medical record (EMR) did not reveal any care conference documentation or any documentation pertaining to dentistry referrals following her readmission on [DATE].III. Staff interviewsRegistered nurse (RN) #1 was interviewed on 6/16/26 at 9:54 a.m. RN #1 said the facility kept a list of residents who needed to see the dentist or other ancillary staff, and said the charge nurse was responsible for adding residents to those lists. RN #1 said the charge nurse would then let the nursing staff know who needed to go to which appointments after they were scheduled.A social services support staff member, who was filling in for the social services director (SSD), was interviewed on 6/16/26 at 10:04 a.m. The social services support staff member said the facility's dentist usually came in once per month. The social services support staff member said if a resident had an identified cavity or needed a dental appointment to examine a toothache and the dentist was not due to arrive soon, she would arrange for the resident to be seen by another dentist in the community. The social services support staff member said if a resident needed a tooth extracted and needed a follow-up appointment to have the tooth extracted, residents were sometimes referred to an oral surgeon. The social services support staff member said she usually tried to schedule the follow-up extraction appointments within a few days of the initial dental exam. The social services support staff member said she was not familiar with Resident #7 but would look into her case.RN #4 was interviewed on 6/16/26 at 10:34 a.m. RN #4 said if a resident told her they had any issues with their teeth, she would first assess the resident to see if the issue was urgent. RN #4 said after her assessment, she would let her charge nurse know about the issue. RN #4 said the facility kept a list of residents who needed to be seen by the dentist.The DON was interviewed on 6/16/26 at 10:44 a.m. The DON said the dentist came to the facility on a quarterly basis. The DON said if a resident attended an appointment and the provider recommended a follow-up visit, the charge nurse or assistant director of nursing (ADON) would identify that information on their discharge paperwork and submit it to the facility's scheduler to get the resident's appointment scheduled. The DON said she expected the SSD to follow up and ensure any follow-up dental appointments were scheduled. The DON said she was not aware of any dental issues for Resident #7.IV. Facility follow-upThe DON submitted additional information via email on 6/17/26 at 1:24 p.m. (after survey exit), including a written statement, care conference notes, dental records for Resident #7 (see record review above) and the resident's weight history. The written statement, undated, revealed Resident #7 had been seen by the dentist for a new patient comprehensive examination and fluoride application for tooth #15, at which time the dentist recommended Resident #7 have another hygiene visit and extraction of tooth #15. Resident #7 was seen again by the dental hygienist on 12/9/25 with a recommendation for perio-maintenance, which would have been due in March 2026 or April 2026, and was scheduled 3/25/26.The statement documented after the facility communicated with the dentistry service provider on 6/16/26 (during the survey process), they found since Resident #7 had been discharged from the facility on 3/20/26, her dental appointment on 3/25/26 was not able to be completed. Resident #7 was then added to the dentistry service provider's list to be seen by the dentist on 7/2/26 and the hygienist on 7/9/26. An email from the dentistry service provider, dated 6/17/26 at 12:22 p.m., revealed Resident #7 was initially scheduled to be seen by the dentist on 3/25/26, but her appointment had been canceled as the resident was discharged from the facility at that time. The service provider confirmed Resident #7 was on their schedule to be seen 7/9/26, and added she could be seen on 7/2/26 if her tooth needed to be extracted more emergently. -However, Resident #7 was not scheduled to be seen by the dentist until 6/16/26 (during the survey process), which was 59 days after the resident's MDS assessment identified she had decay or cavities and 27 weeks after Resident #7's dentist recommended she have tooth #15 extracted.

Based on observations, record review and staff interviews, the facility failed to ensure staffing information was posted in a prominent place, readily accessible to residents and visitors.Specifically, the facility failed to ensure the correct nurse staffing information was updated daily.Findings include:I. ObservationsObservations in the facility on 6/11/26 at 9:30 a.m. revealed the nurse staffing information was posted, however, the date on the posting was 5/18/26 with a census of 59 residents.Observations in the facility on 6/15/26 at 9:08 a.m. revealed the nurse staffing information was posted, however, the date on the posting was 5/18/26 with a census of 59 residents.-The facility failed to update the actual working hours for the nursing staff, the date of the information and the resident census (the facility's census during the survey was 57 residents).II. Staff interviewThe director of nursing (DON) was interviewed on 6/15/26 at 10:10 a.m. The DON said the scheduler was responsible for updating the daily nurse staff posting but she was on a leave of absence. She said since the scheduler was out on leave, the charge nurse was responsible for updating the posting. She said she did not think about ensuring the charge nurse was completing the task. She said the nurse staffing information posting had not been updated since 5/18/26. She said she would immediately update the posting and ensure it was completed daily.

Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards for one (#2) of three residents out of nine sample residents. Resident #2, who had a history of falling and previous fractures that included a burst fracture of the thoracic vertebra (bone in the upper spine caused by trauma), was admitted to the facility on [DATE]. On 2/11/25 at 6:45 a.m. Resident #2, who ambulated independently with her walker, slipped and fell while walking to the bathroom. After the fall, Resident #2 was heard yelling. A licensed practical nurse (LPN) went to check on the resident and found her lying on her left side, complaining of 8 out of 10 pain, on a 1 to 10 pain scale, to her left shoulder and left hip. According to the LPN's documentation of the fall, Resident #2 refused to allow nursing staff to remove her clothing for a skin evaluation and she requested to be transported to the hospital at that time. The LPN notified the director of nursing (DON), who was the registered nurse (RN) on-call, to notify her of his findings, which included Resident #2's complaints of 8 out 10 pain to her left shoulder and left hip. Resident #2 was assisted into a wheelchair by the LPN and a certified nurse aide (CNA). The 2/11/25 at 6:50 a.m. nursing progress note, written by the DON, documented a RN assessment conducted by the DON, based on the findings reported from the LPN on-site at the time of the resident's fall. It indicated Resident #2 had slipped and fallen while ambulating to the bathroom. It documented Resident #2 was able to move all extremities without injury or noted deformity. It documented Resident #2 was to be transported to the hospital after Resident #2 and Resident #2's representative insisted the resident be evaluated at the hospital. -However, there was no RN in the facility at the time of the fall to conduct a hands-on physical assessment of the resident. Resident #2 was moved off the floor and into a wheelchair, despite her complaints of significant pain, refusal to remove her clothes for a skin evaluation and her request to be sent to the hospital. Resident #2 was transported to the hospital on 2/11/25 at 7:48 a.m. after Resident #2's representative was notified of the resident's fall and insisted on Resident #2 being evaluated at the hospital (63 minutes after Resident #2 initially requested to go to the hospital). At the hospital, the resident was diagnosed with a dislocated and fractured left shoulder and a fractured left hip that required surgical intervention, The facility's failure to accurately assess and evaluate Resident #2 after she experienced a fall and complained of acute pain of 8 out of 10 to her left shoulder and left hip, and the facility's failure to honor the resident's request to be sent to the hospital immediately after the fall resulted in Resident #2 not being transported to the hospital in a timely manner for evaluation and treatment of her acute fractures. Findings include: I. Professional reference According to The Cleveland Clinic (5/11/23) Dislocated Shoulder, retrieved on 4/24/25 from https://my.clevelandclinic.org/health/diseases/17746-dislocated-shoulder, The most common symptoms of a dislocated shoulder include extreme pain, weakness, inability to move arm, shoulder being visibly out of place, swelling, bruising and muscle spasms. Any force that is strong enough to push your shoulder joint out of place can cause a dislocation. The most common causes include falls, care accidents and sports injuries. Go to the emergency room right away if you think your shoulder might be dislocated. According to John Hopkins Medicine (2025) Hip Fracture, retrieved on 4/24/25 from https://www.hopkinsmedicine.org/health/conditions-and-diseases/hip-fracture#:~:text=What%20is%20a%20hip%20fracture,of%20patients%20experience%20spontaneous%20fractures, A hip fracture is a partial or complete break of the femur (thigh bone), where it meets your pelvic bone. It is a serious injury that requires immediate medical attention. II. Facility policy and procedure The Fall Management System policy and procedure, revised November 2022, was provided by the director of nursing (DON) on 4/22/25 at 3:50 p.m. It read in pertinent part, When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record. The Monitoring for Significant Change in Condition policy and procedure, revised May 2007, was provided by the DON on 4/22/25 at 3:50 p.m. It read in pertinent part, If, at any time, it is recognized by any one of the team members that the care needs of the resident have changed, the nurse supervisor should be made aware of and he/she will monitor. Change in ability to ambulate or propel wheelchair. Change in ability to transfer or position self. There will be certain circumstances where immediate attention will be warranted and nursing will be responsible for notifying the appropriate department for evaluation. II. Resident #2 A. Resident status Resident #2, age 86, was admitted on [DATE] and discharged to the hospital on 2/11/25. According to the February 2025 computerized physician orders (CPO), diagnoses included hypertension, protein/calorie malnutrition, opioid dependence and a fracture of thoracic vertebra (bone in the upper spine). The 1/13/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required set up assistance with eating, personal hygiene and was independent with toileting, bed mobility and transfers. The assessment indicated Resident #2 used a walker to assist with ambulation. B. Resident representative interview Resident #2's representative was interviewed on 4/22/25 at 9:03 a.m. The representative said Resident #2 had a history of falls prior to being admitted to the facility. He said while she resided at the facility, she fell again (on 2/11/25). He said he was notified by the nurse on duty that his Resident #2 had fallen, approximately 30 minutes after the event. He said he asked the nurse if she was in pain and the nurse responded yes. He said he asked if the resident had requested to go to the hospital and the nurse had responded yes. The representative said he asked the nurse why emergency medical services (EMS) had not been called yet and he said he demanded the resident be sent to the hospital immediately. He said when he met Resident #2 at the hospital she was writhing and screaming out in pain. He said he was frustrated that she was not sent to the hospital when she had sustained multiple fractures, was in a lot of pain and when she had requested to go. C. Record review The acute/chronic pain care plan, initiated 10/10/24, indicated Resident #2 had acute and chronic pain management issues related to low back pain, history of falling and chronic pain. Interventions included administering analgesia (pain) medication per physician's orders, anticipating the resident's need for pain relief and responding immediately to any complaint of pain and identifying, recording and treating the resident's existing conditions, which may increase pain and or discomfort. -However, the care plan did not indicate the resident had chronic pain in her left shoulder or left hip. The 2/11/25 at 6:50 a.m. nursing progress note documented a registered nurse (RN) assessment, conducted by the DON . Resident #2 was noted on the floor lying on her left side by the bathroom. Resident #2 said that she was walking to the bathroom and had slipped. Resident #2 was able to move all extremities with no signs of injury or deformity. It documented that neurological checks were started and at baseline for the resident. It documented that, based on the resident and resident representative's insistence, the resident would be sent to the emergency room for evaluation. -However, the DON's assessment was based upon the reported findings from the LPN who was on-site at the time of the fall (see interviews below). -Additionally, the nursing note was not created in the resident's electronic medical record (EMR) by the DON until 9:39 a.m. The 2/11/25 at 8:14 a.m. nursing progress note, written by the LPN on-site at the time of the resident's fall, documented that at 6:45 a.m. Resident #2 was heard yelling and was found lying on her left side on the floor in front of the bathroom. Resident #2 said she was ambulating with her walker to the bathroom and slipped. Resident #2 complained of pain at an 8 out of 10 to her left arm and left hip and requested to be sent to the hospital. Resident #2 refused to remove her clothing for a skin evaluation. Resident #2 was assisted into a wheelchair by the LPN and a CNA. The resident's representative was contacted and he requested for Resident #2 to be sent out to the hospital. The nurse practitioner (NP) and the DON were notified and Resident #2 was sent to the hospital. -However, the progress note failed to document whether or not the physician was notified that Resident #2 was reporting 8 out of 10 pain in her left shoulder and left hip and refusing to allow the nursing staff to remove her clothing for a skin evaluation, prior to moving the resident off of the floor. -Additionally, the progress note failed to document that physician's orders were obtained for Xrays, based on the resident's reports of 8 out of 10 pain in her left shoulder and left hip and her refusal to allow the nursing staff to remove her clothing for a skin evaluation, prior to Resident #2's representative insisting the resident be sent to the hospital. The 2/11/25 at 9:53 a.m. interdisciplinary team (IDT) fall committee progress note documented Resident #2 had an unwitnessed fall without injuries. It documented Resident #2 was lying on her left side on the floor in front of the bathroom. Resident #2 was sent to the emergency room for evaluation after Resident #2's, per the resident representative's insistence. It documented no injuries or deformities were noted by facility staff. -However, RN #1, who was not at the facility to physically assess Resident #2 at the time of the fall but received a shift hand-off report from the LPN that was on duty indicated the resident's shoulder looked odd (see interview below). -A comprehensive review of Resident #2's EMR failed to reveal documentation of a physician's order to obtain Xrays of the resident's left shoulder and/or left hip. The 2/11/25 hospital progress note documented Resident #2 had a left shoulder dislocation with a proximal humerus fracture (a break in the long bone of the arm close to the shoulder) and a displaced left femur (thigh bone) fracture. It documented the resident's left shoulder was reduced (a procedure where the shoulder was placed back into position) in the emergency room by the orthopedic surgeon and the emergency room physician. The 2/12/25 hospital progress note documented Resident #2 underwent a left hip nailing (a surgical procedure to realign the bone and stabilize the fracture). III. Staff interviews RN #1 was interviewed on 4/22/25 at 1:50 p.m. RN #1 said Resident #2 had a walker which she used independently to walk around the facility. She said Resident #2 had a soft call light which she only used when she wanted her pain medications. She said the resident would not use the call light to ask for assistance prior to getting out of bed and walking with her walker. She said she took care of Resident #2 on the day she fell , but she said the resident had already fallen and been assisted into a wheelchair before she arrived in the facility for her shift. She said the previous nurse (LPN) had said that the physician had ordered Xrays and the facility was waiting for those Xrays to be obtained on her shoulder. She said Resident #2's left shoulder looked odd. She said the facility sent Resident #2 to the emergency room because the facility could not obtain the Xrays in a timely manner. -However, RN #1 did not document a progress note in Resident #2's EMR regarding her assessment that indicated the resident's shoulder looked odd (see record review above). -Additionally, progress notes indicated Resident #2 was sent to the hospital due to the resident representative's request that the resident be sent to the hospital, not because Xrays could not be obtained in a timely manner (see record review above). RN #1 was interviewed a second time on 4/22/25 at 1:55 p.m. RN #1 said she had reviewed her progress notes in Resident #2's EMR. She said Resident #2 had asked to go to the hospital and the LPN had called the physician but he had not received a return call. She said she was the one that had called the physician again and received an order for the resident to be sent to the emergency room because the Xrays could not be completed timely. She said that was the reason why there was a delay of over an hour between when the resident fell and when the resident was sent to the emergency room . RN #1 said the facility's process, unless a situation was immediately life-threatening, was not to call EMS first, but to call the physician to obtain a physician's order to transfer a resident to the hospital. She said the facility did this even if the resident had requested to go to the emergency room . -However, there was no documentation in Resident #2's EMR to indicate RN #1 or the LPN called the physician to obtain physician's orders for Xrays of the resident's left shoulder and left hip (see record review above). The DON was interviewed on 4/22/25 at 2:45 p.m. The DON said the facility's process was to call the physician first to obtain a physician's order to transfer residents to the hospital to mitigate unnecessary hospitalization s, unless it met criteria for an immediate transfer. She said Resident #2 did not meet criteria for immediate transfer to the hospital. She said immediate criteria was any instance that was immediately life threatening. She said Resident #2 did not request to go to the hospital. She said Resident #2 was at baseline for her pain and she complained of pain normally at an 8 out of 10 pain scale. -However, the note documented by the LPN on 2/11/25 at 8:14 a.m. indicated Resident #2 requested to go to the hospital immediately after her fall (see record review above). -Additionally, Resident #2's acute/chronic pain care plan indicated the resident had chronic pain related to low back pain, not left shoulder or left hip pain (see record review above). The DON said Resident #2 normally, at baseline, did not have full range of motion in all of her extremities. She said the facility had contacted the physician and had obtained a physician's order for Xrays, since the facility could do these in the facility. She said Resident #2's representative was contacted and he insisted that Resident #2 be sent to the hospital. She said the facility sent Resident #2 to the hospital after Resident #2's representative insisted and the facility had obtained a physician's order from the NP to transport the resident to the hospital. The DON was interviewed a second time on 4/22/25 at 3:50 p.m. The DON said a RN was not in the facility when the fall occurred. She said she was the RN on-call and she had documented the RN assessment for Resident #2. She said the facility's process when an RN was not in the building was that the LPN would follow a post-fall check list and they would call the RN on-call. She said she was told by the LPN on-site that Resident #2 was not experiencing any pain or range of motion outside of her normal baseline. She said she did not come into the facility to personally assess the resident. She said Resident #2 was moved off the floor and into the wheelchair before the oncoming RN arrived at the facility. -However, the DON said in her previous interview on 4/22/25 at 2:45 p.m. that Resident #2 was at her baseline level of pain at the time of the fall (see interview above). -Additionally, the LPN's progress note documented Resident #2 was complaining of a pain level of 8 out of 10 to her left shoulder and left hip after the fall. -Additionally, the resident's representative indicated Resident #2 was in extreme pain when she arrived at the hospital (see resident representative's interview). IV. Facility follow-up On 4/23/25 at 1:53 p.m., after the survey exit, the DON provided the following timeline of Resident #2's fall via email: On 2/11/25 at 6:45 a.m. Resident #2 was heard yelling from the hallway and a nurse entered the room. On 2/11/25 at 6:50 a.m. the DON was called during the resident's evaluation as part of the required RN assessment. On 2/11/25, between 6:50 a.m to 7:30 a.m: An RN assessment was conducted. Resident #2 was noted on the floor laying on her left side by the bathroom. Resident #2 stated that she was walking to the bathroom and slipped. Resident #2 is able to move all extremities with no signs of injury or deformity. Neurological checks initiated and at baseline for this resident. Resident #2 was assisted up to her wheelchair by LPN and CNA. A call was made to the provider who gave orders for in-house Xrays. A call was placed to the resident's representative to report the incident and the representative requested Resident #2 be sent to the hospital. The provider called back and was informed of Resident #2's representative request to send the resident out to the hospital; an order was received from the provider. -However, a RN was not in the facility to conduct the assessment and the evaluation was provided by a LPN to the DON and Resident #2 was assisted up to the wheelchair by the LPN and a CNA before a RN was in the facility. The DON's 4/23/25 email additionally included the following EMS timeline from 2/11/25, which was provided to the facility by a dispatcher at (name of the EMS provider): On 2/11/25 at 7:30 a.m. call received by EMS from facility; On 2/11/25 at 7:44 a.m. EMS enroute to facility; On 2/11/25 at 7:48 a.m. EMS arrived to facility; On 2/11/25 at 8:07 a.m. EMS departed from the facility; On 2/11/25 at 8:16 a.m. EMS arrived at the hospital; and, On 2/11/25 at 8:19 a.m. Resident #2 was admitted to the hospital.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents at risk for elopement out of seven sample residents received adequate supervision and were kept free from elopement. Specifically, the facility failed to provide Resident #1 the supervision necessary to prevent elopement. The facility failures created a situation with serious harm and a situation of likelihood of serious harm to residents' health and safety if not immediately corrected. Resident #1, diagnosed with metabolic encephalopathy (improper brain function due to underlying medical condition), unspecified psychosis (mental condition caused by loss of contact with reality), dementia and anxiety, eloped from the facility on 2/1/25 at an unknown time. Facility staff were unaware Resident #1 was missing until after 6:00 a.m. on 2/2/25 when certified nurse aide (CNA) #2 began answering call lights at the start of her shift. At approximately 6:20 a.m. on 2/2/25, CNA #2 noticed Resident #1's dinner tray, untouched, in the resident's room. Resident #1's roommate reported to CNA #2 she had not heard Resident #1 in the room since approximately 5:30 p.m. on 2/1/25, the previous day. CNA #2 reported this to a nurse on duty and the assistant director of nursing (ADON) was notified at approximately 6:30 a.m. A full facility check was conducted, the staff checked the surrounding neighborhood and the resident was unable to be located. At 8:10 a.m. the admissions coordinator (AC) informed the interdisciplinary team (IDT) that Resident #1 had been located at a local hospital. The facility began investigating the incident immediately after Resident #1 was discovered in care of the local hospital and determined Resident #1 eloped from the facility after CNA #1 and licensed practical nurse (LPN) #1 failed to monitor Resident #1 every two hours per facility protocol and due to Resident #1's refusal to wear a wanderguard. Findings include: Observations, interviews and record review confirmed the facility corrected the deficient practice prior to the onsite investigation on 2/12/25 to 2/13/25, resulting in the deficiency being cited as past noncompliance with a correction date of 2/4/25. I. Situation of serious harm The facility failed to ensure the facility staff performed a check of Resident #1 every two hours throughout the evening on 2/1/25 resulting in the facility being unaware of Resident #1's whereabouts for approximately 12 to 15 hours. Resident #1 eloped from the facility on 2/1/25 and was found by the local police approximately 0.3 miles from the facility. She was taken to a local hospital for evaluation where she was admitted at 8:36 p.m. and treated for a urinary tract infection (UTI). II. Facility plan of correction The corrective action plan the facility implemented in response to Resident #1's elopement incident on 2/2/25 was provided by the clinical resource (CR) on 2/12/25 at 2:30 p.m. A. Immediate action One-on-one education was provided to the staff who worked on the 2/1/25 overnight/evening shift and CNA #1 and LPN #1 were placed on suspension pending the investigation of Resident #1's elopement. A facility wide resident count was conducted and all other residents were accounted for. An assessment was conducted of all exterior doors and doors and door alarms were all functioning properly. The incident investigation began immediately and was conducted by the director of nursing (DON) and the nursing home administrator (NHA). B. Identification of others affected The facility determined the deficient practice had the potential to affect all the residents in the facility. C. Systemic changes The DON educated all of the staff on the importance of staff expectations with rounding, high risk for elopement residents (if a resident had not been seen in a few hours), reviewing the resident sign out book, any resident that required one-to-one staff to resident monitors, frequent or 15-minute checks and the post test for elopement. Residents in the facility were interviewed and educated on the use of the resident sign out log. D. Monitoring The facility would evaluate the effectiveness of the plan in quality assurance and program improvement (QAPI) committee meetings for three months and implement additional interventions as needed to ensure sustained compliance. Audits, along with resident records reviewed and analysed for trends, would be reported monthly to the QAPI committee. III. Facility policy and procedure The Elopement/Unsafe Wandering policy, undated, was provided by the CR on 2/12/25 at 2:30 p.m. The policy read in pertinent part, This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attending or maintaining their highest practicable level of function through providing the resident adequate supervision and diversional programs to prevent unsafe wandering while maintaining the least restrictive environment for those at risk for elopement. Wandering is defined as random or repetitive locomotion and can either be goal directed or non-goal directed and aimless. Elopement is when a resident leaves the facility premises or a safe area without authorization and/or any necessary supervision to do so. Residents with capabilities of ambulation and/or mobility in a wheelchair will have an unsafe wandering evaluation completed to determine risks for elopement and unsage wandering on admission and with observed behaviors of wandering or attempting to elope. Residents with high risk factors identified on an elopement/wandering evaluation are considered at risk and will have an individualized care plan developed that includes measurable objectives and time frames. The care plan interventions will consider the particular elements of the evaluation that put the resident at risk and the observations of wandering behavior. These interventions will address the individualized level of supervision needed to prevent elopement and unsafe wandering. Staff shall promptly report any resident who is trying to leave the premises, or is suspected of being missing, to the charge nurse or supervisor to evaluate the need for further interventions. If a resident is missing, it is a facility-wide emergency. The missing resident procedures will be initiated. Determine if the resident is out on an authorized leave or pass. If the resident was not authorized to leave, institute a search of the premises. If the resident is unaccounted for after a thorough search of the building and grounds, immediately notify the IDT team, the resident's legal representative or emergency contact, physician and law enforcement. A review of the elopement incident by the IDT will include an investigation to determine safety of the environment and probable cause factors leading to the elopement. A summary of the investigation and recommendations will be documented in the resident's medical record. IV. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE] and discharged to the hospital on 2/1/25. According to the February 2025 computerized physician orders (CPO), diagnoses included metabolic encephalopathy, frostbite, unspecified psychosis, convulsions, dementia and anxiety. The 12/22/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status score (BIMS) of eight out of 15. The 2/1/25 discharge MDS assessment documented Resident #1 required set-up assistance for meals, dressing, personal hygiene and dressing. She was independent with all other activities of daily living (ADL). The assessment documented the resident wandered one to three days during the assessment period, experienced delusions and rejected care. B. Record review 1. Care plans Resident #1's comprehensive care plan, initiated 4/19/24 and revised 6/24/24, documented Resident #1 was an elopement risk and exhibited wandering behaviors related to her impaired safety awareness and had two previous elopements. Pertinent interventions, initiated 6/18/24 and resolved 6/24/24, included one-to-one staff supervision and to document wandering behavior and attempted diversional interventions. Resident #1's dementia care plan, initiated 6/24/24 documented the resident was at risk for acute confusional episodes and had a history of elopements related to dementia with exit seeking behaviors. Pertinent interventions, initiated 6/24/24, included to document wandering behavior and attempted diversional interventions, completing one-to-one staff supervision or 15-minute checks as needed, reminding the resident where her room was and that it was divided by the curtain, identifying the resident's pattern of wandering - was it purposeful, aimless or escapist and intervening as appropriate and redirecting the resident as needed. Resident #1's care plan for ADLs, initiated 12/28/22, revealed she had a self-care performance deficit related to impaired mobility and cognition due to dementia. She refused medications, medical testing and labs, vital signs, assessments and showers. Pertinent interventions, initiated 12/30/22, included to converse with the resident while providing care, explaining all procedure and tasks before starting and providing the resident required set-up assistance to eat. 2. Elopement/wandering evaluation Resident #1's 12/20/24 elopement/wandering evaluation documented she had a predisposing condition of mental illness, was disoriented and ambulated independently and/or with supervision. The evaluation further documented Resident #1 did not have a history of elopement and the resident had no history or current behavior of wandering within the look back period of the previous six months. -However, the resident's February 2025 CPO documented Resident #1 had a diagnosis of dementia, which was not indicated on the elopement/wandering evaluation (see interviews below). The resident's electronic medical record (EMR) documented wandering behaviors (in the last six months prior to the elopement/wandering evaluation) on 6/25/24 and 7/21/24, in which Resident #1 attempted to leave the facility and the wanderguard alarm was activated. 3. Treatment records and progress notes A review of Resident #1's February 2025 treatment administration record (TAR) revealed on the 2/1/25 to 2/2/25 overnight shifts from 6:00 p.m. to 6:00 a.m., LPN #1 documented that Resident #1 had zero exit seeking attempts. The TAR further documented Resident #1 was provided with non-pharmacological interventions for pain that included dim light, a quiet environment, relaxation and distraction. A review of Resident #1's EMR revealed the following documentation completed by CNA #1: -Resident #1's fall prevention intervention of a low bed in place was documented at 9:26 p.m. on 2/1/25 and 1:35 a.m. on 2/2/25; -Resident #1's snack was documented as accepted at 9:26 p.m. on 2/1/25; and, -Resident #1 was documented as being turned and repositioned at 9:27 p.m. on 2/1/25 and at 1:35 a.m. on 2/2/25. -However, Resident #1 was admitted to the hospital on 2/1/25 at 8:36 p.m. after being found downtown by police. -The facility failed to recognize Resident #1 was not in the building until after 6:00 a.m. the following morning (2/2/25). A 2/3/25 IDT note, written at 11:39 a.m. and related to Resident #1's elopement, documented it was noticed by the facility staff on 2/2/25 at approximately 6:10 a.m. that Resident #1 was not in the facility and the facility's elopement protocol was initiated. Resident #1 was located at a local hospital where she was admitted on [DATE] at 8:36 p.m. after being found by police downtown. It was discovered that the assigned LPN (LPN #1) and CNA (CNA #1) did not follow facility policy and procedure during their shift and were placed on suspension pending investigation. The resident had been accepted to a secure unit at another facility after her hospital discharge. C. Review of Resident #1's elopement incident on 2/1/25 On 2/12/25 at 2:30 p.m. the CR provided the investigation of Resident #1's elopement on 2/1/25. The investigation revealed the following: On 2/1/25 staff reported seeing Resident #1 in the hallways from 2:00 p.m. to 3:00 p.m. On 2/1/25 at 5:00 p.m. CNA #1 said Resident #1 was not in her room and to mark her down for the regular meal. On 2/1/25 at 6:00 p.m. Resident #1's dinner tray was delivered to her room. On 2/1/25 at 9:26 p.m. CNA #1 documented Resident #1 ate 100% (percent) of her meal. On 2/1/25 at 11:41 p.m. LPN #1 documented she had completed a pain evaluation for Resident #1 and that the resident had no exit seeking attempts for the 6:00 p.m. to 6:00 a.m. shift. On 2/2/25 at 6:00 a.m. CNA #2 arrived to the facility, took a report from the night shift CNA #1, and immediately went to the hall and answered the call lights. On 2/2/25 at 6:15 a.m. a bath aide told CNA #2 that Resident #1 was not in her room. Resident #1's roommate said she had not heard her roommate in the room since 5:30 p.m. the night before. On 2/2/25 at 6:20 a.m. CNA #2 reported to a nurse and LPN #1 she could not find Resident #1. LPN #1 told CNA #2 she saw Resident #1 walking down the hallway at 3:00 a.m. -However Resident #1 had already been admitted to the hospital on 2/1/25 at 8:36 p.m. On 2/2/25 at 6:30 a.m. CNA #2 called the ADON to report she was unable to find Resident #1. The staff were instructed to conduct a full facility check for the resident, including bathrooms, back hallways, the garden and surrounding outside areas. On 2/2/25 at 7:36 a.m. the IDT was alerted the resident was unable to be located. The DON arrived at the facility immediately after and conducted a second search of the facility and surrounding outside areas. At 8:10 a.m. the AC informed the IDT that Resident #1 had been located at a local hospital. At 8:20 a.m. the DON arrived back at the facility after looking for the resident in the surrounding area and a house wide resident count was conducted and all other residents were accounted for. An assessment was conducted of all exterior doors and door alarms and all were all functioning properly. An internal investigation was initiated by the DON and the NHA. LPN #1 was interviewed on 2/2/25 by the DON. LPN #1 stated she heard Resident #1 in her room around 3:00 a.m. when she was taking care of the resident's roommate. LPN #1 said she had not laid eyes on Resident #1 during her shift. LPN #1 explained that her documentation on Resident #1 on the overnight shift was just documentation on the resident's' usual' to explain Resident #1's pain evaluation and number of times the resident attempted to exit the facility. CNA #1 was interviewed on 2/2/25 by the DON. CNA #1 said she documented Resident #1's meal was 100% of the meal intake because Resident #1 did not like to be bothered when she was in her room. LPN #1 and CNA #1 were asked by the DON during the investigation to provide written statements for the events involving Resident #1 on 2/1/25 and 2/2/25, but they did not. V. Staff interviews The CR was interviewed on 2/12/25 at 2:35 p.m. The CR said the facility placed a wanderguard bracelet on Resident #1's wrist in June 2024 and she removed it multiple times until August 2024 and she refused multiple times to have the bracelet placed back on her wrist. The CR said Resident #1 was supposed to be on two-hour checks at the time of her elopement and staff were to check on her every two hours because she was refusing to have the wanderguard on. The CR said the facility thought it had to be around suppertime that the resident left the building through the front door because the front door closed at 6:00 p.m. Dietary aide (DA) #1 and DA #2 were interviewed together on 2/13/25 at 9:55 a.m. DA #1 said residents could exit the facility through the front door or through one of the dining rooms' side doors. DA #1 said the side doors of the dining room went to a lobby and were alarmed. DA #1 said if a resident had a wanderguard on and tried to exit through the side doors, the wanderguard alarm on the wall would sound. DA #1 said if the alarm sounded, there was a code that could be entered to turn the alarm off. DA #1 said residents could also use the dining room side door to go visit a friend in assisted living or get a coffee in the other dining room of the building. DA #1 said she was not at the facility when Resident #1 eloped but she knew of Resident #1. DA #1 said it seemed as though Resident #1 had days she wanted to leave the buildings more than others. DA #1 said she knew who the at-risk residents were in the building and monitored them in the dining room even if they were not attempting to leave through the side door. DA #2 said the dietary staff knew which residents should be redirected away from the dining room side door and the staff should check the elopement wanderguard book every day. The AC was interviewed on 2/13/25 at 10:20 a.m. The AC said was educated on the facility elopement policy after Resident #1's elopement from the facility. The AC said she came to the facility on the morning of 2/2/25 and called local hospitals. The AC said she discovered Resident #1 was in a local hospital during the first phone call she made. The AC said when elopements happened, the facility staff all had specific assignments. She said some staff contacted the hospital and other staff might contact the jails or homeless shelters. The AC said when she called the hospital, she provided specific resident information and the hospital was able to tell her Resident #1 was there. The AC said the facility staff might have to visit the homeless shelters in person because the homeless shelters did not typically provide information on who was there. The AC said if a resident had previously eloped, the facility would try to find that resident at their known or favorite place first. The social services assistant (SSA) was interviewed on 2/13/25 at 11:15 a.m. The SSA she was educated about Resident #1's elopement. The SSA said she had worked at the facility for a very long time and worked various positions in the facility that included the front desk of the assisted living (AL) facility connected to the nursing facility. The SSA said she knew which residents were at risk for elopement and those residents lived on the nursing side of the facility. The SSA said residents at risk for elopement were noted upon admission. She said she noted residents with a dementia diagnosis, even if that resident was not a high elopement risk and also looked out for those residents. The SSA said if a resident consented, the facility took a picture of the resident and included the resident's picture with their information in the elopement binder. The SSA said when she took her break she locked the front doors of the building so people could not enter from the outside, but residents were still able to exit. She said she locked the entrance doors with a key and on the inside of the door she hung a stop sign. The SSA said the stop sign was effective in deterring residents from exiting through the double doors. The SSA said if a resident who was an elopement risk started to or did exit the building through the AL side of the building, or if she was notified of a resident elopement, she immediately called to the nursing side of the facility. The SSA said she would try to reach the DON or other nursing supervisor to inform them of a potential elopement. The SSA said she would also inform the facility plant manager and then attempt to redirect the resident back inside the building. The SSA said she took her cell phone with her to update other staff by phone if she was successful or not in redirecting the resident. The SSA said the facility employed overnight staff that did laundry and while waiting for the laundry to finish, the overnight staff did security rounds outside the facility and checked entrances and doorways. LPN #2 was interviewed on 2/13/25 at 12:10 p.m. LPN #2 said if he was informed of a resident elopement, he would immediately lock his medication cart and start looking for the resident. LPN #2 said if he had to report a resident missing, it depended on the resident what he would report. LPN #2 said some residents were more independent and could sign themselves out of the facility. LPN #2 said if that was the case, he would check the sign out log to see where the resident signed out to go, and then inform the DON or the ADON if he thought the resident had been gone too long. LPN #2 said a resident that needed to be checked every two hours meant the resident needed to be checked at the start of his shift and every two hours after that. LPN #2 said he would, at minimum, put eyes on the resident and depending on the time of day, might ask the resident how they were doing and if they needed anything. LPN #2 said if a resident needed assistance with repositioning, he would have to physically assist the resident with the repositioning and needed to be able to see them directly. The CR, the DON and the NHA were interviewed together on 2/13/25 at 1:15 p.m. The DON said Resident #1 had a diagnosis of dementia. The DON said the dementia diagnosis should have been marked on Resident #1's elopement/wandering evaluation but it would not have increased Resident #1's risk category. The CR said Resident #1's elopement/wandering evaluation should have included the resident's wandering behaviors from the last six months. The CR said indicating those behaviors on the elopement/wandering evaluation placed the resident as high risk (instead of low) but her interventions would have still been the same. The CR said the resident was in the elopement binder at the front desk due to the resident's risk of elopement. The CR said the elopement/wandering evaluation reviewed as part of the plan of correction was correct. The DON said in IDT meetings, new resident admissions or readmissions were reviewed and one of the key parts of the resident admission assessment was the resident's elopement risk and what interventions were needed. The DON said if a resident was an elopement risk, the resident was included in the elopement binder, as were residents with a wanderguard. The DON said nursing staff, such as the DON or other designee, maintained the elopement binder. The DON said the primary failure revealed in the investigation of Resident #1's elopement was the staff working failed to check on Resident #1 as required. The DON said both LPN #1 and CNA #1 should have checked on Resident #1 every two hours. The DON said it was a standard of care the staff should know. The DON said she interviewed the staff who worked during Resident #1's elopement. The DON said said both LPN #1 and CNA #1 had just finished their overnight shift and were still present to look for Resident #1. The DON said LPN #1 had assisted looking for Resident #1 in the nearby neighborhood. The DON said when she received notice Resident #1 was admitted to the hospital, she asked LPN #1 to come back to the facility to interview her further. The NHA said the facility could not confirm for certain the resident was in the building at 5:00 p.m. when the dinner meal tickets were completed. The NHA said it was not unusual for Resident #1's tray to be dropped off in her room and Resident #1 was very independent. The DON said Resident #1 liked to keep her door closed often and did not like to be bothered. The DON said if the resident's door was closed, staff needed to just put eyes on the resident. The DON said LPN #1 and CNA #1 did not put eyes on Resident #1 in the time frame they should have. The DON said to conduct a resident search, the staff started first in the resident's room, and then checked the dining room, the second dining room, and started the other facility rooms, such as shower rooms. The DON said when she arrived at the facility the morning of 2/2/25, the staff had already done the facility search and she did a second room and facility search herself.

Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#4) of two residents reviewed out of 33 sample residents. Resident #4 was admitted on [DATE] for long term care with diagnoses of type 2 diabetes with diabetic peripheral angiopathy (narrowing of the arteries decreasing blood flow), chronic kidney disease, heart failures, chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), major depressive disorder and anxiety. On 7/12/24 Resident #4 struck her right lower leg on the side of her metal bed frame when she was maneuvering her electric wheelchair near her bed, causing a hematoma (bruise) to her leg. The resident reported the injury was very painful. On 7/15/24 the facility obtained an x-ray of the resident's right lower extremity, which was negative. The facility failed to consistently document observations of the resident's injury. On 7/22/24 the resident reported increased pain and swelling, the nurse practitioner (NP) ordered ice three times a day to the area. On 7/29/24 the wound doctor (WD) visited the resident for a different wound. The WD did not see or assess the resident's wound to her right lower extremity. Due to the facility's failure to consistently monitor and document the status of the resident's wound, the resident was sent to the emergency department on 8/5/24 for increased swelling and pain. At the hospital, Resident #4 was diagnosed with cellulitis to the right lower extremity and she had an increased white blood cell count. The resident had surgery to drain and clean out the right leg wound which had become infected and required treatment with intravenous (IV) antibiotics. Findings include: I. Facility policy and procedure The Skin and Wound Monitoring policy, dated January 2022, was provided by the nursing home administrator (NHA) on 8/15/24 at 9:12 p.m. It read in pertinent part, A licensed nurse will assess/evaluate at least weekly each area of alteration/injury, whether present on admission or developed after admission, which exists on the resident. This assessment/evaluation should include but not be limited to: measuring the skin injury; staging the skin injury (when the cause is pressure); describing the nature of the injury (pressure, stasis, surgical incision); describing the location of the skin alteration; describing the characteristics of the skin alteration; describing the progress with healing, and any barriers to healing which may exist; and, identifying any possible complications or signs/symptoms consistent with the possibility of infection. Weekly skin checks will be conducted by a licensed nurse. All residents will have a head to toe skin check performed at least weekly by a licensed nurse. The licensed nurse should document the findings. II. Resident #4 A. Resident status Resident #4, age 82, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus with diabetic peripheral angiopathy, chronic kidney disease, heart failure, chronic obstructive pulmonary disease , major depressive disorder and anxiety. The 7/13/24 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 could hear adequately, was able to understand others and made herself understood. B. Resident interview Resident #4 was interviewed on 8/13/24 at 10:33 a.m. Resident #4 said she returned from the hospital yesterday (8/12/24). She said she had an infection in her leg that required surgery. Resident #4 said about a month ago (July 2024), she hit her leg on her bed frame when she was trying to maneuver her electric wheelchair in her room. She said there were no staff around and she was trying to get to her call light, which was on the floor. She said her leg started swelling and hurting right away. Resident #4 said an x-ray was done a couple of days later and there was no fracture so the staff stopped monitoring her leg. Resident #4 said the swelling continued to worsen and the area became warm and painful. Resident #4 said she was told by the nurses she just needed to ice the area to decrease the swelling. Resident #4 said after a few weeks, a red bump formed on top of the swollen area of her leg. She said when this occurred, the nurse called the doctor and was concerned about a blood clot. She said when her leg started draining, the facility decided to send her to the hospital. C. Record review The 7/12/24 incident report, completed by the director of nursing (DON), revealed Resident #4 hit her right leg on the metal part of her bed frame while maneuvering her electric wheelchair in her room. The report documented she obtained a large hematoma with red, blue and purple discoloration. The resident reported the leg was very painful. The DON applied ice to the area and instructed the resident to elevate her leg in the recliner. The physician was notified. The 7/15/14 interdisciplinary team (IDT) progress note indicated x-rays were obtained of the resident's right leg which were negative for a fracture. The note documented the IDT recommended therapy to evaluate the resident's environment and assess the resident's electric wheelchair for safety. According to the nurse progress notes, alert charting (charting done when a resident's condition needs to be monitored) was initiated after the incident on 7/12/24. -However, there were no progress notes documented on 7/13/24 or 7/14/24 to indicate the injury was assessed or was being monitored. The 7/15/2024 alert charting indicated it was the third day of the skin alteration to the resident's right lateral (outside) lower extremity. The area had a dark purple discoloration to the mid-outer calf with an indentation to skin proximal to the ankle with a possible hematoma above the indentation. The resident reported the area was tender to soft touch. An x-ray was completed that morning and the results were pending. The 7/16/24 alert charting indicated it was the fourth day of the skin alteration to the right lateral lower extremity. The area was dark purple discoloration to the mid-outer calf. There was an indentation to the skin proximal to the ankle with a possible hematoma above the indentation. The resident reported the area was tender to soft touch. The x-ray results were negative for fractures. The 7/17/24 alert charting indicated the resident had a skin alteration of a left calf hematoma due to hitting her leg on her bed frame while in an electric wheelchair. The nurses were monitoring for signs and symptoms of infection, pain to sight, or complications every shift for the hematoma to the left lower extremity for three days. There were no signs or symptoms of infection to the resident's left calf. The resident did not have complaints of pain. -However, the resident sustained an injury to her right leg, not the left leg (see record review above and DON interview below). -A review of the resident's electronic medical record (EMR) did not reveal any documentation from 7/18/24 to 7/21/24 regarding the status of the resident's right leg injury. The 7/22/24 nursing progress note documented the nurse practitioner (NP) was notified of increased swelling in Resident #4's right lower leg. The 7/23/24 NP progress revealed the NP visited Resident #4 at the facility. The NP note documented Resident #4 said her leg had decreased in swelling since 7/22/24 but she still had discomfort to the touch. The NP ordered ice to the area three times a day for three days, to encourage elevation and continue to monitor the area. -A review of the residents EMR did not reveal any additional nursing documentation to indicate the staff were monitoring the status of Resident #4's leg from 7/23/24 to 8/4/24. The 7/29/24 wound doctor (WD) progress note documented the WD visited Resident #4 for continued monitoring of a wound in her groin area. -The WD note did not document that the WD examined the resident's injury to her right lower extremity. The 8/5/24 nursing progress note, documented at 8:24 a.m., indicated a phone call was received from the NP with orders for a Doppler (an ultrasound test showing blood flow), to start Keflex (an antibiotic) for possible cellulitis (skin infection) and tramadol (an oral pain medication) for the resident's pain in her leg. The 8/5/24 nursing progress note, documented at 9:31 a.m., indicated the nurse placed a call to Resident #4's physician at 6:40 a.m. regarding the pain to her right lower leg approximately at the mid-calf. The area was red, warm and slightly elevated. The nurse requested a Doppler to rule out deep venous thrombosis (DVT - a blood clot). The 8/5/24 nursing progress note, documented at 1:39 p.m., indicated there was no evidence of a DVT in the resident's right lower extremity according to the Doppler test. The 8/5/24 nursing progress note, documented at 3:00 p.m., indicated the NP was called and notified the hematoma on Resident #4's right lower extremity had opened and was draining. The 8/5/24 nursing progress note, documented at 4:52 p.m., indicated Resident #4 was sent to the hospital emergency department for possible incision and drainage of a right lower extremity hematoma with bloody drainage and a foul smell. The 8/5/24 nursing progress note, documented at 5:28 p.m., revealed Resident #4 left the facility by emergency transport. The 8/5/24 hospital admission record revealed Resident #4 was diagnosed with cellulitis of the right lower limb, a cutaneous (on the skin) abscess of the right lower limb, local infection of the skin and subcutaneous (under the skin) tissue and an elevated white blood cell count of 13.6 (normal range is 4 to 11). The hospital physician's note indicated, upon admission, Resident #4 had a large area of fluctuant (fluid filled) swelling over the anterior pretibial (front of shin bone) space of the right lower leg. It was tender to palpation (touch). There was erythema (redness) with increased skin temperature. The area measured 14 centimeters (cm) length by 10 cm width by two cm depth. There was bloody, malodorous (foul smelling) and copious (large amounts) drainage. Resident #4 was complaining of pain to the right lower extremity which she rated at an 8 out of 10 and described as sharp in nature. The resident said she had been feeling poorly over the last several days. The hospital documentation indicated Resident #4 had surgery overnight for the wound incision and drainage, which was completed at 12:44 a.m. on 8/6/24. She was started on IV antibiotics. The resident returned to the operating room on 8/7/24 for removal of packing, wound re-evaluation and excisional debridement (cutting away of dead tissue) of the wound cavity and repacking. The culture of the wound determined it was infected with multi-drug resistant Escherichia coli (a common bacteria normally found in feces that can infect wounds). On 8/9/24, Resident #4 returned to the operating room for a wound washout and complex wound closure with drain placement. The wound size was 8 cm length by 7 cm width by 2 cm depth. III. Staff interviews The NP was interviewed on 8/16/24 at 3:07 p.m. The NP said she was aware of the injury on Resident #4's leg. The NP said she received a phone call on 7/22/24 from the facility regarding increased swelling in the resident's leg. The NP said she visited Resident #4 on 7/23/24. The NP said the leg did not show signs of infection at that time and she ordered ice to the area. The NP said she received another phone call from the facility on 7/30/24 regarding Resident #4 having increased pain in her leg. She said the resident did not want to take narcotics so she did not order any new medication. The NP said the nurses at the facility should have been monitoring the injury daily and documenting the status. The DON was interviewed on 8/15/24 at 6:36 p.m. The DON said the nurses should have continued to monitor Resident #4's leg until the injury was resolved. The DON said the NP did see Resident #4 on 7/23/24 and ordered ice to the area. The DON said the nurses should have documented their observations of the wound. The DON said there were no signs or symptoms of infection until right before the resident's hospitalization but this was not documented (see record review above). IV. Facility follow-up A chart review was received from the NHA on 8/19/24 at 10:37 a.m. (after the survey). The review was performed by the medical director (MD). The MD confirmed Resident #4 was visited by the wound doctor on 7/29/24 who said he remembered seeing a lesion on the right lower leg but he did not include this observation in his progress note. The MD confirmed that Resident #4 was hospitalized for an infected hematoma on the right lower leg resulting from trauma occurring at the nursing facility.

Based on observations, record review and interviews, the facility failed to honor resident choices for four (#7, #59, #4 and #23) of six residents out of 33 sample residents. Specifically, the facility failed to: -Ensure Residents #59, #7 and #4 received bathing according to their comprehensive choice and plan of care; and, -Ensure Resident #23 was provided assistance to be able to hear his television when he had a conflict with his roommate. Findings include: I. Facility policy and procedure The Resident Rights policy and procedure, revised April 2022, was provided by the nursing home administrator (NHA) on 8/15/24 at 9:15 p.m. It revealed in pertinent part, It is the policy of this facility that all resident rights be followed per state and federal guidelines as well as other regulatory agencies. To be treated with consideration, respect, and full recognition of his or her dignity and individuality. II. Resident #59 A. Resident status Resident #59, age 72, was admitted on [DATE] and readmitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included Parkinson's disease. The 8/7/24 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. He required partial or moderate assistance with activities of daily living. B. Resident interview Resident #59 was interviewed on 8/13/24 at 10:07 a.m. He said had only received one shower since he had been admitted to the facility. He said he usually showered multiple times a week when he was home. He said he was only offered two showers per week when he was admitted . Resident #59 said he was frustrated because he was promised he would receive two showers per week and the facility had not honored that promise. C. Record review The self-care deficit care plan, initiated on 7/12/24, documented Resident #59 had a self-care performance deficit due to a diagnosis of Parkinson's disease. It indicated that the resident required the assistance of one to two staff members for bathing. The July 2024 certified nurse aide (CNA) shower task documentation revealed Resident #59 did not receive bathing between his admission on 7/11/24 to 7/18/24, when the resident returned to the hospital. The documentation indicated the resident refused bathing on one occasion on 7/17/24. -Resident #59 should have received two showers during that one week timeframe in July 2024. The August 2024 CNA shower task documentation revealed Resident #59 received bathing once, on 8/4/24, between 8/1/24 to 8/15/24. -Resident #59 should have received four showers during the two week timeframe in August 2024. III. Resident #7 A. Resident status Resident #7, age 88, was admitted on [DATE]. According to the July 2024 CPO, diagnoses included heart failure, chronic respiratory failure with hypoxia, type 2 diabetes, unsteadiness on feet and pain in the left knee. The 7/13/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was dependent upon staff for bathing assistance and partial to moderate assistance with toileting and dressing. B. Resident interview Resident #7 was interviewed on 8/12/24 at 2:51 p.m. Resident #7 said she was frustrated because she had not been receiving showers according to the established schedule. She said she was supposed to receive a shower on Mondays and Thursdays but she did not always get them. She said the facility had recently changed the shower aides schedule and ever since, she said she had not been receiving her showers. C. Record review The Kardex (a tool utilized to enable staff to provide consistent care) documented Resident #7 should receive showers on Tuesday and Friday evenings. The resident required substantial to maximum assistance of staff for bathing. -However, according to Resident #7, her showers were supposed to be on Mondays and Thursdays (see resident interview above). The June 2024 CNA shower task documentation revealed Resident #7 only received a shower on four occasions (6/3/24, 6/6/24, 6/13/24 and 6/27/24) out of eight opportunities, missing four showers. The July 2024 shower documentation revealed Resident #7 only received a shower on five occasions (7/4/24, 7/8/24, 7/11/24, 7/22/24 and 7/29/24) out of nine opportunities, missing four showers. The August 2024 shower documentation, from 8/1/24 to 8/15/24, revealed Resident #7 only received a shower on two occasions (8/5/24 and 8/12/24) out of four opportunities, missing two showers. IV. Resident #4 A. Resident status Resident #4, age 82, was admitted on [DATE]. According to the August 2024 CPO, diagnoses included type 2 mellitus diabetes with diabetic peripheral angiopathy (narrowing of the arteries decreasing blood flow), chronic kidney disease, heart failure, chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), major depressive disorder and anxiety. The 7/13/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She could hear adequately, was able to understand others and made herself understood. Resident #4 was dependent on staff for bathing and did not reject care during the assessment period. B. Resident interview Resident #4 was interviewed on 8/15/24 at 9:17 a.m. Resident #4 said a CNA offered her a shower on 8/14/24 but she declined due to her recent surgery. She said the CNA did not offer her a bed bath. C. Record review The activities of daily living (ADL) care plan, initiated 10/17/18, indicated Resident #4 required substantial assistance with bathing and two-person assistance to transfer her into a shower chair. Resident #4 preferred showers. The behavior care plan, initiated 8/29/17, revealed Resident #4 would refuse showers at times. Interventions included leaving and returning five to10 minutes later and offering care again. The CNA task shower documentation in Resident #4's electronic medical record (EMR) revealed Resident #4 was to have a shower every Wednesday. The CNA shower task documentation was reviewed from 4/1/24 through 8/14/24. The documentation revealed the following: -Resident #4 received a shower on two out of four Wednesdays in April 2024; -Resident #4 received a shower on two out of five Wednesdays in May 2024; -Resident #4 received a shower on two out of four Wednesdays in June 2024; -Resident #4 received a shower on three out of five Wednesdays in July 2024; and, -Resident #4 received a shower on one out of two Wednesdays in August 2024. -From 4/1/24 through 8/14/24, Resident #4 received 10 showers out of 20 opportunities for a shower. The CNA shower task documentation further revealed Resident #4 refused her shower five times and there was no documentation regarding whether or not a shower occurred on five occasions from 4/1/24 through 8/14/24. -Review of Resident #4's nurse progress notes revealed no documentation from 4/1/24 through 8/14/24 to indicate the resident refused her shower on the five dates the documentation was left blank, the reason for the five shower refusals or if the resident was reapproached at a later time when she refused her shower. V. Staff interviews CNA #6 was interviewed on 8/15/24 at 3:53 p.m. CNA #6 said she offered Resident #4 a shower on 8/14/24 but Resident #4 declined. CNA #6 said she forgot to chart the refusal for 8/14/24 and that was why the charting was blank. CNA #6 said Resident #4 preferred a shower one time per week. She said sometimes she did not feel good and did not want a shower. CNA #6 said if the resident refused her shower, she would offer one the next day or on Saturdays. CNA #3 was interviewed on 8/15/24 at 5:20 p.m. CNA #3 said the facility used to have two shower aides but currently only had one. She said the facility had recently changed their hours from eight hour shifts five days per week to 10 hour shifts three days per week. She said she found the schedule change made it very difficult to provide showers to all the residents. CNA #3 said the shower aides were the staff members who provided showers to the residents. She said the floor CNAs did not provide showers. She said the other shower aide was injured so she had been the only shower aide for the past few weeks. CNA #3 said she tried her best to get to all of the residents' showers but sometimes she was not successful. The director of nursing (DON), the NHA and the clinical consultant (CC) were interviewed on 8/15/24 at 5:44 p.m. The DON said the facility employed two shower aides to provide all the resident showers throughout the facility. She said she had recently changed the shower aide schedule from eight hours five days per week to three days per week for 10 hours per day. She said she changed the shower aide schedules to address the staffing needs. The DON said the shower aides should document which residents did not receive a shower and provide that list to the nurse at the end of their shift. She said if a resident did not receive a shower, that resident should receive a shower the next day. The DON said she was aware the showers were not being completed according to the shower schedule. She said the shower schedule was a work in progress. The NHA said the facility would look at the shower aide schedule again to see if another alteration needed to be made to ensure residents were receiving their showers per their preferences. 48114 VI. Resident #23 A. Resident status Resident #23, age 71, was admitted on [DATE]. According to the August 2024 CPO, diagnoses included hemiplegia and hemiparesis (impaired communication between the brain and muscles) and chronic systolic (congestive) heart failure. The 2/2/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. He was dependent on staff assistance for showering/bathing himself, lower body dressing, putting on/taking off footwear, lying to sitting, sitting to stand, chair to bed and bed to chair transferring and tub/shower transferring. B. Resident interview Resident #23 was interviewed on 8/14/24 at 8:49 a.m. Resident #23 said his roommate kept the television on all the time and it was loud. He said he could not hear his television and could not sleep due to the noise level. He said he talked to staff about the problem and was informed that if he filed a grievances then he would need to move to a different room. He said the facility staff did not provide any other solutions for the problem and told him he would have to deal with it. Resident #23 was interviewed on 8/15/24 at 11:55 a.m. Resident #23 said when his roommate had his television on loud then he would turn the volume up on his television so that he was able to hear. He said it was a constant problem that he dealt with every day. He said the facility staff did not offer to provide headphones or address the situation. C. Record review The care plan for psychosocial needs, revised 5/13/24, revealed Resident #23 had the potential for psychosocial well-being problems related to a recent disagreement with another resident in the facility. Interventions included consulting with psychiatric services, which the resident declined, encouraging the resident to attend activities and meals in the dining room and social services to provide psychosocial check-ins as needed. A progress note dated 4/27/24 documented Resident #23 had a noise complaint made by the resident's roommate. The registered nurse (RN) went into Resident #23's room and asked him if he could turn down his music to a respectable level. Resident #23 proceeded to turn up his music. The resident's roommate then turned up his television louder than the music. Resident #23 was asked two more times by the assigned certified nurse aide (CNA) as well as the assigned RN to turn the music down and Resident #23 did not comply. -The nursing progress note did not document any interventions put into place to address the noise level concerns for either resident. D. Staff interviews The social services director (SSD) was interviewed on 8/15/24 at 3:32 p.m. The SSD said she was responsible for handling problems/concerns between residents but she said she got other staff/administrators involved when needed. The SSD said it was not the facility protocol to move someone to a different room when there was a problem/concern between roommates. She said moving someone was not the only solution and other interventions could be implemented. She said she could get the resident headphones to help with the noise complaint. She said she was not informed about the concern between the two roommates. The SSD said she would reeducate staff and let them know if there were any problems/concerns between roommates to notify social services. She said she would follow up with Resident #23 regarding his concern with the noise of his roommate's television. LPN #1 was interviewed on 8/15/24 at 5:06 p.m. LPN #1 said said Resident #23's roommate had brought up concerns about Resident #23's television noise. She said that before both residents got into bed she reminded both of them to be mindful of each other's environment. She said both residents were hard of hearing. LPN #1 said it had never been discussed that Resident #23 would have to move rooms. She said moving rooms was not a solution to the problem. She said if there were any threatening behaviors, that would warrant a room move but a noise complaint would not warrant a room move. She said she was not sure where Resident #23 would have gotten the information about needing to move. She said it was not standard practice to move someone for a noise complaint. CNA #4 was interviewed on 8/15/24 at 5:20 p.m. CNA #4 said he was aware of television volume concerns between Resident #23 and his roommate. He said he had gone into the room on occasions and turned down the volume. The SSD was interviewed a second time on 8/15/24 at 6:00 p.m. She said she spoke with Resident #23 and his roommate. She said she provided headphones to Resident #23's roommate. She said he was agreeable to use the headphones to solve the problem with the noise level of the television. The DON was interviewed on 8/15/24 at 6:48 p.m. The DON said Resident #23's roommate should have been offered headphones since he liked to listen to his television loudly. The DON said moving residents out of their room was not the process or protocol. She said staff should be mediators, help residents and involve social services when needed. 50853

Based on record review and interviews, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group. Specifically, the facility failed to make prompt efforts to resolve resident grievances about a variety of concerns, including grievances not being answered in a timely manner, staffing shortages with provision of timely care and responding to resident call lights. Findings include: I. Facility policy and procedure The Grievance policy and procedure, revised August 2024, was provided by the nursing home administrator (NHA) on 8/15/24 at 9:14 p.m. It read in pertinent part, It is the policy of this facility to establish a grievance process to address resident concerns without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, other concerns regarding their facility stay and make prompt efforts to resolve grievances the resident may have. The facility's grievance official is responsible for overseeing the grievance process, receiving and tracking grievances; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident, if requested and coordinating with state and federal agencies as necessary. The grievance official evaluates and investigates the concern and takes immediate action to resolve the concern and prevent further potential violations of any resident's right while the alleged violation is being investigated. The grievance official or designee responds to the individual expressing the concern within three working days of the initial concern to acknowledge receipt and describe steps taken toward resolution. II. Resident group interview Six alert and oriented residents (#23, #17, #22, #52, #1 and #3) who regularly attended the resident council meetings were interviewed on 8/14/24 at 10:08 a.m. The residents were identified as alert and oriented through facility and assessment. The group of residents said they had turned in grievances and the staff did not get back to them regarding the concerns. The residents said they were unhappy with the staff shortages, especially the certified nurse aides (CNA). The group of residents said the facility needed more staff, especially during the hours of 2:00 p.m. to 10:00 p.m. and on the weekends. The group of residents said most days they only had one CNA working the hallways. Resident #22 said he was told that the facility did not use agency staff. The group of residents all discussed how long they had had to wait for call lights to be answered by staff. The group of residents said when they turned on their call lights, staff should be coming into their rooms to find out what was going on. The group of residents said most days the staff just walked by and ignored their call lights. Resident #23 and Resident #17 said they had had a couple of accidents where they had an incontinence episode because the staff did not answer their call light in a timely manner. The group of residents said they had had to wait 20 to 30 minutes before staff would respond to their call lights. The group of residents said the facility needed extra CNAs to walk the halls and help the residents. III. Additional resident interviews Resident #7, who was cognitively intact based on facility assessment, was interviewed on 8/12/24 at 2:51 p.m. Resident #7 said it took a long time for call lights to be answered at the facility. She said when she activated her call light, the staff would talk to her roommate first, even though she was the one who had activated the call light. She said it took even longer for the staff to attend to her needs because of that. Resident #7 said the staff would often enter her room, turn off her call light, ask her what she wanted and then say they would return. However, she said staff would not come back. She said she felt like the staff did not care about the residents. She said there had been a lot of recent turnover with the nursing staff and the new staff did not care like the other staff had. Resident #7 said she had expressed her concerns to the nursing staff during care conferences and her family had brought it up to management staff. She said the facility staff had not followed up on her concerns and she felt they were not being addressed. Resident #14, who was cognitively intact based on facility assessment, was interviewed on 8/12/24 at 3:21 p.m. Resident #14 said she let the facility staff know her concerns constantly but felt they did not care and her concerns were not addressed. She said an example was the call lights. She said it would take between 30 minutes to over an hour to get the call light answered, especially on the weekends. She said she had sat in her dirty brief for over an hour at times waiting for someone to come in and provide her assistance. Resident #14 said she had expressed her concerns to the director of nursing (DON) on multiple occasions, however, she said the problems never got any better. She said she did not think the DON liked her very much and would disregard any of her concerns. Resident #14 said there had been a lot of nursing staff turnover recently and she felt the environment at the facility was not a caring environment. Resident #14 said, that morning (8/12/24), the nursing staff did not wake her up in time for breakfast. She said by the time she woke up, the CNA told her breakfast was over and she could not have anything. She said she ate cereal and a banana every morning for breakfast. She said her favorite CNA, who was working another hallway, entered her room around 10:15 a.m. to see how she was doing. She said that CNA, after being told the resident did not have breakfast, went to the kitchen and got her cereal and a banana. She said this particular CNA was rare and was one of the only staff members who truly cared about the residents. Resident #14 said she had written up a lot of grievances. She said she turned them into the nursing staff or the DON and then would not hear any follow up. She said her concerns were never addressed. Resident #36, who was cognitively intact based on facility assessment, was interviewed on 8/13/24 at 9:38 a.m. Resident #36 said he felt the nursing staff at the facility did not care about the residents. He said when he would voice a concern, he felt like it fell on deaf ears. He said he had expressed his concerns a lot and did not feel like the facility tried to resolve them. Resident #36 said he had expressed on multiple occasions his frustration with his medications being administered late. He said the nursing staff would answer his call light and say they would be back but then not return. He said he would often find the staff sitting in the computer room on their cell phones and call lights would be going off in the hallway. Resident #59, who was cognitively intact based on facility assessment, was interviewed on 8/13/24 at 10:07 a.m. Resident #59 said the facility took a long time to answer the call lights. He said sometimes he would wait for longer than 30 minutes. He said he had expressed his frustration to the therapy department and the nursing staff. Resident #59 said he had been living with Parkinson's disease for a long time. He said a side effect of the disease that he dealt with every day was hand tremors. Resident #59 said he had never experienced this bad of hand tremors. He said the facility had not been administering his medication appropriately. Resident #59 said his hand tremors had been worse since he was admitted to the facility. He said he had expressed his frustration to the nursing staff. He said the facility had never followed up with him regarding his concerns. Cross reference F760: the facility failed to ensure Resident #59's Parkinson's medications were administered according to the manufacturer's guidelines. IV. Staff interviews CNA #1 was interviewed on 8/15/24 at 11:08 a.m. CNA #1 said she had worked in the facility for a long time. She said when a resident voiced a concern, if she was able to handle it herself, she would, otherwise she said she would tell the nurse on duty. She said she was aware the facility had a grievance policy, however, she was not sure what it entailed. CNA #1 said she had never filled out a grievance form for a resident. The social services director (SSD) and the social services consultant (SSC) were interviewed together on 8/15/24 at 3:02 p.m. The SSD said the social services department was responsible for reviewing the grievances, distributing them to the appropriate department and ensuring follow-up occurred with the resident. She said each department was responsible for addressing the grievance with the resident. The SSD said the amount of grievances received had gone up in the last three months. She said she had not seen an improvement yet, but was working to make sure the grievances were addressed timely for the residents. The SSD said she had received a lot of grievances related to call light response times, especially on the weekends. She said the grievances documented that residents were waiting a long time for call lights to be answered. She said the residents had voiced concerns over call light wait times during meals. The SSD said she did not know what the response was for the call light grievances or if the residents were satisfied with the response. The SSD said the facility had implemented ambassador rounds for all the department heads. She said the department head was responsible for meeting with their list of assigned residents three times per week and turning in a form every Friday about the resident rounds. The SSD said the ambassador rounds did not formally follow up with written grievances for any concerns. She said she was not aware of what happened to any resident concerns documented on the ambassador round forms. Licensed practical nurse (LPN) #1 was interviewed on 8/15/24 at 5:06 p.m. LPN #1 said she had never filled out a grievance form for a resident. She said she knew the grievance form went through a chain of command but did not know what department received the grievance forms. She said she did not know the facility's policy for grievances. She said she thought grievances should be addressed within 24 to 48 hours. The director of nursing (DON), the NHA and the clinical consultant (CC) were interviewed together on 8/15/24 at 5:44 p.m. The DON said grievances were filed through the ambassador rounds, from an individual resident or from the resident council meeting. She said any staff member who was told a concern by a resident should fill out a grievance form and turn it into the social services department. The DON said each grievance should be investigated within 72 hours of the form being completed. She said each grievance should have a plan developed to address the concern and follow up with the resident to ensure their satisfaction. The DON said the residents had voiced their concerns over call light response times. She said she felt like the residents only wanted their favorite CNAs to answer the call light and would not allow other staff to assist them. The NHA said she had recently implemented the ambassador rounds to assist with resident concerns. The DON said she felt the residents saying they felt some of the staff did not care was unfair because she had tried to change the culture of the facility. However, she said she could not point to anything specific she had done to change the culture. The NHA was interviewed again on 8/15/24 at 7:08 p.m. The NHA said the ambassador rounds were non-existent when she first started at the facility a couple of months prior. She said the department heads had not completed grievance forms for resident concerns that they were documenting on the ambassador rounds. She said that was an oversight in direction that she would fix. The NHA said she felt that receiving grievances was not a bad thing, but pointed to areas where the facility could improve. She said she thought the rest of the department heads did not feel the same way. She said she was trying to change that mindset. The NHA said she thought the culture at the facility needed a change but she was not sure what that change would entail just yet. She said she had been trying to come up with different ideas for the staff to change their mindset. The NHA said all grievances should be followed up on to ensure the facility staff were doing everything they could to do right by the residents. 48114

Based on observations and interviews, the facility failed to provide a clean, comfortable and homelike environment for residents. Specifically, the facility failed to ensure resident rooms, bathrooms and hallways received necessary maintenance repairs. Findings include: I. Observations and resident interviews On 8/12/24 at 10:24 a.m. the corner edge of the sink in room [ROOM NUMBER] was chipped. The left side of the sink had a chipped piece missing. The side wood panel to the sink was chipped on the right side. On 8/12/24 at 1:14 p.m. the dresser next to the bed in room [ROOM NUMBER] was missing both of the drawer fronts that had handles to open the drawers. The drawer front to the bottom drawer The resident who resided in room [ROOM NUMBER] reported that the dresser drawer had been broken for a while. On 8/12/24 at 3:20 p.m. room [ROOM NUMBER]'s window curtain on the left side was disconnected from five hooks. A family member of the resident who resided in room [ROOM NUMBER] said the curtain had been disconnected for two weeks. On 8/14/24 at 2:30 p.m. the door going into the dining room down across from room [ROOM NUMBER] had missing baseboards and trim around all of the edges of the door. On 8/14/24 at 2:32 p.m. one ceiling tile in room [ROOM NUMBER] had a brown water stain on it. In the bathroom of room [ROOM NUMBER], behind the toilet, there was a part of the wall that had been patched and needed to be painted. On 8/14/24 at 2:33 p.m. room [ROOM NUMBER] had two ceiling tiles that were discolored and brown. In the bathroom in room [ROOM NUMBER], the wall behind the toilet had a part of the wall that had been patched and needed to be painted. The bathroom wall on the left side as one exited the bathroom was chipped. The side panel on the sink was chipped. One of the dresser drawers that were built into the wall in room [ROOM NUMBER] were chipped on the left side. In room [ROOM NUMBER], one of the residents who resided in the room had a fan that was attached to the wall by the head of the bed that was coming off the wall. The resident said she was afraid the fan was going to come off the wall and hit her in the head. The same resident's light fixture at the head of the bed in room [ROOM NUMBER] was missing the light cover. On 8/14/24 at 2:35 p.m. room #S2 had two ceiling tiles that were stained brown. On 8/14/24 at 2:36 p.m. room #S1 had one ceiling tile with a white circular stain. On 8/14/24 at 2:37 p.m. the hallway between room #S2 and room #S1 had three stained ceiling tiles that were brown. On 8/14/24 at 2:38 p.m. the floor down the Silverthorn unit was removed and covered up with flooring paper and tape. On 8/14/24 at 2:40 p.m. at the main entrance of the facility there were six ceiling tiles that had brown stains on them. On 8/15/24 at 4:03 p.m. the ceiling in the [NAME] hallway shower room had approximately five inches of paint that was peeling off by the toilet. The wall by the sink in the [NAME] shower room was patched but needed to be painted. II. Staff interviews An environmental tour was conducted on 8/15/24 at 4:17 p.m. with the maintenance director (MTD) and the above concerns were observed. The MTD said staff should be putting in work orders when they noticed something was broken. He said the facility utilized an electronic work system to track needed repairs. He said the facility staff also verbally let him know what needed to be repaired. He said the receptionist or the maintenance staff put the work orders into the electronic work system. He said most of the facility staff did not have access to the electronic work system. He said all of the maintenance staff knew how to put a work order into the electronic work system. The MTD said he did a walk through with new employees to show them the facility. He said he did a morning walk through every day he was working. He said the walk through usually took him 30 to 40 minutes to complete. He said he would do a walk through by himself or with two of his technicians that worked with him. He said he would take notes on what needed to be repaired. He said every Monday and Wednesday he did a building inspection where he checked the water temperature, air temperature and fans in the bathroom. The MTD said if he found any issues during the building inspection he would let the nursing home administrator (NHA) know. He said the NHA did a walk through the building with him once a week. He said the last time he did a walk through with the NHA was on Monday 8/12/24. He said they noticed the ceiling tiles were stained and needed to be repaired. He said he replaced the ceiling tiles three to four times a year. The MTD said when there was an empty resident room his staff would do a whole remodel and find out what needed to be fixed and repaired before another resident was admitted to the room. The MTD said work orders could take a while to get approved depending on how much it cost to fix the issue. He said anything that cost over 2500 dollars had to be approved by the NHA and the corporate office prior to him fixing it. He said the approval process could take one week, three weeks or even one month He said if he was working on a big project he needed to get two separate quotes from contractors and then the corporate office decided who they were going to use. He said he had gotten one quote for the floor down the S hallway and was waiting on another quote before he could send it off for approval. He said he did not know how long it would be before the floor would be replaced down the S hallway.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for three (#18, #45 and #5) of three residents reviewed for assistance with ADLs out of 33 sample residents. Specifically, the facility failed to: -Ensure Resident #18 and #45's fingernails were trimmed and clean; and, -Ensure Resident #5 received staff assistance with getting dressed. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADLs) policy and procedure, dated October 2022 was received by the nursing home administrator (NHA) on 8/15/24 at 9:12 p.m. It read in pertinent part, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living, bathing, dressing, grooming and oral care. The facility will provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility will maintain individual objectives of the care plan and periodic review and evaluation. II. Resident #18 A. Resident status Resident #18, age 78, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included chronic kidney disease stage four and dementia. The 8/26/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He required set up or clean up assistance with eating, oral hygiene, showering/bathing self, upper and lower body dressing, putting on/taking off footwear and personal hygiene. B. Observations and resident interview Resident #18 was interviewed on 8/12/24 at 10:30 a.m. Resident #18 said his fingernails were long and the staff did not cut them when he received his showers. He said he wanted his fingernails cut. He said he did not know the last time his fingernails were trimmed. Resident #18's fingernails extended past the tip of his fingers and had brown matter underneath them. He had fingernail clippers on his dresser and he said they were too small and did not work for him. C. Record review The ADLs care plan, revised on 6/1/23, documented Resident #18 had an ADL self care performance deficit related to impaired mobility/cognition due to dementia, chronic renal failure with hypoxia. Interventions included conversing with the resident while providing care, explaining all procedures/tasks before starting, praising all efforts at self-care and encouraging the resident to discuss feelings about self-care deficits. -The care plan did not include information regarding the resident's nail care. -A review of the certified nurse aide (CNA) task documentation for nail care (reviewed from 7/12/24 to 8/15/24) revealed there was no documentation indicating the resident had received nail care during that time period. III. Resident #45 A. Resident status Resident #45, age 76, was admitted on [DATE]. According to the August 2024 CPO, diagnoses included Alzheimer's disease, dementia and stage four chronic kidney disease. The 7/3/24 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of seven out of 15. He was dependent on staff assistance with toileting hygiene, showering/bathing, upper and lower body dressing and putting on/taking off footwear. He required set up or clean-up assistance with personal hygiene. B. Observation and resident interview Resident #45 was interviewed on 8/12/24 at 1:17 p.m. Resident #45 said his fingernails were long and had not been trimmed since his admission. He said staff had never offered to trim his nails. He said he would like his fingernails to be trimmed. Resident #45's fingernails extended past the tip of his fingers and he had brown matter underneath all of his nails. C. Record review The ADL care plan, revised 6/24/24, documented Resident #45 had an ADL self care performance deficit. Interventions included encouraging the resident to discuss feelings about self-care deficits, encouraging the resident to participate to the fullest extent possible with each interaction and providing maximum assistance of one to two people for personal hygiene. -The care plan did not include information regarding the resident's nail care. -A review of the CNA task documentation for nail care (reviewed from 7/12/24 to 8/15/24) revealed there was no documentation indicating the resident had received nail care during that time period. D. Staff interviews CNA #1 was interviewed on 8/15/24 at 10:34 a.m. CNA #1 said the CNAs and shower aides were responsible for cutting the residents ' fingernails. She said the residents' fingernails should be cut once a week or every other week. She said the best time to cut the residents ' fingernails was during their showers. She said she did not know the last time Resident #18 and Resident #45 had their fingernails trimmed. CNA #1 said Resident #18's and Resident #45's fingernails needed to be cut. She said she did not know why both residents had not had their fingernails cut recently. She said both of the residents should have had their fingernails cut before they got that long. Licensed practical nurse (LPN) #2 was interviewed on 8/15/24 at 11:33 a.m. LPN #2 said if the resident was not diabetic that the CNAs could cut the residents' fingernails. She said if the resident was diabetic then the nurses were responsible for cutting the residents' fingernails. She said she did not know how often the residents' fingernails should be cut. She said the best time for the residents to have their fingernails cut was when they were taking a shower. LPN #2 said Resident #45 could not cut his own fingernails because he had vision impairments. She said Resident #18 was not able to cut his own fingernails. She said all of the residents should have received assistance cutting their nails and should not cut them on their own. She said did not know when the last time Resident #18 and Resident #45 had their fingernails cut. She said both residents should have had their fingernails cut. She said she did not know why both residents' fingernails were not cut. The director of nursing (DON) was interviewed on 8/15/24 at 6:44 p.m. The DON said the CNAs, shower aides and nurses could cut the residents' fingernails. She said if the resident was diabetic a nurse needed to cut the fingernails. She said residents' fingernails should be cut when they were long, sharp or dirty and when they requested it. She said during shower times the residents' fingernails should be checked and cut if needed. The DON said she did not know when the last time Resident #18 and Resident #45 had their fingernails cut. She said she would provide education to the staff about checking and cutting fingernails. 50853 IV. Resident #5 A. Resident status Resident #5, age 68, was admitted on [DATE]. According to the August 2024 computerized CPO, diagnoses included type 2 diabetes mellitus, chronic respiratory failure, hypertension (high blood pressure), chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems) and bipolar disorder (a mental illness causing severe mood swings). The 7/25/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. She was dependent on staff for transfers, dressing and toileting hygiene. The 4/24/24 MDS assessment indicated it was very important for Resident #5 to choose which clothes to wear. B. Resident observations and interview On 8/14/24 at 11:22 a.m. Resident #5 was sitting in her wheelchair in her room wearing a hospital gown. Resident #5 said the staff did not have time to get her dressed this morning (8/14/24) and she went to the dining room for breakfast in a hospital gown. Resident #5 said she usually got dressed in her clothes in the morning, which was what she preferred to do. She said she would go to lunch in her hospital gown because it was too much trouble to get dressed now that she was up. At 12:34 p.m. Resident #5 was sitting in her wheelchair in the dining room for lunch wearing a hospital gown. C. Record review The activities of daily living (ADL) care plan, initiated 2/14/24, revealed Resident #5 required substantial assistance from one staff member to get dressed and she preferred to go to the dining room for meals. -The care plan did not indicate she preferred to wear a hospital gown when out of bed. -The CNA documentation (8/1/24 to 8/14/24) did not indicate the resident refused to get dressed on 8/14/24. D. Staff interviews The DON was interviewed on 8/15/24 at 6:13 p.m. The DON said residents should be given a choice of what they wanted to wear each day. She said residents should receive assistance getting dressed in personal clothing unless it was their preference not to. The DON said she did not know why Resident #5 was not dressed in the clothes she preferred to wear on 8/14/24.

Based on observations and interviews, the facility failed to ensure medications and biologicals were properly stored and labeled in accordance with professional standards in two of three medication carts and one of one medication storage rooms. Specifically, the facility failed to: -Ensure controlled medications were securely stored under double lock; -Ensure expired medications were removed from the medication carts and the medication storage room; and, -Ensure medications were labeled with an expiration date. Findings include: I. Professional reference The United States Food and Drug Administration (USFDA) (2/8/21) Don't Be Tempted to Use Expired Medicines, was retrieved on 8/19/24 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It read in pertinent part, Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed there is no guarantee that the medicine will be safe and effective. If your medicine has expired, do not use it. II. Facility policy and procedure The Storage of Medication policy, dated January 2024, was provided by the nursing home administrator (NHA) on 8/15/24 at 9:12 p.m. It read in pertinent part, Controlled medications should be stored separately from non-controlled medications. The access system (key, security codes) used to lock controlled medications, cannot be the same access system used to obtain the non-controlled medications. Outdated, contaminated, discontinued or deteriorated medications are immediately removed from stock and disposed of according to procedures for medication disposal. III. Observations On 8/14/24 at 4:35 p.m. the medication storage room was observed with the director of nursing (DON). The following items were found: -Four one ounce (oz) tubes of bacitracin ointment (first aid antibiotic) that expired in March 2024. The following personal medications were found in a plastic grocery bag in the medication room. The DON said a resident brought them in from home upon admission. -One three oz tube of Theragesic cream (pain relieving cream) that expired in December 2018; -One 1.8 oz tube of hemorrhoid cream that expired in July 2020; -One 5.5 oz tube of Neosporin ointment (first aid antibiotic) that expired in November 2014; -One 3.8 oz bottle of lidocaine hemorrhoid spray that expired in October 2023; -One bottle of Lexapro 10 milligrams (mg) (antidepressant medication) that expired on 6/1/24; -One bottle of hydrochlorothiazide 25 mg (diuretic medication) that expired on 5/17/24; and, -One bottle of lorazepam 0.5 mg, (a controlled anti anxiety medication) containing two tablets, that was not in a locked cabinet. On 8/15/24 at 1:00 p.m. the Aspen hall medication cart was observed with licensed practical nurse (LPN) #1. The following item was found: -One bottle of Pro-Stat (liquid protein supplement) 30 oz that expired on 7/31/24. On 8/15/24 at 1:44 p.m. the [NAME] hall medication cart was observed with registered nurse (RN) #1. The following items were found: -Three bottles of magic mouthwash with no expiration date on the pharmacy label; and, -One bottle of Systane lubricant dry eye relief 1.5 oz that expired in July 2024. IV. Staff interviews LPN #1 was interviewed on 8/15/24 at 1:00 p.m. LPN #1 said the night shift nurse checked the medication carts for expired medications, cleaned the carts and checked for loose pills. She said if a medication was expired, the night shift nurse removed it from the cart and placed it in the designated area in the medication room for expired medications. The DON was interviewed on 8/14/2024 at 4:45 p.m. The DON said if a resident brought medications from home, the medications should be reviewed with the doctor to determine if the resident was still taking them. She said if the medication had been discontinued or changed, the resident's family should take the medications home. The DON said medications brought from home should be checked for expiration dates. The DON said controlled medication should be secured under a double lock.

Based on observations, record review and interviews, the facility failed to ensure residents were treated with respect and dignity for two (#4 and #5) of five residents reviewed out of 33 sample residents by providing care in a dignified, respectful and individualized manner. Specifically, the facility failed to: -Ensure staff knocked or announced themselves prior to entering Resident #4's room; and, -Ensure Resident #5 was provided with timely incontinence care when requested. Findings include: I. Facility policy and procedure The Dignity and Respect policy, dated April 2024, was provided by the nursing home administrator (NHA) on 8/15/24 at 9:12 p.m. It read in pertinent part, It is the policy of this facility that all residents be treated with kindness, dignity and respect. Residents will be appropriately dressed in clean clothes arranged comfortably on their persons, and be well groomed. Residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the resident from passers-by. Staff members shall knock before entering the residents' room. II. Resident #4 A. Resident status Resident #4, age 82, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus with diabetic peripheral angiopathy (narrowing of the arteries decreasing blood flow), chronic kidney disease, heart failure, chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), major depressive disorder and anxiety. The 7/13/24 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 could hear adequately, was able to understand others and made herself understood. B. Resident observations and interview On 8/13/24 at 10:35 a.m. certified nurse aide (CNA) #1 entered Resident #4's room without knocking or announcing herself. CNA #1 walked into the room and delivered hot tea to Resident #4. Resident #4 said staff did not always knock. She said sometimes the staff came into her room and did not even speak to her. On 8/13/24 at 1:52 p.m. CNA #1 entered Resident #4's room without knocking. CNA #1 took the resident's lunch plate cover from the room and left without speaking to the resident or her roommate. On 8/15/24 at 1:21 p.m. CNA #2 entered Resident #4's room without knocking. She delivered the lunch tray to Resident #4's roommate, sat it on the bedside table and left without speaking to either resident. C. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 8/15/24 at 3:19 p.m. LPN #1 said staff should knock and announce themselves prior to entering a residents' room. She said staff should let the resident know who they were and what they were going to do. The director of nursing (DON) was interviewed on 8/15/24 at 5:45 p.m. The DON said staff should knock and announce themselves before entering a residents' room. III. Resident #5 A. Resident status Resident #5, age 68, was admitted on [DATE]. According to the August 2024 CPO, diagnoses included type 2 diabetes mellitus, chronic respiratory failure, hypertension (high blood pressure), chronic obstructive pulmonary disease and bipolar disorder (a mental illness causing severe mood swings). The 7/25/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. She was dependent on staff for transfers and toileting hygiene. She was frequently incontinent of urine. B. Resident observations and interview On 8/13/24 at 1:12 p.m. Resident #5 told an unidentified CNA that she needed her brief changed before she went to the music program that started at 2:00 p.m. Resident #5's husband assisted the resident to her room and turned the call light on. During a continuous observation on 8/13/24, beginning at 1:17 p.m. and ending at 1:40 p.m. the following was observed: At 1:17 p.m. CNA #5 went into Resident #5's room and turned off the call light. CNA #5 said she had to help another resident and would be back. At 1:28 p.m. CNA #5 was pushing a mechanical lift into another resident's room. At 1:30 p.m. CNA #2 was picking up lunch trays from two residents' rooms. At 1:40 p.m. Resident #5's husband came into the hall and told CNA #5 that the staff ran out of time and Resident #5 needed to go to the activity program. The resident's husband assisted Resident #5 to the activity program without having her brief changed. -Resident #5 had waited 28 minutes for CNA #5 to return to her room to provide her assistance. At 3:07 p.m. Resident #5 returned from the activity and went into her room. She turned on her call light. -Resident #5 had been in a wet brief for one hour and 55 minutes after informing a staff member she needed her brief changed. At 3:08 p.m. registered nurse (RN ) #2 went to Resident #5's room. RN #2 left, did not turn off the call light and retrieved the mechanical lift. CNA #2 and RN #2 took the mechanical lift into Resident #5's room. RN #2 said they were going to lay Resident #5 down and change her. Resident #5 was interviewed on 8/14/24 at 11:23 a.m. Resident #5 said she was upset when she did not get her brief changed before she went to the music program activity on 8/13/24. She said she was uncomfortable sitting in the wet brief during the program. C. Staff interviews CNA #5 was interviewed on 8/15/24 at 3:42 p.m. CNA #5 said if a resident was incontinent, staff should check on them every two hours and change their brief if needed. CNA #5 said Resident #5 used her call light when she needed to be changed but sometimes she forgot so the staff needed to check on her. CNA #5 said it was important to change incontinent residents frequently to prevent skin breakdown. The DON was interviewed on 8/15/24 at 5:45 p.m. The DON said residents should be checked on for incontinence care at a minimum of every two hours. The DON said it was a priority for CNAs to change an incontinent resident before picking up room trays. 48114

Based on observations, record review and interviews, the facility failed to provide reasonable accommodations necessary to accommodate mobility and accessibility in the resident's environment for one (#8) of one resident reviewed out of 33 sample residents. Specifically, the facility failed to ensure Resident #8's call light was consistently accessible to her. Findings include: I. Facility policy and procedure The Call Lights Accessibility and Timely Response policy and procedure, undated, was provided by the nursing home administrator (NHA) on 8/15/24 at 9:12 p.m. It read in pertinent part, The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. All residents will be educated on how to call for help by using the resident call system. Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system. Staff will ensure the call light is within reach of the resident and secure, as needed. II. Resident #8 A. Resident status Resident #8, age 83, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease and dementia. The 7/20/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. She was dependent on staff assistance with toileting hygiene, upper and lower body dressing, putting on/taking off footwear, sitting to lying, lying to sitting on side of bed, sitting to standing, chair to bed/bed to chair transfers and toileting transfers. III. Resident interview and observations Resident #8 was interviewed on 8/12/24 at 3:30 p.m. Resident #8 said she did not know where her call light was. -Resident #8's call light was on the floor at the foot of her bed. On 8/13/24 at 9:35 a.m. an unidentified staff member entered Resident #8's room. The resident's call light was on the floor at the foot of her bed. At 9:41 a.m. the unidentified staff member exited Resident #8's room. The resident's call light was still on the floor. -The unidentified staff member did not pick the call light up off of the floor and place it within reach of Resident #8 while in the resident's room. During a continuous observation on 8/13/24, beginning at 1:45 p.m. and ending at 4:52 p.m., the following was observed: At 1:45 p.m. an unidentified staff member entered Resident #8's room and closed the door. At 1:47 p.m. the unidentified staff member exited Resident #8's room and the call light was located on the floor at the foot of the resident's bed. -The unidentified staff member did not pick the call light up off of the floor and place it within reach of Resident #8 while in the resident's room. At 2:29 p.m. an unidentified staff member entered the resident's room. Resident #8 was lying down in her bed and her call light was on the floor at the foot of her bed. -The unidentified staff member did not pick the call light up off of the floor and place it within reach of Resident #8 while in the resident's room. At 4:12 p.m. an unidentified staff member entered the resident's room. The resident was lying down in bed and her call light was on the floor at the foot of her bed. -The unidentified staff member did not pick the call light up off of the floor and place it within reach of Resident #8 while in the resident's room. At 4:48 p.m. an unidentified staff member entered Resident #8's room and closed the door. At 4:52 p.m. the unidentified staff member exited the room. The resident was lying in her bed and the call light was located on the floor at the foot of her bed. -The unidentified staff member did not pick the call light up off of the floor and place it within reach of Resident #8 while in the resident's room. On 8/14/24 at 9:31 a.m. an unidentified staff member entered Resident #8's room. The resident was in bed lying down and her call light was located on the floor at the foot of her bed. -The unidentified staff member did not pick the call light up off of the floor and place it within reach of Resident #8 while in the resident's room. IV. Record review The behavior care plan, revised 8/8/24, documented Resident #8 had the potential to demonstrate physical behaviors related to dementia with behaviors. She could become combative with cares and frequently refused her cares. The care plan indicated Resident #8 would frequently throw her call light on the floor after it had been clipped to her bed or clothing. The interventions included assessing and anticipating the resident's needs, food, thirst, toileting needs, comfort level, body positioning and pain, documenting observed behavior and attempted interventions and providing a guide away from source of distress when agitated, engaging calmly in conversation and, if response was aggressive, staff was to walk calmly away and approach later. The 10/26/23 progress note documented Resident #8 was in rehabilitation services for physical and occupational therapy. The note documented the staff would continue to focus on safety with bed mobility and training/education on use of call light. Due to memory issues, the resident had a decreased follow through with education and would benefit from repetitive training. The note documented the staff would continue to monitor for further needs and safety as appropriate. The 8/15/24 behavior note, documented during the survey, revealed Resident #8 continued to kick the call light on the floor after certified nurse aides (CNA) had placed it multiple times on the bed with a clip. -A review of Resident #8's electronic medical record (EMR) did not reveal any additional documentation regarding Resident #8 kicking her call light on the floor. V. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 8/15/24 at 10:28 a.m. CNA #1 said the call light should always be within reach for all of the residents. She said if the call light was not within reach she would put it back where the resident could reach it. She said if the call light was on the floor she would not know when the resident needed assistance. She said the call light should never be on the floor. She said she was responsible for making sure the call light was within the resident's reach. She said if any of the staff saw the call light on the floor they needed to pick it up and make sure that it was within reach for the resident. CNA #1 said she did not know if Resident #8 could use her call light. CNA #1 said she checked on Resident #8 all the time. She said Resident #8 was a fall risk, so she checked on her more frequently. She said sometimes the residents did not press their call light, so she frequently checked in on the residents. Licensed practical nurse (LPN) #2 was interviewed on 8/15/24 at 11:28 a.m. LPN #2 said the call light should be placed somewhere the resident could reach it. She said if the call light was not within reach for the resident, she would let the resident know where the call light was located. LPN #2 said the call light should never be placed on the floor where it was out of reach for the resident. She said if the call light was on the floor or out of reach then the resident could not call for help and that could be a problem. She said any staff who went into Resident #8's room should have picked up her call light and put it within reach. LPN #2 said she was not sure if Resident #8 was able to use her call light. She said she thought Resident #8 might not have been able to use her call light due to her cognition. The director of nursing (DON) was interviewed on 8/15/24 at 6:02 p.m. The DON said the call light needed to be within reach when a resident was in bed and within reach while a resident was in a chair where the resident could reach it safely. She said if the call light was not within reach, the staff needed to move it so that it was within reach. She said the staff should be checking at least every hour to ensure the call light was within reach. She said the call light should never be on the floor. The DON said Resident #8 could use her call light but chose not to and would yell out for help instead. She said Resident #8 kicked the call light off her bed. She said the staff should be doing rounding and checking on those things to make sure the call light was within reach for all of the residents.

Based on record review and interviews, the facility failed to ensure one (#4) of three residents out of 33 sample residents was provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to provide a resolution to Resident #4's grievance, which he had communicated to staff on multiple occasions, regarding the resident's care. Findings include: I. Facility policy and procedure The Grievance policy and procedure, revised August 2024, was provided by the nursing home administrator (NHA) on 8/15/24 at 9:14 p.m. It read in pertinent part, It is the policy of this facility to establish a grievance process to address resident concerns without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, other concerns regarding their facility stay and make prompt efforts to resolve grievances the resident may have. The facility's grievance official is responsible for overseeing the grievance process, receiving and tracking grievances; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident, if requested and coordinating with state and federal agencies as necessary. The grievance official evaluates and investigates the concern and takes immediate action to resolve the concern and prevent further potential violations of any resident's right while the alleged violation is being investigated. The grievance official or designee responds to the individual expressing the concern within three working days of the initial concern to acknowledge receipt and describe steps taken toward resolution. II. Resident #4 A. Resident status Resident #4, age 82, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus with diabetic peripheral angiopathy (narrowing of the arteries decreasing blood flow), chronic kidney disease, heart failure, chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), major depressive disorder and anxiety. The 7/13/24 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 could hear adequately, was able to understand others and made herself understood. B. Resident interview Resident #4 was interviewed on 8/13/24 at 10:33 a.m. Resident #4 said she filed a grievance right before she went to the hospital on 8/5/24. Resident #4 said a certified nurse aide (CNA) was unfamiliar with her care and did not know how to transfer her with the sit to stand mechanical lift. Resident #4 said the CNA left the room to get another staff member to help her and was gone for 30 minutes. When the CNA returned, Resident #4 said she was upset because she had waited so long. She said the CNA argued with her and spoke in a disrespectful manner. Resident #4 said she wrote out a grievance and gave it to her regular CNA to give to the NHA. C. Record review A nursing progress note, dated 8/3/24 at 3:46 p.m., documented Resident #4 said a CNA was incompetent to care for her. -The progress note did not indicate a grievance was filed by the resident. On 8/14/24 at 4:30 p.m. the NHA provided a grievance form dated 4/5/24, regarding call light times. The facility follow-up was educating staff and monitoring of call light times. On 8/15/24 at 5:45 p.m. the NHA provided an additional grievance form, dated 8/5/24 which noted an investigation was started upon review of a progress note from 8/3/24 related to Resident #4. The follow-up action on the grievance form indicated Resident #4 was spoken to regarding the importance of skin hygiene and teaching new CNAs her preferences for care. -The grievance did not address Resident #4's concern of the CNA arguing with her and speaking to her in a disrespectful manner. The resident's name was not on the grievance form and the section for the resident's concern was blank. III. Staff interviews The director of nursing (DON) was interviewed on 8/15/24 at 5:45 p.m. The DON said grievances came through staff rounding with the residents, individual resident concerns and through reports from a CNA or other staff member. She said grievances had to be followed up on by the manager of the department the concern pertained to within three days. She said the grievance was supposed to have some sort of resolution that was satisfactory for the resident. The DON said Resident #4 had a history of self-sabotaging and not allowing care if she thought the CNA did not know how to care for her. The DON said the resident would say the staff were incompetent. She said Resident #4 did not tell the staff how she wanted them to care for her. The DON said they had tried to train other staff how to care for Resident #4 but she still preferred only certain staff.

Based on observation and interviews, the facility failed to ensure that professional standards of practice were followed during medication administration for one (#4) of one resident reviewed out of 33 sample residents. Specifically, the facility failed to ensure medications were not left at Resident #4's bedside. Findings include: I. Facility policy and procedure The Medication Administration policy, dated January 2023, was provided by the nursing home administrator (NHA) on 8/15/24 at 9:12 p.m. It read in pertinent part, Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. Residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care center's interdisciplinary team (IDT), and in accordance with procedures for self-administration of medications and state regulations. The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the medication administration record (MAR), and action is taken as appropriate. II. Resident #4 A. Resident status Resident #4, age 82, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus with diabetic peripheral angiopathy (narrowing of the arteries decreasing blood flow), chronic kidney disease, heart failure, chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), major depressive disorder and anxiety. The 7/13/24 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 could hear adequately, was able to understand others and made herself understood. She was independent with eating and drinking. B. Observations and interview On 8/15/24 at 9:17 a.m. Resident #4 was in bed in her room. There were two cups of pills on her bedside table. One cup contained seven pills and the other cup contained two pills, one of the pills was broken in half. Resident #4 said she asked for fresh ice water to take her seven pills this morning but no one had brought her any so she was unable to take her medications. Resident #4 said the cup containing two pills was from last night (8/14/24). Resident #4 said the night nurse delivered the pills to her but did not return to see if she had taken the medications. C. Record review The self-administration of medication evaluation, completed on 8/12/24 (during the survey), revealed Resident #4 was able to self-administer medication. -A review of Resident #4's electronic medical record (EMR) did not reveal a physician's order for the resident to self-administer oral medications. -A review of Resident #4's comprehensive care plan did not reveal documentation regarding the resident's ability to self-administer medications. A review of the August 2024 medication administration record (MAR) indicated licensed practical nurse (LPN) #3 administered cetirizine HCl 5 milligrams (mg) and calcium carbonate with vitamin D 600 mg-400 mg at 11:04 p.m. on 8/14/24. D. Staff interviews LPN #1 was interviewed on 8/15/24 at 9:17 a.m. LPN #1 said she delivered medications to Resident #4 that morning (8/15/24). LPN #1 said the nurses left Resident #4's medication at her bedside and she took her medication when she was ready. LPN #1 said she checked in with the resident about two hours after she gave the resident the medication cup to see if the resident had taken the medication. LPN #1 said Resident #4 did not ask for fresh ice water when she delivered her medication that morning. LPN #1 said she only delivered one medication cup containing seven pills. LPN #1 said she did not see the other medication cup containing two pills when she delivered Resident #4's morning medications but she said the medications must have been from the previous night. LPN #1 said she would document that the resident did not take the two pills and dispose of the medications. LPN #1 said she would get fresh ice water for Resident #4 and make sure she took her morning medications. The director of nursing (DON) was interviewed on 8/15/24 at 6:23 p.m. The DON said medications could be left at the bedside if a resident was independent and had been assessed to safely self-administer their medications. The DON said if the nurse left medications at the bedside, the nurse should go back and check with the resident before the end of their shift to make sure the resident took the medications. E. Facility follow up On 8/15/24 at 5:45 p.m. the DON provided a copy of a counseling notice, dated 8/15/24 (during the survey), for LPN #3. The notice indicated LPN #3 received a written warning via telephone for documenting medications as administered on the evening of 8/14/24 without verifying the medication was taken by the resident. The counseling notice was signed by the DON.

Based on record review and interviews, the facility failed to develop and implement effective discharge planning for one (#59) of two residents reviewed for discharge planning out of 33 sample residents. Specifically, the facility failed to develop and implement a collaborative discharge plan that involved Resident #59's discharge goals. Findings include: I. Resident #59 A. Resident status Resident #59, age 72, was admitted on [DATE] and readmitted on [DATE]. According to the August 2024 computerized physician orders (CPO), the diagnoses included Parkinson's disease. The 8/7/24 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. He required partial or moderate assistance with activities of daily living. B. Resident interview Resident #59 was interviewed on 8/13/24 at 10:07 a.m. Resident #59 said he was admitted to the facility for short-term rehabilitation. He said his goal was to move back to the community. He said his previous living arrangement was with a family member who had passed away and he was not sure if he was able to return. Resident #59 said the facility staff had not asked him what his discharge plan goal was except for when he was first admitted . He said he did not feel like anyone was working toward a goal of him discharging but were instead planning on him staying at the facility under long-term care services. Resident #59 said he was aware of his limitations with Parkinson's disease, but he wanted to be as independent as possible for as long as possible, which included his living situation. He said facility staff had not developed goals with him for discharge or provided him different options for when he would return to the community. Resident #59 said he did not want to stay at the facility for long-term care. He said he had never told the facility staff he wanted to stay, but he felt that they were planning to do whatever they wanted without consulting him. C. Record review The 8/8/24 social services assessment documented the resident previously lived alone with a family member who had passed away. It indicated that a family member was the resident's only support, however, the resident was still in touch with his brother-in-law. The social services assessment documented the resident had a discharge plan of long-term care placement at the facility. -The assessment did not document the resident's wish to return to his previous living situation, nor did it provide any documentation or follow-up with the brother-in-law to determine if the resident living with the brother-in-law was a viable option. -A review of the resident's comprehensive care plan did not reveal documentation that a care plan had been developed with the resident's discharge goals and any interventions to assist the resident in achieving those goals. -A review of the resident's electronic medical record (EMR) did not reveal documentation that active discharge planning had been conducted for Resident #59. II. Staff interviews The social services director (SSD) and the social services consultant (SSC) were interviewed on 8/15/24 at 3:02 p.m. The SSD said social services was responsible for discharge planning. The SSC said discharge planning was fluid and should begin at the resident's admission and continue throughout their stay at the facility. She said the comprehensive care plan should include the resident's discharge goals and interventions to assist the resident to achieve those goals. The SSD said the discharge goals were obtained during the initial social services assessment when the resident was admitted to the facility. She said from there, the comprehensive care plan would be developed within the first seven days of the residents' admission. The SSC said the least restrictive goal was the initial plan and development of that plan would lead to achievement or alteration of the goals. The SSD said Resident #59 planned to remain at the facility for long-term care. She said she had documented that on the social services assessment. She said she did not know the resident wanted to return to his previous living arrangement or a possible assisted living. She said she had not provided Resident #59 with any discharge alternatives other than long-term care. The SSD confirmed she had not developed a discharge care plan within the comprehensive plan of care. She said that should have been developed immediately following the completion of the social services assessment. The SSD said she would meet with Resident #59 and provide him with alternative discharge options and a list of different assisted living communities. She said she would develop his discharge plan and interventions to reach his goals. The SSD was interviewed again on 8/15/24 at 5:11 p.m. The SSD said she went to Resident #59's room to speak about his discharge goals, however the resident said he had a migraine and asked if she could visit later. She said she set up a care conference to discuss his discharge goals for the following week.

Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free from accident hazards as possible, affecting three (#1, #2, and #3) out of five residents. Interviews with leadership revealed the facility had transitioned in March 2024 from a non-smoking to a smoking facility. However, a review of the facility's smoking policy (revision date 9/8/22) and the resident smoking safety evaluation in effect in March 2024, revealed they were not reviewed and revised and failed to address oversight and safety interventions for staff to implement as a smoking facility. Further, there were no resident smoking agreements since the transition. None of these documents included adequate consideration of the risks and the procedures to ensure the safety of residents with an order for oxygen who smoked. Interviews with leadership revealed staff had not received training on smoking safety when the facility transitioned to a smoking facility. And, on 3/27/24, Resident #1, a supervised smoker due to his increased confusion and change in safe smoking practices, was given a cigarette and a lighter by the registered nurse (RN) while in the building and walked ahead of the certified nurse aide (CNA) supervising him to the designated smoking area. The resident had his oxygen on, and his nasal cannula in place when he stepped outside the door and lit his cigarette. The oxygen from the cannula ignited immediately. The CNA who followed the resident immediately turned off the resident's oxygen and removed the cannula. While the facility revised the smoking policy after the incident on 3/27/24, record review and observations revealed the revisions were inadequate and ineffective. Smoking and oxygen use were not adequately addressed with residents who smoked and on 4/9/24, observations revealed supervised smoker Resident #1 with a cigarette on his bedside table that had been smoked, with three-quarters to one-half left. The facility's failure to implement interventions to ensure resident safety from smoking accidents before and after 3/27/24 created a situation with the likelihood of serious harm. Resident #1, who had severe cognitive impairment, sustained first-degree burns to the neck, head, and face after lighting a cigarette on 3/27/24, while wearing oxygen administered via nasal cannula. Findings include: I. Immediate Jeopardy A. Findings of immediate jeopardy Interviews with leadership revealed the facility had transitioned in March 2024 from a non-smoking to a smoking facility. However, a review of the facility's smoking policy (revision date 1/1/23) and the resident smoking safety evaluation in effect in March 2024, revealed they were not reviewed and revised and failed to address oversight and safety interventions for staff to implement as a smoking facility and related to resident oxygen use and smoking. Further, there were no resident smoking agreements since the transition. None of these documents included adequate consideration of the risks and the procedures to ensure the safety of residents with an order for oxygen that smoked. Interviews with leadership revealed staff had not received training on smoking safety when the facility transitioned to a smoking facility. And, on 3/27/24, Resident #1, a supervised smoker due to his increased confusion and change in safe smoking practices, was given a cigarette and a lighter by the registered nurse (RN) while in the building and walked ahead of the certified nurse aide (CNA) supervising him to the designated smoking area. The resident had his oxygen on, and his nasal cannula in place when he stepped outside the door and lit his cigarette. The oxygen from the cannula ignited immediately. The CNA who followed the resident immediately turned off the resident's oxygen and removed the cannula. Resident #1, sustained first-degree burns to the neck, head, and face after lighting a cigarette on 3/27/24, while wearing oxygen administered via nasal cannula. While the facility smoking policy was amended on 3/27/24 to provide that the smoking products of residents who required supervision to smoke would be kept secured in either the medication room or nurses' cart, on 4/9/24, Resident #1 was found with a cigarette on his bedside table. It had been lit and three-quarters to one-half remained. B. Imposition of Immediate Jeopardy On 4/9/24 at 3:35 p.m., the Colorado Department of Public Health and Environment (CDPHE) informed the nursing home administrator (NHA) that the facility's failure to implement safe smoking interventions for residents who smoked and to implement effective interventions to prevent injury from cigarettes to Resident #1, created a situation of immediate jeopardy with the potential for serious resident harm. C. Facility Response On 4/10/24 at 3:42 p.m., the facility submitted the following plan (draft #4) to remove the immediate jeopardy. The plan read: Removal of Immediacy Plan: Unsafe Smoking Date/Time Presented to Surveyors: 4/10/24 at 3:35 p.m. Identified here are the steps and immediate action(s) (name of facility) will take to address the reported non-compliance, keep residents safe and free from serious harm or death, and prevent serious harm from occurring or recurring. 1. Resident #1 was identified as a supervised smoker on 03/19/2024. On 3/27/24 Resident #1 was given a cigarette and lighter by a RN while in the building. The CNA supervising did not ensure oxygen was removed prior to Resident #1 lighting cigarette which in turn led to oxygen from cannula igniting. CNA immediately following turned oxygen off. The smoking UDA was updated to include questions referring to oxygen use on 4/9/24. Items added: -Can the resident light their own cigarette? -Does the resident utilize oxygen? -Is the resident able to manage oxygen safety, remove and store for safe smoking practices, -Observe the resident smoking in designated smoking area, -Is the resident able to safely light smoking materials, hold smoking materials safely and dispose of smoking materials appropriately, -Has the resident been educated on safe smoking practices? On 4/10/24 an additional smoke detector was placed in residents (Resident #1's) bathroom. 2. Director of nurses (DON)/Designee and Clinical Resource completed a full house audit of all smoking evaluation(s) by 4/9/24 and updated all residents' care plans. Facility placed an updated smoking list out at the units on 4/9/24. DON to complete additional full house audit of all smokers starting on 4/9/24 to identify need for supervision or adaptive equipment, facility will review all residents BIMS score, and update a smoking assessment (completed 4/9/24). Any resident who smokes with a BIMS (brief interview of mental status) of 12 or below will be placed on supervised smoking (Resident #1 identified). Smoking policy updated on 4/9/24 to reflect the change. Administrator or designee to review updated smoking Policy with all residents who smoke on 4/9/24 or their representative. 3. All Staff/All residents who smoke to be educated on updated Smoking Policy to address the following: -Use of oxygen, -Who is Supervised and Unsupervised, - How to properly supervise smokers -Supervised smoking times -Proper adaptive equipment available and locations, -Proper smoking equipment indicated in smoking area such as blankets/extinguisher,g -Cleanliness of smoking area, and -Monitoring for proper disposal of cigarette butts. -Safety education was provided to residents regarding our smoking policy and -Use of oxygen to ensure that they remove oxygen prior to going out to smoke. -Smoking materials need to be safely stored out of sight of other residents. -No cigarettes or lighters [will] be given to other residents. 4. Staff education to be completed by Administrator, Nurse Manager, SDC (staff development coordinator), Social Worker, or Activity Director. This education will be provided to all staff/residents who smoke by 4/10/24, any staff that is not able to come in for education will be educated over the phone and will be reviewed with Administrator prior to start of next scheduled shift. 5. On 4/9/24 Resident #1 was found to have a cigarette butt on his bedside table. All staff will be educated on Proper Supervision of smokers to include disposing of any non smoked tobacco product in proper receptacle before re-entering building. A facility audit was implemented on 4/10/2024 to include observations of any smoking materials in resident rooms or on their person. An order was initiated to monitor the residents' room for smoking items every shift. If any are found, remove and provide education to the resident on facility smoking policy and safety. This education will be completed by 4/10/24 any staff that is not able to come in for training education will be educated over the phone and will be reviewed with Administrator prior to start of next scheduled shift. This education will be provided by DON/NHA/Designee. Monitoring: DON/Designee will audit all new admissions for smoking preference, complete a smoking evaluation (to include oxygen use and if they are to be supervised or unsupervised) and update the care plan with current interventions. Assessment and care plan to be completed within 24 hours. Smoking assessments will be completed by ADON (assistant director of nursing) or designee. DON/Designee to review all those residents who smoke weekly and document if they continue to follow safe smoking rules, or if there are changes needed to their care plan. Specifically, for Resident #1 daily audits of resident's room and on his person to ensure he has not brought in any smoking materials from the smoking area. Maintenance to monitor smoking area daily for cigarette butts, safety blankets, and No Oxygen use signs x 12-weeks or until compliance is achieved, any issues identified will be discussed in monthly QAPI (quality assurance performance improvement). These audits will continue for 12-weeks until compliance is achieved, any issues identified will be discussed in monthly QAPI. 6. NO OXYGEN WITHIN 10 FEET signage ordered for designated smoking area to arrive 4/12/24. D. Removal of immediate jeopardy On 4/10/24 at 4:00 p.m., CDPHE notified the NHA that the immediate jeopardy was removed based on observations that the facility was taking steps to begin implementation of the above correction action plan. However, based on observations, interviews, and record review, the deficient practice remained at a G level, actual harm that is isolated. II. Resident #1 - smoking incident 3/27/24 A. Resident #1 Resident #1, age 70, was admitted on [DATE]. According to the 4/10/24 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, emphysema, dementia, and acute respiratory failure with hypoxia (insufficient oxygen to the body tissues). The 2/19/24 minimum data assessment (MDS) showed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. A 3/23/24 MDS documented the resident had moderately impaired decision-making skills, had poor cues, and required supervision. Per the MDS, he used oxygen. Per the resident's care plan, oxygen was to be administered as ordered by the physician. B. Smoking status Review of Resident #1's care plan, initiated on 3/6/24 for smoking, revealed he had a history of smoking in his room. Pertinent interventions included smoking materials to be kept at the nurses' station or other designated areas. The cigarettes/lighter were to be kept with the nurse and the resident was to ask for them. Review of a resident safe smoking evaluation completed on 3/19/24 at 3:31 p.m. revealed the resident, who smoked five times a day, was determined to be unsafe to smoke without supervision due to increased confusion and cognitive loss. Review of a smoking evaluation completed on 3/27/24 at 2:47 p.m. (prior to the smoking incident the same day) revealed the resident, who now smoked six times a day, remained unsafe with smoking independently. He had cognitive loss and fell forward while standing. The clinical resource nurse assisted the resident in removing his oxygen before attempting to stand from his wheelchair and walk to the designated smoking area. There, he was able to light his cigarette and flick the ashes away from his body but was unable to extinguish his cigarette butt into the receptacle. Failure: There was no evidence the resident's care plan was updated on 3/19/24 to document the resident's status as a supervised smoker. Further, there was no evidence the IDT considered additional safety interventions to instruct staff on how to assist the resident in smoking safely. There was no evidence the resident was educated regarding what staff expected of him as a supervised smoker to ensure his and other residents' safety when smoking. C. Smoking incident on 3/27/24 1. Nurses' notes A review of nurses' notes from 3/27/24 at 3:45 p.m. revealed Resident #1 was assisted to smoke outside by the CNA. The resident was walking ahead of the CNA when he lit his cigarette. The CNA turned off the resident's oxygen and removed the nasal cannula from his face. The resident was noted to have seared facial hair and nose pain. The resident was transferred to the emergency department for evaluation and a review of Resident #1's emergency department records revealed a diagnosis of mild first-degree burns to the face. 2. NHA interview The NHA interviewed on 4/8/24 at 5:34 p.m., said she completed an investigation following the resident's smoking incident. The NHA said the investigation revealed Resident #1 was observed walking outside with CNA #1. RN #1 had given the cigarette and lighter to the resident, rather than to the CNA. CNA #1 said she was assisting the resident outside; he was moving swiftly with his front wheel walker and had his oxygen on. Before she could remove the oxygen and turn it off, the resident lit the cigarette. The NHA said the resident had singed his mustache and the hair to the left side of his face along with the oxygen tubing. She said the resident's primary physician was in the building and had him assessed. The primary physician had him sent to the emergency department for further evaluation as the resident complained of burning in his nose. III. Facility failures contributing to the smoking incident on 3/27/24. 1. Facility failure to review and revise the facility smoking policy and resident safe smoking evaluations, and obtain smoking agreements that addressed oversight and safety interventions after the facility transitioned to a smoking facility, allowing smoking on campus and supervised smoking. On 4/8/24 at 5:34 p.m., the social services director (SSD) and NHA were interviewed. The SSD said before March 2024, the facility was a non-smoking facility, which meant residents who chose to smoke had to smoke cigarettes off campus. She said in March 2024 (a definite date was not provided), the facility became a facility that would allow smoking on campus and there could be supervised smoking. On 4/9/24 at 12:38 p.m., the NHA provided the facility smoking policy and smoking evaluation in effect after the transition to a smoking facility and before the incident with Resident #1 on 3/27/24. a. Smoking Policy The policy, last revised 9/8/22 read that its purpose was to address the wishes of both smoking and nonsmoking residents without compromising the safety of either. Procedures read in part: -The facility does not allow smoking of any kind to occur within the facility. Designated smoking areas outside the building are available for this purpose. -Upon admission, residents who desire to smoke will be assessed for their ability to do so safely. Until the completion of the initial smoking safety evaluation residents will be on supervised smoking. Supervised smoking will be offered during designated smoking times and last no more than 20 minutes. -If IDT (interdisciplinary team) determines that the resident is unable to safely store their smoking materials or require supervision to smoke safely, smoking products will be kept secured in either medication room or nurses cart. -Upon quarterly review by the IDT, or any time a significant change of condition occurs, smoking residents will be re-evaluated as to their ability to smoke safely, either independently or under supervision, and their ability to understand and comply with facility smoking policy. Failure: There was no evidence the smoking policy had been reviewed and revised to address the safety risks associated with the facility's transition to a smoking facility and the plan to allow smoking on campus and supervised smoking. The policy failed to include adequate consideration of the risks and the procedures necessary to ensure the safety of residents with an order for oxygen who smoked. The NHA was interviewed on 4/9/24 at 12:38 p.m. She said residents who are supervised smokers should not be handed their cigarettes or their lighter. Rather, the smoking material needed to be handed to the staff member responsible for assisting the resident outdoors, and oxygen needed to be removed before exiting the facility. -However, these safety interventions were not part of the facility's smoking policy. b. Resident safe smoking evaluation The evaluation asked all residents who smoked the following questions. 1. Cognition- Resident has cognitive loss? 2. Vision- Has a visual deficit? 3. Dexterity- Has a dexterity problem (e.g tremors, paresis, etc)? 4. Balance- Falls forward? Falls leans sideways? 5. Smoking frequency- How many times does the resident smoke per day? 6. Safety- Can resident light own cigarette? Resident need for adaptive clothing, device or assistance? Plan of care is used to assure resident is safe while smoking. Failure: The evaluation failed to include any questions regarding oxygen use and, if the resident, whether an independent or supervised smoker, understood the safety considerations of oxygen use and smoking. c. Smoking agreement The facility failed to provide evidence that residents signed smoking agreements after the facility transitioned to a smoking facility in March 2024 and before Resident #1's smoking incident on 3/27/24. 1. Review of Resident #1's record (see above) revealed his care plan read to administer oxygen as ordered and smoking evaluations revealed he was a supervised smoker. Failure: Record review revealed no smoking agreements signed after the facility transitioned to a smoking facility and before his smoking incident on 3/27/24. 2. Review of the record for Resident #2, admitted on [DATE], revealed orders on 1/15/23 that included use of oxygen at 3 liters per minute via nasal cannula, to keep her oxygen saturation at or above 90%. Smoking evaluations revealed she was an independent smoker. Smoking evaluations revealed she had no dexterity problems, could light her own cigarette, and had no need for adaptive clothing, devices, or supervision. Failure: Record review revealed no smoking agreements signed after the facility transitioned to a smoking facility and before the smoking incident involving Resident #1 on 3/27/24. Further, there was no evidence the resident was educated on the facility's smoking policy. 3. Review of the record for Resident #3, admitted on [DATE], revealed a progress note dated 9/4/23 that read the resident was oxygen at 2 liters per minute continuously. Smoking evaluations revealed she had no dexterity problems, could light her own cigarette, and had no need for adaptive clothing, devices, or supervision. Failure: Record review revealed no smoking agreements signed after the facility transitioned to a smoking facility and before the smoking incident involving Resident #1 on 3/27/24. Further, there was no evidence the resident was educated on the facility's smoking policy. 2. Facility failure to educate staff regarding the transition to a smoking facility and the oversight and necessary safety interventions when allowing smoking on campus and supervised smoking. The assistant director of nursing (ADON) was interviewed on 4/11/24 at approximately 11:00 a.m. The ADON said staff were not provided training on the smoking program before the building transitioned to a smoking facility. She said it was just rolled out. She said after the incident on 3/27/24 with Resident #1, the staff were provided education on the facility smoking program. IV. Continued facility failures after 3/27/24 A. NHA interview The NHA was interviewed on 4/8/24 at 5:34 p.m. She said she immediately provided education to CNA #1 and RN #1 after the incident on 3/27/24. A review of the education revealed it read in pertinent part: -Residents who are supervised smoking should not be handed their stored smoking material. Smoking materials should be handed to the staff member responsible for assisting residents outside for a supervised smoke. -When assisting residents outside for supervised smoking, if residents are noted to be on oxygen, staff is to remove the portable concentrator prior to exiting the facility and prior to handing over the residents smoking materials or assisting with lighting cigarettes. The NHA further stated she then provided training to all staff regarding the smoking policy, which she revised after the incident on 3/27/24, and about safety issues with oxygen. All residents were assessed and all the residents signed a smoking agreement that included the rules of the facility. 1. Smoking policy Review of the facility's revised smoking policy revealed the substantive changes from the 9/8/22 revisions (see above) included the removal of the frequency of smoking for residents that required staff supervision. However, as noted above, the policy failed to include adequate consideration of the risks and the procedures necessary to ensure the safety of residents with an order for oxygen who smoked. Safety interventions disclosed in the NHA's 4/9/24 interview regarding when to hand cigarettes to the supervised resident were not part of the smoking policy. 2. Resident safety smoking evaluation However. as noted above, the resident safety evaluation failed to include any questions regarding oxygen use and, if the resident, whether an independent or supervised smoker, understood the safety considerations of oxygen use and smoking. 3. Smoking agreement However, as noted above, the facility failed to provide evidence that residents signed smoking agreements after the facility transitioned to a smoking facility in March 2024 and before Resident #1's smoking incident on 3/27/24. While smoking agreements were signed by Resident #1, #2, and #3 on 3/29/24, two days after the 3/27/24 incident, the agreements were incomplete. Resident #1's agreement read, all smoking supplies will be kept out of sight within rooms. However, as a supervised smoker, per the smoking policy, smoking products were to be kept secured in either the medication room or nurses' cart. Finally, a review of Resident #1, #2's, and #3's smoking agreement revealed they failed to include specific safety interventions, such as the residents agreeing to remove the nasal cannula before leaving the facility or lighting a cigarette. V. Observations confirmed continued noncompliance with oversight and implementation of safety interventions. Record review revealed the facility updated Resident #1's care plan on 3/28/24 to read Resident #1 was to be provided 1:1 observation while smoking. And, on 4/5/24, a new care plan related to smoking read that a smoke detector was in place in the resident's room and staff was to ensure the resident was escorted to the designated smoking area by staff. However, on 4/9/24 at 9:50 a.m., Resident #1 was observed lying in bed with oxygen on and being administered via a nasal cannula. The resident had a bedside table near his bed. On the bedside table was a cigarette that had been previously lit. Three-quarters to one-half of the cigarette remained. The assistant director of nurses (ADON) was notified at 9:52 a.m. and she removed the cigarette. The ADON told the resident that the cigarette was being removed and the resident responded that it was his cigarette. The ADON told the resident that he was not allowed to keep cigarettes. The ADON said the cigarette would be put with the others in his medication cart. VI. Action taken on 4/9/24 after notification of immediate jeopardy The smoking policy was reviewed and updated on 4/9/24. The changes to the policy were in pertinent part: Smoking times for supervised smokers: 6:00, 9:30, 11:30, 1:30, 3:30, 6:00, 8:30. If the IDT determines that the resident is unable to safely store their smoking materials or [to] require supervision to smoke safely, smoking products will be kept secured in either the medication room or nurses cart. If a resident is deemed an independent smoker, they may keep their smoking supplies in their rooms as long as they kept out of site. If a resident is on oxygen, the tank must be left inside the building and not taken outside to the designated smoking area. For independent residents, cigarettes will not be lit until they are within the designated smoking area. For supervised smokers, once within the designated smoking area, the resident may be given their cigarette and the supervisor will light the cigarette. The lighter is not to be given to the resident. Upon completion of the smoking task, the supervisor will ensure that the cigarette has been put out and the remaining cigarette will be placed inside the cigarette butt receptacle. No partially smoked cigarettes are to be kept. No smoking supplies will be allowed to stay with the supervised smoker. Any resident with a brief interview for mental status (BIMS) score of 12 and below and/or demonstrates the inability to perform safe smoking practices will be placed on supervised smoking. No resident is to give cigarettes or lighters to other residents. 50690

Based on interviews and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for one (#6) of two residents reviewed for falls out of 23 sample residents. The facility failed to timely implement appropriate interventions, including assistance with all activities of daily living as documented in her 10/19/22 minimum data set (MDS) assessment. The facility failed to provide staff education and increase resident's supervision to prevent falls when she could not initiate staff assistance by using her call light due to severely impaired cognition. Due to the facility's failures, lack of appropriate supervision and effective interventions resulted in four falls. Furthermore, the facility failed to ensure adequate supervision and effective interventions were in place to prevent falls for Resident #6, with a fall on 12/26/22 that resulted in major injury with right distal and proximal femur (hip) fractures and surgery, and required hospitalization for eight days. Findings include: I. Resident status Resident #6, age 86, was admitted on [DATE] and readmitted on [DATE]. According to the February 2023 clinical physician orders (CPO), diagnoses included encounter for other orthopedic aftercare, fracture of unspecified part of neck of right femur, displaced spiral fracture of shaft of right femur, pain in right leg and history of falling. The 10/19/22 MDS assessment revealed the resident's cognition was moderately impaired with BIMS score 10 out of 15. No behaviors or rejection of care were noted. She required extensive assistance of two staff with bed mobility, she was totally dependent on two staff with transfers, required limited assistance with dressing, and was independent with eating. The 1/6/23 minimum data set (MDS) assessment revealed intact cognition with a brief interview for mental status (BIMS) score 15 out of 15. No rejection of care was noted. She required limited assistance with bed mobility, dressing, toilet use and personal hygiene, supervision of two staff with transfers and supervision with eating. The resident was frequently incontinent of urine. The resident had a fall with a fracture prior to admission. Medication she was administered included an anticoagulant, antidepressant and opioid. II. Record review Care Plan: The resident's records were reviewed on 2/15/23 and revealed the comprehensive person-centered care plan was canceled on 12/30/22. The facility failed to timely develop a care plan addressing falls risk for Resident #6 who was readmitted on [DATE]. Interdisciplinary notes: On 10/18/22 a social worker documented in part: New admit following a fall with fracture of her hip. Patient is a resident here at (facility) on the AL (assisted living) floor. She is hopeful to return back after she completes her therapy. (Resident) was administered a BIMS (Brief Interview for Mental Status) by Speech Therapy where she scored 10 indicating moderate impairments with cognitive functioning. She has a dx (diagnosis) of cognitive communication deficits as well as aphasia. She is very much aware that at times she is forgetful and has word finding difficulties. It is obvious that she has been counseled because several times during the interview with SS (social services) she told herself to slow down when she was communicating. SS (social services department) will continue to follow with IDT (interdisciplinary team) members and assist as needed with discharge planning and providing assistance with any necessary adjustment concerns. On 10/19/22 a registered nurse documented, in part: Barriers to safe and effective discharge: assist with ADL (activities of daily living) cares and cognition. TTWB to RLE (toe touch weight bearing to right lower extremity); max x 2 (maximum assistance of two staff) for transfers; noted with delusions and confusion on readmit. IDT (interdisciplinary team) plans for this week: continue therapy services for swallowing, dressing, grooming/hygiene, transfers and strength. Additional Information: nursing for pain/medication management, obtaining and monitoring vitals/labs; assist with ADL (activities of daily living) cares. -The interdisciplinary team plan did not include resident's risk for falls. Falls with no major injuries: On 10/25/22 at 1:00 p.m. a nurse documented in part: This nurse notified that pt (patient) had fallen. When entering the room she was sitting on the floor, leaning against her bed frame. She stated she was trying to get in bed by herself. A therapist was walking by and assisted her the rest of the way to the ground. She states she did not hit her head. Assessed pt (patient) for injury, none noted. Assisted pt (patient) into bed x3 (with three) staff members and a gait belt. Pt is able to move all extremities, equal hand grasps, pupils are equal and reactive. PCP (primary care physician) and DON (director of nursing) notified. On 10/27/22 the DON documented, in part: Fall committee IDT (interdisciplinary team) follow up for fall on 10/25/2022. Predisposing factors: weakness, ORIF (open reduction internal fixation) of right hip, lack of safety awareness, cognitive deficit, hx (history) of falling. Interventions: Resident is being followed by therapy services for post right hip ORIF for safety awareness, endurance and strengthening as well as ambulation and transfers. Therapy to eval (evaluate) for visual reminders to ask for assistance. On 10/28/22 the director of rehabilitation (DOR) documented: Pt (patient) is receiving therapy services focusing on strength, balance, safety. Pt (patient) cognitively impaired following her surgery and requires verbal and visual reminders to not transfer herself. Sign placed as a reminder to call for help. On 11/1/22 a nurse documented in part: Pt (patient) out to see ortho (orthopedic physician) today. Continue TTWB x2 (toe touch weight bearing for two) weeks. F/U (follow up) in 1 (one) month. WBAT (weight bearing as tolerated) on 11/15/22. On 11/26/22 at 1:00 a.m., a nurse documented: CNA (certified nurse aide) came to this nurse stating resident on floor in room. Upon entering room resident sitting on buttocks next to bed, facing door to hall, denies hitting head, c/o (complains of) pain in buttocks and RLE (right lower extremity), no visible injuries upon assessment, stated 'my brief was wet, I was going to the commode.' Denies injuries and hitting head, c/o (complained of) pain in buttocks, states 'I'm fine, the floor is just hard.' Resident placed back into bed x3 (with three) staff assist. Vital signs taken, assessment completed, neuro checks initiated, all responsible parties notified. On 11/28/22 a nurse documented, in part: Fall committee IDT (interdisciplinary team) Follow up for fall on 11/26/2022. Predisposing factors: history of falling, muscle weakness, lack of coordination, right femur fx (fracture). Interventions: educate staff to keep w/c (wheelchair) closer to the bed, therapy to evaluate room layout. On 11/29/22 the DOR documented: Pt (patient) sustained a fall without injury when attempting to transfer herself to the bedside commode when was paced at the foot of the bed. Pt (patient) is progressing in therapy and felt she was able to perform the transfer. Recommend that the BSC (bedside commode) placed at bedside to lessen distance for transfer and to improve successful transfer. Falls with injuries: On 12/16/22 at 10:15 a.m., a nurse documented: CNA notified this nurse that resident was found on floor. This nurse entered resident's room and visualized resident sitting on floor next to bedside commode. Resident was holding right knee and complaining of pain to right knee and elbow. Resident stated she was sitting at the edge of her bed and attempted to adjust her commode and slid off the bed onto right knee and elbow. Resident noted with abrasion and swelling to right knee, bruising and abrasion to right elbow. Neuro sheet started, neuros WNL (within normal limits), vitals WNL (within normal limits). Resident assisted back to bed and educated on use of call light for assistance. NP (nurse practitioner) notified and ordered STAT (immediate) x-ray of right knee, right hip, and right elbow. Resident's daughter notified. On 12/16/22 a nurse documented in part: X-ray results received. Results reviewed with (physician), new order for NWB (no weight bearing) to RLE (right lower extremity) until f/u (follow up) ortho apt (orthopedic appointment). On 12/17/22 a nurse documented: Resident returned from ED (emergency department), transferred by (ambulance). CT (computed tomography) pelvis and x-ray R (right) femur completed, no significant findings noted. No new orders. On 12/19/22 the DON documented, in part: Incident committee IDT (interdisciplinary team). Follow up for fall on 12/16/2022. Injuries: Abrasion to right elbow and right knee. Bruise to right elbow. Predisposing factors: History of falls, muscle weakness, unsteady gait, impulsiveness. Interventions: Will speak with resident about moving rooms closer to the nurses' station. On 12/20/22 the DOR documented: Pt (patient) is receiving therapy services. Pt (patient) has a bedside commode due to her not wanting to use her regular shared room bathroom. Pt (patient) often attempts to transfer herself to the commode despite education to always call for assistance. Pt (patient) is impulsive and would benefit from moving closer to the nursing station for increased level of supervision. Therapy working on safety with transfers and bedside commode use. On 12/26/22 at 5:07 p.m., the DON documented: Called to residents room by cna (certified nurse assistant) as resident had fallen. When resident asked what happened she stated 'I was trying to get from here to there' pointing from the commode to the recliner. RN (registered nurse) assessment: Resident noted sitting on the floor with her back against her recliner. Right leg externally rotated and resident screamed out in pain with slight touch to the area. She is able to wiggle her toes, but unable to move extremity. (Ambulance) called for emergent transfer to hospital for further evaluation. MD (physician) and daughter notified. The 12/26/22 x-ray report from the hospital revealed in part: Displaced angulated spiral/oblique fracture near the distal third of the right femoral shaft; proximal right femur subtrochanteric fracture surgically addressed with orthopedic metallic fixation hardware, near normal anatomic alignment; persistent right superior and inferior pubic rami fracture deformities. Patient presents with mechanical fall and obvious right leg deformity. Orthopedic surgery recommended placing patient in Buck's traction (device/traction to restore normal bone alignment and length) which was performed in the emergency department and she will be admitted for ongoing pain control and operative intervention. On 12/27/22 the DON documented, in part: Incident committee IDT. Follow up for fall on 12/26/2022. Injuries: right hip with external rotation. Predisposing factors: History of falls, muscle weakness, unsteady gait, impulsiveness. Interventions: Resident sent to ED (emergency department) for further evaluation. On 12/28/22 the DOR documented: Pt (patient) sustained a fall attempting again to transfer herself. Pt (patient) is currently in the hospital and will be evaluated by therapy upon her return. On 1/4/23 the DON documented, in part: Fall Committee Follow-up for fall on 12-26-22. Resident returned to the facility on [DATE]. Resident's room moved closer to the nurses' station by the door for better observation. Resident with PT & OT (physical therapy and occupational therapy) services in place. On 1/11/23 the DON documented, in part: Deep dive into frequent faller with fish bone diagram for root cause analysis review. Care plan reviewed and updated, as indicated. New interventions include perimeter mattress for safety awareness. Resident also placed on frequent toileting schedule during the day. Consent obtained from POA (power of attorney) for perimeter mattress and aware of clinical situation. III. Staff interviews The clinical resource registered nurse (CRRN) was interviewed on 2/16/23 at 8:45 a.m. She said Resident #6's care plan was canceled during her stay in the hospital. She said the comprehensive care plan was not reinstated and updated since the resident returned to the facility on [DATE] (over a month previous). Certified nurse aide (CNA) #2 was interviewed on 2/16/23 at 8:55 a.m. She said she was aware of the resident's risk for falls. She said after return to the facility Resident #6 was moved to a room close to the nurses' station and had not had any falls since. She said the resident did not have or use a bedside commode and the nursing staff was checking on her frequently. She said the staff offered toileting to the resident every two hours and was taking her to use the bathroom in the shower room across the hallway. She said most of the time the resident did not remember to use her call light. The DON, the DOR and the CRRN were interviewed on 2/16/23 at 11:40 a.m. The DOR said after the resident's fall on 10/25/22, the therapy team focused on visual reminders to ask for assistance and signs were placed on the resident's walker. The DOR said prior to the fall on 11/26/22, while transferring to the commode, Resident #6's weight bearing status was upgraded to as tolerated, she required supervision with bed mobility and contact guard assistance from staff with transfers. The DON said staff education was provided and the resident's wheelchair was to be kept close to her bed. The DOR said after the resident's fall on 12/16/22, staff tried to remove the commode and the resident did not allow it. The resident declined to move closer to the nurses' station previous to when she was moved closer. -There were no notes in Resident #6 records about the resident declining to move closer to the nurses' station. The DON said before the fall with injury, the resident refused to use the bathroom in her room as it was difficult for her to get to the toilet, therefore the bedside commode was an option at the time. She said the interdisciplinary team did not consider removing the bedside commode from the resident's room and staff could take the resident to a bathroom in the shower room. IV. Facility follow-up On 2/16/23 at 11:30 a.m., the CRRN provided a copy of the resident's new and updated comprehensive care plan. On 2/16/23 at 11:35 a.m., the DON provided a copy of all facility staff training on falls prevention and the Performance Improvement Plan (PIP). The PIP was dated 1/10/23 and read, She admitted to facility with fracture, and has severe osteopenia (loss of bone mineral density) and osteoarthritis to bilateral knees. She is noncompliant with using call light. She will be placed on toileting program while awake and we will place her on concave mattress (a mattress with concave sides). -The above noted interventions were in place for the resident. On 2/16/23 at 4:42 p.m., the CRRN provided a copy of the 12/26/22 hospital record, read in part: Patient had a hip fracture with hip nail placed 2 and half months ago and is unclear if she refractured this area or if it has not fully healed yet.

Based on interviews and record review, the facility failed to ensure two (#23 and #11) of four residents reviewed had the right to a dignified existence out of 32 sample residents. The facility failed to ensure residents experienced a dignified living experience by not being subjected to disrespectful remarks when the resident questioned the way staff were providing care; and not leave residents waiting for care (i.e. incontinent care) when they asked for and needed assistance. The feelings of dehumanization and being treated in an undignified manner were evidenced by the residents' and interviews. Resident #23 was able to perform some care on her own but needed assistance with some activities of daily living (ADL) care tasks. The resident specifically needed assistance to get out of bed and was particularly concerned that staff would not answer her call light timely when she had to get up to use the bathroom. On a number of occasions staff did not answer the call light timely and she soiled the bed as a result waiting for staff. The resident medical record showed the resident was usually continent of bowel and bladder, but was at risk for incontinence due to weakness and being slow performing tasks necessary to get to the bathroom. Resident #23 did not really want to discuss incontinent episodes, but said she was frustrated and embarrassed if she was unable to make it to the bathroom on time. She also felt staff were disrespectful towards her and did not want to help her, because they told her she could move out if she did not like living in the facility. Resident #23's care plan documented that the resident had a potential for adjustment issues due to nursing home placement. She had complaints of care and needed reassurance and cueing, to help with anxiety or frustration. Resident #11 was totally dependent on two staff with transfers by a mechanical lift to get onto the toilet so she could eliminate bowel and bladder. The resident said she preferred to be on a toileting schedule so the certified nurse aides (CNAs) could help her to the bathroom on a regular schedule. When the resident had to call the CNA without a scheduled bathroom visit, the responding CNA had to find another CNA to assist with the transfer, and this always seemed to take an hour or more each time the resident requested assistance. Resident #11 got emotional as she discussed her feelings about care and treatment at the facility, expressing feelings of frustration, humiliation and depression over her situation. Cross-reference F585, failure to respond to resident grievances. Findings include: I. Facility policy and procedure The Dignity and Respect policy, revised April 2021, was provided by the nursing home administrator (NHA) on 10/21/21 at 2:00 p.m. It read in pertinent part, It is the policy of this facility that all residents be treated with kindness, dignity and respect. II. Resident #23 A. Resident status Resident #23, age 85, was initially admitted on [DATE] and readmitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/11/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required extensive assistance from two staff members to perform bed mobility, transfers, dressing and toilet use. She required extensive assistance from one staff person for personal hygiene. She was continent of bowel and occasionally incontinent of bladder. B. Resident and family interview Resident #23 was interviewed on 10/18/21 at 2:58 p.m. Resident #23 said she had several concerns about care and treatment within the facility. Her main complaint was that staff took a long time to answer her call light and they did not seem to care. When the resident questioned staff about these concerns, staff response was that she could move to a different facility if she was not satisfied with the way she was being cared for. The resident said this did not make her feel welcome, and she felt that staff did not like her. A family member of Resident #23 was interviewed on 10/19/21 at 2:47 p.m. The family member, who was highly involved in the resident's life, said the resident reported to her that the staff were slow to answer the resident's call light on several occasions. The family member said she was on the phone several times when the resident had activated her call light and the staff's response was less than timely. The family member said based on her observations while waiting on the phone with the resident on several occasions, she had to wait anywhere from 30 to 60 minutes for staff to respond to the call light. The most alarming wait time was on 6/20/21 when the resident waited 65 minutes for staff to respond to the call light. When staff arrived, Resident #23 asked the responding staff what took you so long? The nurses' response was to tell Resident #23 that she did not need to live at the facility, and she could have her family move her out if she did not like the service. Several minutes later a CNA, who was also in the room, told Resident #23 she did not have to be a resident at the facility. The family member said, We felt the staff's responses were rude and unprofessional. It would be too detrimental to Resident #23's health to move her at her age, and the threat of being moved was stressful enough to Resident #23. Last time she moved from one unit to the other within this facility, the resident was confused and it took a long time for her to adjust and stabilize to the new surroundings. The family member said she just wanted Resident #23 to get the best professional care possible and be treated with respect and kindness. C. Record review The resident's comprehensive care plan identified the following care needs: Resident #23 has ADL self-care performance deficit related to weakness, malaise, [CONDITION(S)] and pain, initiated: 7/2/17, revised 9/23/21. Interventions: Explain all procedures/tasks before starting .Promote dignity .Toilet use requires assistance when requested. The resident does take herself to the toilet at times .Encourage the resident to discuss feelings about self-care deficit .Encourage the resident to use the call bell to call for assistance . Resident #23 has potential for adjustment issues due to nursing facility placement. The resident has complaints of cares and needs reassurance and cueing as needed to help with anxiety or frustration at time, initiated: 7/2/17, revised 1/21/2020. Interventions: .The resident needs the opportunity to communicate feelings regarding attended activities. Provide the resident with as many situations as possible which give control over the environment and care delivery. Resident #23 was at risk for re-traumatization related to a history of trauma, initiated 7/14/21, revised 9/21/21. Interventions: Approach in a calm manner. Evaluate risk and determine a plan to mitigate triggers of re-traumatization . Resident #23 had potential for mood problem .as evidenced by frustration at staff if services are not performed on time .Resident will call daughter or tell daughter if things are not done timely or correctly and daughter will contact social services director (SSD) and nurse management to report issues, which are then followed up on as needed; initiated 9/3/2020, revised 5/27/21. Resident #23 was at risk for depression .as evidenced by feeling down and feeling bad about herself; initiated 5/13/21, revised 5/27/21. Interventions: encourage the resident to express feelings. III. Resident #11 A. Resident status Resident #11, age 80, was admitted on [DATE]. According to the October 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/11/21 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required extensive assistance from two staff members to perform bed mobility, transfers, toilet use and dressing. The resident required the use of a mechanical lift. She was continent of bowel and occasionally incontinent of bladder. B. Resident interview Resident #11 was interviewed on 10/21/21 at 1:40 p.m. Resident #11 said the care had been progressively worse. Staff were less responsive to requests for care assistance. She understood call lights were to be answered within 15 minutes but that did not always happen. It usually took approximately 30 minutes for a staff to respond to her call light and if she was calling to use the bathroom, the staff person answering the call light had to go find another staff to assist with the transfer to the toilet. Resident #11 required two staff to transfer her with a mechanical lift, and action on toileting requests took longer when the CNAs were not prepared to take her to the bathroom at a certain scheduled time. Resident #11 said she would have to wait an hour or more for two staff to come back to take her to the bathroom. On several occasions she had to wait an entire shift or longer to get cleaned up because she was not able to hold her bladder after asking for help and not getting it. Resident #11 said it was frustrating, humiliating and caused her to feel depressed over her current living situation, to have to continually ask for assistance only to have staff ignore her request for help by saying they would be right back and then not coming back in a reasonable time. Resident #11 said she developed some moisture related skin breakdown, as a result of not being able to hold her bladder when it took staff longer than 30 minutes to respond to her request for assistance, and having to sit in a wet brief for an extended period of time. As a result of long waits she had often been left wet and soiled. She said that was not a good feeling, and she had some moisture associated skin breakdown on her buttocks and in the folds of her groin. She was being seen by the wound care doctor, but felt that better and timely care would improve skin integrity. She felt frustrated when this happened, and said, I feel that we are warehoused here; services are impersonal and concerns are not adequately addressed. I have to prepare myself for the weekend and fight off depression because I know the care on the weekends will be even worse. The weekends are worse because there is no leadership here to supervise the staff. C. Record review The resident's comprehensive care plan identified the following care needs: Resident #11 had ADL self-care performance deficit related to polymyalgia rheumatica, [CONDITION(S)], generalized weakness, and a need for assistance with ADLs; initiated 10/18/17, revised 10/12/21. Interventions: .Toilet use requires two staff participation to use the toilet. Use a [NAME]-lift (sit to stand) to transfer onto the commode. Bed mobility requires two staff participation to reposition and turn in bed . Resident #11 had potential for a psychosocial well-being problem related to anxiety, dependent behavior, ineffective coping, lack of motivation. Resident #11 is specific on how she likes certain cares performed and how she likes her items placed, etc. She will get anxious when these things are not done right. She is dependent with cares for all mobility related tasks; initiated 1/11/1, revised 9/30/2020. Interventions: Allow time to answer questions and to verbalize feelings, perceptions, and fears. CNA are aware of preferences for care. IV. Frequent visitor interview A frequent visitor in the facility was interviewed on 10/20/21 at 9:56 a.m. The visitor had heard from other residents that the nursing staff were not treating them respectfully, and that the nurses did not talk nice to them. V. Staff interviews CNA #1 was interviewed on 10/20/21 at 1:56 p.m. CNA #1 said that some of the residents were more needy than others. CNA #1 had received reports from residents that some of the nursing staff had been rude or were rushing through providing care. When management received reports of staff being rude towards a resident, the staff was given a break from being assigned to the resident's care, and it was explained to the resident that a particular staff member may just be having a bad day and did not mean to treat them in a rude or disrespectful way. The CNA said she had participated in reeducation during an all staff meeting of the facility's expectations for providing good customer service and being kind and respectful to the residents. Staff were instructed to treat all residents like you would want to be treated, and to seek assistance from a coworker if they were having a hard time with a difficult resident. CNA #2 was interviewed on 10/20/21 at 2:07 p.m. CNA #2 said was aware of members of the nursing staff who would rush through providing care to residents, and who would not take the time to listen to resident concerns. CNA #2 said some staff would refuse to go into certain resident rooms if they felt the resident was difficult. The CNA said that the residents were justified in being upset over not being cleaned or cared for properly, and it made her work more difficult when other staff would refuse to assist particular residents. CNA #2 believed that when a staff refused to provide care to a resident it was a means of intimidation especially when it was done after a resident filed a complaint. The CNA believed these incidents needed to be reported to the nurse on duty. The director of nursing DON was interviewed on 10/21/21 at 10:02 a.m. The DON said it was the expectation that each resident was treated with respect and no staff was to refuse to care for a resident. All call lights were to be answered within 15 minutes. Staff were expected to address the resident request immediately. If the request was going to take some time to complete, the staff was to explain to the resident how they would address the request and if they had to seek the assistance of another staff to complete the request. There were some residents who needed two staff to complete a care task. Sometimes it took staff a few extra minutes to locate an available staff to assist, but it was expected that if the responding CNA could not find another CNA to assist within a reasonable time, the CNA should alert the nurse on duty they needed assistance with the resident's care so the resident's needs could be met timely. In response to the resident complaining of long call light wait times and not getting care needs met timely, the DON brought this concern to the quality assurance team and the facility developed a performance improvement plan (PIP). The PIP dated 9/7/21, documented that staff were to answer all call lights within 15 minutes or less, and the resident request was to be taken care of at the time the light was answered or shortly thereafter, if the staff had to get another staff to assist with the care request. When not answering call lights, staff were to be engaged in constant rounding, having a presence on the floor, to ensure resident needs were being met. The DON said they had routinely provided several all staff in-service sessions to instruct staff of the facility's expectations on good customer services and treating each resident with dignity and respect. The DON said she was aware of Resident #23's grievance/complaint that staff told her they could assist her to find an alternative placement if the facility was not meeting her care needs. The DON felt staff were trying to be helpful and felt the resident took it the wrong way. The DON acknowledged that there had been an increase in residents reporting that staff had been rude or not taking care of their care concerns timely, as evidenced by the reviewed grievance reports (cross-reference F585, grievances.) The DON said she responded to resident grievances by providing staff with education and expectations at the monthly all staff meetings since April 2021. The DON expected staff to provide timely care and always be curious and always go the extra mile to satisfy the residents in their care.

Based on record review and resident interviews, the facility failed to promptly and thoroughly address and attempt to resolve resident complaints and grievances concerning issues of resident care and life in the facility that were important to the residents. The facility failed to ensure residents felt their concerns with call lights, incontinent care, staff treatment and physical plant repairs were addressed and resolved for residents residing in the facility. Due to the facility's failures to answer resident grievances, the residents felt frustrated bringing up the same concerns and not having them addressed. Resident #11 expressed feelings of helplessness and depression over being dependent on staff who were not always responsive to her care needs (see resident interview below). As Resident #11 expressed her concerns she became emotional stating she felt the staff were uninterested in doing a good job to take care of her and other residents. She said staff expressed verbal dislike for working with residents on the unit because they needed a lot of care and several required two staff to provide care or the use of a mechanical lift due to physical limitations and excessive weight. This made the resident frustrated and depressed to know staff did not want to work with residents like herself. The resident felt that staff deliberately avoided answering her call light in hopes that someone else would assist her. This resulted in long waits for care and being left in uncomfortable situations of not being able to hold her bladder and being left wet. Findings include: I. Facility policy and procedure The Grievances policy, [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 2:00 p.m. It read in pertinent part, It is the policy of this facility to establish a grievance process to: address resident's concerns without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment, which has been furnished as well as that which has not been furnished, the behavior of staff and other residents; and other concerns concerning their facility stay; and make prompt efforts to resolve the grievances the residents may have. -The facility's grievance official is responsible for overseeing the grievance process, receiving and tracking grievances; leading necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievances decisions to the resident, if requested; and coordinating with state and federal agencies as necessary. -The grievance official evaluates and investigates the concern and takes immediate action to prevent further potential violation of the resident's rights while the alleged violation is being investigated. -The grievance official will immediately report all alleged violations involving neglect, abuse, including injuries of unknown source and/or misappropriation of resident property to the administrator; and as required by state law. II. Resident interviews A. Resident group interview The resident group interview was held in the facility on [DATE] at 10:00 a.m. with four residents (#13, #34, #22, and #15) who regularly attended resident council meetings, identified by assessment and facility to be interviewable. The residents were asked if the facility followed up on grievances and complaints generated during resident council meetings. The residents said, there had been a problem with call lights being answered timely and they had to bring it to the attention of the facility several times before the concern started to improve. The concern was not completely remedied but it was getting better but delays in response time continue to occur. Delayed response to call lights was written into the resident council minutes over several months. The resident said it was frustrating to keep bringing up the same concerns. The residents said the facility did not write up grievance concern forms for the concerns brought forward during the resident council meeting but they expected the facility to address their concerns brought up during the meeting and remedy group concern in a timely way. B. Resident interviews Resident #11 was interviewed on [DATE] at 1:40 p.m. Resident #11 said she had filed numerous grievances and never received resolution to her concerns. One of her biggest concerns was that it takes anywhere from 30 minutes to two (2) hours to get on the toilet once she pushes her call light for assistance. Resident #11 said she had asked for a toileting schedule but staff rarely arrive to assist as requested. When she pressed the call light for assistance it took approximately 30 minutes for staff to respond then it took another two hours for the responding staff to find an available certified nurse aide (CNAs) to assist in getting the mechanical lift and get her to the toilet then once done on the toilet she had to reinitiate the process again with it taking a long time for staff to get her off the toilet. Resident #11 said she has asked administration numerous times for a resolution to her grievance but there had never been a reasonable or sustaining solution. Resident #11 acknowledged there had been one occasion where she filled out a grievance report because staff was not responding to a request to use the bathroom and she wet the bed and was left wet for and without toileting assistance for approximately 24 hours. Resident #11 never received a reasonable response to that grievance. (Cross-referenced to F610 for failure to investigate an allegation of abuse/neglect). Resident #23 was interviewed on [DATE] at 2:58 p.m. Resident #23 said she reported all concerns about care to her daughter and her daughter helped file grievances with the facility. Resident #23's biggest concern was the length of time it took for staff to answer her call light. They eventually help me but take their sweet time; some staff are not very nice to me when they come in to help me. My daughter helped me to file several grievance forms but the concerns were unresolved. Resident #23 said she does as much for herself as she can. (Cross-reference to F550 failure to treat a resident in a dignified and respectful manner). III. Record review A. Resident council minutes The Resident Council minutes were provided by the director of nursing (DON) on [DATE]. Review of resident council meeting minutes for [DATE], [DATE] and [DATE] revealed resident had the following concerns: -Long call light wait times, call lights not working properly and/or staff not leaving the call light within a resident's reach. -Customer service concerns (CNAs and nursing staff not getting back to the resident with answers to questions; some staff having a bad attitude; and staff do not knock and or knock and do not wait for an invitation to enter.) B. Grievance log The [DATE] grievance log identified the following: On [DATE], a resident no longer residing in the facility filed a grievance that she activated the call light to request assistance from the day shift staff to get up for the toilet when no one responded; she had to get herself off the toilet. The facility response was to educate the resident to wait for staff, however there was no investigation or response as to how long the resident waited or why no staff responded to the call light. On [DATE], Resident #23 with the assistance of a family member filed a grievance reporting the night staff did not respond to the call light and she had to wait for the morning staff to come on duty and assist her out of bed to get cleaned up. The resident had the ability to tell when she needed to urinate but was unable to get out of bed on her own. The resident had to wait so long she could no longer hold her bladder and was upset over soiling the bed. In response, the facility documented the night staff were educated to keep an eye on the resident call light and assist the resident as needed. There was no documentation of an investigation into the grievance, associated failures or assessment if staffing was sufficient to meet the functional needs of the resident in their care. On [DATE], Resident #11 filed a grievance reporting that staff had not changed her in over 24 hours. The facility response was that the resident did not use the call light and a new CNA and agency CNA on duty were not familiar with the resident's care routine. The plan was not to schedule agency staff to care for the resident. The facility did not investigate why the staff were not aware of the resident care needs when they were assigned to care of her. The [DATE] grievance log identified the following: On [DATE], Resident #15 and #33 filed a grievance identifying concerns that communication with their CNAs was poor and certain CNAs were taking long periods of time to answer call lights. The CNAs were educated on the expectations for customer service and answering call lights timely. There was no documentation of an investigation into the grievance, associated failures, or any plans to monitor for continued compliance with facility expectations. The [DATE] grievance log identified the following: On [DATE], Resident #23 filed a grievance that she activated the call light for assistance to get out of bed to use the bathroom; the responding CNA said it seems to me you always need to go to the bathroom. The staff's attitude and response bothered Resident #23. The facility response was to educate the night staff regarding customer service. There was no documentation of an investigation into the grievance associated failures, or any plans to monitor for continued compliance with facility exceptions. On [DATE], Resident #14 filed a grievance that she activates her call light responding staff turn off the light and say they will be back with a second CNA to assist, then 30 minutes or more go by and staff do not return. After pressing the call light again, the same thing happens. On another occasion, Resident #14 reported being in the hall and needed assistance. Several CNA ignored her and she had to wheel herself to the nurse's station; she hurt her shoulder in the process. The facility response was to encourage the resident to get up for lunch and stay up for two hours does not address the resident grievance of why it takes so long to get assistance when she presses the call light. There was no investigation to rule out potential abuse or neglect for the lack of staffs response to provide timely care to any of the above resident who filed a complaint IV. Staff Interview CNA #3 was interviewed on [DATE] at 10:01 a.m. CNA #3 said if a resident voiced a grievance/ complaint and it could be fixed right away staff were expected to fix the problem. If the concern could not be fixed staff were to let the nurse on duty know. Staff would assist the resident to complete one of the pink grievances /concerns form and the form was given to the social services director (SSD) who would meet with the resident to work on their concern. The SSD was interviewed on [DATE] at 1:20 p.m. The SSD said grievance forms are available to every resident and staff. If the resident had a grievance they want addressed they can fill out a form. If the resident was unable to complete the form, they can have a family member or any staff assist then to fill one out. The forms are located in the hall by the social services office. Completed forms are provided to the SSD. The SSD was responsible for reviewing all forms and provided to the appropriate department manager responsible for the area of concern. The grievance process begins on the morning following the date that the grievance form was submitted when it was reviewed at morning meeting with the interdisciplinary team (IDT). Grievances were usually addressed and followed up on within three days of when the form was completed. Some complaints take longer to solve. The director of nursing DON was interviewed on [DATE] at 10:02 a.m. The DON said in response to recent grievances filed by residents, staff were provided training specific to each particular grievance concern. Most of the training provided had a focus of providing good customer service, answering call lights timely, and being respectful to residents asking for assistance. The NHA was interviewed on [DATE] at 5:20 p.m. The NHA said when a resident reports a concern an inquiry begins. Staff are expected to investigate the concern to make sure the concern did not rise to a level of abuse, neglect, or misappropriation of resident property. If the resident reports abuse, injury or fear then the incident is to be reported to the State incident portal within two hour of discovery. All grievances were to be investigated by the department manager responsible for the concern area. All concerns should be addressed within three days. The NHA, DON and SSD were interviewed on [DATE] at 4:42 p.m. The SSD said if a resident voices any concern it initiates a grievance. All grievances were to be provided to the SSD for initial review and then given to the department manager who was to address the concern and have a response within three working days. The NHA said every grievance was brought to the morning meeting where the IDT reviewed the allegation for any factors that stand out to make sure the department managers took appropriate action towards resolution to the residents concern(s) and prevent future violations in care. The DON said it was the goal of clinical services for staff to answer call lights within 15 or less and for staff to always be respectful to residents while providing care. Staff have been provided with several training regarding customer service expectations. The DON provided a record of the all staff training developed in response to resident grievances to train staff about the expectations of good customer services. V. Staff training Review of staff training records revealed the following staff expectations: On [DATE], staff were trained on customer service practice Remember that all of our residents here are our 'customers'. Simply stated 'customer is always right.' This is their home. They have the same rights we do as when we are home. Consider what it would be like to not be able to go into the community the way the staff are able to. They can't go to restaurants, can't go to family events/get-togethers, and can't have visitors, etc. We are the only line that families have to their loved ones here. Remember that when answering the phone. Always be polite and go the extra mile. If you weren't able to see your parents in a year, what would that look and feel like to you? You would want to call frequently to check on them too. On [DATE], staff were trained on customer service practice Types: verbal, nonverbal, written, visualization. Filters to be used before speaking: intention, choice, compassion, empathy. -Good communication skills: make eye contact, no swearing/shouting, no chewing gum, no texting. -Speak clearly, use words everyone can understand, make positive facial expressions, listen, have relaxed body language, don't speak over other people, keep to the point. -Interpersonal relationships at work: Quality of customer service and appropriate demeanor; Characteristics of superior service; Conveying a positive and helpful attitude; Conveying effective messages; Improving relationships; Encourage trust and cooperation; Learning the importance of constructive feedback. -Be mindful of your customer service. There has been an increase in residents' complaints stating that staff are 'rude. On [DATE], staff were trained on customer service practice Please be mindful of how you speak to one another and the residents. We all get frustrated at times, please take a short break when needed and notify your supervisor. The expectation is that everyone is treated with respect. On [DATE], staff were trained on customer service practice This is the residents' home and it should be treated as such. Be mindful of your language and the way that you are speaking to them. Cussing is not acceptable, even if it is to yourself in the hallway. If you need to vent, please go behind closed doors or outside. -Call light complaints. There have been multiple complaints of increased wait times. Remember to not take breaks at the same time, complete multiple tasks in the room at once, go back at the time that you tell them you're going to come back. On [DATE], staff were trained on customer service practice Be mindful of your interactions with residents, other staff and any interactions that may take place in resident care places including hallways. There has been an increase in complaints. Residents state that staff are rude, call lights not being answered timely, and staff complaining about having to provide care. If you need to take a quick break and remove yourself from the floor, please let your supervisor, teammates, etc., know and take a break. Notify managers of other assistance that you may be needing. -Neglect is a type of abuse. Types of neglect include: not answering call lights, placing items not within resident reach, call light not in place, leaving the floor short staffed when others are on break, .

Based on observations, record review and resident and staff interviews, the facility failed to ensure four of 33 sample residents (#34, #17, #53 and #70) received the care and services necessary to attain and/or maintain their highest practicable level of physical well-being. Specifically: -The facility failed to address resident #34's pain during a dressing change, contributing to the resident experiencing pain at a level 12 which exceeded the pain scale (0 - 10 with 10 being the worst pain). -The facility failed to address resident #17's chest pain, contributing to the resident feeling dizzy and weak, falling, and sustaining a skin tear, back bruising and abrasions. -The facility failed to adequately monitor residents #53 and #70's pain and failed to manage resident #70's diabetes as ordered. The findings include: 1. Resident #34 Resident #34, age 72, was admitted to the facility on [DATE]. According to the 6/14 Computerized Physician order [REDACTED]. The resident's 5/1/14 admission minimum data set (MDS) assessment coded the resident as able to make herself understood, with clear speech and no rejection of care exhibited. The assessment identified the resident with occasional pain limiting her day-to-day activities and noted that the patient rated her pain an "8" on a "0-10" scale, with 0 indicating no pain and 10 indicating the worst possible pain. The assessment noted the resident received pain medications as needed, but was not on a scheduled pain medication regimen and did not receive non-medication interventions to help manage pain. The assessment also noted the presence of a surgical wound upon admission. Review of 1/13/14 documentation from the resident's primary provider noted the resident had a history of [REDACTED]. A 4/24/14 skilled daily nurses note indicated the resident was admitted for wound care for 3 areas (a right hip graft from the right lower extremity with a resultant wound area and a left lower extremity wound). The resident had pain in her shoulders, knees and back related to [MEDICAL CONDITION]. A note for the time period of "2-10 p.m." on 4/24/14 documented that the resident was on pain medication 45 minutes prior to her dressing changes. a. Pain Assessment and Pain Management Plan Pain medication order: [MEDICATION NAME] HCl 5mg tablet 1 tablet orally every 8 hours as needed for pain above 5/10 with an order start date of 4/24/14. The resident had no other "as needed" pain medications ordered (contrary to pain assessment references to Ultrum and [MEDICATION NAME] below). Review of the resident's 6/14 PRN (as needed) Pain Medications sheet revealed the resident had an order for [REDACTED]. The resident received the dose of [MEDICATION NAME] once or twice a day from 6/1/14 to 6/6/14 according to the document and staff noted the pain medication was effective. Specifically, the resident received pain medication (one [MEDICATION NAME] 5mg tablet taken orally) on: -6/1/14 at 10:54 a.m. for general body pain, documented as effective at noon -6/2/14 at 8:00 a.m. for general pain (6 out of 10), documented as effective (3 out of 10) at 9:00 a.m. -6/2/14 at 11:25 p.m. for general pain " all over " (6 out of 10), documented as " asleep " at 1:00 a.m. -6/3/14 at 4:00 p.m. for " all over " pain (6 out of 10), documented as effective at 5:00 p.m. -6/3/14 at 11:15 p.m. for leg pain, documented on 6/4/14 at 12:30 a.m. as effective -6/4/14 at 7:00 a.m. for leg pain (8 out of 10), documented as effective at 8:00 a.m. -6/5/14 at 7:30 p.m. for right and left shoulder and leg pain, documented at 8:30 p.m. as effective -6/5/14 at 6:56 a.m. for bilateral lower leg pain (9 out of 10), documented at 8:00 a.m. as effective (3 out of 10) -6/5/14 at 10:00 p.m. for bilateral lower extremity "hurting " documented as effective at 11:00 p.m. -6/6/14 at 6:00 a.m. for general pain, documented at 7:00 a.m. as effective Review of the 6/14 CPO revealed a 4/24/14 order under the "Treatments" section for Dermoplast spray (a topical anesthetic), to be applied topically to wounds daily . The order noted that the Dermoplast should be applied in the morning, but contained no further specifications. -However, review of the resident's 6/14 treatment administration record (TAR) revealed the Dermoplast treatment order was crossed through with"d/c" (discontinued) written next to it with no date when it was discontinued. -Licensed Practical Nurse (LPN) #4, identified by the Director of Nurses (DON) as the skin/wound nurse, was interviewed on 6/7/14 at 2:00 p.m. LPN #4 was not able to find an order discontinuing the Dermoplast. Review of the 6/14 CPO noted a 4/24/14 order that directed staff to conduct a pain assessment using a " 0-10 " scale during each eight-hour shift and, if pain was above level 4, to take action. Documentation of per shift pain assessments revealed that the resident experienced pain that she rated between 5 and 8 during 11 of 17 assessments. Care plan: The resident's 5/5/14 plan of care identified the resident experienced an alteration in comfort related to, among other things, a recent skin graft and ulcers with a goal of managing her pain to a satisfactory level over the next 90 days. -The approaches included administering pain medications as ordered and as needed, conducting a comprehensive pain assessment at identified time frames and as needed, as well as monitoring pain every shift. -Additionally, the plan of care directed staff to notify the physician if the current regime was not controlling pain and to provide non-pharmacological interventions as needed, such as gentle massage, heat and distraction. Pain Assessments: An undated Pain Evaluation form noted that the resident had right hip and right and left lower extremity wounds. The resident rated the pain of the right lower extremity wound at a level 6. The resident rated the pain of the left lower extremity wound at a level 4. -For both wounds, the intensity of the pain decreased one hour after pain medication was given and decreased further three hours after pain medication was given. The form listed the resident ' s pain medications as [MEDICATION NAME] and [MEDICATION NAME] identified on the assessment form as "effective. " -Based on the Wong-Baker FACES Pain Rating Scale, the resident noted that a range of 2-3 was an acceptable level of pain. The assessment identified that, due to pain, the resident suffered incontinence, a change in her ability to perform activities of daily living and a change in her participation in activities. The assessment noted that the resident experienced relief of her pain using medication and distraction techniques. According to the assessment form, the patient described her pain as tender, exhausting, stabbing, hot/burning and sharp. Another undated "Pain Evaluation," identified as "#2" in the top left corner, noted the resident experienced "ongoing" aching, tender, throbbing, shooting, hot/burning and stabbing pain of her right hip and right and left lower extremity wounds. The assessment identified the resident's acceptable pain level as a "4" on the 1-10 Wong Baker FACES Pain Rating Scale, noting that the resident received "Oxy" ([MEDICATION NAME]) for pain, which was effective for the resident two hours after administration. b. Observations On 6/5/14 at 11:53 a.m., resident #34 was observed during wound care performed by LPN #2 on the resident's right and left lower extremities. The resident stated she anticipated wound care would be painful and as LPN #2 administered wound care, the resident grimaced and cried out on several occasions. Wound care began at 11:53 a.m. and ended at 12:10 p.m. The LPN did not stop wound care when the resident cried out. -When asked her level of pain by LPN #2 at 12:10 p.m. after wound care was completed, the resident identified her pain was a "12" on a "0-10" scale with 10 being the worst pain possible. -When asked if the resident was medicated with an [MEDICATION NAME] prior to wound care, LPN #2 noted that the resident had received "Oxy" ([MEDICATION NAME]) at 6:56 a.m. that morning. When asked if a topical anesthetic was used prior to wound care, LPN #2 identified that there was no topical anesthetic for the resident, but she would ask the physician about it. On 6/5/14, LPN #2 documented in a Skilled Daily Nurses Note for " 6-2 (p.m.) " that the resident complained that day of bilateral lower leg pain rated as "12 out of 10" and that the physician was contacted due to the resident's increased pain with dressing changes. No new orders were received, but the physician recommended that staff try to plan administering the resident's "as needed" pain medication around her dressing changes. LPN #2 was interviewed on 6/5/14 at approximately 1:30 p.m. LPN #2 stated that she had called the physician that day and he did not want a topical anesthetic to be used on the wounds as it would likely cause the resident to experience a "burning" sensation. Instead, the physician directed nursing staff to administer the resident's existing pain medication closer to the performance of wound care. Review of the resident's pain care plan (see above) revealed no updates following LPN #2's communication with the physician regarding administering PRN medication closer to the performance of wound care. 2. Resident #17 Resident #17 was admitted to the facility on [DATE]. The admission record stated that among other conditions, she suffered from [MEDICAL CONDITION] and hypertension. a. Resident Status The resident's most recent MDS dated [DATE] revealed the resident suffered from heart failure. The resident's medication administration record (MAR) dated May 2014 stated the resident was taking "Aspirin, 81 mg chewable tab orally on Mon, Wed and Fri and [MEDICATION NAME] for [MEDICAL CONDITION] Fibrillation," as well as [MEDICATION NAME] for hypertension Weekly skin checks on 5/22 and 5/29 noted "Discolorations to right hand and left arm " and noted that the resident had fragile skin. Observations of resident #17 on 6/2/14 at 3:37:11 p.m. in the common area, sitting in her wheelchair, revealed the resident had a dark purple bruise, approximately 4 cm in diameter, on her right hand. The resident also was observed to have multiple bruises, dark purple in color and between 1 and 2 cm in diameter on her left forearm. Finally, the resident was noted to have a large bruise, dark red on the outer edges with a dark purple core that covered the posterior side of her upper left arm. Interview at 9:18 a.m. on 6/6/14 with the resident's CNA #2 regarding the resident's bruises revealed the resident was frequently observed with new bruises, but that the resident usually knew how she had gotten them. CNA #2 said, "She'll say, 'Oh, I bumped my arm on the table." CNA #2 stated that sometimes staff was not aware of the bruises until they had to help the resident with dressing, but that when they did become aware of the bruising, they would do an incident report. When asked about the bruises on the resident's arm, the CNA stated that she had seen them, and assumed that there would be an incident report. All incident reports for resident #17 beginning in March 2014 were requested from the DON. The DON confirmed there were three reports; one on 3/31/14 regarding a fall, one on 5/20/14 regarding the discovery of two bruises (on the resident's right buttock and on the left knee), and one other report on 6/5/14 regarding a fall on the evening of 6/5/14 (see below). No incident reports were filed regarding the bruises observed on 6/2/14 (see above). The bruises were also not noted in the nurses' notes, acute care plan, 72 hour monitoring notes, or treatment record. b. Fall 6/5/14 - Failure to timely and adequately respond to resident's complaint of chest pain. An incident report, dated 6/5/14, documented the resident fell the evening of 6/5/14 and "skin tear sustained to an existing lg bruise left upper arm." On 6/6/14, CNA #2 was interviewed. The CNA stated the resident was usually pretty independent, usually she dressed herself and transferred independently. The CNA then stated the resident had fallen the previous evening, and that as a result, she had required some help dressing that morning and pulling up her pants, and said the resident also had been observed during transfers that morning. The CNA stated that resident #17 had bruises from the fall last evening on her back, over her ribs, and also that the resident had steristrips on her left arm. On 6/6/14 at 11:04 a.m. resident #17 was interviewed regarding her fall and bruising on 6/5/14. -The resident stood and lifted her shirt showing a large bruise with scratches on her right lower back and hip area, a large bruise on her right posterior upper arm which was almost black in color, a bandage on her right upper arm and a hematoma on her left leg. She stated she had a skin tear with seven steri-strips holding it together. -The resident said she got the skin tear, back bruising and abrasions, and leg hematoma when she had fallen the previous night. She stated that she often transferred herself and valued her independence. She stated that she had fallen the previous day because she was nauseous and dizzy from the chest pain she was experiencing. -The resident said she had reported chest pain to the nurse on duty the previous night and the nurse had told her that because her pacemaker was not clicking she was not having a [MEDICAL CONDITION]. She described the pain as being " so bad, I had chest pain, and it went down my arm: it made my stomach not feel well and made me dizzy. " -The resident stated the nurse gave her a Tylenol and some [MEDICATION NAME], but they did not help. She stated that she was still experiencing chest pain. Record review on 6/6/14 at 11:30 a.m. revealed there was no nursing note regarding the resident having chest pain on 6/5/14. The note did document the resident had a fall; however, it did not include any assessment or notification to the physician of possible heart issues or chest pain. c. Staff Interview The director of nursing (DON) was interviewed on 6/6/14 at 11:58 a.m. -He said it was his expectation for nursing to report any chest pain to the physician, and follow up with assessment and observation. He was unaware of a pacemaker clicking to indicate a resident was having cardiac issues. -He stated he had interviewed the resident this morning (following the above resident interview) and the resident had reported that she was still suffering from chest pain. He had reviewed the record and noted there was no nursing note indicating the resident had chest pain on 6/5/14, and as a result he called the nurse (RN #6) who had been on duty then. -He stated the nurse told him that she did not think it was a ' big deal ' and the DON had initiated education with the nurse. He stated that he would start education with all nurses immediately regarding appropriate assessment and intervention when a resident complained of chest pain. He had notified the nurse practitioner regarding the issue, and she was assessing the resident onsite at this time. 3. Resident #53 Resident #53, age 89, was admitted to the facility on [DATE]. According to the Computerized Physician order [REDACTED]. a. Resident Status According to 3/30/14 Minimum Data Set (MDS), the resident required extensive assistance with bed mobility, transferring, moving between locations, dressing, toilet use and personal hygiene. The resident did not walk in her room or the corridor. -The resident was not on a urinary or bowel toileting program. The resident was frequently incontinent of bladder with seven or more episodes of incontinence but at least one episode of continent voiding. The resident was incontinent of bowel with two or more episodes of bowel incontinence but at least one episode of continent movement. -The resident was not on a scheduled pain medication regimen or receiving non-medicinal pain intervention but was receiving pain medication as needed. -The resident was appropriate for pressure reducing devices for bed and chair. Medication orders to address pain per Computerized physician's order [REDACTED].=650mg): start date 12/10/11; [MEDICATION NAME] ([MEDICATION NAME]) 500mg tablet for Tylenol-1 tab orally every 4 hours as needed for pain not to exceed 3gm APAP/24 hrs from all sources PRN: start date 10/8/12; [MEDICATION NAME] HCL 50mg - 1 tab orally every 4 hours as needed for pain PRN: start date 6/21/13. Review of the resident's Pain assessment dated [DATE] indicated the resident's pain location was chronic in her legs. A 0-10 pain scale with ratings of 4-6 on the medication administration record (MAR) was documented. The resident's pain was relieved by [MEDICATION NAME] for leg pain. Page 2 was missing on this form; per Director of Nurses interview on 6/6/14 (see below), staff should be using a different form. Review of the resident's Care Plan (CP) revealed the resident was care planned for urinary tract [DIAGNOSES REDACTED]. b. Recent history of pain in area other than legs Review of nurses' notes on 5/24/14 documented the resident complained of perineum pain with a pain scale of 10/10. The registered nurse (RN) administered [MEDICATION NAME] and documented it was slightly effective. The nurse observed the labia majora skin was rigid, no redness noted and patchy white on the inside with pain at touch. Review of nurses' notes on 5/30/14 documented the resident has vaginal pain with irritation and included white discharge in the inner labia. The resident complained of pain and discomfort. Review of nurses' notes on 5/31/14 at 2:00 a.m. documented the resident had a fungal infection in the vaginal area and was being treated with prescription and cold packs. Review of the nurses' notes on 6/2/14 documented the resident was still on flucanozale ([MEDICATION NAME]) for a yeast infection, with the vagina cleared of white film. The resident stated she was still sore when wiping. Review of the 05/14 medication administration record (MAR) indicated [MEDICATION NAME] was administered at 6:00 p.m. on 5/27/14 for perineal pain and body aches of 9/10 pain with a somewhat effective result of 9/10 pain at 7:00 p.m. No other pain medication was given for the remainder of the evening. On 5/28/14, [MEDICATION NAME] was given for perineal pain with 4/10 pain at 11:35 p.m. with an effective result noted at 1:00 a.m. A pain level of 6/10 was indicated on 5/29/14 with no nursing observation follow up noted or for what reason given. The MAR noted a [MEDICATION NAME] suppository, [MEDICATION NAME] tabs (both in 325mg and 500mg), and [MEDICATION NAME] were available for pain as needed. [MEDICATION NAME] was available for application as needed for peri area rash twice daily; however, none was documented on the MAR as administered in May. c. Failure to timely respond to resident's requests for assistance and complaints of pain On 5/28/14 at 5:45 p.m., the resident was observed seated in her wheelchair in her room by the front door. She stated she needed help changing her pants and rubbed her genital area. On 6/2/14 at 11:20 a.m., the resident stated her bottom was sore and staff was using lotions to help her. At 11:44 a.m., the resident repeatedly stated her bottom was sore and rubbed her genital area. On 6/4/14 at 9:30 a.m, the resident stated her bottom was still sore and staff was still applying lotion. The resident stated she wasn't a complainer but her bottom was really hurting and when she had to urinate, the staff did not come to help her. The resident stated she was frustrated and sat in wet for a long time, causing soreness. The resident stated she had been assisted in the bathroom once today and she utilized her call light although it was awkward to get to. The resident stated the staff would give her something for pain if she asked for it but she did not not like to complain. The resident stated she was not one to take pain medication. -At 10:30 a.m., the resident stated the staff was slow getting around in the mornings and the rash on her bottom was really a bother. The resident stated staff did not provide assistance timely. On 6/5/14 at 1:50 p.m., the resident's bottom and perineum was observed with CNA #8 present after the resident ' s permission was obtained. The resident's labia was red as well as the area around her rectum. The resident stated the [MEDICAL CONDITION] at times with urination and she was unable to recall how long she had the pain. On 6/5/14 at 1:50 p.m., certified nurse aide (CNA) #8 stated the resident had told her that she experienced most of her pain while wiping (after incontinence). On 6/6/12 at 9:30 a.m., CNA #8 stated the resident was able to reposition herself in her wheelchair and that she (CNA #8) routinely provided continence care when resident woke up for the day, again at approximately 10:30 a.m. and again after lunch. On 6/6/14, at 5:40 p.m., RN #7 stated she felt the [MEDICATION NAME] as needed addressed the resident's pain appropriately since the resident was able to tell them when she experienced pain. RN #7 stated she would apply [MEDICATION NAME] tonight. On 6/6/14 at approximately 11:00 a.m., the DON stated the expectation for follow up on administering pain medication was to provide explanations (on the MAR) regarding nurse observation such as documentation that on recheck, the resident's pain was now 2/10 with no further complaints. The DON stated the recheck should be done within the hour. In a subsequent interview on 6/6/14 at 4:15 p.m., the DON stated he had noticed a spike in pain levels in the short-term residents and had designed an action plan to utilize quarterly assessments of pain. The DON stated the plan of action was a three day pain assessment and evaluation with all new admissions. The DON stated an action plan will be put into place now for long-term residents and he was working on writing out procedures. The DON stated per the facility's pain policy, the nurse was to document effectiveness of pain interventions and document when there were spikes in pain. The DON stated this was his expectation and these pain protocols would be documented on the MAR. The DON stated his expectation of nursing comments and observations after pain medication administration was documentation of effectiveness and asking the resident to rate the pain (0-10) scale. The DON stated when nurses observed a resident's pain was not being controlled by medications and pain was up to a 10 on a 0-10 pain scale, the physician should be contacted. The DON stated with the new action plan, the unmanaged pain would initiate charting of a three day pain assessment. Upon review of the pain assessment form dated 3/28/14 (see above), the DON provided the Briggs Pain Evaluation form that was to be used in assessing residents' pain from now on. 3. Resident #70 Resident #70, age 78, was admitted to the facility on [DATE]. According to the Computerized Physician order [REDACTED]. According to 3/9/14 Minimum Data Set (MDS), the resident required extensive assistance with bed mobility, transferring, locomotion off unit, dressing and toilet use. The resident did not walk in her room or the corridor. The resident was on a scheduled pain medication program and was not receiving as needed pain medications or non-medicinal interventions for pain. The resident was appropriate for a pain assessment interview and indicated a presence of pain and experienced pain frequently. The resident was documented as receiving seven insulin injections in the last seven days. The resident was documented as having seven orders in the last seven days for insulin. a. Pain Observations and Interview: On 5/29/14 at 12:37 p.m., the resident was interviewed in her room while seated in her recliner. She stated she had pain in her knees. The resident ' s legs were observed to be swollen. On 6/4/14 at 9:20 a.m., the resident was interviewed again in her room. She stated she had some pain in her knees, like a constant nag. The resident stated she told staff if she had pain and if staff was available, she would take pain medication. . -At 9:45 a.m., when the certified nurse aide (CNA) #4 was overhead asking the resident if she had leg pain due to [MEDICAL CONDITION] (swelling), the resident replied yes. The resident ' s legs were observed again to be swollen. The CNA left the resident's room and at 10:05 a.m., the registered nurse (RN) #5 entered the resident's room and placed socks on the resident, cutting a slit in the top due to the resident's leg swelling. -At 10:10 a.m., the resident stated to RN #5 that her pain level was 8 in her legs, using a scale of 1 (least pain) - 10 (worst pain). The resident requested [MEDICATION NAME] when RN #5 asked if she would like pain medication. -At 10:15 a.m., RN #5 administered the resident's pain medication and stated to the resident she would return in one hour to check in on pain level. Record Review: Computerized Physician order [REDACTED]. -[MEDICATION NAME] 100 mg capsule: 2 caps PO at bedtime for restless leg syndrome: start date 12/10/13 -[MEDICATION NAME] 1% PLO gel 2ml topically to both hands twice daily for pain: start date 1/25/14 -[MEDICATION NAME] 1% PLO gel 2ml topically to both knees twice daily: start date 1/25/14 -[MEDICATION NAME] 500mg tab: 1 tab orally three times per day for chronic pai[DIAGNOSES REDACTED] not to exceed 3gm apap/24hrs from all sources: start date 9/1/13 -[MEDICATION NAME] 100mg capsule: 1 cap orally twice daily for restless leg syndromes: start date 12/10/13: start date 12/10/13 Review of the Medication Administration Record (MAR) for 5/14 revealed an order [MEDICATION NAME] .2ml SL every 4 hours PRN for CAD,SOB, End of life Care: start date 4/29/14 Review of the MAR for 6/14 revealed an order for [REDACTED]. Review of a Pain assessment dated [DATE] indicated the resident's pain location was chronic in her knees/hands. A 0-10 pain scale with ratings of 2-6 on the medication administration record (MAR) was documented. The resident's pain was relieved by repositioning and routine medications. The assessment did not identify the resident ' s acceptable pain level. (See Director of Nurses (DON) interview below; this was not the form staff was to use to assess pain.) Review of the 05/14 MAR documented resident pain level at 10/10 on 5/16/14, 5/17/14 and 5/18/14. -On 5/16/14, [MEDICATION NAME] was administered at 7:05 a.m. with the next nursing observation at 10:30 a.m., documenting the medication was effective with 5/10 pain scale. [MEDICATION NAME] was administered again at 1305 (1:05 p.m.) for leg pain of 8/10 with no nursing follow up noted. -On 5/18/14 and 5/31/14, [MEDICATION NAME] was administered with no documentation of nursing observation regarding the effectiveness of the medication in addressing the resident's high level of pain per 0-10 pain scale.. Moreover, there was no documentation in the progress notes on these dates that the physician was notified of the resident's pain level of 10/10. Interview: See DON interviews above on 6/6/14 at approximately 11:00 a.m., and again at 4:15 p.m., regarding monitoring and addressing residents' pain. b. Diabetic Management Review of the 05/14 diabetic administration record documented finger sticks ordered for blood sugar twice daily before breakfast and supper for diabetes mellitus II with insulin held if less than 80. Review of the diabetic administration record revealed on 5/14/14, 5/22/14, 5/23/14 and 5/24/14, insulin was administered for to the resident for sugar levels of 68, 77, 62, 59 and 53, respectively. On 6/6/14 at approximately 3:00 p.m., the DON confirmed the physician's orders [REDACTED].

Based on record review, observation and staff interviews, the facility failed to implement appropriate and timely interventions to ensure three (#25, #49 and #70) of 33 sample residents received the necessary care and treatment to prevent the development of new pressure ulcers and the decline in their condition. Specifically: Resident #25 developed a pressure ulcer on his spine in 2/14 that had not healed in three months, but rather had increased in size and was unstageable. Observations revealed the facility failed to provide the resident pressure relief in the area of the ulcer for extended periods of time. Observations further revealed the ulcer had a foul odor. Findings include: 1. Resident #25 a. Resident Status Resident #25, age 81, was admitted to the facility on [DATE]. According to the 5/14 Computerized Physician Orders, [DIAGNOSES REDACTED]. According to the most recent Minimum Data set ((MDS) dated [DATE] the resident had cognitive impairments with moderately impaired decision making skills. The resident was coded as requiring extensive assistance with activities of daily living. The resident was on a hospice program. b. Documentation of skin breakdown (1) Right heel Review of the medical record showed the resident had a history of [REDACTED]. Specifically: -The pressure ulcer scale for healing tool (PUSH) dated 2/6/14 showed the resident had acquired a pressure ulcer on his right heel. The ulcer measured 2.5 cm X 2.5 cm distal. -The PUSH dated 2/12/14 documented the resident's heel measurements were 1.5 cm X 1.5 cm distal. -The PUSH dated 3/6/14 documented the resident's right heel was completely resolved. (2) Spine Further record review revealed a pressure area on the resident's spine was acquired on 2/7/14. The ulcer began to heal and then worsened. Review of the skin assessments documented the following: -The PUSH dated 2/17/14 documented distal open .3 cm X .3 cm and proximal red/pink 1.5 cm X 1.5 cm - The PUSH dated 3/5/14 documented distal .9 X .5 and .5 X .5 proximal - The PUSH dated 3/11/14 documented distal 0.6 X 0.4 open and proximal 0.6 X 0.5 open -The PUSH dated 3/17/14 documented distal 1 X 0.6 and proximal 0.6 X 0.5 - The PUSH dated 3/25/14 documented distal 0.5 X 0.2 with yellow slough and proximal 0.3 X 0.3 yellow slough - PUSH dated-4/1/14 documented distal 0.6 X 0.5 and proximal .4 X .4 - The PUSH dated 4/7/14 documented distal 0.5 X 0.7 and proximal 1.8 X 1 cm -The PUSH dated-4/15/14 documented distal 0.2 X 0.2 and proximal 1.4 X 0.6 yellow slough with pink edges - The PUSH dated 4/22/14 documented distal not open pink 1 X1 and distal 1.6 X 0.5 cm - The PUSH dated 4/29/14 documented distal resolved and proximal 1.5 X 1.3 with bleeding and yellow slough - The PUSH dated 5/5/14 documented 1.5 X 1 cm yellow slough center with pink edges - The PUSH dated 5/12/14 documented 2.6 X 1.5 with yellow slough in center 1.4 X 1.3 outer edge pink - The PUSH dated 5/19/14 documented 2.9 X 2.7 open moist yellow slough with outer edge pink. - The PUSH dated 5/28/14 documented 3.5 X 2 cm with 2 X 1 white slough, with pink outer edge - The PUSH dated 6 /2/14 documented 3 X 2 cm yellow slough. c. Facility response to skin breakdown (1) Review of the resident's care plan, last updated on 3/5/14, identified the resident was at risk for alteration in skin integrity related to incontinence of bowel and bladder and impaired mobility secondary to [MEDICAL CONDITION]. The care plan identified the resident currently had a spine pressure ulcer. Pertinent approaches included the following: --Air mattress; --Will assist with repositioning and off loading frequently; --Skin treatments as ordered; --Additional cushion added to the wheelchair in back rest. (2) Physician Orders -Review of the 5/14/14 physician's telephone order documented to cleanse spine wound with wound cleanser, cut small piece of [MEDICATION NAME] Ag (a silver alginate dressing made from seaweed that can absorb large amounts of wound fluid) to fit wound bed, cover with foam dressing and secure Q (every) 3d (third day) and prn (as needed). -Review of the 5/14 CPO documented the resident received Prostat 30 ml orally twice a day (30 grams of protein) to promote wound healing. (3) Review of a nurses' note dated 6/3/14 documented sheepskin was being placed in the resident wheelchair to protect the resident's back although (see above) this intervention was not documented on the care plan. d. Observations - failure to relieve pressure to the resident's spine 5/29/14: -At 9:30 a.m., the resident was observed in the lounge. The resident was sitting in a mobile chair, which resembled a lounge chair on wheels. A sheepskin was in place on the back of the chair; however, it was high on the resident's back and it was not under his pressure ulcer. 6/2/14: -At 1:00 p.m. the resident was observed sitting in the lounge area. The resident was observed sitting in a 95 degree angle which put pressure on his spinal ulcer. The sheepskin was in place, however, it was high on his back and it was not under his pressure ulcer. -At 2:00 p.m. the resident was in an activity in the lounge area. The resident continued to sit in the same position which placed pressure on his spinal ulcer. -At 3:15 p.m., the resident continued to sit in the lounge area where an activity was in progress. His positioning placed pressure on his spinal ulcer. -At 4:00 p.m., the resident remained in the lounge area, sitting in the same position as first observed at 1:00 p.m. -At 5:07 p.m., the RN #6 was observed to assist the resident to the dining room. The resident was not taken to his room to be repositioned. The resident was assisted to the table in the dining room. The resident was not repositioned. 6/4/14: -At 9:10 a.m., the resident was assisted down the hallway to the common area by the hospice certified nurse aide (CNA hospice) after receiving a shower. The resident was positioned in the common area. A group activity began at 9:26 a.m. and at 9:40 a.m., the activity ended. The resident remained positioned at approximately a 120 degree angle which by observation placed pressure on his spinal ulcer. After lunch the resident was placed in the activity room from the dining room at 1:15 p.m. and stayed in the activity room until 2:41 p.m., positioned and without any repositioning in his wheelchair with pressure placed on his spinal ulcer 6/5/14: -At 6:30 a.m., the resident was observed lying in bed on an air mattress. The resident was positioned directly on his back where his spinal ulcer was located. -From 8:45 a.m. to 11:40 a.m. the resident was observed continuously in the common area. Throughout the observation period, the resident was not repositioned or pressure on his back offloaded. e. Observation of spinal ulcer Resident #25 was observed during wound care on 6/6/14 at 10:34 a.m. Observations revealed CNA #10 and licensed practical nurse (LPN #11) prepared the resident for wound care, washing their hands and preparing the dressings. The resident was placed in his bed and rolled to his left side. This exposed his back and spine, which had an undated dressing on the mid spine area. -LPN #11 removed the old dressing, exposing a long open area on the resident's back, approximately 4 cm long with a smaller area in the center approximately 2 cm which had increased depth. The nurse wiped the dressing from the wound bed exposing the wound base as red. A foul odor was released with the removal of the dressing. It was observed to be full thickness (Stage 3). The nurse cleaned and dressed the wound with the prescribed treatment. LPN #11 initialed the dressing; however, she did not date it. f. Interviews CNA #8 who routinely cared for the resident was interviewed on 6/5/14 at 2:30 p.m. The CNA stated that the resident required total care and said he was unable to do any care for himself. The CNA stated the resident was cooperative. LPN #4 who routinely changed the resident's wound dressing was interviewed on 6/6/14 at approximately 4:00 p.m. LPN #4 stated the resident was to be repositioned every two hours. She said at times the resident will lie down, but he enjoys going to activities. The LPN stated that the resident had a sheepskin which was placed in between the back of the seat back of the resident's chair and the resident's back. She stated that the hospice nurse ordered a back cushion which would arrive early next week. -The LPN did not know if the resident's mobile chair was able to be moved in different positions to shift pressure points. She stated that the resident should be moved forward if the chair moved to ensure that the resident did not have pressure on his spinal ulcer. -The LPN said the resident's wound had started as two separate areas, one proximal and one distal. The proximal area cleared up but then the distal area had progressed. -The LPN described the ulcer as unstageable. She stated that she measured the pressure ulcer one time a week and did the treatment and dressing change once a week. She said other times, the medication nurse and sometimes (but not routinely) the hospice nurse did the treatment and dressing change. -The LPN #4 stated that she was not wound certified. -When informed of the wound observations above (foul odor), the LPN #4 stated that the resident's pressure ulcer had changed. She said she was not aware of this change and would expect for the floor nurse to inform her. The director of nurses (DON) was interviewed on 6/6/14 at approximately 5:30 p.m. The DON stated that hospice nurse does not evaluate the spinal pressure ulcer weekly; rather, s/he evaluates it more like every two weeks. The DON stated that he had not ever observed the resident's spinal wound and was therefore not aware if it was getting better or worse. 2. Resident #49 Resident #49, age 79, was admitted to the facility on [DATE]. The resident's plan of care cover sheet noted [DIAGNOSES REDACTED]. The resident's 4/6/14 admission minimum data set (MDS) assessment coded the resident with memory problems, moderately impaired cognitive skills for daily decision-making, continuously present inattention, no behavioral symptoms, dementia, and no rejection of care. -The resident had frequent urinary incontinence, no bowel incontinence and required extensive assistance for bed mobility/transfer, toilet use and personal hygiene. The resident utilized a wheelchair for mobility and required extensive assistance for locomotion on the unit. -The resident had one Stage "2" pressure ulcer and was at risk for developing other pressure ulcers. Ulcers were addressed with ulcer care and pressure-relieving devices in the resident's wheelchair and bed per the assessment. The MDS coded that there was no turning/repositioning program for the resident. a. Record Review -The resident's 6/14 treatment administration record (TAR) contained an undated order directing staff to conduct weekly skin checks (every Thursday). Review of the weekly skin observation documentation revealed that the resident had "right buttock rub" on 4/2/14 which was "healing" on 4/9/14 and not present by 4/16/14. No further skin breakdown was noted from 4/23/14 to 5/29/14 on the weekly skin observation sheets; however, a "72 Hour Monitoring" sheet identified that on 4/2/14, the resident had a 0.2x0.2 pinpoint open area to the left ischial tuberosity. -Also on the TAR was a 3/27/14 order noting that the patient was to be out of bed and up in her chair for each meal (breakfast, lunch and dinner). Additionally, staff were directed to "toilet" the resident at "regular intervals per need and before bed." The resident's 4/7/14 plan of care identified the resident with the potential for skin breakdown related to her urinary incontinence, increased weakness and history of open area on ischial tuberosity, with a goal of having no skin breakdown related to pressure over the next 90-day period. The plan of care directed staff to cue/assist the resident to reposition/off-load frequently, to prompt adequate fluid intake, to provide a pressure-relieving mattress to the bed and a cushion to her wheelchair, to monitor for signs and symptoms of skin breakdown by checking skin weekly and to provide peri-care after incontinence. b. Observations (1) 6/4/14 At 10:40 a.m. the resident was observed lying on her back in bed on a pressure-relieving mattress. At 12:10 p.m., the resident was in her wheelchair, which contained a pressure-relieving pad. (2) 6/5/14 At 6:35 a.m. the resident was observed in her wheelchair in the activities room. At 8:40 a.m. and until 10:30 a.m., the resident was observed in her wheelchair in the front lobby area. At 11:50 a.m. (over five hours after the first observation of the resident in the wheelchair), the resident was transferred to bed for an incontinence check/brief change before being transferred back to her wheelchair for lunch. -During this observation, the resident was rolled to the right with the help of certified nurse aide (CNA #4). A small, round, open area approximately 2-3 millimeters was visualized on the resident's left buttock. The resident had been incontinent of bowel. CNA #4 identified the open area as new. CNA #4 left the room to find licensed practical nurse (LPN #4), the Clinical Resource Nurse, to assess the resident's open area. On 6/5/14, the facility documented on the Weekly Observation Sheet that the resident had a pink, moist open area (Stage II pressure ulcer) on her left inner buttock measuring 0.3 x 0.3. The documentation noted that the resident had no scheduled repositioning plan and received no moisturizing/protectant cream. The resident's June 2014 Medication Administration Record [REDACTED]. The resident's June 2014 TAR contained an addition for 6/5/14 directing staff to cleanse the resident's left inner buttock open area with wound cleanser, dry, and apply Exuderm every 3 days and as needed. (3) 6/6/14 From approximately 8:00 a.m. to 2:00 p.m. (six hours) resident #49 was observed in her wheelchair except for a transfer to bed for an incontinence check/brief change at 11:10 a.m. after which the resident was transferred back into her wheelchair and taken to the front lobby area. c. Staff Interview LPN #4 was interviewed on 6/6/14 at 9:35 a.m. -LPN #4 identified the resident's risk for skin breakdown as "high," noting that the resident was admitted to the facility with old scars on her buttocks (bilaterally) from previous breakdown. Due to her high risk, the resident received weekly skin checks, although she said both high and low risk residents receive weekly skin checks. -LPN #4 stated that, ideally, residents would receive a thorough skin check every day, but due to staffing and lack of time, it wasn't possible. LPN #4 speculated that the resident's skin breakdown was due to the resident "wiggling" in bed and that, when the resident was incontinent, they couldn't always clean her up right away. The Director of Nursing (DON) was interviewed on 6/6/14 at 2:09 p.m. The DON confirmed that LPN #4 was the only nurse assessing the residents for appropriate skin interventions and confirmed that as an LPN, she was not qualified to assess the residents. The DON confirmed that the residents lacked a proper Registered Nurse (RN) assessment. The DON was interviewed again on 6/6/14 at approximately 4:00 p.m. and informed of the observations above on 6/6/14. -At 5:45 p.m., the DON said the resident's CNA (#8) had confirmed that he had failed to get the resident out of her wheelchair from 8:00 a.m.to 2:00 p.m. (other than to change her brief before lunch) because he was busy. The DON stated he intended to create more specific turning and repositioning plans for the CNAs to utilize that would be taped to the inside of each resident's wardrobe closet to ensure that residents received care specific to their needs and situation. Also, the plan would be available for the nurses overseeing the care given by the CNAs. 3. Resident #70 Resident #70, age 78, was admitted to the facility on [DATE]. According to the Computerized Physician order [REDACTED]. According to the nurse practitioner (NP) monthly note dated 5/13/14, the NP called the power of attorney and reviewed the resident's request for comfort care only, palliative care, medications, prognosis and hospice. a. Resident Status According to 3/9/14 Minimum Data Set (MDS), the resident required extensive assistance with bed mobility, transferring, locomotion off unit, dressing and toilet use. The resident did not walk in her room or the corridor. The resident was documented as at risk of developing pressure ulcers. The resident required a pressure reducing device for bed and chair. According to the Braden Scale for predicting pressure sore risk dated 6/3/14, the resident's skin was often moist and linens needed to be changed at least once a shift. The resident was chair fast with very limited mobility. Friction and shear were problems, requiring moderate to maximum assistance in movement. b. Documentation of skin breakdown - facility response The nurses' noted dated 4/28/14 on the 2-10 p.m. shift identified the resident's bilateral buttocks were excoriated (left greater than right). The nurse cleansed the area with foam and applied dressing. A physician's telephone order (TO) dated 4/30/14 documented medi-honey application with dressing to left buttock for seven days for excoriation, and every day as needed. The nurse's notes dated 5/14/14 at 9:00 a.m. identified follow up by the LPN #4 on the resident's skin with the buttocks as superficial with moist pink sporadic open areas, left greater than right side and showed improvement. The LPN #4 documented application of thera-honey and dressings. The resident was repositioned. The nurse's notes dated 5/29/14 at 6:15 a.m. identified follow up on the left buttock excoriation approximately 1.5 x 1 cm with superficial pink tissue more dry than moist. The LPN #4 cleansed and dried wound and applied thera-honey with dressing and the resident's position was changed. The physician's TO dated 5/16/14 documented [MEDICATION NAME] ointment to coccyx every 72 hours and to report to the nurse practitioner the effectiveness for [DIAGNOSES REDACTED]. The physician's TO dated 5/30/14 documented the left buttock excoriation; cleanse, dry and apply medi-honey and dressing (at resident's request) every day until resolved. The nurse's notes dated 5/30/14 at 7:00 a.m. documented LPN #4 spoke with the NP regarding the skin near the coccyx and buttock and would continue use of medi-honey to the left buttock and [MEDICATION NAME] cream to coccyx area until resolved. c. Observations and Interviews (1) 6/2/14 -At 10:30 a.m. the resident was observed asleep in her chair. -At 12:05 p.m. the resident was observed asleep in her chair in the same position as at 10:30 a.m. -At 12:45 p.m. the resident was observed asleep in bed lying on her back. -At 4:10 p.m. the resident was observed asleep in bed lying on her back. -At 5:20 p.m. the resident was observed asleep in bed lying on her back. (2) 6/3/14 -At 9:35 a.m., the resident was observed asleep in bed lying on her back. -At 5:55 p.m., the resident was asleep in bed on her back. At this time, CNA #6 and CNA #7 repositioned the resident via Hoyer lift to a semi-reclined/seated position in bed. (3) 6/4/14 -At 9:15 a.m., the resident was lying in bed on her back with her knees propped with pillows. -At 9:20 a.m., the resident stated her bottom was hurting and where the skin came together was cracked and split. -At 12:00 noon, the resident was observed sleeping in her recliner. -At 2:40 p.m., the resident was observed sleeping in her recliner with no change in position from 12 noon. -At 4:45 p.m., the resident was observed sleeping in her recliner with no changes in position from 2:40 p.m. (other than the resident was holding her forehead in her right hand). (4) 6/5/14 -At 6:10 a.m., the resident was asleep in bed in a seated position. -At 7:45 a.m., the resident was asleep in bed in a seated position with no changes in position as noted at 6:10 a.m. -At 9:05 a.m., the resident was asleep in bed in a seated position with no changes in position as noted at 7:45 a.m. -At 2:45 p.m., the resident was transferred via Hoyer Lift from her recliner to the bed by CNA #8, CNA #9, and another CNA. A patch was observed on the resident, covering a few superficial open areas with a large area of red to purple darkening above the rest of the area where the buttocks meet. When the patch was removed, there was evidence of drainage stains on the patch. Registered nurse (RN) #6 came in to change the dressing and stated the resident did not like to lie on her side. RN #6 agreed that the discolored area was from pressure, although she initially stated the open area was from shearing. RN #6 stated the open area comes and goes and placed bordered gauze on the wound with two pads on the outside of the gauze to be utilized as padding. -At 5:00 p.m., a special gel mattress was observed on the resident's bed. The resident stated she had just received it from the nurse. The resident stated the nurse told her a special gel cushion has been ordered for her recliner. d. Staff Interviews On 6/5/14 at 4:00 p.m., LPN #4 was interviewed. -The LPN stated she was not sure the resident's wound was a pressure ulcer and that when she first observed the area, it was more of an excoriation-superficial, not a pressure ulcer presentation. LPN #4 stated the resident was incontinent with the resident staying in bed more frequently and no longer being mobile. These were changes in condition that had been occurring for several weeks - up to one month ago. -The LPN stated the resident had various medications discontinued and there were multiple things going on. The LPN stated the wound did not present as a pressure ulcer. The LPN #4 stated the resident had an order for [REDACTED].#4 stated Calazine also was being used. -The LPN stated the resident was not part of her weekly assessment for pressure ulcers. However, she believed she observed the wound earlier in this week, as the wound was observed as part of the resident's weekly skin assessment. -The LPN stated she was unsure if the resident had a special mattress but said she had a regular recliner with no gel cushion. The LPN stated a special cushion and mattress would be appropriate for the resident. The LPN stated the resident's condition was related to her decline and some things 'you can't fix.'

Based on observation, record review and interviews, the facility failed to ensure one of 28 sample residents (#42) received the care and services necessary to promote urinary continence and to prevent urinary complications. Specifically: -the facility failed to ensure resident #42's catheter was removed as soon as the catheter was not clinically warranted. The resident was admitted to the facility on [DATE]. According to treatment administration records, continence assessments and care plans, the resident was catheterized on 6/8/11 for "[MEDICAL CONDITION]." As of 6/27/13, the resident still had the catheter in place. There was no evidence any attempts were made over the two-year period to remove the catheter. The resident experienced pain and infections because of the catheter. The findings include: A. Facility Policy The facility's Management of Indwelling Catheters policy, dated 1/14/13, included the following protocols: -"The Continence Assessment form will provide medical justification for the initiation and continuing need for catheter use, determination of which factors can be modified or reversed (or rationale for why those factors should not be modified), and the development of a plan for removal." -"Appropriate indications for continuing use of an indwelling catheter beyond 14 days may include: a. [MEDICAL CONDITION] that cannot be treated or corrected medically or surgically, for which alternate therapy is not feasible, and which is characterized by: 1) Documented post void residual (pvr 0 volumes over 200 cc; 2) Inability to manage the retention/incontinence with intermittent catheterization; 3) Persistent overflow incontinence, symptomatic infections and/or renal dysfunction." -"Reassess the resident with an indwelling catheter periodically to determine whether a voiding trial or bladder retraining may be effective in eliminating the need for the indwelling catheter." B. Resident Failures 1. Resident #42 - [AGE] years of age - was originally admitted to the facility on [DATE], with readmission on 3/1/11. According to a physician progress notes [REDACTED]. The quarterly minimum data set (MDS) assessment, dated 3/15/13, indicated the resident was cognitively intact, with a BIMS (brief interview for mental status) score of 14 out of 15, and required extensive assistance for all activities of daily living, except for eating, for which she was independent. The resident had an indwelling catheter. a. Record Review 1) Nurses' notes (August 16, 2012 - October 22, 2012) The resident's record included the following nurses' notes, starting from August 2012: 8/16/12 - "1800 - Res c/o (complains of) discomfort with Foley cath (catheter). Med nurse unable to flush cath or reinsert new cath because of res c/o pain and discomfort ...received new orders from ...NP (nurse practitioner) to leave out cath and reinsert within 12 hours." 8/16/12 - "2135 - Res voided x 4 = moderate amt. Res denies pain or discomfort. No bladder distension noted, no tenderness to abd (abdominal) area. Res stated vaginal area still sore. Noted no distress. Alert and appropriate ..." 9/8/12 - "Noted dk (dark) red blood in cath tubing. Res went to dentist during the day on 9/7/12. States they moved her from chair to chair a lot. Cath irrigated easily - return to pink in color ...." 10/13/12 - "Resident pale in color. C/O moderate pain; PRN (as needed) [MEDICATION NAME] given. Sentences are mixed words." 10/20/12 - "Res slept well all noc (night). No c/o pain or discomfort except during cath irrigation. c/o urgency feeling." 10/22/12 - "Resident with SOB (shortness of breath, faint and rapid. Pulse. Res unresponsive..fading in and out of consciousness. Res pale, clammy and gurgling. Received new orders to d/c (discharge) to hospital ..." 2) hospitalization (October 23, 2012 - October 25, 2012) The hospital report, dated 10/25/12, indicated the resident's primary [DIAGNOSES REDACTED]. Ok to go to SNF (skilled nursing facility) today." 3) Readmission to the facility from the hospital (October 25, 2012) Nurses notes: 10/25/12 - "...Foley intact ...Notified (nurse practitioner) ...regarding clarification for Foley D/C order ..." 10/27/12 - "Res requested to have catheter removed. Explained that the doctor wanted to keep it in. Res said "okay." (The record did not contain documentation as to the reason the physician did not want to make an attempt to discontinue the Catheter at this time, as recommended by the hospitalist). physician progress notes [REDACTED]. 11/20/12 - "..There is a Foley catheter for [MEDICAL CONDITION] ..." 1/10/13 - " ...Her catheter is for [MEDICAL CONDITION] bladder, which is the reason she has [MEDICAL CONDITION] ..." Nurses notes: 2/28/13 - "ABO (antibiotics) in progress for UTI (urinary tract infection)- did c/o burning around foley cath. Peri care given ..." 4) Assessments/Care Plan Conferences The resident's record contained a Continence Assessment, completed by a nurse on 3/13/13. The Assessment: -documented the resident had an indwelling Foley catheter for "[MEDICAL CONDITION] bladder - 1/10/13." The assessment did not indicate the reason the [DIAGNOSES REDACTED]. There was no documentation referencing post void residual tests, or a urology consult, which would warrant a change of diagnosis. -did not include the development of a plan for removal, per facility policy. The resident's care plan, last updated on 6/20/13, listed the following Problem: "(Resident) has DX (diagnosis) of [MEDICAL CONDITION] bladder and requires use of Foley catheter. Start date: 6/8/11." The documented goal was: "(Resident) will have no complications of Foley cath, i.e. retention, s/sx (signs/symptoms) of infection, etc. thru next 90 days." Approaches included: "Notify physician of any noted complications r/t use of Foley; and "dignity bag to house Foley cath bag at all times." The annual Care Plan Conference Summary, dated 3/21/13, documented the resident had a "UTI in the last 30 days." There was no indication the resident's catheter use was discussed during the care plan conference. The resident's record did not contain a comprehensive assessment pertaining to a careful examination and review of the history and physical, progress notes, nurses' notes, or the resident's response to the use of a catheter. There was no documented evidence the resident and representative were informed of the risks and benefits of catheter use. b. Observations During an initial interview with resident #42 on 6/25/13 at 9:00 a.m., the resident was observed to be reclining on her bed, finishing her breakfast room tray. She was observed to have a Foley catheter. The resident explained she did not participate in group activities because she preferred to stay in her room. She did not elaborate as to the reason she declined group activities. During intermittent observations of the resident on 6/25/13, 6/26/13, and 6/27/13 (various times in the morning and afternoon) the resident was observed to spend most of her day on her bed. c. Interviews 1. On 6/26/13 at 8:30 a.m., the charge nurse stated that on 5/21/13, there was an order to clamp the resident's Foley catheter for four hours every day for one week, and then for six hours every day for bladder training. The charge nurse verbalized that the recent attempts to clamp the resident's catheter, including a new order for clamping on 6/14/13, were "not effective because it's been leaking." -Review of the physician progress notes [REDACTED]. On 6/25/13, a nurse wrote, "Foley cath clamped 7 1/2 hours...urine leakage noted in her brief. Resident refuses to clamp Foley..." -There was no documentation in the record as to the reason a post void residual test was not conducted in the months leading up to this first attempt at bladder re-training. 2. On 6/26/13 at 10:15 a.m., the director of nursing (DON) was interviewed. -The DON explained that when the resident's catheter was removed back on 8/16/12 for 12 hours due to bladder discomfort, "She was tolerating it fine. There was no distress, no distension." When asked why an attempt to discontinue the catheter was not made at that time, the DON verbalized that a bladder scan would be needed for a more definitive evaluation. -The DON confirmed the resident's catheter use was not periodically evaluated by an interdisciplinary team, per facility policy. The DON explained that nurses would report any problems or resident preferences to the physician as they came up, but "The physician will make a determination." 3. On 6/26/13 at 10:20 a.m., the regional consultant verbalized that residents with catheters should be assessed quarterly. The consultant stated she would expect to see a urology report for a resident with longstanding catheter use. The consultant confirmed the resident's record did not contain a urology report. 4. On 6/26/13 at 2:00 p.m., the Administrator reported that in January 2013, the Quality Assessment and Assurance (QAA) committee identified that resident #42's [DIAGNOSES REDACTED]. As a result of the discussion which took place at that meeting, the physician changed the [DIAGNOSES REDACTED]." No notes were provided regarding this assessment or change in diagnosis. d. Action taken during the survey On 6/26/13, the physician wrote the following order: "On 6/27/13, remove foley catheter for 8 hrs, strict I & O at the end of 8 hrs, do PVR, if greater than 300, call NP." A nurses' note, dated 6/27/13 at 6:00 a.m. - read, "Catheter removed per orders ..." On 6/27/13 at 3:00 p.m., a nurse wrote, "PVR 20 cc, voided lots today, incontinent of B & B (bowel and bladder)." On 6/27/13 at 4:00 p.m., a nurse was asked about the status of resident #42's Foley catheter. The nurse responded, 'It's been d/c'd because her PVR was only 20." e. Resident Interview On 6/27/13 at 3:10 p.m., resident #42 was observed sitting in her chair in her room. The resident responded (to the discontinuation of the Foley), "It's wonderful. It's great!"