Every finding on record at Mountain View Post Acute

Based on record review and interviews, the facility failed to ensure one (#2) of three residents was kept free from physical abuse out of six sample residents.Specifically, the facility failed to protect Resident #2 from physical abuse by Resident #3.Findings include:I. Incident of physical abuse towards Resident #2 by Resident #3 on 2/9/26The facility investigation documented that on 2/9/26 at 10:05 p.m. Resident #2 reported that Resident #3 called him a homosexual slur after requesting alcohol from him. Resident #2 said he was frustrated, confronted Resident #3 and grabbed his shirt. Resident #2 said after he grabbed Resident #3's shirt, Resident #3 then made contact with Resident #2's face with an open hand. Staff members intervened and ensured both residents stayed separated. Both residents were immediately assessed by nursing staff following the incident. No injuries were observed or reported for either resident. Fifteen minute checks and psychosocial check-ins were initiated, and nursing assessments were completed. The facility reported the incident to the police, updated both residents' care plans, educated staff on resident-to-resident altercations and monitored Resident #2 and Resident #3 to ensure they remained separated from each other in common areas. II. Resident #2 (victim)A. Resident statusResident #2, age less than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included acquired absence of left leg above knee, acquired absence of right leg above knee and neuritis (nerve inflammation).The 1/14/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was independent with transfers and toileting, and required supervision for slide board transfer to showers. The MDS assessment indicated the resident did not have any behaviors.B. Resident interviewResident #2 was interviewed on 4/2/26 at 12:46 p.m. Resident #2 said the incident with Resident #3 happened in the activities room. Resident #2 said Resident #3 was talking too much, and he told him to stop, but Resident #3 yelled at Resident #2 with racial and sexual orientation insults and hit him on his face. Resident #2 said he grabbed Resident #3's shirt, and then turned around and left. Resident #2 said he was just protecting himself during the incident, and there were no staff members present. Resident #2 said after the incident with Resident #3, the facility staff moved him to a different hallway since both residents used to live in the same hallway. He said since then, the incident, staff members had kept them separated. Resident #2 said he did not have any injuries after the incident.C. Record reviewThe trauma informed care plan, initiated 9/13/25, documented Resident #2 reported a history of trauma and life threatening illness or injury. Resident #2 became a double amputee in March 2025. Interventions included encouraging the resident to seek support as needed, offering behavioral health services as needed, educating the staff on the resident's trauma history and triggers to avoid instances of re-traumatization, mental health referrals as needed and updating the resident's trauma informed care plan as needed.The 2/10/26 progress note documented the assistant director of nursing (ADON) at approximately 10:05 p.m., revealed that Resident #2 and Resident #3 were involved in a fight in the activities room. Both residents were separated by and assessed by the ADON and licensed practical nurse (LPN) #4.III. Resident #3A. Resident status (assailant)Resident #3, age less than 65, was admitted on [DATE]. According to the April 2025 CPO, diagnoses included type 2 diabetes mellitus with diabetic neuropathy, acquired absence of left leg below knee, acquired absence of right foot, phantom limb syndrome, unspecified mood (affective) disorder and depression.The 3/23/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He was independent for transfers, bathing and most of his ADLs.The MDS assessment indicated the resident did not have any behaviors. B. Resident interviewResident #3 was interviewed on 4/1/26 at 12:59 p.m. Resident #3 said Resident #2 got out of control on 2/9/26, so he had to put him under control. Resident #3 said during the incident, there were no staff members present and no one suffered an injury. C. Record reviewThe behavior care plan, initiated 8/15/24, documented Resident #3 had a potential and history of being verbally aggressive (cursing and yelling at staff members) related to ineffective coping skills. Interventions included analyzing key times, places, circumstances, triggers, and what de-escalated the resident's behavior and documenting, assessing and anticipating the resident's needs and comfort level, monitoring behaviors, providing positive feedback for good behavior, psychiatric consult as indicated and, when the resident became agitated, intervening before the agitation escalated.The psychosocial and behavioral care plan, initiated 2/10/26 (the day after the incident with Resident #2), documented Resident #3 exhibited or was at risk for behavioral symptoms (striking out, grabbing others, being combative, verbally aggressive, and the use of derogatory words, including sexual orientation towards others, or physically abusive) due to depression, and to an unspecified mood (affective) disorder diagnosis. Interventions included assessing diversional activities, anticipating needs and meeting them promptly, documenting and recording behavioral episodes, encouraging the resident to verbalize his feelings, and establishing rapport.-Review of Resident #3's progress notes revealed no documentation of the incident between Resident #3 and Resident #2.IV. Additional resident interviewResident #6 was interviewed on 4/1/26 at 4:04 p.m. Resident #6 said she was present when the incident between Resident #2 and Resident #3 occurred (on 2/9/26). She said Resident #3 was talking too much and too loudly, and Resident #2 told him to calm down. She said Resident #3 overreacted, insulted Resident #2, and hit Resident #2 in the face. Resident #6 said there were no staff members in the activities room at the time of the incident and it took a long time for staff to come and separate them. She said by the time staff arrived in the activities room, Resident #2 had already left the room.V. Staff interviewsCertified nurse aide (CNA) #4 was interviewed on 4/1/26 at 3:32 p.m. CNA #4 said she did not hear about the incident between Resident #2 and Resident #3. However, she said that Resident #3 exhibited aggressive behavior, and staff members respected his personal space. CNA #4 said she did not hear anything about any new interventions for Resident #3's behaviors to prevent further incidents.LPN #3 was interviewed on 4/1/26 at 4:40 p.m. LPN #3 said the incident between Resident #2 and Resident #3 happened in the evening. She said the ADON told her that there was an incident between Resident #2 and Resident #3 in the activities room. LPN #3 said Resident #3 insulted and then hit Resident #2. LPN #3 said the incident was reported to management, and the staff moved Resident #2 to a different hallway, even though it was the only time both residents were involved in an incident. LPN #3 said since the incident, the staff avoided having both residents smoking outside at the same time.The director of nursing (DON), the ADON, and the regional nurse consultant were interviewed together on 4/1/26 at 5:15 p.m. The ADON said several residents were hanging out and listening to music that night (2/9/26) in the activities room. The ADON said she heard someone screaming for a nurse and went to check on the residents. The residents in the activities room reported there had been a verbal and physical altercation between Resident #2 and Resident #3. The ADON said she did not see what happened, but she went to assess both residents after the incident. The ADON said the facility initiated the following interventions after the incident: 15-minute checks, moving Resident #2 to a different hallway and keeping both of the residents separated from each other. The ADON said residents were allowed to go to the activities room at night and be there without supervision. The DON said she talked to Resident #3. The DON said Resident #3 reported that Resident #2 grabbed his shirt, so he pushed Resident #2 away. The regional nurse consultant said the incident between Resident #2 and Resident #3 was substantiated as abuse by the facility.

Based on observations and interviews the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen and three of three nourishment rooms. Specifically, the facility failed to:- Ensure employees performed hand hygiene appropriately;- Ensure food was labeled, dated and stored appropriately; - Ensure dishes were washed and sanitized at the correct temperature,- Ensure equipment was stored properly; and,- Ensure the nourishment room refrigerators were clean and maintained at safe temperatures. Findings include:I. Ensure employees performed hand hygiene appropriatelyA. Professional referenceThe Colorado Retail Food Regulations, (3/16/24) and retrieved on 12/15/25 read in pertinent part, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; using tobacco products, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands. (2-301.15)B. ObservationsOn 12/9/25 during continuous observation, beginning at 3:40 p.m. and ending at 3:45 p.m., the following was observed:Dishwasher #1 was wrapping utensils in napkins with bare hands. He had removed the utensils from a flat bin where the silverware was laying in all directions, and he proceeded to touch all areas of the utensils. Dishwasher #1 touched his face, removed and replaced his hat, touched other surface areas and continued to wrap utensils without washing his hands. On 12/9/25 during continuous observation, beginning 5:10 p.m. and ending 5:45 p.m., the following was observed:At 5:10 p.m. cook (CK) #2 prepared sandwiches wearing gloves. While CK #2 prepared the sandwiches he touched the box of plastic wrap, the outside of the bread bag and utensils without changing his gloves. CK #2 removed the gloves and washed his hands for 10 seconds. He then proceeded to donned (put on) gloves and went to the refrigerator, removed deli turkey and cheese, opened the packages and continued to make sandwiches without changing the gloves. At 5:25 p.m. dishwasher #1 was placing the crackers and condiments onto the meal trays. Dishwasher #1 wiped sweat off of his forehead and continued to set up the meal tray without washing his hands. On 12/10/25 at 12:25 p.m. restorative certified nurse aide (CNA) was assisting Resident #82 with her meal. The restorative CNA #1 was stopped assisting Resident #82, helped another resident pull up her pants and fix her shirt, she then immediately went back to feeding the resident. She stopped again and assisted another resident with setting up their plate. She then picked up a knife off of the floor. She proceeded to assist Resident #82 with eating without washing her hands. C. Staff interviewThe lead restorative CNA was interviewed on 12/10/25 at 5:15 p.m. The lead restorative CNA said anytime a resident was being assisted with eating, The CNA's hands should be clean. The lead restorative CNA said hand hygiene should be performed in between assisting residents. The lead restorative CNA was interviewed a second time on 12/11/25 at 10:00 a.m. The lead restorative CNA said the restorative CNA #1 received education on handwashing on 12/10/25 (during the survey). The dietary manager (DM) was interviewed 12/11/25 at 4:23 p.m. The DM said staff should be washing hands between glove changes for 25 seconds. She said gloves should be changed and hands washed when residents or other surface areas were touched before continuing the task.II. Failed to ensure time and temperature controlled food was labeled, dated and stored appropriately. A. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, (3/16/24), retrieved on 12/11/25 read in pertinent part, A date marking system that meets the criteria may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded or using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the department upon request. (Chapter 3-29).Except during preparation, cooking, or cooling, or when time is used as the public health control time/temperature control for safety food shall be maintained at 135 degrees fahrenheit (F) or above at 41 F or less. (3-501.16)B. ObservationsDuring the initial initial main kitchen tour on 12/8/25 at 8:45 a.m. the following was observed:-A refrigerator with a freezer compartment located near the walk-in refrigerator, off of the main kitchen, contained three unmarked, undated containers filled with juice-like liquids. -The reach-in refrigerator, located off of the main kitchen, contained nine 10 pound rolls of thawed ground meat, two sides of beef, and nine packages of pork which were not labeled or dated. -A second reach-in refrigerator, located in the main kitchen, had an outside reading of 59 F. There was no thermometer in the refrigerator. The refrigerator contained eggs, in their shells, sitting in a metal bin loosely wrapped with plastic wrap, a container filled with a yogurt-like substance and two bags of lettuce. None of these food items were labeled or dated. -A small refrigerator located in the dining room for the self-serve cereal showed the temperature log had not been filled out since 12/5/25. There was no thermometer in the refrigerator. There were several small milk containers. On 12/8/25 at 11:30 a.m. the following was observed in the Monarch unit nourishment refrigerator and freezer:-The temperature log had not been filled out since 12/5/25 and there was not a thermometer in the refrigerator.-Fourteen health shakes with no pull dates (date when removed from freezer).On 12/9/25 at 3:35 p.m. the following was observed in the walk-in refrigerator in the main kitchen:-A container of what appeared to be seafood salad was loosely wrapped with a plastic wrap in a mixing bowl with no label or date. -A bin of sliced tomatoes wrapped in plastic wrap with no label or date. On 12/10/25 at 2:35 p.m. the following was observed in the Monarch unit nourishment area:-Three turkey sandwiches wrapped in plastic wrap were sitting on the counter and were not dated. -Four plastic containers holding fruit-like food were sitting on the counter and were not labeled or dated. On 12/10/25 at 2:50 p.m. the following was observed in the [NAME] nourishment area:-A resident opened soy milk that did not have an open date marked on the container.-A cup of fruit that was not labeled or dated.-An opened container of hummus that was not labeled or dated. -Twelve health shakes were sitting on the counter. The temperature of one of the shakes was 68.2 degrees F. At 3:13 p.m. the following observations with the DM-On the Monarch unit the undated turkey and cheese sandwiches sitting directly on the counter the temperature was 72.5 degrees. At 3:22 p.m. the medication cart on the [NAME] unit had a supplement bin with no ice. The bin contained an opened pudding cup which was made in the kitchen. The temperature was taken with the DM and was 58 degrees F. Licensed practical nurse (LPN) #4 said she was unaware the pudding needed to have a holding temperature of 41 degrees and below. C. Staff interviewsCertified nurse aide (CNA) #12 was interviewed on 12/10/25 at 2:37 p.m. CNA #12 said she did not know what the written pull dates on the health shakes meant. She looked for a printed manufacturer expiration date. She said she looks for the expiration date on the carton. An unidentified CNA was interviewed on 12/10/25 at 3:00 p.m. The unidentified CNA said she first looked at the carton for a printed expiration date. She said she was not certain what the written date meant and needed to ask. She returned and said the written dates were when the cartons were pulled from the freezer. The DM was interviewed on 12/10/25 at 3:15 p.m. The DM said she observed the Monarch and [NAME] nourishment stations. She said the temperature reading for the sandwiches was 72.5 F. She acknowledged the health shakes temperature had a reading of 68.2 F. She said the sandwiches and shakes were taken to the nourishment station by the dietary staff. She said the dates on the health shakes was the date the shakes were pulled from the freezer and needed to be used within 14 days. The DM said the director of nursing (DON) was responsible for providing education to the staff on food safety. The DM said she disposed of the turkey sandwiches and health shakes. The DM said the holding temperatures for cold food needed to be below 41 degrees and the hot foods above 135 degrees F.The DM was interviewed again on 12/11/25 at 4:23 p.m. She said she was aware when the meat was delivered and aware of the dates when it needed to be used or frozen, however, she was unable to find dates on the two sides of beef and all of the rolled hamburger meat. III. Failure to ensure dishes and utensils were washed and sanitized at correct temperatures. A. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, (3/16/24), retrieved on 12/15/25 read in pertinent part, A warewashing machine shall be equipped with a temperature measuring device that indicates the temperature of the water: (A) In each wash and rinse tank; and (B) As the water enters the hot water sanitizing final rinse manifold or in the chemical sanitizing solution tank. (4-204.115) The temperature of the wash solution in spray-type warewashers that use chemicals to sanitize may not be less than 120 F. (4-501.110)B. Observations and interviewOn 12/11/25 at 10:05 a.m. the temperature log for the dish washing machine had not been filled out since 12/8/25. The dishwashing machine was being used. The gauge on the dish washing machine, during the cleaning cycle, read 104 F. The rinse cycle temperature did not go above 104 F. The DM said the wash and rinse cycles do not rise above 104 F. The DM left to notify the maintenance director (MTD). When she returned, she called the company who services the dish washing machine and said a repair person would be out shortly. She said she would pull the plates and utensils from service and used paper goods. The DM said they rewashed the dishes and utensils in the three compartment sink. C. Staff interviewsDishwasher #1 was interviewed 12/11/25 at 10:06 a.m. He said the facility had a high temperature machine. He said the water needed to be 120 F. He said there were also chemical testing strips. -However, the facility had a low temperature dishwashing machine.The DM was interviewed 12/11/25 at 10:20 a.m. She said the dishwashing machine was low temperature and the temperature was to be checked at least twice daily. She said the temperatures should be marked on the temperature log sheet. The DM said she was going to run a thermometer through the dish washer but could not locate the thermometer. The DM was interviewed again on 12/11/25 at 4:23 p.m. She said the temperature gauge was broken and there was also a problem with the hot water connection in the kitchen. The DM said she had run a thermometer through the warewasher that morning and the temperatures were correct. -However, the DM did not log the temperature anywhere or share this information earlier in the day when it was revealed the hot water was not the correct temperature (see observations above).The MTD was interviewed on 12/11/25 at 8:00 p.m. The MTD said the dishwasher machine was leased and earlier in the day the gauge on the machine was replaced. He said the water was connected to a separate boiler, so the temperature could be higher. He said the dishwasher washer continued to not get to the proper temperature and so a plumber was called in earlier that same day. He said the plumber was able to fix the water temperature. IV. Failure to ensure food pans were dry when stacked and stored. A. Profession referenceThe Colorado Retail Food Establishment Rules and Regulations, (3/16/24), retrieved on 12/15/25 read in pertinent part, Equipment and utensils, laundered linens, and single-service and single use articles shall be stored in a clean dry location, where they are not exposed to splash, dust, or other contamination, and at least 6 inches above the floor. Clean equipment and utensils shall be stored in a self-draining position that allows air drying and covered or inverted. (4-903)B. ObservationsOn 12/9/25 at 3:30 p.m. the following was observed in the kitchen:-There were three stacks of different sized stainless steel pans in the clean dish storage area. The pans had water droplets on the edges of the pans and visible moisture on the sides when pans were lifted up. On 12/11/25 at 10:30 a.m. the following was observed in the main kitchen:-There were stainless steel pans that were stacked on top of each other with visible moisture on the sides when pans were lifted up. C. Staff interviewThe DM was interviewed on 12/11/25 at 10:30 a.m. The DM said the pans should be dried prior to being stacked. She said the dishwasher had a towel which should be used to dry equipment before it was stacked. V. Failure to maintain clean nourishment refrigerators.A. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, (3/16/24), retrieved on 12/15/25 read in pertinent part, Equipment food-contact surfaces and utensils shall be clean to sight and touch. Non-food-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. (4-601.11)B. ObservationsOn 12/8/25 at 8:45 a.m. in the main kitchen the refrigerator's freezer compartment had green fluid frozen on a shelf in the freezer. The refrigerator contained food debris and spilled liquid. On 12/8/25 at 11:30 a.m. the Monarch nourishment refrigerator had food debris scattered throughout the freezer compartment. The refrigerator had food debris on the door shelves. On 12/10/25 at 2:27 p.m. the Monarch unit's nourishment refrigerator had food debris scattered throughout the freezer compartment and food debris in the door shelves in the refrigerator.On 12/10/25 at 2:50 p.m. the [NAME] unit's nourishment refrigerator's freezer compartment had brown frozen liquid on the bottom shelf. The refrigerator drawers had food debris on the bottom of the drawers and discolored stains in the drawers. The door shelves contained food debris. On 12/10/25 at 3:00 p.m. the Columbine nourishment refrigerator's freezer compartment had food debris scattered throughout the freezer. Food crumbs were observed in the refrigerator.C. Staff interviewsThe DM was interviewed on 12/10/25 at 3:15 p.m. She said the housekeeping department was responsible for cleaning the refrigerator and freezer compartment which should entail removing the items. The MTD was interviewed on 12/10/25 at 3:45 p.m. The MTD said he was not sure who was responsible for cleaning out the nourishment refrigerators but thought it was either the nursing or nutrition department. He said housekeeping would clean the front of the refrigerator. The MTD stepped out to make a call and returned shortly after. He then said the housekeeping department was responsible for cleaning out the nourishment refrigerators. He said if staff spilled any food or liquid this should be cleaned immediately and housekeeping did a deeper clean weekly, taking items out of the refrigerator and freezer compartments. He said there was no log of the cleaning schedule.

Based on observations and staff interviews, the facility failed to provide adequate outside ventilation by means of windows and/or mechanical ventilation in four of four shower rooms.Specifically, the facility failed to ensure the residents' shower room vents were functioning in four shower rooms. Findings include:I. Facility policy and procedureThe Resident Environmental policy, undated, was provided by the corporate consultant on 12/11/25 at 8:33 p.m. It read in pertinent part, It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.Have adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two (resident bathrooms and service areas should be ventilated, as required by code).II. ObservationsOn 12/11/25 at 1:03 p.m., an environmental tour was conducted. The ventilation fan outlets in four out of four residents shower rooms were without a motor.The [NAME] unit did not have a window nor mechanical ventilation. The ventilation outlet on the Monarch unit was being repaired. The outlet was without a motor, and there was no switch to operate. The two shower rooms on the Columbine unit's ventilation outlet had no motor.A small square of single-ply toilet paper was placed against the vent in all four shower rooms. All the outlets were unable to hold the toilet tissue in place, indicating the fans did not function.III. Staff interviewAn environmental tour was conducted with the maintenance director (MTD) on 12/11/25 at 7:39 p.m. The MTD confirmed the exhaust fans in all four shower rooms were without a motor and not functioning. The MTD said the ventilation outlet had not been working since he became the maintenance director. The MTD said he did not know the reason the ventilation outlets were without a motor. The MTD said he would immediately work on getting a new motor for all four shower rooms.

Based on observation and interviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality in two of two dining rooms. Specifically, the facility failed to:-Provide a meal in a timely manner and did not notify the residents of the delay,-Serve residents at a table at the same time, and-Provide residents on the Monarch who were sitting in the dining room waiting for their meal that was delayed, with a drink or diversion. Finding include:I. Facility policy and procedureThe Resident Rights policy statement, dated 2/21/25, was provided by the nursing home administrator (NHA) on 12/11/25 at 4:11 p.m. It read in pertinent part, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence and be treated with respect, kindness, and dignity.II. Observations of the main kitchen and dining roomDuring a continuous observation on 12/8/25, beginning at 11:55 a.m. and ending at 12:30 p.m., in the main dining room the following was observed:At 12:00 p.m. several unidentified staff members assisted with the meal service. The staff members could be heard asking who the residents were in order to deliver the tray. A table with two residents who were seated at the same time were served at different times. The first resident was served at 12:00 p.m. and the second resident was served at 12:14 p.m. The first resident had finished the meal and left the table, leaving the second resident to eat by themself. Another table with two residents who were socializing were served at different times. The first resident was served at 12:05 p.m. The first resident ate and left the table before the second resident was served at 12:15 p.m. The second resident asked the staff twice when she would receive her meal. A table with three residents, had the first resident served at 11:58 a.m. the second resident was served at 12:05 p.m. and the third resident was not served until 12:11 p.m.During a continuous observation on 12/9/25, beginning at 4:40 p.m. and ending 6:20 p.m., the following was observed during the meal preparation and service in the main kitchen:During a continuous observation on 12/10/25, beginning at 11:35 a.m. and ending at 12:48 p.m., in the main dining room the following was observed:The dining room had approximately 15 tables. Several unidentified certified nurse aides (CNA) were passing drinks and taking meal orders. The first tray went to the dining room at 11:55 a.m. Throughout the meal different tables were served the meal at random, leaving residents at the same table with meal trays and others waiting. The first tray was served to a table with three residents. The resident with the first tray was at 11:55 a.m. The resident began to eat. At 12:09 p.m. the second resident received his meal. The minimum data set (MDS) coordinator who served the meal told the third resident it would be right up. At 12:14 p.m. the third resident received her meal. At 12:11 p.m. Resident #134 received her meal. Resident #134 asked Resident #164 if it was ok if she ate,. Resident #134 said yesterday she waited to eat until all of her tablemates were served their meals, and when they received their food hers was cold. Resident #164 told her to eat her meal. Resident #134 offered her tablemate some crackers to eat while she waited. At 12:14 p.m. Resident #164 flagged a CNA down and asked for her meal. At 12:30 p.m. Resident #164 received her meal. The posted dinner menu was seafood salad croissant, coleslaw, sliced tomatoes, crackers, and iced gelatin poke care.At 4:50 p.m. the dietary manager (DM) began to take the temperature readings of the food. The cold foods were not at serving temperature (41 degrees Fahrenheit or less). The seafood salad was 50.5 degrees Fahrenheit (F), the coleslaw was 56 degrees F, the pureed bread was 67.6 degrees F, the pureed was coleslaw 58 F and the sliced tomatoes were 46.2 F. The DM pulled the cold meal from the serving line and directed the dietary aides (DA) to put the meal in the freezer to reach serving temperatures. At 5:10 p.m. the cold items temperature were checked and it had not reached the correct serving temperatures. At 5:25 p.m. Resident #11 went to the kitchen window and asked what was taking so long. Dishwasher #1 told the resident it would be coming soon, however, no explanation was given.At approximately 5:25 p.m. the menu items were checked and had not reached 41 F or below. The DM said she was to plate sandwiches for the room trays. At 5:32 p.m. Resident #2 went to the window and asked what was happening. He said he was not feeling good as he needed to eat. The MDS coordinator offered him orange juice, but he said he would wait for his food. The resident was not given an explanation, only that it would be coming soon. At approximately 5:40 p.m. the meal items were ready to be served. The DM plated the menu items for residents who had not received sandwiches. There was no announcement made to the residents regarding the delay in meal delivery.At 5:45 p.m. the DM asked the CNAs in the main dining room to ask residents what deli sandwich they wanted. There was no explanation to the CNAs as to why the change so they could explain to the residents. At 6:01 p.m. the alternative meal of a grilled cheese sandwich with a tomato that was for Resident #11 came back to the kitchen window because the cheese was not melted. At 6:10 p.m. the seafood sandwich was at proper temperature and it was being plated for the residents who had not been served sandwiches.At 6:11 p.m. an unidentified CNA came to the window and said Resident #11 was still waiting for her meal, the DM said she had to wait.At 6:30 p.m. Resident #11 received the grilled cheese sandwich.At 6:41 p.m. the last resident in the dining room received her meal. III. Observations in the Monarch dining roomDuring continuous observation on 12/9/25, beginning at 4:53 p.m. and ending at 6:30 p.m., the following was observed in the Monarch dining room:The posted meal time for the Monarch unit was 5:00 p.m. to 5:15 p.m.At 4:53 p.m. the residents were all sitting in the dining room and an unidentified resident started to chant bring the food, bring the food. The drinks had not been served. At 5:25 p.m. Resident #135 said out loud, next time she will bring her own food so she knows she would have food at dinner time. At 5:27 p.m. CNA #1 told the residents the staff was waiting on the meal from the kitchen. She did not offer a snack or drinks, while they were waiting.At 5:28 p.m. Resident #97 said, We are all waiting around. I would have brought my cards if I knew it would take this long.At 5:30 p.m. the residents continued to sit in the dining room. The residents had not been offered drinks, There was no activity for the residents who were sitting in the dining room. At 5:35 p.m. Resident #97 asked CNA #1 what the hold up was and there should have been an announcement explaining the food was going to be late. Resident #98 said the residents were wondering what was going on. At 5:47 p.m. Resident #97 suggested the staff provide music or some type of entertainment. At 5:47 p.m. the activity director (AD) announced the staff were still waiting for the meal but the kitchen was working on it. He then left the unit. At 5:54 p.m. the residents had not been offered a snack or a drink while they waited. At 6:10 p.m. Resident #97 said the residents should keep themselves entertained and suggested they sing. Other residents began to sing Christmas carols. At 6:11 p.m. Resident #97 asked for water. At 6:12 p.m. the CNA and other unidentified staff members started to pass out drinks to the residents. At 6:20 p.m. the meal carts arrived and staff began to pass out the meals. Residents sitting at a table were not served at the same time. The trays were passed out in what appeared to be a random fashion, leaving tablemates waiting on food as other residents began to eat. The last resident was served at 6:30 p.m. which was an hour and 15 minutes after the posted time. IV. Resident interviewsResident #164 was interviewed on 12/9/25 at approximately 12:50 p.m. The resident said that it was a common theme to not be served at the same time. She said she would always ask where her meal was and had hopes of it coming soon.Resident #11 was interviewed on 12/10/25 at 9:30 a.m. The resident said that she was frustrated by the previous night's meal (12/9/25). She said that she was tired of the meals being late. She said that when she did get the alternative grilled cheese, the cheese was not melted. She said there needed to be more order in the kitchen. Resident #134 was interviewed on 12/10/25 at 4:15 p.m. The resident said that the meal tables did not get served at the same time. She said it was frustrating when her tablemates did not get their meal served at the same time then it was awkward to eat in front of them. V. Resident group interviewThe group interview was conducted on 12/10/25 at 10:30 a.m. Six residents (#11, #21, #25, #52, #97, #128), were identified as alert and oriented through facility and assessment attended. The group said the meal tray wait seemed to vary and depended on how busy the staff was during that time and what staff was working because agency staff took longer to deliver the trays.VI. Staff interviewsThe DM was interviewed on 12/9/25 at 6:30 p.m. The DM said the cook (CK) #2 started prepping for the meal service at 1:30 p.m. on 12/9/25. She said the crab meat should have been cold enough to serve because it was in the refrigerator, taken out to prepare for the meal and put back in the refrigerator. The DM said the coleslaw was mixed up and left in the large mixing bowl in the refrigerator, however, the DM said the coleslaw should have been scooped into the serving cups prior to being put back in the refrigerator. The DM said the food was prepared the same day that it was going to be served and not prepared a day ahead of time. She said the practice was not to put the cold food items into large pans and that it should have been put into smaller pans and then refrigerated. She did not know why CK #2 deviated from the normal practice. The regional clinical resource was interviewed on 12/10/25 at 8:30 a.m. The regional clinical resource said all residents were spoken to after dinner to fill out grievances in regards to the late dinner meal which was served on 12/9/26. She said that they were looking more into the situation as to how they prevent this situation happening again. The DM was interviewed on 12/11/25 at 4:23 p.m. The DM confirmed the tables were not served at the same time. She said that she had requested the meal tickets to be given to the kitchen window in order of the tables, however that did not occur. She said the meal tickets were completed by the CNAs prior to the meals. The DM said the tickets were delivered to the kitchen prior to plating the meals. She said there was a DA who managed the dining room, however that position was eliminated and now the CNAs deliver the tickets to the kitchen. The DM said the DAs, who were working the tray line, were unable to see which residents had entered the dining room or which table they were at, so therefore the tickets needed to be in order. The DM said the goal was for everyone to be served at the table prior to moving to another table.

Based on observations and interviews, the facility failed to maintain a comfortable and homelike environment for residents on three of four units.Specifically, the facility failed to:-Ensure residents were provided clean washcloths;-Ensure broken towel racks and window seals in residents room were fixed timely,-Ensure residents' rooms were clean; and,-Ensure the lights in the residents' shower room were fixed timely. Findings include:I. Facility policy and procedureThe Homelike Environment policy, revised February 2021, was provided by the nursing home administrator (NHA) on 12/11/25 at 4:11 p.m. It read in pertinent part, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a clean, sanitary and orderly environment.II. Environmental tour and interviewEnvironmental tours were completed on 12/10/25 at 2:20 p.m. and on 12/11/25 at 5:05 p.m. The following was observed: Resident rooms #300, #301, #304, #400, #401, #404, #410, #500, #503, #506, #507, #702, #703, #704, #705, #706, #1103, #1104, #1106, #1108, #1208, #1307, #1404, #1406, #1410, #1503, #1506, #1510, #1603, #1605 and #1607 had broken towel racks and there were no towels in the resident rooms.Rooms #1308, #1407, and #1408 had two resident occupants and only one towel rack. The resident in room [ROOM NUMBER]B had a broken window seal. There was a trash bag left on the floor outside the bathroom.Resident room [ROOM NUMBER] was dirty, with the tile floor appearing hazy and muted. The light fixture in the main shower room of the [NAME] unit had broken loose from the mounting and was dangling from the ceiling. A jagged ring of cracked drywall surrounded the gaping hole where the fixture once sat, leaving the internal electrical box exposed. The glass cover hung suspended y by a pair of twisted, color-coded wires.III. Resident interview The resident in room [ROOM NUMBER]B said the broken window seal enabled ants to enter the room when it rained. She said they used paper towels and they only received wash towels when they asked for it. The resident said they have not had a towel rack for a while.IV. Staff interviewCertified nurse aide (CNA) #3 was interviewed on 12/10/25 at 2:14 p.m. CNA #3 said all nursing staff were responsible for ensuring the residents' rooms were clean and were stocked with towels each day. He said wash towels were provided to the residents who asked for them.The maintenance director (MTD) was interviewed on 12/11/25 at 5:00 p.m. The MTD said he was not aware most of the residents' rooms had broken and missing towel racks. He said he completed a facility-wide room audit of all towel racks and had placed an order for 45 towel racks. The MTD said she will begin installation of all the broken racks as soon as the order arrives at the facility. The MTD said nursing staff were to initiate work orders through the facility's electronic work order system for the replacement of towel racks when they were broken. He said the window seal in room [ROOM NUMBER] would be immediately fixed. The MTD said the maintenance department completed monthly audits of all equipment, and he could not tell the reason the towel racks were missed.The assistant director of nursing (ADON) was interviewed on 12/11/25 at 6:35 p.m. The ADON said the CNA's, together with all nursing staff, were responsible for providing towels for all residents. She said every resident's room should have a towel rack for the resident's towel.

Based on observations, record review and interviews, the facility failed to ensure four (#44, #74, #62 and #82) of six residents reviewed for activities out of 53 sample residents received an ongoing program of activities , designed to meet the needs and interests, and promote physical, mental and psychosocial well-being.Specifically, the facility failed to offer and provide personalized and group activity programs for Resident #44, #74, #62 and #82. Findings include: I. Facility policy and procedure The Activities policy, revised 2025, was provided by the nursing home administrator (NHA) on 12/11/25 at 3:05 p.m. It read in pertinent part, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and shall include, but is not limited to: activity assessment to include resident's interest, preferences and needed adaptations, and social history. Activities will be designed with the intent to: enhance the resident's sense of well-being, belonging, and usefulness; create opportunities for each resident to have a meaningful life; promote or enhance physical activity, cognition, emotional health, self-esteem, dignity, pleasure, comfort, education, creativity, success and independence; reflect resident's interests, age, cultural, religious interests, and choice. Activities may be conducted in different ways, one-to-one programs or in a combination of large and small groups, Residents are encouraged, but not mandated, to participate in scheduled activities. Each resident's interest and needs will be assessed on a routine basis. Special considerations will be made for developing meaningful activities for residents with dementia and special needs. All staff will assist residents to and from activities when necessary. Activities can occur at any time and are not limited to formal activities provided by the activities staff and can include other facility staff members, volunteers, visitors, residents, and family members. The physician, in coordination with the comprehensive assessment, approves activity programs. II. Resident #44 A. Resident status Resident #44, age [AGE], was admitted on [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included senile degeneration of the brain, unspecified dementia, and chronic kidney disease. The 10/2/25 minimum data set (MDS) assessment revealed the resident had a severe cognitive impairments with a brief interview for mental status (BIMS) score of two out of 15. She was dependent on staff for bed mobility, oral and personal hygiene, toileting and dressing and she required a mechanical lift for transfers and bathing. The MDS assessment documented it was important to the resident to participate in group activities and also to do her favorite activities. B. Observations On 12/8/25 at 9:00 a.m. Resident #44 was seated in front of the nurses' station. The resident was not engaged in a meaningful activity. On 12/8/25 at 9:45 a.m. Resident #44 remained seated at the nurses' station. On 12/8/25 at 10:20 a.m. Resident #44 remained by the nurses' station. On 12/8/25 at 11:20 a.m. Resident #44 remained by the nurses' station. On 12/9/25 at 9:03 a.m. Resident #44 was sitting in the common area and was not engaged in any meaningful activity. On 12/9/25 at 9:45 a.m. Resident #44 was in the same position by the nurses' station. On 12/9/25 at 10:30 a.m. Resident #44 was still sitting in front of the nurses' station. There were no meaningful activities observed. On 12/9/25 at 11:30 a.m. Resident #44 was assisted to the dinner table. On 12/9/25 at 11:50 a.m. Resident #44 was awaiting her lunch. The staff did not communicate with the resident. On 12/10/25 at 9:00 a.m. Resident #44 was sitting in front of the nurses' station and there were no meaningful activities. On 12/10/25 at 10:15 a.m. Resident #44 remained in front of the nurses' station. On 12/10/25 at 11:00 a.m. Resident #44 was sitting in the front of the nurses' station. On 12/10/25 at 12:31 p.m. Resident #44 was served her meal. On 12/10/25 at 12:40 p.m. CNA #13 on duty assisted Resident #44 with her meal, but did not talk to the to Resident #44 while the resident ate her meal. On 12/10/25 at 12:48 p.m. Resident #44 was assisted to her room. She was sitting in the room without meaningful activity. On 12/11/25 at 8:30 a.m. Resident #44 was sitting in front of the nurses' station. The resident was not engaged in a meaningful activity. On 12/11/25 at 8:50 a.m. Resident #44 was sitting in front of the nurses' station. On 12/11/25 at 9:48 a.m. Resident #44 was sitting in front of the nurses' station. C. Record review The activities care plan, dated 4/25/25, identified Resident #44 enjoyed singing activities, holiday parties, food-and-drink socials, games, arts and crafts, being around others, watching television or movies and listening to music. Pertinent interventions included encouraging activities designed to meet the interests of and support physical, mental, and psychosocial well-being, providing activity materials like books, magazines, newspapers, arts and crafts, television, and radio, in accordance with the resident's interests and supporting the resident's choices for preferences regarding customary routine and activities. The November 2025 activity participation record documented the resident was active daily in resting/relaxing and thinking. She had family visits/socializing and talked on the phone daily. The log documented she was invited to bingo/trivia or card games twice on 11/5/25 and 11/7/25, but she was sleeping. The log documented the resident participated in exercise group on 11/7/25, 11/14/25 and 11/20/25. There was no further documentation that indicated the resident was invited or participated in group activities per her preference. The December 2025 (12/1/25 to 12/11/25) participation record showed the resident had family visits, resting and relaxation. She attended exercise on 12/5/25. The participation record documented the resident attended arts crafts on 12/10/25. The log documented she was unavailable for religious activities on 12/5/25, 12/6/25 and 12/7/25. D. Staff interviews The activities director (AD) was interviewed on 12/11/25 at 2:00 p.m. The AD said Resident #44 did not participate in the activities program because she preferred not to. The AD said when residents were admitted to the facility, the staff obtained the resident's activity and religious preferences. The AD said he had not invited Resident #44 to any group activities. The AD said he did not know her preferences very well and that activities assistant #1 knew her better. He said he delivered the daily chronicle daily to Resident #44. AA #1 was interviewed on 12/11/25 at 2:25 p.m. AA #1 said Resident #44 preferred observing activities. AA #1 said Resident #44 required assistance to the activities. AA #1 said the resident liked musical activities. AA #1 said Resident #44 needed to be invited to each activity. AA #1 said when she was not participating in activities she was sitting by the nurses' station. III. Resident #74 A. Resident status Resident #74, age less than 65, was admitted on [DATE]. According to the December 2025 CPO, diagnoses included anoxic brain damage (due to lack of oxygen to the brain), quadriplegia, and attention deficit hyperactivity disorder (ADHD). The 10/2/25 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15. The resident was dependent on staff with maximal assistance for transfers, dressing, and bathing. The MDS assessment documented it was important to the resident to do favorite activities and also to go outside and get fresh air. B. Observations On 12/8/25 at 10:00 a.m. Resident #74 was awake in his bed. The television was on, but there was no sound. On 12/8/25 at approximately 2:00 p.m. Resident #74 was awake in his bed. The television screen saver was on. There were no meaningful activities for the resident. On 12/8/25 at 4:00 p.m. the resident was sitting in his wheelchair. He was sitting in front of the nurses' station, with no activity. On 12/9/25 at 9:03 a.m. Resident #74 was awake and lying in bed, with nothing to do. The television was not on. The resident was looking outside the door. On 12/10/25 at 9:02 a.m. Resident #74 was lying in bed awake. The television was not on. On 12/10/25 at 2:51 p.m. Resident #74 was lying in bed awake The television was not on. On 12/10/25 at 4:11 p.m. the resident was lying in bed. The television was on, however, the volume was low. On 12/11/25 at 8:41 a.m., Resident #74 was awake while lying in bed. The television was not on, and he had no meaningful activity. C. Record review The activity care plan, revised 10/21/25, documented Resident #74 was not able to communicate with words and was mostly bed bound. It documented Resident #74 was unable to participate in groups but enjoyed being read to, listening to music, being around animals, watching television and being around others. Pertinent interventions included encouraging activities designed to meet the interest of and support physical, mental, and psychosocial well-being encouraging independence and interaction in the community, encouraging autonomy and independence with preferred activity pursuits, providing activity materials like books, magazines, newspapers, television, radio, arts and crafts, in accordance with resident's interest and supporting the resident's choices for preferences regarding customary routine and activities. The care plan had additional interventions that included activities and book reading three times a week and daily chronicle every morning. -Review of the care plan did not address the resident's interest to go outside as identified on the MDS assessment. The November 2025 activity task documentation record did not document Resident #74's participation shows watching television and relaxation daily. The log documented the resident was sleeping on various days for group activities. The log documented the resident did not participate in group activities from 11/1/25 to 11/15/25. The December 2025 (12/1/25 to 12/11/25) activity task documentation record did not documented the resident participated in any group activities. The log documented the resident watched television daily and listened to music. Review of Resident #74's electronic medical record (EM)R revealed the last one-to-one activity that was provided to the resident was on 6/9/25. D. Staff interviews CNA #3 was interviewed on 12/11/25 at 12:30 p.m. CNA #3 said Resident #74 did not like activities but loved watching television, listening to music. CNA #3 said the resident had his own television streaming channels and playlists. CNA #3 said Resident #74 liked the bedroom door open. AA #1 was interviewed on 12/11/25 at 2:25 p.m. AA #1 said Resident #74 was on the one- to-one activity program. AA #1 said she visited Resident #74 every morning, set up music, a television show, or a movie, and Resident #74 participated in observing a flower arrangement as a monthly activity. -However, record review revealed the last time Resident #74 participated in a one-to-one activity was 6/9/25 (see record review above). AA #1 said the CNAs helped take some residents to the activities area. She said it was hard to monitor an activity while also inviting residents. The assistant director of nursing (ADON) and the regional clinical resource were interviewed together on 12/11/25 at 6:53 p.m. The ADON and regional clinical resource said the activity assistants, nurses or CNAs took the residents to an activity if a resident wanted to go. The ADON said if the resident refused to attend an activity, the staff discussed it at care conferences. The ADON said the activities staff conducted activity participation reviews quarterly. The ADON said it was essential that the staff interacted with residents by engaging and inviting them to activities. IV. Resident status A. Resident status Resident #62, age greater than 65, was admitted on [DATE]. According to the December 2025 CPO, diagnoses included hereditary and idiopathic neuropathy, displaced bicondylar fracture of the right tibia hemarthrosis (bleeding into a joint space causing pain), acute kidney failure, chronic respiratory failure with hypoxia, nutritional anemia, heart failure, and anxiety disorder. The 10/23/25 MDS assessment revealed Resident #62 was cognitively intact with a BIMS score of 15 out of 15. The resident was dependent on staff for activities of daily living and required maximum assistance for transfers, moderate assistance with toileting, and personal hygiene. The 10/30/25 MDS assessment revealed it was very important for the resident to listen to music, keep up on the news, attend religious services, participate in group activities and go outside for fresh air. B. Resident interviews and observations Resident #62 was interviewed on 12/10/25 at 11:25 a.m. Resident #62 she did not participate in any activities and only watched television in her room. Resident #62 said the staff used to assist her into her wheelchair, however they stopped. The resident said she could not remember the last time the facility staff had assisted her to an activity. Resident #62 was interviewed again on 12/10/25 at 3:14 p.m. She said she had not been invited to Bingo that was currently going on. She said the facility staff had not informed her of the event and expressed that she would have been interested in getting out of bed to attend the activity. During a continuous observation on 12/10/25, beginning at 1:06 p.m. and ending at 3:10 p.m., the following was observed: At 1:15 p.m., Resident #62 was in bed. There was a group ice cream social in the activity room on the Columbine unit. The resident said she was not invited to this activity. At 1:33 p.m. an unidentified CNA entered the resident's room to pick up her lunch tray. The CNA did not offer to assist the resident with any activity. At 2:00 p.m. the resident remained in her bed and occasionally closed her eyes. At 2:30 p.m. AA #1 walked down the hallway and spoke to a resident about an upcoming Bingo activity scheduled for 3:00 p.m. At 3:10 p.m. the resident remained in her bed and no staff members assisted the resident to Bingo During a continuous observation on 12/11/25, beginning at 10:04 a.m. and ending at 2:00 p.m., the following was observed: At 10:04 a.m. Resident #62 was lying flat on her back with her arms at her sides, staring at the ceiling. At 10:30 a.m. the resident closed her eyes. At 11:00 a.m. Resident #62 was awake and remained in her bed while the word puzzle activity was ongoing. At 1:15 p.m. the resident remained in her bed, and no staff members invited her to the ongoing coloring and aromatherapy activity. C. Record review The activities care plan, initiated on 10/29/25, revealed Resident #62 would benefit from small, supportive group activities and independent leisure in her room. Interventions included assisting the resident to and from activity locations as needed, assisting the resident with in-room activities as required with peers that had similar interests, encouraging the resident to socialize and encouraging her to attend activities of her interest. The activities participation log for November 2025 and December 2025 (12/1/25 to 12/11/25) was provided by the AD on 12/11/25 at 3:26 p.m. It documented the following: The resident participated in watching television, resting and relaxation 22 times. -Review of the logs did not reveal the resident was involved in one-to-one activities. -Review of the logs did not reveal small group activities, independent leisure, in-room activities or assistance to and from activities were offered. V. Resident #82 A. Resident status Resident #82, age greater than 65, was admitted on [DATE]. According to the December 2025 CPO, diagnoses included degenerative disease of the nervous system, unspecified dementia, chronic respiratory failure and a history of falling. The 6/24/25 MDS assessment revealed the resident was severely cognitively impaired and unable to participate in a BIMS assessment. The assessment revealed that the resident accepted care, and it was very important for the resident to be around animals and listen to music. B. Observations On 12/9/25 at 2:15 p.m. Resident #82 was sitting in her wheelchair at the [NAME] nurses' station. At 3:25 p.m. the resident was sitting at the nurses station. Several unidentified staff members walked past the resident and did not engage with her. At 5:00 p.m. the resident was assisted to the dining area for diner. On 12/10/25 at approximately 10:18 a.m. an unidentified CNA assisted the resident to a tree planting activity. The CNA turned around and brought the resident back to the nurses' station. The unidentified CNA said the resident would not be interested in the tree planting activity. However, the CNA did not ask the resident. The CNA left the resident at the nurses' station. Resident #82 sat in her wheelchair at the nursess station. C. Record review The activities care plan, revised 3/28/25, identified Resident #82's activities preferences included observing her environment, watching television and movies, listening to music, being read to and being around others. Pertinent interventions included assisting the resident and from activity locations as needed, assisting the resident with in-room activities as required and encouraging the resident to attend an activity of her interest. Review of the November 2025 activities participation revealed the resident participated in family visits and watching television during the month. There was no further documentation indicating the resident participated in activities during the month. VI. Staff interviews CNA #8 was interviewed 12/10/25 at 2:05 p.m. CNA #8 said the AD and assistants were responsible for carrying out the activities programs. She said Resident #62 preferred getting up early during the day and refused any assistance to get up later in the afternoon. CNA #8 said she had not seen Resident #62 being offered activities in her room. She said the resident only watched television in her room. The AD was interviewed on 12/11/25 at 2:25 p.m. The AD said Resident #62 liked to stay in her room. He said Resident #62 was not currently participating in any one-on-one activities in her room. The AD said the AA should be reminding the residents of upcoming activities and encouraging them to attend. The AD said the activities department should be doing more to engage participation in the activities program for those residents who required assistance to and from activity programs. He said he would conduct an audit of all the resident activity preferences and initiate one-on-one preferred activities for those residents who were unable to attend daily activities. He said he would ensure the AAs remind the residents and assisted them to the activities location with the help of the CNAs. The AD said most of the residents would not know if there was an activity going on without being informed. The AD said the staff should return and offer the activity again, even when they had refused the first time.

Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for five of 10 residents reviewed on the secured unit out of 53 sample residents. Specifically, the facility failed to keep five resident beds in a safe position to prevent accident hazards. Findings include:I. Professional reference According to Effects of Bed Height on Balance during INgress and Egress from a Hospital Bed, (8/9/24) retrieved on 12/18/25 from https://pmc.ncbi.nlm.nih.gov/articles/PMC12439613/#:~:text=Additionally%2C%20optimizing%20hospital%20bed%20heights,balance%20and%20increasing%20fall%20risks, When a bed is set too high, the process of getting into it becomes difficult; patients may attempt to pull themselves up, which can cause instability and increase their chances of falling.II. Observations and interviewsOn 12/8/25 at 12:12 p.m. the bed in room [ROOM NUMBER] was elevated with the mattress surface level at approximately four feet.On 12/8/25 at 2:33 p.m. the resident bed in room [ROOM NUMBER] was elevated with the mattress surface level at approximately four feet. On 12/9/25 at 2:55 p.m. the bed in room [ROOM NUMBER] was elevated with the mattress surface level at approximately four feet.On 12/9/25 at 3:08 p.m. two beds in room [ROOM NUMBER] were elevated with the mattress surface level at approximately four feet.On 12/9/25 at 4:26 p.m. the bed in room [ROOM NUMBER] remained in the elevated position. The resident who resided in room [ROOM NUMBER] walked to the bed, reached up and climbed into bed.The resident then began opening a clean brief while she sat sitting on top of the bed. Her legs were dangling approximately one foot above the floor. Certified nurse aide (CNA) #10 was notified of the residents position. CNA #10 walked into the room promptly and said the resident's bed should not be up that high. CNA #10 used the electronic bed remote to lower the bed until the resident's feet were able to touch the floor.On 12/10/25 at 2:49 p.m. beds in rooms #408, #410 and #401 were elevated with the mattress surface level at approximately four feet.On 12/10/25 at 6:00 p.m. the clinical resource consultant observed the bed position in rooms #309, #401 A and B and #410 A and B. The clinical resource consultant said the beds were too high.III. Staff interviewsCNA #11 was interviewed on 12/10/25 at 3:07 p.m. CNA #11 said the staff placed the beds in an elevated position so the residents would not transfer themselves and use them. She said some of the residents were a fall risk and most of them had dementia which could lead to falls. CNA #11 said because many residents had dementia, the nursing staff brought residents to a common area during the day. CNA #11 said if a resident was tired, the CNA would bring the resident to their room and then lower the bed in order for the resident to sleep. CNA #11 said Resident #72 tried to transfer herself to her bed often. CNA #12 was interviewed on 12/10/25 at 3:31 p.m. CNA #12 said nursing staff should keep the beds lowered and make sure they were locked. She said residents on the secured unit wandered and elevating beds could create a potential safety issue. CNA #12 said she had observed residents climb up onto high beds before. CNA #2 was interviewed on 12/10/25 at 3:48 p.m. CNA #2 said staff maintained resident beds in an elevated position unless a resident wanted to go to bed, at which point staff lowered the beds. CNA #2 said she had previously observed the resident who resided in room [ROOM NUMBER] wandered into another residents' room and the resident was found lying on an elevated bed. CNA #2 said the beds should be low because the resident could climb into high beds.Licensed practical nurse (LPN) #1 was interviewed on 12/10/25 at 4:12 p.m. LPN #1 said nursing staff were told to keep some beds elevated so the residents did not get back into bed.LPN #1 said that Resident #72's bed should be maintained in an elevated position to keep other residents from using the bed.The ADON was interviewed on 12/10/25 at 7:00 p.m. The ADON said the CNAs had good intentions leaving beds elevated She said the CNAs thought leaving the beds elevated would prevent residents from self- transferring into bed. The ADON said elevated beds were an accident hazard. The ADON said education was being provided to the CNAs to maintain resident beds at a safe level.

Based on interviews and record review, the facility failed to ensure certified nurse aides (CNA) received at least 12 hours of annual in-service training that also included dementia management training and resident abuse prevention training to ensure continued competence for three out of five certified nurse aides (CNA) reviewed.Specifically, the facility failed to ensure CNA #3, CNA #4, and CNA #5 received 12 hours of continuing education annually. Findings include:I. Facility policy and procedureThe In-Service Training policy, revised in 2001, was provided by the corporate consultant on 12/11/25 at 8:33 p.m. It read in pertinent part, All staff must participate in initial orientation and annual in-service training.Training requirements are met prior to staff providing services to residents, annually, and as necessary based on the facility assessment.Completed training is documented by the staff development coordinator, or his or her designee, and should include the date and time of the training, the topic of the training, the method used for training, a summary of the competency assessment, and the hours of training completed.II. Training record reviewFive randomly selected CNA training records were reviewed on 12/11/25. Of the five CNAs reviewed, CNA #3, CNA #4 and CNA #5 did not receive 12 hours of annual training. The corporate consultant said CNA #3 (hired 10/8/24), CNA #4 (hired 5/22/24) and CNA #5(hired 11/30/23) did not have 12 hours of training.III. Staff interviewsThe staff development coordinator was interviewed on 12/11/25 at 4:40 p.m. The staff development coordinator said she was responsible for ensuring that all CNAs completed the mandatory 12 hours of in-service training. The staff development coordinator said she did not have a timeline for checking staff competencies but would immediately begin checking regularly to ensure each staff member complied with the policy.

Based on record review and interviews, the facility failed to inform residents of the possible outcome of their noncompliance with nutritional supplements for one (#62) out of three residents reviewed for weight loss out of 53 sample residents. Specifically, the facility failed to inform Resident #62 of the risks of significant weight loss. Findings include:I. Facility policy and procedureThe Resident Rights policy, revised on 2/2021, was provided by the nursing home administrator (NHA) on 12/11/25 at 3:51 p.m. It revealed in pertinent part, The resident would be notified of his or her medical condition and of any changes in his or her condition and would be informed of, and participate in, his or her care planning and treatment.II. Resident #62A. Resident statusResident #62, age greater than 65, was admitted on [DATE]. According to the December 2025 computerized physician order (CPO), diagnoses included hereditary and idiopathic neuropathy, displaced bicondylar fracture of the right tibia hemarthrosis (bleeding into a joint space causing pain), acute kidney failure, chronic respiratory failure with hypoxia, nutritional anemia, heart failure and anxiety disorder.According to the 10/23/25 minimum data set (MDS) assessment Resident #62 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident was dependent on staff for activities of daily living and required maximum assistance for transfers, moderate assistance with toileting, and personal hygiene.B. Resident's observation and interviewDuring a continuous observation on 12/8/25, beginning at 12:46 p.m. and ending at 12:56 p.m. the following was observed: Resident #62's lunch was The resident was observed poking at her food with a knife but did not take any bites. She picked up a small package and attempted to open it without success. The resident looked malnourished and pale, and her mouth was dry. The resident said she had lost a significant amount of weight since her admission to the facility. She said she did not eat her meals because she did not want to be obese. She said she either skipped dinner or had applesauce most of the time. She said the staff had not discussed the risks of significant weight loss with her.C. Record reviewThe nutrition care plan, revised on 11/12/25, revealed the resident was at nutritional risk related to varied oral intake, diagnoses of hypothyroidism, a history of significant weight loss, anticipated weight fluctuations related to fluid status, diuretic use, and heart failure. Interventions included dietary supplements as ordered, honoring to food preferences, notifying the physician and representative of significant weight changes, providing vitamins and minerals, ensuring a registered dietitian (RD) reassessed as indicated and obtaining weights weekly for four weeks and monthly thereafter if stable.The physician progress note, dated 12/3/25, documented that the resident had lost close to 40 pounds and was very unmotivated to perform daily activities, including eating. The physician documented that if this trend continued, it likely indicated she was approaching the end of life.The 12/3/25 interdisciplinary team (IDT) progress note documented the snack box, fortified food at all meals and the Magic cup (frozen nutritional supplement) were discontinued due to the resident's refusals.The 12/5/25 nutritional narrative weight loss note documented the resident weighed 144 pounds (lbs) on 11/4/25. The resident currently weighed 114.2 lbs on 12/5/25. The resident was noted to have lost 11.9 lbs in three weeks and would be placed on weekly nutritional at risk (NAR) meeting list due to continued weight loss.-Review of Resident #62's electronic medical record (EMR) did not reveal documentation that indicated the facility provided the resident with education regarding the risks of weight loss. III. Staff interviewsRegistered nurse (RN) #2 was interviewed on 12/10/25 at 2:46 p.m. RN #2 said she had worked With Resident #62 since her admission. She said the resident had lost a lot of weight since admission due to the refusal of her nutritional supplements. RN #2 said the resident consumed 0 to 25 percent of the dietary nutritional supplements, resulting in continued weight loss. RN #2 said she had not offered education on the effects of the resident's non-compliance with the dietary nutritional supplements.RN #1 was interviewed on 12/10/25 at 3:05 p.m. RN #1 said she was the unit manager and was aware of Resident #62's significant weight loss. She said she had consulted the resident's physician regarding the considerable weight loss, suggested reviewing the resident's chart and asked the physician to consider an appetite stimulant. RN #1 said the physician denied her request and wrote a note indicating the resident's weight was unavoidable. RN #1 said she had not discussed or provided education to the resident of the possible effects of her continued non-compliance with dietary nutritional supplements.The dietary manager (DM) was interviewed on 12/10/25 at 3:25 p.m. The DM said she first tried the food approach then introduced Magic cup, Medpass 2.0 (oral nutritional supplement) and a snack box. She said the resident continued to lose weight due to non-compliance with the nutritional supplements. The DM said she recommended Remeron (a medication that can be used to stimulate the appetite) to help boost the resident's appetite, but the resident's physician denied the request on 12/5/25.The DM said she discussed her weight loss concerns with Resident #62, but did not document them or any education provided in the resident's EMR.The RD was interviewed on 12/10/25 at 3:35 p.m. The RD said Resident #62 refused most of her nutritional supplements and did not consume enough of her meals. She said Resident #62 had been placed on weekly weights to monitor her status. The RD said the IDT had met to discuss the significant weight loss and had implemented several interventions. She said however, the resident had been non-compliant with the interventions recommended by the IDT.She said that she had not provided education to the resident regarding the possible health effects of her non-compliance with the nutritional supplements, which resulted in the continued decline of her weight.VI. Facility follow upThe NHA provided documentation of education on 12/12/25 at 5:13 p.m. The documentation indicated the ADON provided education to Resident #62 on 12/11/25 regarding the possible outcome of the resident's continued non-compliance with the nutritional supplement and her refusal of tray meals.The documentation included a physician's order that initiated on 12/11/25. The physician's order prompted the staff to document a progress note every shift on the resident's compliance, non-compliance, or refusals with nutritional supplements. The physician's order also prompted the staff to document interventions attempted, and different approaches tried to promote the resident's compliance with interventions to improve her nutritional status.An additional physician's order was initiated on 12/11/25 at 11:20 a.m. for mirtazapine (Remeron) oral tablet 7.5 milligrams, one tablet by mouth at bedtime for appetite stimulation.

Based on record review and interviews, the facility failed to protect two (#111 and #66) of eight residents from abuse out of 53 sample residents.Specifically, the facility failed to protect Resident #111 and Resident #66 from physical abuse from each other. Findings include:I. Facility policy and procedureThe Abuse, Neglect, and Exploitation policy, undated, was provided by the nursing home administrator (NHA) on 12/10/25 at approximately 4:00 p.m. It read in pertinent part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, intimidation, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking.II. Incident of physical abuse between Resident #111 and Resident #66 on 10/18/25A. Facility investigationThe facility abuse investigation was provided by the NHA on 12/10/25 at approximately 4:00 p.m.The facility investigation documented on 10/18/25 at 6:15 p.m. certified nurse aide (CNA) #9 witnessed Resident #111 and Resident #66 facing each other and making hand-to-hand, swatting gestures at each other's hands and arms and making contact. The investigation documented CNA #9 immediately intervened by separating the residents and redirecting each resident in separate directions. CNA #9 notified the nurse on duty of the interaction. No injuries were reported at the time of the incident. -However, record review revealed Resident #111 sustained a skin tear to the back of her left hand (see record review below).The investigation documented both residents were interviewed after the incident. Both residents were unable to answer questions when interviewed. The investigation documented staff were reminded of the importance of monitoring resident interactions in common areas. B. Resident #1111. Resident statusResident #111, age [AGE], was admitted on [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included severe unspecified dementia with other behavioral disturbances (cognitive decline with behavioral issues like agitation, wandering, depression) and cognitive communication deficit (difficulty talking or understanding due to impaired thinking skills).The 10/22/25 minimum data set (MDS) assessment identified Resident #111 was severely cognitively impaired with a brief interview for mental status (BIMS) score of six out of 15. The resident walked independently and required set up assistance with eating and substantial/maximal assistance with showering and dressing.C. Record reviewResident #111's psychosocial/behavioral care plan, revised 10/20/25, revealed Resident #111 exhibited behaviors of striking out, grabbing others and verbal aggression toward others. Pertinent interventions included to encourage and supply the resident with activities of her interest and offering to remove her from areas of high traffic and stimulation. The care plan directed staff to observe Resident #111 and ensure the resident stayed away from residents she had known altercations with.The 10/18/25 nursing progress note at 6:15 p.m. documented at 6:15 p.m. Resident #111 and Resident #66 were both being physically aggressive towards each other. No injuries were noted at the time. The two residents were separated. Resident #111 was assessed and found to have a skin tear on the back of her left hand. The residents were placed on 72-hour charting checks following the altercation with no further physical aggression noted.C. Resident #661. Resident statusResident #66, age [AGE], was admitted on [DATE]. According to the December 2025 CPO, diagnoses included vascular dementia (a decline in thinking skills from reduced blood flow to the brain often from strokes or chronic high blood pressure) and muscle weakness.The 9/9/25 MDS assessment identified Resident #66 was severely cognitively impaired with a BIMS score of seven out of 15 and used a wheelchair. The MDS assessment identified Resident #66 had vocal symptoms such as screaming and making disruptive sounds.2. Record reviewResident #66's psychosocial/behavioral care plan, revised 10/20/25, revealed Resident #66 exhibited behaviors of physical aggression with other residents. Pertinent interventions included encouraging and supplying the resident with activities of her interest and to offer to remove her from areas of high traffic and stimulation, observing Resident #66 and ensuring the resident stayed away from residents she had known altercations with.D. ObservationsOn 12/10/25 at 4:00 p.m. Resident #111 was yelling Get your (explicit language) out of here in the main common area where multiple residents were located. Resident #111 had furrowed eyebrows, pressed lips, and her stare was fixed in the direction of the residents in front of her. She was leaning forward with her walker and her head and neck were also extended forward. Her elbows were slightly outward and her hands were clenched onto her walker. An unidentified CNA came up to her, put her hand on her shoulder and looked at her, redirecting her attention to the CNA. Resident #111 dropped her elbows, her hands relaxed on the walker, her eyes and eyebrows relaxed and her mouth was no longer pursed as she turned her head away from the residents and focused on the CNA. The CNA assisted her in walking toward a more spacious area of the room. III. Staff interviewsCNA #2 was interviewed on 12/11/25 at 5:17 p.m. She said she was not present for the altercation on 10/18/25, but she was told that Resident #111 and Resident #66 were cussing at each other and swatting at each other's hands and wrists. She said before the altercation, staff kept eyes on residents and made sure they were safe. She said after the altercation, they ensured the Resident #111 and Resident #66 did not sit together in the common area or in the dining room. CNA #2 said Resident #66 would start cussing if other residents around her were cussing. She said Resident #111 was not aggressive but was also known to cuss or yell. CNA #2 said if staff saw either resident start to become agitated, they redirected them with an activity or snack and made sure they kept their distance.CNA #1 was interviewed on 12/11/25 at 5:20 p.m. CNA #1 said Resident #111 was known to yell and cuss. She said in general, they kept Resident #111 closer to the CNAs or nurses to keep focus on her because she could get grumpy easily. CNA #1 said Resident #66 seemed to get overstimulated with loud environments but was easy to redirect.Licensed practical nurse (LPN) #5 was interviewed on 12/11/25 at approximately 5:30 pm. LPN #5 said Resident #111 and Resident #66 had behaviors and needed to be closely watched to ensure altercations did not occur.CNA #9 was interviewed on 12/11/25 at approximately 5:40 p.m. CNA #9 said she witnessed the altercation between Resident #111 and Resident #66. CNA #9 said she was coming out of the shower room with a different resident when she saw Resident #111 walking with her walker toward Resident #66, who was in a wheelchair. She said Resident #111 shuffled next to Resident #66 and both residents began swatting their hands at each other. She said she did not know which resident initiated the aggressive behavior. She said the residents made physical contact with each other's hands. CNA #9 said she separated Resident #111 and Resident #66. CNA #9 said Resident #111 was taken to the dining room and Resident #66 returned to her room. She said a skin tear was later discovered on Resident #111's hand. She said it was unknown whether the skin tear occurred from Resident #111's bracelets or from contact with Resident #66. CNA #9 said it was the first time she had seen Resident #111 and Resident #66 in an altercation. She said the residents occasionally yelled at each other, but had not previously been physically aggressive toward one another. CNA #9 said after the incident, staff kept the residents separated as much as possible to avoid further issues.Registered nurse (RN) #3 was interviewed on 12/11/25 at 5:45 p.m. RN #3 said he recalled there was an incident between Resident #111 and Resident #66. RN #3 said he did not witness the altercation between Resident #111 and Resident #66. He said he assessed the residents after the altercation and found some superficial skin tears on Resident #111 which appeared to be recent and could have occurred during the altercation. RN #3 said Resident #66 did not have any injuries. RN #3 said before the incident, staff used the resident's care plans to understand their likes and dislikes in order to help keep them calm. RN #3 said after the incident, staff implemented safety checks for 72 hours. RN #3 said the residents were observed and remained separated if they were exhibiting behaviors to avoid conflict.The assistant director of nursing (ADON) was interviewed on 12/11/25 at 6:30 p.m. The ADON said prior to the incident, to prevent resident-to-resident altercations, staff observed all residents closely and were quick to react to potential escalations. She said if staff sensed agitation in the residents, they would redirect them and ensure there was distance between those residents. The ADON said when the incident with Resident #111 and Resident #66 occurred, she ensured the residents were separated and had assessments completed. She said there were no injuries at the time of the incident but upon later assessment, the nurse noticed a skin tear on Resident #111's hand. The ADON said the facility was taking measures to ensure no further abuse occurred. She said the facility met to review the incident with the psychologist and primary care provider (PCP) and it was determined the incident was a spontaneous event. The ADON said after the incident, staff were more aware of the need to observe interactions between Resident #111 and Resident #66. The NHA was interviewed on 12/11/25 at 7:00 p.m. The NHA said the facility had concluded the physical abuse between Resident #111 and Resident #66 was substantiated

Based on interviews and record review, the facility failed to ensure one (#93) of three residents out of 53 sample residents received the proper treatment and assistive devices to maintain vision.Specifically, the facility failed to:-Follow up after an eye appointment for Resident #93; and,-Assist Resident #93 to make an appointment for cataract surgery. Findings include:I. Facility policy and procedureThe Hearing and Vision Services policy, undated, was provided by the nursing home administrator (NHA) on 12/11/25 at 4:00 p.m. It read in pertinent part, It is the policy of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. Staff should refer any identified need for hearing or vision services/appliances to the social worker/social service designee. Once vision or hearing services have been identified, the social worker/social service designee will assist the resident by making appointments and arranging for transportation.II. Resident #93A. Resident statusResident #93, age [AGE], was admitted on [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included dry eye syndrome of the bilateral lacrimal glands (tear glands do not produce enough tears), dementia and depressive episodes. The 12/4/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 13 out of 15. She required supervision when walking and transferring. The MDS assessment did not identify the resident having vision difficulty or requiring glasses.-However, Resident #82 had difficulty seeing (see interviews below).B. Resident interviewResident #93 was interviewed on 12/8/25 at 11:20 a.m. Resident #93 said she could not see out of her left eye. She said she had an eye appointment at least a month ago and she was told she needed cataract surgery. She said the facility had not followed up to arrange for the surgery. Resident #93 said she could not obtain new glasses until the cataract was repaired. Resident #93 was interviewed again on 12/10/25 at 5:25 p.m. Resident #93 said it was hard to live with the vision issues because she had difficulty seeing things up close. She said she used to read novels and was not able to do this anymore because of her vision difficulty. Resident # 93 said not being able to see made her feel depressed.C. Record reviewResident #93's care plan identified the resident had eyeglasses to assist with vision. The vision care plan directed staff to monitor for changes in Resident #93's ability to perform daily activities and mobility, to monitor for dilated pupils, double vision, grey or milky eye color, and blurred or hazy vision, to monitor Resident #93's eyes for irritation, redness, and increased dryness and to report these symptoms to the physician.A social services progress note, dated 9/11/25,documented Resident #93 requested assistance to schedule cataract surgery. The note documented the social services assistant (SSA) contacted the hospice provider for consent and the request was forwarded to transportation to schedule. The note documented the SSA was to follow up as needed.A physician's progress note, dated 10/24/25, documented Resident #93 was to receive eye drops in both eyes four times a day for her left eye cataract.The nursing progress note, dated 10/27/25, documented Resident #93 returned from her medical appointment. Per the transporter, Resident #93's eye physician said she was approved to have surgery and would send a message to her primary physician who would contact the facility to coordinate the cataract surgery. -Review of Resident #93's electronic medical record (EMR) did not reveal any additional documentation that the facility had attempted to schedule Resident #93's cataract surgeryD. Staff interviewsCertified nurse aide (CNA) #2 was interviewed on 12/10/25 at 3:48 p.m. CNA #2 said she did not know whether or not Resident #93 had vision issues, but she believed Resident #93 did have cataracts.Licensed practical nurse (LPN) #1 was interviewed on 12/10/25 at 4:12 p.m. LPN #1 said she thought Resident #93 went to an appointment a couple months ago to have her eye surgery, but recently learned the resident just received approval for the surgery at that appointment. LPN #1 said Resident #93 sometimes complained about dry eyes and received eye drops to help with that.The SSA was interviewed on 12/10/25 at 4:16 p.m. The SSA said Resident #93 had been concerned about her vision. She said in September 2025, Resident #93 had a cataract evaluation and was then sent for a referral for the B Scan (an ultrasound test that creates an image of the internal eye and checks for underlying issues that could affect surgical outcomes) on 9/26/25. She said the facilty resent the referral on 10/16/25 and the B scan appointment was scheduled for 10/27/25. She said the transportation coordinator called and set up the appointments and should therefore be aware of when appointments need to be made.The social services director (SSD) was interviewed on 12/11/25 at 12:17 p.m. The SSD said the eye care center had received the referral and was contacting the incorrect facility to set up the surgical appointment. The SSD said that after the B Scan was completed and the doctor gave approval for Resident #93 to receive cataract surgery, the facility should have followed up with the eye care center after about a week to make sure a surgical appointment was scheduled. The SSD said it was the responsibility of the scheduler to make sure follow up and appointments were created. The SSD said the facility created an appointment for Resident #93's surgery that day (12/11/25), during the survey. The scheduler was interviewed on 12/11/25 at 1:00 p.m. The scheduler said she received a referral from the facility's eye doctor, which she then sent to eye care center for follow-up related to Resident #93's cataract She said the eye care center referred Resident #93 for further testing. She said when the testing was completed, the eye care center was supposed to contact the scheduler to coordinate the date of surgery. The scheduler said the eye care center did not contact her, so she assumed there had been an issue related to testing. She said she did not follow-up with the eye care center. The scheduler said she later learned Resident #93's testing was completed on 10/27/25 and the resident could have been scheduled for surgery at that time. She said the eye care center never contacted the scheduler to inform her that Resident #93 completed the tests. The scheduler said she was ultimately responsible to make sure all appointments were getting scheduled and she should have called and checked in with the eye care center sooner to coordinate the cataract surgery appointment for Resident #93. LPN #3 was interviewed on 12/11/25 at 1:13 p.m. LPN #3 said she would contact the facility's scheduler to coordinate an appointment if the physician determined the appointment was neededThe assistant director of nursing (ADON) was interviewed on 12/11/25 at 2:00 p.m. The ADON said the scheduler was responsible for scheduling appointments in a timely manner. The ADON said the scheduler should have followed up with the eye care center within two weeks of the testing when she had not been contacted by the eye care center to arrange the surgery.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection.Specifically, the facility failed to:-Ensure housekeeping staff followed proper cleaning procedures for cleaning and disinfecting resident rooms and high-frequency touched areas; and ,-Ensure housekeeping staff performed hand hygiene and glove changes appropriately. Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures (5/4/23) was retrieved on 12/18/25 fromhttps://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html?CDC_AAref_Val=https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.htmlHigh-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility.Common high-touch surfaces include: bedrails; IV (intravenous) poles; sink handles; bedside tables; counters; edges of privacy curtains; patient monitoring equipment (keyboards, control panels); call bells; and, door knobs.According to the CDC's Hand Hygiene for Healthcare Workers (2/27/24), retrieved on 12/18/25 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, To protect themselves and their patients from deadly germs, all healthcare personnel should understand proper hand care and cleaning techniques. Hand hygiene, which protects both staff and patients, involves cleaning hands by washing with soap and water, using antiseptic hand rubs (such as alcohol-based foams or gels), or performing surgical hand antisepsis. Cleaning your hands reduces the potential spread of deadly germs, including those resistant to antibiotics, to patients. It also lowers the risk of healthcare personnel becoming colonized or infected by germs acquired from patients. Because some healthcare personnel may need to clean their hands as often as 100 times during a work shift to keep everyone safe, maintaining healthy skin is a common challenge.According to the CDC Hand Sanitizer Guidelines and Recommendations (3/12/24), retrieved on 12/18/25 from https://www.cdc.gov/clean-hands/about/hand-sanitizer.html,Germs are everywhere. They can get onto hands and items we touch during daily activities and make us sick. Cleaning hands at key times with soap and water or hand sanitizer that contains at least 60% alcohol is one of the most important steps you can take to avoid getting sick and spreading germs to those around you.There are important differences between washing hands with soap and water and using hand sanitizer. Apply the gel product to the palm of one hand (read the label to learn the correct amount). Cover all surfaces of hands. Rub your hands and fingers together until they are dry. This should take around 20 seconds. Wash your hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom.II. Facility policy and procedureThe Cleaning and Disinfecting Resident Rooms policy, revised September 2022, was provided by the nursing home administrator (NHA) on 12/11/25 at 4:11 p.m. It read in pertinent part, Resident-care equipment, including reusable items and durable medical equipment, will be cleaned and disinfected according to current CDC disinfection recommendations and the OSHA Bloodborne Pathogens Standard.Critical items consist of items that carry a high risk of infection if contaminated with any microorganism. Objects that enter sterile tissue (urinary catheters) or the vascular system (intravenous catheters) are considered critical items and must be sterile when used, based on acceptable sterilization procedures. Sterilization destroys all viable microorganisms to prevent disease transmission associated with the use of that item.The Hand Hygiene policy, revised October 2023, was provided by the NHA on 12/11/25 at 3:51 p.m. It read in pertinent part, This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors.III. ObservationsDuring a continuous observation on 12/11/25, beginning at 9:03 a.m. and ending at 9:43 a.m., housekeeper (HK) #1 was cleaning resident room [ROOM NUMBER] on the Columbine unit.HK #1 donned (put on) a new pair of gloves without performing hand hygiene. HK #1 entered resident room [ROOM NUMBER] with a bottle containing a purple-colored disinfectant solution labeled (BNC-15) and began spraying the entire surface of the sink area. HK #1 picked up articles from the floor around the resident's bed. She started rearranging personal items on the resident's bedside table. HK #1 returned to her cart, removed her gloves and donned a new pair of gloves without performing hand hygiene. HK #1 retrieved a blue rag from her cart, sprayed the purple-colored disinfectant solution (BNC-15) on the sink area, waited three to four minutes while she arranged resident items on the sink counter. She began cleaning the area around the sink, the mirror surface, and the sink faucet.HK #1 removed her gloves and put on a pair of gloves without performing hand hygiene. She retrieved a bleach germicidal spray bottle and sprayed the inside of the toilet bowl and the surrounding surfaces. HK #1 went to her cart, took off her gloves and donned a new pair of gloves. She picked up a toilet brush, a blue cleaning rag and began scrubbing the toilet. HK #1 wiped from top to bottom of the toilet and returned to her cart. She put the toilet brush and the cleaning rag back onto the cart and took off her gloves.-HK #1 failed to disinfect the toilet brush after use.-HK # failed to clean the side rails in the resident bathroom.HK #1 returned to her cart, removed her gloves, applied hand sanitizer, and immediately put on a pair of gloves. HK #1 picked up a trash can from bed A and placed it on top of the surface of the resident's sink that she had already cleaned. She emptied the trash can, applied a new liner, and placed it by the resident's bed. HK #1 returned to her cart, picked up a mop pad and a stick and started mopping the floor around the resident's bed without changing her gloves.-HK #1 failed to disinfect high-touch areas such as the resident's call lights and door knobs-HK #1 failed to ensure that already cleaned surfaces were not re-contaminated. HK #1 returned to her cart, picked up a broom and a dustpan and swept a portion of the room after she completed mopping the floor.-HK # did not sweep the entire floor prior to moping.During a continuous observation on 12/11/25, beginning from 10:07 a.m. to 10:30 a.m. HK #2 was observed cleaning resident room [ROOM NUMBER].At 10:07 a.m. HK #2 donned gloves without performing hand hygiene. HK #2 entered room [ROOM NUMBER] and began rearranging and picking up objects from the floor. HK #2 emptied the trash can and replaced the bags. HK #2 returned to her cart, changed her gloves and did not perform hand hygiene. HK #2 picked up a plastic container with a cleaning brush from her cart, together with a bleach germicidal cleaner. She sprayed the toilet bowl and placed the bottle on the floor in the resident's bathroom, closer to the toilet. HK #2 rearranged the resident's bedside table and repositioned the resident's bed. She picked up a cup of juice from the resident's bedside table with her right hand and her left hand held a dirty rag. She placed the cup of juice on another table, closer to the window, and continued cleaning the bedside table. After cleaning the bedside table, she used the same gloves to place the juice cup back where it was initially.-HK #2 failed to clean and disinfect the residents call light, grab bar and door knobs-HK #2 failed to change gloves and perform hand hygiene between dirty and clean surfaces.IV. Staff interviewsHK #1 was interviewed on 12/11/25 at 9:45 a.m. HK #1 said she applied hand sanitizer when she finished cleaning the bathroom and when she completed cleaning room [ROOM NUMBER].HK #1 said she should have used the hand sanitizer each time she changed gloves. She said she forgot to the clean high-touch areas such as doorknobs, resident call lights, and grab bars in the resident's toilet. HK #1 said that as soon as she placed the trash can on the clean surface, she knew it was not right and should have cleaned it again. She said she would remember to change her gloves more often in between tasks and also perform hand hygiene.The infection preventionist (IP) was interviewed on 12/11/25 at 4:37 p.m. The IP said gloves should be changed between tasks, and hand hygiene should be performed each time gloves were changed when cleaning resident rooms. She said high-touch areas such as resident call lights, grab bars in residents' bathrooms and door knobs needed to be cleaned each day and when visibly soiled. The maintenance director (MTD) was interviewed on 12/11/25 at 5:05 p.m. He said the HKs should know when to perform hand hygiene and change gloves during cleaning tasks. He said high-touch areas included door knobs, call lights, light switches, bedside tables, nightstands and bed remotes. He said high touch areas should be disinfected daily. He said HK #2 should have changed her gloves and performed hand hygiene before touching the resident's juice cup.The MTD said he would immediately retrain housekeeping staff on the correct process for cleaning resident rooms and provide on-the-spot hand hygiene training.

Based on observations, record review and interview, the facility failed to ensure the call light system was functioning properly in its entirety. Specifically, the facility failed to ensure staff could hear the call light alerts when working in areas away from the centralized staff work area, where the call light alarm sound was heard when there were no staff in the centralized work area to hear the alarm. Findings include: I. Facility policy and procedure The Call Lights: Accessibility and Timely Response policy, revised 1/25/25, was provided by the nursing home administrator (NHA) on 4/16/25 at 3:45 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 resident's 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. II. Observations On 4/15/25 at 10:56 a.m., during the walkthrough of the facility, the call light system was observed. The audible call light alarm only sounded at the nurses'station and could not be heard down the unit's hallways. A light board was located in the nurses'station with a square button for each resident room that illuminated when a resident activated the call light. Outside of the enclosed nurse's station, the activated call lights were not easily visible. There was no way to know how long the lights had been alarming or who called first. Due to the layout of the facility, the call lights were not audible down the long hallway. When standing near the nurse's station, the call lights were hard to hear due to low alarm volume Additionally, the view of the resident's overhead door call lights was obstructed from the nurses'station because the light was placed on the ceiling and the lights were obstructed by low-hanging door frames at the entrance to each hallway from the nurses station. III. Resident interviews Resident #4 was interviewed on 4/15/25 at 1:27 p.m. Resident #4 said the staff seemed to be working more than one hall at a time. She said sometimes her call light was on for up to two hours before someone can help her to the bathroom or respond when she needed pain medication. Resident #4 said she was in her room just before 3:00 p.m. when her roommate, Resident #1, began to have difficulty breathing. Resident #1 called out for help. Resident #4 said her roommate had already activated the call light and had been waiting for staff. Resident #4 said she began to blow her whistle for help just before 3:00 p.m. Resident #4 said she blew her whistle for 15 minutes before a staff member heard the whistle blowing and entered the room. Resident #4 said she knew it took an additional 15 minutes to get staff's attention because she had a clock on the wall directly across from her bed, which she watched frequently to time staff response time. Resident #5 was interviewed on 4/15/25 at 1:35 p.m. Resident #5 said she was in the facility for a short term, awaiting surgery and was frequently in pain due to her health condition. She said on several occasions she activated her call light to request pain medication and her call light was not answered timely. Resident #5 said she waited in pain for more than two hours for staff to respond to her call light. Resident #5 said she heard people in other nearby rooms calling out for help for 20 to 30 minutes at a time. Resident #2 was interviewed on 4/15/25 at 2:02 p.m. Resident #2 said she waited for 40 minutes this morning after she used her call light, waiting for staff to assist her to get cleaned up after having an incontinence episode. Resident #6 was interviewed on 4/15/25 at 2:48 p.m. until 3:42 p.m. Resident #6 said staff rarely checked on her unless she used her call light and even then, it took staff a long time to hear and answer her call light. Resident #6 expressed surprise when four staff members entered the room during the interview to check on her. Resident #6 said she could not remember exactly how long it took staff this morning to answer her call light but knew it was over an hour that she was sitting in her own urine waiting for staff to answer her call light. Resident #6 said yesterday (on 4/14/25) she was in her room eating lunch and became short of breath. When she felt her oxygen tubing she could not feel air coming out of the tubing so she pressed her call light for staff assistance. Resident #6 said staff did not respond and nobody came until she began to yell for help. IV. Record review The NHA provided documentation of the facility's internal audit of call light response times on 4/15/25 at 4:50 p.m. The facility's internal audit of call light response times that were conducted on 3/11/25 from 10:08 a.m. through 3:20 p.m. revealed a range of call light response times while staff was observed by facility administration. The times ranged from one minute at the fastest response time to one hour and 42 minutes at the slowest response time. The facility's internal audit of call light response times conducted on 3/28/25 from 8:39 a.m. through 4:36 p.m. revealed a range of call light response times while staff was observed by facility administration, ranged from one minute at the fastest response time to 25 minutes at the slowest response time. A respiratory therapist's (RT) note in Resident #1's electronic medical record (EMR), dated 2/5/25 at 3:12 p.m., documented while the RT was completing respiratory care rounds at the facility, he heard a whistling sound coming from a resident's room. No other staff were responding to the alarm and the call light was not heard. When the RT arrived to the room, Resident #1 was in need of immediate medical attention. -However, because the facility's call light system was unable to show the order in which call lights were received, and was not able to be heard in the resident hallway, there was no way for staff to respond in a timely manner and no way to know how long Resident #1 waited in distress for the staff's response. Review of resident grievance forms from 2/3/25 through 4/7/25 revealed five resident initiated grievances were filed, documenting long call light response times with staff not responding to requests for care in a timely manner. The grievances documented a resident's were waiting over 30 minutes for incontinence care on 2/4/25 and other complaints documented long call light waits occurring on the overnight shift on 3/7/25, 3/14/25 and 4/7/25. The resident council minutes, dated 1/15/25, documented the residents had complaints that nursing staff were not providing timely care and the resident council requested the facility work on call light response times. The resident council minutes from 2/19/25 revealed there were improvements in call light response times after the start of audits by facility managers. However, the minutes report call light response times remained an issue during night shift and on weekends. V. Staff interviews A frequent visitor to the facility was interviewed on 4/15/25 at 4:37 p.m. The frequent visitor said the most frequent complaint received from residents in the facility was long call light waits. The frequent visitor was aware that the NHA was working on the concern but said the complaints remain problematic and have not been fully resolved. Certified nurse aide (CNA) #3 was interviewed on 4/16/25 at 10:22 a.m. CNA #3 said she could not hear the call light alarms when she was down the hall away from the nurse''s station and some other locations on the unit. She said she took care of residents on multiple hallways throughout her shift and often had to cover for the CNA when they left their assigned units to cover the dining room during meal times to ensure resident care needs were met. CNA #3 said it was difficult to hear the call light when down the long hallways and if she was able to hear the call light it took time to investigate who was calling because you could only see the outside door call light from certain view points in the hall. CNA #3 said staff had to go from hall to hall to see which light was on or go to the nurse's station to see whose light was on. -However, there was no way for the staff to know which resident had their light on the longest. Licensed practical nurse (LPN) #1 was interviewed on 4/16/25 at 10:30 a.m. LPN #1 said despite the staff having good teamwork, it was difficult to see some of the call lights depending on where she [NAME] on the unit. LPN #1 said the call light alarm sound only had two different tones, one for the bedside and one for the bathroom. LPN #1 said she did not know if there was any way to tell which resident called first or how long the resident had been waiting for assistance by looking at the board of call lights. CNA #1 was interviewed on 4/16/25 at 10:39. CNA #1 said the resident's call lights did not have an audible sound by the resident's room and the only way to know if they were activated was to notice the hallway door light was on. CNA #1 said there was no way to know who activated their call light first and she did her best to answer call lights as they came on in a timely manner. She said it was hard to see the activated call lights due to the low door frames placed midway down the hall. To see the call lights she had to frequently duck or squat down to see if a light was activated. The nursing home administrator (NHA) was interviewed on 4/16/25 at 1:15 p.m. The NHA said that the leadership team responded to resident complaints and grievances related to call light response times by completing internal audits of different units at various times and provided staff training on the expectations of answering call lights timely. The NHA said he expected call lights to be responded to within at least 30 minutes, preferably within 15 minutes. The NHA said he also educated staff on where to look to see lights in certain halls that are partially obstructed due to the layout of the building. The NHA said he was aware the technology of the call light system could use improvement and requested funding to improve the system but did not know if funding will be approved or not.

Based on observations, record review and interviews, the facility failed to ensure one (#6) of three residents out of seven sample residents received the highest practicable treatment and care per professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to ensure Resident #6 received her medications in a timely manner, as prescribed. Findings include: I. Professional reference According to [NAME], P.A. and [NAME], A.G. et.al., (2021), Fundamentals of Nursing, 10 edition, pp 607-609. Medication errors can cause or lead to inappropriate medication use or patient harm. Medication errors include inaccurate prescribing, administration of the wrong medication, giving the medication using the wrong route or time interval. Administering extra doses, and/or failing to administer medications. Preventing medication errors is essential. Professional standards such as the scope of nursing and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medication .The right medication, the right dose; the right patient; the right route; the right time; right documentation; and the right indication. Give priority to time-critical medications that must act and therefore be given at certain times. Give all routinely ordered non-time-critical medications within one hour before or after the scheduled time. According to Vallerand, A.H and Senoski, C.A. et.al., (2021), Davis's Drug Guide, 16th edition pp 605-606. When taking Gabapentin (a medication for neurological pain management), Take medication exactly as directed. Patients on three (3) times daily dosing should not exceed 12 hours between doses. According to the National Library of Medicine, Medline Plus, 2025, retrieved 4/25/25, online from https://medlineplus.gov/druginfo/meds/a682530.html Baclofen is used to treat pain and certain types of spasticity (muscle stiffness and tightness) from multiple sclerosis, spinal cord injuries, or other spinal cord diseases. Baclofen is in a class of medications called skeletal muscle relaxants. Baclofen acts on the spinal cord nerves and decreases the number and severity of muscle spasms caused by multiple sclerosis or spinal cord conditions. It also relieves pain and improves muscle movement. Baclofen is usually taken three (3) times a day at evenly spaced intervals. Follow the directions on your prescription label carefully. Do not take a double dose to make up for a missed one. According to Northwestern Medicine, Department of Pharmacy, Apixaban (Eliquis) September 2023 retrieved on line 4/25/25 from https://www.nm.org/-/media/northwestern/resources/patients-and-visitors/patient-education/medication/northwestern-medicine-apixaban-eliquis.pdf Apixaban (Eliquis) is a medication that prevents blood clots from forming in your blood. It is known as an anticoagulant or blood thinner. Apixaban does not actually thin the blood. It prevents new clots from forming and keeps existing clots from getting bigger and causing more serious problems. Apixaban does not dissolve clots that have already formed. It is used to prevent harmful clotting related to certain blood vessels, or heart and lung conditions. Take apixaban exactly as prescribed at the same time each day, in the morning and at night. If you miss a dose of apixaban, take it as soon as you remember, unless it is close to your next dose. This way, you do not take a double or extra dose. Then, go back to your regular dosing schedule. II. Facility policy and procedure The Administering Medications policy, revised April 2019, was provided by the nursing home administrator (NHA) on 4/16/25 at 3:45 p.m. It read in pertinent part, Medications are administered in a safe and timely manner, and as prescribed. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: Enhancing optimal therapeutic effect of the medication; preventing potential medication or food interactions; and honoring resident choices and preferences, consistent with his or her care plan. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: -The date and time the medication was administered; -The dosage; -The route of administration; -The injection site (if applicable); -The complaints or symptoms for which the drug was administered; -Any results achieved and when those results were observed; and, -The signature and title of the person administering the drug. III. Resident #6 A. Resident status Resident #6, age greater than 65, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), respiratory failure, atrial flutter, heart failure, and atrioventricular block (blockage in the heart). The 4/11/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) score of 15 out of 15. She was dependent on staff assistance to complete most activities of daily living (ADL). B. Resident interview Resident #6 was interviewed on 4/15/25 at 2:48 p.m. Resident #6 said she was worried she was not receiving her medication at the right time. Resident #6 was not sure if it was dangerous to take the medication late or early, but sometimes she did not get her morning medications (scheduled at 7:00 a.m.) until almost noon. She said she did not remember staff telling her that there would be changes to her medication times recently. Resident #6 said she had not had any adverse reactions to the delayed medication administration times. C. Record review Review of Resident #6's April 2025 medication administration audit report (4/1/25 to 4/15/25) revealed the following: -A total of 102 medications were given late. Eighty-seven of these late medication administration events were given by licensed practical nurse (LPN) #2. On 4/7/25, 12 medications prescribed to Resident #6 were scheduled to be given between 7:00 a.m. and 10:00 a.m. All 12 medications were given at 11:27 a.m. (one hour and 27 minutes late). This included medications ordered to be given twice or three times a day. The April 2025 CPO revealed a physician's order for Baclofen oral tablet 5 milligram (mg), give one tablet by mouth three times a day for muscle spasticity of the spinal origin, ordered on 01/08/2025. -Between 4/1/25 and 4/15/25 the Baclofen was administered over an hour past the administration window 16 times. -This medication was scheduled to be given between 7:00 a.m to 10:00 a.m each morning, scheduled for 2:00 p.m. administration and to be given between 7:00 p.m. to 10:00 p.m. each day. On 4/7/25, the resident's 2:00 p.m. scheduled Baclofen was administered at 5:19 p.m. (three hours and 19 minutes late). The scheduled evening dose of Baclofen was then administered timely at 7:16 p.m., less than two hours later. -The administration of scheduled Baclofen was problematic because the resident's first and second doses were administered late and the next dose was given timely. The doses were not evenly administered to promote a consistent level of pain and spasm management (see professional reference above). The April 2025 CPO revealed a physician's order for Eliquis oral tablet 5 mg, give one tablet by mouth twice a day for the prevention of blood clots related to the diagnosis of atrial flutter, ordered 3/26/25. Between 4/1/25 and 4/15/25 the Eliquis was administered past the scheduled administration window nine times. -This medication was scheduled to be given between 7:00 a.m to 10:00 a.m each morning and to be given between 7:00 p.m. to 10:00 p.m. each day. The April 2025 CPO revealed a physician's order for Gabapentin oral capsule 300 mg, give one tablet by mouth twice a day for the treatment of neuropathic pain, ordered 3/26/25. Between 4/1/25 and 4/15/25 gabapentin was administered past the scheduled administration window nine times. -This medication was scheduled to be given between 7:00 a.m to 10:00 a.m each morning and to be given between 7:00 p.m. to 10:00 p.m. each day. On 4/11/25, all medications scheduled between 7:00 a.m. and 10:00 a.m. (13 medications) were administered at 12:19 p.m. (two hours and 19 minutes late). This included Resident #6's morning doses of Eliquis and gabapentin. -The administration of scheduled gabapentin was problematic because the resident's first dose was administered late and the next dose was given timely. The doses were not evenly administered to promote a consistent level of pain management (see professional reference above). -The administration of scheduled Eliquis was problematic because the resident's first dose was administered late and the next dose was given timely. The doses were not evenly administered as recommended in order to maintain a therapeutic level of medication to prevent blood clots (see professional reference above). IV. Staff interviews The staff development coordinator (SDC) was interviewed on 4/16/25 at 10:03 a.m. The SDC said she was working the medication cart this morning (4/16/25) due to a call off. The SDC said she had 16 residents to pass medications to this morning, including Resident #6. The SDC said the medication cart she was passing medications for used to have four more residents to pass medications for. She said starting today (4/16/25), four of the residents were moved to another medication cart on the unit because it was too difficult for the nurse assigned to this cart to finish their assigned medications on time. She said many of the residents in the hallway required two staff to reposition or provide other care, which often interrupted the medication pass because the nurse had to assist the CNAs with care tasks. The SDC said scheduled morning medications should be given from 7:00 a.m. to 10:00 a.m. unless they were time specific, like a blood sugar reading. The unit manager (UM) was interviewed on 4/16/25 at 10:11 a.m. The UM said she was not sure if the residents, including Resident #6, were receiving their medication on time or not. The UM said the director of nursing (DON) recently started to review medication administration times. The UM said she decided to change the assignments for the medication carts on the unit after multiple nurses reported to her that they were having difficulty administering medications on time, given the acuity of the residents assigned to the cart. The assistant director of nursing (ADON) was interviewed on 4/16/25 at 1:15 p.m. The ADON said the facility recently implemented a change to the way medications were ordered in the medication administration record (MAR). The ADON said that scheduled medications that did not need to be given at the same time every day were ordered with a three-hour window. She said for example, a medication typically ordered at 7:00 a.m. was scheduled for 7:00 a.m. to 10:00 a.m. She said the resident was also involved in their care and may opt out of the new schedule or request medications at specific times. The DON was interviewed on 4/16/25 at 3:07 p.m. The DON said the new medication administration schedule was initiated to better accommodate the preferences of the residents while also trying to manage the workflow of the nurses. The DON said with the schedule of medications changed to a three-hour window in the MAR, she expected her staff to administer the medication in the window. She said the one-hour window on either side of the scheduled time was typical of professional standards for nurses, was included in the three-hour window; medications given after the three-hour window are late. The DON said she was not aware of how many late medication administration times occurred for Resident #6 until the audit was requested by the survey team. The DON said she spoke with LPN #2, the nurse involved with the majority of the late medications, about professional standards and timely medication administration after she saw the results of the audit. The DON said LPN #2 told her medications might have been administered earlier than the recorded time and charted on the computer later. The DON said recording routine medication administrations in the chart after administering was also not in line with professional nursing practice.

Based on record review and interviews, the facility failed to ensure residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain and maintain the highest practicable mental and psychosocial wellbeing for one (#2) of three residents reviewed out of five sample residents. Specifically, the facility failed to ensure services and individualized care approaches were provided, and monitored with ongoing assessment, for Resident #2 in order to meet the emotional and psychosocial needs of the resident. Findings include: I. Resident #2 A. Resident status Resident #2, age 69, was admitted on [DATE] and discharged to another long-term care facility on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included anxiety, head injury, dementia, depression and epilepsy. The [DATE] 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. He required supervision with dressing, bathing, ambulation, transfers and hygiene. The assessment indicated the resident had no behaviors. B. Record review Resident #2's psychosocial emotional trauma care plan, initiated [DATE], revealed the resident was at risk for psychosocial and adjustment issues related to emotional distress, ineffective coping skills, and poor impulse control with a history of traumatic events, to include the sudden and expected death of his wife and recent appointment of a guardian. Interventions included attempting non-pharmacological approaches, such as music therapy, breathing exercises, talking to the resident about his feelings, meditation, aroma therapy, offering reading materials and offering behavioral and psychological services as indicated. Review of Resident #2's February 2025 CPO revealed the following physician's orders: Trazodone 50 mg (milligrams), give one tablet by mouth for insomnia one time per day, ordered [DATE]. Celexa 40 mg, give one tablet by mouth for depression one time per day, ordered [DATE] and discontinued [DATE]. Behavior tracking for antidepressant medication-monitoring for self isolation and refusing to participate in activities. Document interventions attempted: one-on-one interaction and encouraging meditation, ordered [DATE]. Write a behavior note every shift for discontinuation of Celexa and initiation of Zoloft, ordered [DATE]. Zoloft 50 mg, give one tablet by mouth for depression one time per day, ordered [DATE] and discontinued [DATE]. Sertraline (Zoloft) 100 mg, give one tablet by mouth for depression one time per day, ordered [DATE]. Counseling for depression, ordered [DATE]. Olanzapine 5 mg, give one time for aggression, ordered [DATE] and discontinued [DATE]. Olanzapine 5 mg, give one tablet by mouth for aggression one time per day, ordered [DATE]. Behavior tracking for antipsychotic medication-monitoring for verbal aggression and delusions. Document interventions attempted: redirection, removal from environment, music, and offer quiet environment, ordered [DATE]. Review of Resident #2's electronic medical record (EMR) from [DATE] through [DATE] revealed the following progress notes: The behavior note, dated [DATE], revealed Resident #2 displayed visible distress shortly after admission. The resident paced and approached staff with delusions and paranoia. The resident told staff his wife was killed and his house was taken from him. He demanded from staff to tell him why he was in the facility or he would call the police. The staff encouraged the resident to express his concerns and reminded him that he was safe. The nurses requested a one-on-one staff member to sit with Resident #2 but the resident's guardian was unable to find anyone to sit with the resident. The guardian spoke with the resident over the phone and the physician ordered Trazodone to help the resident sleep. The 72-hour charting note, dated [DATE], revealed Resident #2 reported visual hallucinations of a dog to the staff. The nursing note, dated [DATE] at 5:32 a.m., revealed the resident expressed paranoia when staff requested to collect a urine sample from him to test for a possible infection. The resident told staff he believed the facility was testing him for drug use. The nursing note, dated [DATE] at 11:46 a.m., revealed Resident #2 told the staff he needed to leave and did not belong in the facility. The social services note, dated [DATE], revealed the resident was moved out of the memory support unit, which was not a locked secure unit, to the general population due to no longer showing interest in exit-seeking. The nursing note, dated [DATE], revealed Resident #2 became agitated when he told the nurse he was unable to reach his wife by phone. The resident said there were thugs in his home with his wife and he needed to go save her. The nurse told him the facility was now his home and his wife was not in danger. The resident continued to pace and search for an exit. The resident located an exit and threatened bodily harm to the staff if they attempted to prevent him from leaving the building. Resident #2 left the building and staff followed him until he calmed down and agreed to return. The social services note, dated [DATE], revealed Resident #2 told the social services staff he had heard from his son who informed him the resident's wife was deceased . The resident's guardian was contacted to provide comfort to the resident and to calm him down. The nursing note, dated [DATE], revealed the facility was seeking a facility with a locked secure memory care unit to move Resident #2 to. The nursing note, dated [DATE], revealed the pharmacy had to provide a week's supply of Celexa 40 for the resident until the prior authorization was complete. The nursing note, dated [DATE], revealed the physician had received the prior authorization for the Celexa but would wait to evaluate the necessity for the medication on his next visit with the resident then complete the authorization. The interdisciplinary team (IDT) note, dated [DATE], revealed Resident #2 missed nine doses of his antidepressant, Celexa. The Celexa was discontinued and Sertraline was started. The behavior note, dated [DATE], revealed Resident #2 attempted to leave the facility but was easily redirected. The social services note, dated [DATE], revealed the resident was accepted at another facility with a secure memory care unit. The behavior note, dated [DATE], revealed Resident #2 was packing his belongings and voicing he was going to leave that evening. The nurse was not able to redirect him. The social services note, dated [DATE], revealed the accepting facility said they could not accept the resident until [DATE]. The behavior note, dated [DATE] at 2:49 a.m., revealed Resident #2 was displaying delusions and paranoia that staff had stolen items from him. He was perseverating and hyperfixating on the delusion and was not redirectable. The resident started to believe the staff were not going to help him and he began to threaten bodily harm. The resident began to beat his chest and started to chase the nurse. The police had to be contacted to defuse the situation. The change of condition note, dated [DATE], revealed the resident was displaying new or worsening delusions and hallucinations and was a danger to himself or others. The alert note, dated [DATE], revealed the facility was seeking alternative placement for the resident. The note instructed staff to approach the resident with care when he was distressed about missing clothing. The behavior note, dated [DATE] at 6:36 a.m., revealed Resident #2 claimed to staff that someone had entered his room and stolen his wallet. Staff were unable to redirect him and the resident began pacing and yelling. The resident began throwing items in the hallway from the nurses station and then made physical threats to the staff. The resident punched the glass at the nurses station, breaking it. The staff had to contact the resident's guardian to speak with him in order for him to calm down. The behavior note, dated [DATE] at 11:04 a.m., revealed the resident was perseverating on missing items and the staff spent two hours attempting to redirect the resident. The resident became angry and hit his fist into his forehead. The resident told the staff his wallet was missing and he was worried about his wife being upset if there were fraudulent charges on his cards. After staff helped the resident search his room and the laundry for missing items and the social services staff assured him they would assist with any fraud resources, the resident was redirectable and went to activities. The social services note, dated [DATE], revealed Resident #2 was accepted for admission at a secure unit long term care facility. The resident was discharged from the facility on [DATE]. -Review of Resident #2's progress notes from [DATE] through [DATE] failed to reveal the social services director (SSD) followed up with the resident or the staff regarding the repeated behaviors or the interventions used to de-escalate the behaviors. -Review of Resident #2's EMR did not reveal any psychological and/or psychiatric behavior health provider notes or psychoactive drug meeting reviews regarding the resident. -A review of the resident's medication administration records (MAR) and treatment administration records (TAR) from [DATE] to [DATE] did not reveal any behaviors had been documented for Resident #2. -A review of the certified nurse assistant (CNA) task documentation records failed to reveal documentation of behaviors or interventions attempted for Resident #2. IV. Staff interviews CNA #1 was interviewed on [DATE] at 12:45 p.m. CNA #1 said Resident #2 displayed behaviors of delusions, hallucinations and paranoia. She said the resident could become verbally aggressive. CNA #1 said the interventions the staff were to provide for the resident were redirection and reassurance. Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 12:50 p.m. LPN #1 said Resident #2 was agitated when he was on the memory support unit and frequently wanted to leave. She said he could display paranoia when agitated and the staff were to provide redirection. The SSD, the social services director for the memory care unit (SSDMC), and the nursing home administrator (NHA) were interviewed together on [DATE] at 11:41 a.m. The SSDMC said Resident #2 came to the facility over the holiday break in [DATE]. She said the resident's home environment was not appropriate, as he was living alone without food, water, lights or gas. The SSDMC said the resident had a son but the son did not act as a support unit for Resident #2. She said she did not know if the resident's wife had left him or if she had died and the facility chose not to ask. She said the wife was a trigger and Resident #2 would perseverate on where she was or what was happening to her. The SSDMC said Resident #2 had behaviors of wandering and becoming more agitated as the day progressed. She said when he became more agitated in the evening, Resident #2 would become increasingly possessive of his belongings and paranoid that people were stealing from him. She said in the evening, the resident would search for his items or pack his belongings and tell the staff he was going to leave. The SSDMC said the interventions the staff would try were to help the resident search for his belongings, redirecting and contacting the resident's guardian to talk to the resident. The SSDMC said the non-pharmacological interventions for Resident #2 included redirection, calling the resident's guardian, offering music therapy, breathing exercises, meditation, aroma therapy and offering reading materials to the resident. She said the IDT determined the behavior interventions, along with input from the unit manager. She said the unit manager communicated the person-centered interventions to the floor staff. The SSDMC said the CNAs documented behaviors in the CNA tasks and the tasks were personalized by the IDT to reflect person-centered behaviors and interventions. She said the interventions the nurses used with Resident #2 came from the behavior tracking order in the resident's physician's orders. The SSD said residents taking psychoactive medications would be added to a list to be reviewed in the monthly psychoactive drug meetings, which the behavioral health providers attended. She said a new resident with a diagnosis of cognitive deficits or mental illness who was also taking psychoactive medications was reviewed within the first sixty days of admission. She said if a resident was displaying behaviors, that would warrant including the resident to be reviewed in the psychoactive drug meeting. She said the facility conducted psychoactive drug meetings every third week of the month. The SSD said Resident #2 was not reviewed in the [DATE] or [DATE] psychoactive drug meeting reviews. She said Resident #2 was taking psychoactive medications and his medications were being monitored by a primary care physician. The SSD said she did not know why Resident #2 was not scheduled to be reviewed in the psychoactive drug meetings or why Resident #2 was never scheduled to be evaluated by the psychiatrist. The SSD said it was the responsibility of the social services department to send referrals to the behavioral health provider for counseling services, but she did not know why a referral was never sent for behavioral health counseling for Resident #2. The NHA said the facility began looking for alternative long-term care placement for Resident #2 in [DATE]. He said it was determined Resident #2 needed to be in a facility that specialized in aggressive behaviors. The NHA acknowledged, without providing the resident with psychiatric or psychological support or a review in the psychoactive drug meeting, the NHA could not confirm the facility was unable to meet Resident #2's behavioral needs. The NHA acknowledged Resident #2 admitted to the facility with a traumatic history, such as caregiver and spousal loss, the inability to meet his basic needs and legal intervention to appoint a guardian to take over decision making for the resident. -Despite the traumatic history of the resident, the recent displacement from his home to a care facility, and the escalating behaviors displayed after admission, the facility failed to provide Resident #2 with all available resources to remain in the facility and receive psychosocial support.

Based on record review, observations and interviews, the facility failed to establish a system of records and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and failed to determine that drug records are in order and that an account of all controlled substances is maintained and periodically reconciled. Specifically, the facility failed to: -Maintain a system of controlled substance records for discontinued controlled substances. Findings include: I. Facility policy and procedure The Controlled Substance policy, revised November 2022, was provided by the nursing home administrator (NHA) on 9/5/24 at 10:56 a.m. The policy read in pertinent part, The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Dispensing and reconciling controlled substances: -Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. -The system of reconciling the disposition of controlled substances includes the destruction and waste. -Waste and/or disposal of controlled medication are done in the presence of the nurse and a witness who also signs the disposition sheet. -Disposal methods are used to prevent diversion and/or accidental exposure to controlled or hazardous substances. -The consultant pharmacist or designee routinely monitors controlled substance storage records. II. Observations On 9/5/24 at 8:35 a.m., the inventory of discharged /discontinued controlled substances waiting for destruction was observed with the director of nursing (DON) and the NHA. The controlled medications were stored in a four drawer file cabinet that was secured with a padlock. The file cabinet was locked inside the DON's office. The DON unlocked and opened each file cabinet drawer. The drawers contained controlled medications and each drawer was completely full. The medications were dated March 2024 to September 2024. IV. Record review On 9/5/24 at 8:45 a.m., a request was made for the documentation that indicated a system was in place to ensure controlled drugs were periodically reconciled. The DON said there was not a system in place to document the process that medications were tracked after they were discontinued and taken into her custody for destruction (see interview below). V. Staff interviews The DON and the NHA were interviewed together on 9/5/24 at 8:45 a.m. The DON said when the medication nurses alerted her to remove controlled substance medications from the medication cart, she reviewed the controlled medication count and signed the control sheet with the nurse. She said after she took the medication into her custody, she stored the controlled medications in the locked file cabinet inside her office. The DON said the NHA and herself had keyed access to her office and she had the keys to the padlocks. The DON said the process to destroy medications included two nurses to witness every destruction and the destroyed items would be entered on a tracking log. She said she placed the discontinued medication in her office until she had the opportunity to complete destruction of the controlled substances. The DON said when she took custody of the controlled substance medication she did not have a system in place to reconcile the discontinued medications. The DON said she had not destroyed any items since took her position in February of 2024. The NHA and DON said the file cabinet drawers included medications from March 2024 to September 2024. The NHA said he was unaware of the large inventory of medications awaiting destruction. He said he would review the facility's resources and consider using a third party to assist in destroying the controlled medications. The NHA said that he contacted the facility pharmacy and said the pharmacist had not completed reconciliation monitoring of controlled substance destruction.

Based on observation, record review and interviews the facility failed to provide the necessary services to maintain personal hygiene for one (#11) of three residents reviewed for services to maintain highest practicable quality of life out of 25 sample residents. Specifically, the facility failed to provide timely incontinence care for Resident #11. Findings include: I. Facility policy and procedure The Supporting Activities of Daily Living (ADL) policy, revised March 2018, was received from the nursing home administrator (NHA) on 9/5/24 at 5:08 p.m. It revealed in pertinent part, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with elimination (toileting). II. Resident #11 A. Resident status Resident #11, age less than 65, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes with diabetic neuropathy (nerve damage caused by diabetes), benign prostatic hyperplasia (BHP) (a noncancerous enlargement of the prostate gland) and phantom limb syndrome with pain (the perception of pain or discomfort in a limb that is no longer there). The 8/6/24 minimum data assessment (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 supervision to touching assistance with toileting hygiene and dressing. The resident was always incontinent of bowel and occasionally incontinent of bladder. B. Resident interview and observations On 9/4/24 during a continuous observation, beginning at 12:31 p.m. and ending at 3:16 pm., the following was observed: Resident #11 was interviewed on 9/4/24 at 12:31 p.m. Resident #11 said he was sitting in his own feces during the interview. Resident #11 said an unidentified certified nursing aide (CNA) had entered the room approximately five minutes before the interview and left to go get the supplies she needed to change his brief but had not yet returned. Resident #11 said it was a normal occurrence to have a CNA enter the room to turn off the call light and leave without addressing the resident's needs and that it happened more frequently on the weekends. The room had a strong fecal odor. At 1:07 p.m. several unidentified nursing staff members started passing out lunch trays for Resident #11's hallway. -The unidentified CNA that Resident #11 said had entered his room and turned off the call light did not return to provide him assistance. At 1:13 p.m. an unidentified CNA walked into Resident #11's room to deliver his lunch tray. The CNA walked out of the room promptly after delivering the tray. At 1:43 p.m. an unidentified staff member walked into Resident #11's room to retrieve his lunch tray. The staff member left the room promptly after retrieving the tray. At 2:58 p.m. Resident #11's call light was activated. At 3:00 p.m. CNA #2 entered Resident #11's room and shut the door to provide care for the resident. At 3:14 p.m. Resident #11 left his room. Resident #11 said his brief had just been changed. -Resident #11 waited two hours and 45 minutes for a staff member to assist him with his incontinence episode. Resident #11 was interviewed a second time on 9/5/24 at 10:57 a.m. Resident #11 said he had to wait a long time to have his brief changed on a daily basis and that he once had to wait for five hours. Resident #11 said he felt frustrated by this issue. D. Record review The bladder incontinence care plan, initiated 5/10/24, revealed Resident #11 was at risk for incontinence due to reduced mobility and BHP. Pertinent interventions included ensuring Resident #11 had an unobstructed path to the bathroom, monitoring intake and output per facility policy and monitoring the resident for signs and symptoms of a urinary tract infection. -The care plan did not reveal any focus areas nor interventions related to his bowel incontinence or ADLs. The 8/22/24 annual exam notes revealed Resident #11 required moderate assistance for some ADLs. The provider also indicated Resident #11 was incontinent of both bowel and bladder. E. Staff interviews CNA #2 was interviewed on 9/4/24 at 3:19 p.m. CNA #2 said she primarily did brief changes for Resident #11 and that he was independent for everything else. CNA #2 said Resident #11 was able to turn himself but she needed to perform the whole brief change and clean him, since he could not perform these activities himself. CNA #2 said Resident #11 was mostly incontinent of bowel. She said he was able to use the urinal himself. CNA #2 said Resident #11 used his call light whenever he had episodes of incontinence. CNA #2 said she checked incontinent residents every two hours to see if they needed incontinence care. CNA #2 said there was quite a lot of fecal matter and some urine in the brief that she had just changed for Resident #11. Licensed practical nurse (LPN) #1 was interviewed on 9/5/24 at 8:49 a.m. LPN #1 said residents regardless of their continence status should be checked at least three to four times each eight hour shift. LPN #1 said the length of time residents could go without having incontinence care depended on the staff that were on shift, but that wait times had improved. LPN #1 said she recently had a resident tell her a CNA came into their room, turned off their call light and left to go get supplies to provide incontinence care but never came back. LPN #1 said she immediately went to the CNA in question and had her correct this issue. LPN #1 also said she had residents tell her that they had been left for a while without having incontinence care performed. LPN #1 said she followed up with these residents to see if they spoke with their nurses and ensured their nurses were aware of the issue. CNA #1 was interviewed on 9/5/24 at 1:50 p.m. CNA #1 said incontinent residents should be checked every two hours. CNA #1 said this timeframe varied resident-to-resident and that some residents were incontinent more often than others. CNA #1 said Resident #11 needed help with incontinence care and changing his brief whenever he had bowel movements. The director of nursing (DON) was interviewed on 9/5/24 at 2:00 p.m. The DON said staff performed checks for incontinent residents. She said the care plan indicated if the resident was incontinent. The DON said the nursing staff tried to assess things like incontinence care when the resident was initially admitted and that the nursing staff and residents have their routines. The DON said the facility generally did not write their care plans to have specific timeframes on incontinence checks like saying they needed to be checked every two hours. Registered nurse (RN) #1 was interviewed on 9/5/24 at 2:06 p.m. RN #1 said Resident #11 needed help with changing his incontinence briefs and providing incontinence care. RN #1 said Resident #11 asked for help whenever he needed it, but that he waited longer than he should have when asking for help. RN #1 said incontinent residents should be checked at least every two hours.

Based on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for three (#2, #12 and #7) out of 25 sample residents. Specifically, the facility failed to: -Ensure the physician's orders for skin and wound care were followed for Residents #2 and #12; and, -Ensure Resident #7 received medication as ordered by the physician. Findings include: I. Facility policy and procedure The Wound Care policy, revised October 2010, was provided by the nursing home administrator (NHA) on 9/5/25 at 5:08 p.m. The policy read in pertinent part, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. The following information should be recorded in the resident's medical record: The type of wound care given, the date and time the wound care was given, the position in which the resident was placed, the name and title of the individual performing the wound care, all assessment data (wound bed color, size, drainage) obtained when inspecting the wound, how the resident tolerated the procedure, any problems or complaints made by the resident related to the procedure, if the resident refused the treatment and the reason(s) why, and the signature and title of the person recording the data. Notify the supervisor if the resident refuses the wound care. Report other information in accordance with facility policy and professional standards of practice. II. Resident #2 A. Resident status Resident #2, age less than 65, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), the diagnoses included cerebral palsy (disorder affecting balance and posture), chronic respiratory failure, type 1 diabetes mellitus, muscle weakness, anxiety, necrotizing fasciitis (soft tissue infection) and osteomyelitis (bone infection) of the left tibia (shin bone). The 8/22/24 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. He required substantial assistance to move left to right/right to left, to move from sitting to lying and sitting to stand in bed, and substantial assistance for transfers and lower body dressing. He needed moderate assistance for toileting and bathing, supervision for upper body dressing and oral hygiene and set up only for eating. The MDS assessment documented the resident was at risk of developing pressure ulcers and had an unhealed pressure ulcer present upon admission to the facility. B. Record review Resident #2's skin care plan, revised on 8/7/24, documented he was at risk for skin breakdown related to anxiety, heart disease, chronic obstructive pulmonary disease (COPD), depression, existing other skin problems, impaired mobility, incontinence of bowel, incontinence of bladder, kidney disease, neuropathy, obesity, perspiration, a pressure ulcer of the right heel, surgical wounds, a history of wound infection, and diabetes. He scored as an at risk resident on the Braden Scale (pressure ulcer risk assessment) used to assess the risk of developing pressure ulcers. Pertinent interventions included to administer medications and administer treatments as ordered (initiated on 6/4/24) and elevating and off loading the right heel while in bed (initiated on 8/7/24). The 8/7/24 wound note revealed the resident was seen on 8/7/24 for an unstageable pressure ulcer to his right heel which was present upon admission. The note documented prevention interventions were in place which included staff encouragement for Resident #2 to float his heel while he was in bed. His risk factors included limited mobility, poor impulse control, poor safety awareness, a history of necrotizing fasciitis, a history of cellulitis to his right lower extremity, type two diabetes mellitus, history of below knee amputation, chronic kidney disease, and a preference to spend prolonged periods of time in a wheelchair despite education and encouragement to lay down between meals. The August 2024 CPO revealed Resident #2 had the following physician's orders: -Cleanse and apply barrier cream to the peri-area every day and night shift for skin integrity, ordered on 6/4/24; hold administration from date 8/15/24 to 8/17/24. -Elevate and off load right heel and left below knee amputation while in bed every day and night shift for pressure injury to the right heel and left surgical wound, ordered on 8/7/24; hold administration from date 8/15/24 to 8/17/24. -A review of Resident #2's August 2024 medication administration record (MAR) and progress notes revealed the treatments (above) were documented as not administered per the physician orders on the 8/23/24 day shift and on the 8/27/24 and 8/31/24 overnight shifts. III. Resident #12 A. Resident status Resident #12, age greater than65, was admitted on [DATE]. According to the September 2024 CPO, the diagnoses included heart disease, high blood pressure, anxiety, type 2 diabetes mellitus and polyneuropathy (damage to multiple nerves throughout the body). The 6/27/24 MDS assessment revealed the resident was cognitively intact with aBIMS score of 15 out of 15. She required substantial/maximum assistance with oral, personal and toileting hygiene, bathing, dressing, transfers, and moving from sitting to standing position. She needed moderate assistance with lying to sitting/sitting to lying in bed, and set up help with eating. B. Resident #12's representative interview Resident #12's representative was interviewed on 9/4/24 at 1:07 p.m. She said Resident #12's post surgical skin treatments were not being provided as ordered and the facility nurses responded they were not aware of Resident 12's physician's orders for post surgical site care. C. Record review Resident #12's skin care plan, revised on 5/31/24, documented she was at risk for skin breakdown due to impaired mobility, diabetes mellitus, cardiac disease, polyneuropathy, weakness, assistance with activities of daily living (ADL), a history of skin issues, incontinence, perspiration, shearing and friction risk, and impaired cognition. She scored as an at risk resident on the Braden Scale assessment (assessment used to assess the risk of developing pressure ulcers). Pertinent interventions, initiated on 9/5/23, included checking Resident #12's skin daily while providing care and to notify the physician of any abnormal findings. Resident #12's pressure ulcer care plan, revised on 3/27/24, documented she had potential for pressure ulcer development due to immobility, incontinence, impaired cognition, anxiety and aphasia (difficulty expressing and understanding language). Pertinent interventions, revised on 3/27/24, included following the facility policies and protocols for the prevention and treatment of skin breakdown. The August 2024 CPO revealed Resident #12 had the following physician's orders: -Treatment for surgical site to upper mid back: cleanse with warm water and soap, pat dry and pack wound with aquaphor and cover with a dry dressing twice daily two times a day for wound management, ordered on 8/19/24 and discontinued on 8/21/24. -Wound care for the surgical site to the upper mid back, cleanse with wound cleanser, pat dry, apply silver sulfadiazine cream, ag alginate to wound bed, cover with adhesive foam dressing. one time a day for wound management, ordered on 8/22/24 and discontinued on 8/26/24. -A review of Resident #2's August 2024 MAR, TAR and progress notes revealed the following treatments were documented as not administered and left blank per the physician orders on 8/20/24. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 9/5/24 at 8:49 a.m. LPN #1 said most physician's orders for skin or wounds were scheduled once each shift or twice a day. LPN #1 said nursing staff never knew which orders were completed because the orders were not always marked as completed on the treatment administration record (TAR) and dressings were not always dated or initialed to indicate the dressing was changed. Registered nurse (RN) #3 was interviewed on 9/5/24 at 3:26 p.m. RN #3 reviewed the MAR and confirmed there was no documentation on 8/23/24 indicated the wound care was completed. RN #3 said she was trying to figure out if Resident #2 was out for an appointment that day. RN #3 said it was possible that a nurse was not sure how to sign off in the MAR to indicate Resident #3 was out for an appointment. RN #3 said Resident #2 must have been out for an appointment the morning of 8/23/24 as his barrier cream and heel offloading tasks in the MAR were also left blank. RN #3 said she was not sure why they were left blank if Resident #2 was out for an appointment. RN #3 confirmed there were blank spots in the MAR for the barrier cream and heel unloading tasks on 8/27/24 and 8/31/24. RN #3 said she was not sure why they were blank. -However, there was no documentation that Resident #2 was out of the facility on 8/27/24 and 8/31/24. RN #3 said wound care was not marked as complete in the MAR for Resident #12 for one day. RN #3 said whenever residents missed wound treatments due to being out of the facility, the process was to let the nurse on the next shift know the resident still needed to have their wound treatment whenever the resident returned from their appointment. RN #3 said a blank spot in the MAR could be the result of a progress note not being saved by the software. RN #3 said the facility was having issues with their software in August 2024, that had since been resolved. The regional director of clinical services (RDCS) was interviewed on 9/5/24 at 2:00 p.m. The RDCS said the nurses should have documented in the medication administration record (MAR) if the resident refused a treatment or what the circumstance was. She said it was a missed opportunity to have the correct documentation. 50219 V. Resident #7 A. Resident status Resident #7, age less than 65, was admitted to the facility on [DATE]. According to the September 2024 CPO, diagnoses included non-pressure chronic ulcers to the left and right lower legs with fat layers exposed, cellulitis (a bacterial infection that affects the skin's deeper layers and underlying tissue) of the right lower limb, third degree burns to multiple sites over the left and right lower limbs and long-term use of opiate analgesics (pain medications). The 8/9/24 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status BIMS score of 15 out of 15. The assessment revealed the resident had chronic pain. B. Resident interview Resident #7 was interviewed on 9/5/24 at 10:03 a.m. Resident #7 said he had ongoing issues with his methadone (pain medication) being administered. Resident #7 said the pharmacy did not keep the medication in stock and there had been several instances where he ran out of the medication on a Friday and could not get it again until the following Monday. Resident #7 said he had to take Oxycodone (pain medication) more frequently when his methadone was out of stock, which led to him feeling doped up. Resident #7 said the other medications they use for his pain did not control his pain as effectively, and whenever the methadone was back in stock it took a while for his pain levels to become regulated again. C. Record review The analgesic/opioid care plan, revised on 10/23/23, revealed Resident #7 may have side effects related to his use of methadone. Pertinent interventions included administering the methadone as ordered and not having any abrupt discontinuation as it could cause withdrawal symptoms. The chronic pain care plan, initiated on 4/8/21 and revised on 11/28/23, revealed Resident #7 was at risk for alterations in comfort related to chronic wounds on both of his lower extremities and chronic pain. Pertinent interventions included administering medications as ordered. A review of Resident #7's September 2024 CPO revealed a physician's order for Methadone HCl 10 milligram (mg) oral tablets. Instructions were to give one tablet by mouth every eight hours for severe pain related to type two diabetes, ordered on 4/27/24. A review of Resident #7's MAR from June 2024 (6/1/24 to 6/30/24) revealed the following: -The 8:00 a.m. dose on 6/4/24 was marked with a nine, which indicated other/see nurses notes; -The 4:00 p.m. dose on 6/4/24 was marked with a nine, which indicated other/see nurses notes; and, -The 12:00 a.m. dose on 6/7/24 was marked with a nine, which indicated other/see nurses notes. A review of Resident #7's MAR from July 2024 (7/1/24 to 7/31/24) revealed the following: -The 8:00 a.m. dose on 7/8/24 was marked with a nine, which indicated other/see nurses notes; and, -The 4:00 p.m. dose on 7/8/24 was marked with a nine, which indicated other/see nurses notes. -Review of the progress notes from 6/1/24 to 8/30/24 did not reveal any nursing notes related to the missed doses on 6/4/24, 6/7/24 and 7/8/24. VI. Staff interviews LPN #2 was interviewed on 9/5/24 at 7:47 a.m. LPN #2 said a nine marked on the MAR usually indicated a medication was on order. LPN #2 said there would be something recorded in the notes on the MAR if a nine was marked. RN #2 was interviewed on 9/5/24 at 8:00 a.m. RN #2 said a nine marked on the MAR meant other. RN #2 said if this was marked, the nurse would put a note as to why the medication was not administered. RN #2 said this note would also appear in the progress notes. LPN #1 was interviewed on 9/5/24 at 8:49 a.m. LPN #1 said she had noticed medications had ran out of stock frequently. LPN #1 said there was not an established system of who was ordering what and when it was being ordered. LPN #1 said if a medication ran out, she needed to mark on the MAR that it was unavailable, call the pharmacy to try to get the medication in stock, and alert the DON. LPN #1 said she would alert the resident's provider if it was a medication that was dire or if the medication was not going to be in stock for an extended period of time. The DON was interviewed on 9/5/24 at 2:00 p.m. The DON said she had not heard about any delays from the pharmacy. The DON said if a medication ran out, the nursing staff should call the pharmacy to see when the medication was coming and to check the emergency medication back-up supply. The DON said her phone number was posted everywhere. The DON said with any missed doses the nursing staff needed to contact a provider. RN #1 was interviewed on 9/5/24 at 2:06 p.m. RN #1 said the process for reordering medications began with the nurse running the medication cart noticing a medication was starting to run low. RN #1 said the facility nurses were able to use their software to order the medication directly but the nurses could call the pharmacy if the medication was nearly out of stock. RN #1 said a nine in the MAR meant the medication was not administered and the nurse would have to put a note into the record indicating why the medication was not given. RN #1 said the note would be in the progress notes along with the MAR. RN #1 said she could not find any notes indicating why a nine was marked in the MAR for Resident #7's methadone. RN #1 said Resident #7's Methadone had last been refilled on 8/6/24 but none of the missed doses were around that refill date. RN #1 said Resident #7 was on the methadone for his neuropathy and his pain was very difficult to manage due to his chronic wounds.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to ensure nursing staff followed proper infection control procedures for a resident on enhanced barrier precautions (EBP). Findings include: I. Professional reference The Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (4/2/24), was retrieved on 9/9/24 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. It read in pertinent part, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated (when contact precautions do not otherwise apply) for residents with wounds or indwelling medical devices, regardless of MDRO colonization status. II. Facility policy and procedure The Enhanced Barrier Precautions policy, revised March 2024, was received from the nursing home administrator (NHA) on 9/5/24 at 5:08 p.m. It read in pertinent part, EBPs are used as an infection prevention and control intervention to reduce the transmission of MDROs to residents. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include changing briefs or assisting with toileting. III. Observations On 9/4/24 at 12:31 p.m. a sign indicating that Resident #25 was on EBP was posted next to his door below the room number. The sign read in pertinent part, everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting At 3:16 p.m. certified nursing aide (CNA) #2 left a resident' s room across the hall from Resident #25 with a bag of soiled linens. CNA #2 put the soiled linens away then went into Resident #25' s room and closed the door to perform incontinence care (see interview below). -CNA #2 did not perform hand hygiene before entering the resident' s room, nor was she observed donning (putting on) the PPE necessary to perform EBP. IV. Record review The September 2024 CPO revealed Resident #25 had a physician's order for EBP due to Resident #25' s chronic wound, ordered on 5/11/24 at 6:00 a.m. V. Staff interviews CNA #2 was interviewed on 9/4/24 at 3:19 p.m. CNA #2 said she went into Resident #25' s room and interacted with that resident specifically. CNA #2 said during this interaction she checked to see if Resident #25 needed incontinence care. CNA #2 said to accomplish this she donned gloves, lifted the bed sheet and opened Resident #25' s brief to see if it was soiled. CNA #2 said Resident #25 had not been incontinent, so she wiped his peri-area with a wipe and put his brief back on. CNA #2 said she was not sure if the EBP signs meant the room itself needed EBP or if it was for a resident. CNA #2 said she did not see the EBP sign next to Resident #25' s door before she entered the room and that she did not wear any of the EBP PPE while she was in his room. Licensed practical nurse (LPN) #2 was interviewed on 9/5/24 at 7:47 a.m. LPN #2 said Resident #25 was on EBP for an open wound. LPN #2 said the EBP signs next to the resident' s door were there to let the staff know which precautions when caring for the residents. LPN #2 said the staff needed to don a gown and gloves when performing activities such as wound care, but would not need a gown for no-contact interactions such as setting a meal tray down. Registered nurse (RN) #2 was interviewed on 9/5/24 at 8:00 a.m. RN #2 said that EBP was used for residents with catheters, ports and wounds. RN #2 said any time the staff had to touch the resident or come into contact with their bodily fluids, they would need to wear PPE including a gown and gloves. RN #2 said checking or changing a brief would require EBP PPE. CNA #3 was interviewed on 9/5/24 at 1:29 p.m. CNA #3 said EBP meant the resident had a colostomy bag or a catheter. CNA #3 said this meant staff needed to wear PPE including gloves and a gown when working with those residents. CNA #1 was interviewed on 9/5/24 at 1:50 p.m. CNA #1 said EBP meant the resident had an open wound or catheter, and that the staff needed to wear a gown, mask and gloves when working with those residents. CNA #1 said she had not worn PPE while working with a resident that needed EBP the day prior, as she was moving so fast that she did not even look at the sign before she went in. The infection preventionist (IP) was interviewed on 9/5/24 at 4:42 p.m. The IP said she did rounds each morning and audits to see how well staff followed EBP when working with residents. The IP said she did training when the new EBP guidance was established and had started additional training that day (9/5/24). The IP said she had provided additional spot-trainings during her audits if she saw any staff failures to follow EBP. The IP said staff needed to wear a gown and gloves when making any sort of physical contact, including checking and changing a brief, for residents with wounds or indwelling devices. The IP said hand hygiene should be performed before entering an EBP room, if they become soiled during care, and after leaving the room.

Based on observations, record review and staff interviews the facility failed to provide services according to professional standards of practice for one (#1) out of three sample residents. Specifically, the facility failed to monitor Resident #1, who had a change of condition after suspected illicit drug use. Findings include: I. Facility policy and procedure The Acute Condition Changes policy, revised March 2018, was received from the nursing home administrator (NHA) on 2/5/24 at 2:59 p.m. The policy documented in pertinent part, The physician will help the staff monitor a resident with a recent acute changes of condition until the problem or condition resolved or stabilized. II. Resident #1 Resident #1, less than age 65, was admitted on [DATE] and readmitted on [DATE]. According to the February 2024 computerized physician order (CPO), diagnoses included diabetes mellitus, epilepsy (seizures), acute respiratory failure, bipolar disorder, anxiety and stimulant use. The 1/1/24 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. The resident was independent with transfers, dressing, toileting and personal hygiene. III. Record review On 2/2/24 at 6:16 a.m. the nursing notes documented a certified nurse aide had seen the resident getting out of a car the previous night around 11:00 p.m. -There were no progress notes regarding the resident getting out of a car on 2/1/24. On 2/2/24 at 7:32 a.m. the nursing notes documented the resident's blood pressure (BP) 156/126 mmHg (millimeters mercury), and 160/109 mmHg (elevated) when manually checked. Her pulse was 127 bpm (beats per minute). The resident's pupils were dilated. She denied shortness of breath and chest pain. The provider was notified. The resident's previous blood pressure and pulse were reviewed for January 2023 through November 2023. The resident's baseline pulse varied greatly from 72 bpm to 120 bpm. Her baseline blood pressure was documented as 98/65 mmHg to 137/73 mmHg. On 2/2/24 at 9:17 a.m. the provider ordered a urinalysis (UA) drug screen. The resident refused the drug screen and refused to go to the hospital. She said she wanted to go outside and smoke to calm down. On 2/2/24 at 9:30 a.m. a situation, background, assessment recommendation (SBAR) note documented the resident's blood pressure was 176/120 and her resting pulse was 131 and irregular. A UA and EKG (electrocardiogram) were ordered. On 2/2/24 at 5:17 p.m. the nursing notes documented the EKG showed sinus tachycardia (fast heartbeat) and the resident's blood pressure and pulse were still elevated. The blood pressure was now 160/109 and the pulse was 131 and irregular. The provider was texted the results of the EKG and was informed the nursing staff would monitor the resident's change of condition for the next 72 hours. On 2/2/24 at 5:26 p.m. the nursing notes documented the provider returned the nurses call and said of the resident refusal to do the UA or go to the hospital. The note documented the provider said if the resident showed signs of shortness of breath, chest pain or any other symptoms she must go to the emergency room -However, there were no further nursing notes, vital signs or assessment of the resident by the start of the survey on 2/5/24. -There was no documentation the resident refused vital signs or an assessment. IV. Staff interviews The interim director of nursing (IDON) was interviewed on 2/5/24 at 12:16 p.m. She said Resident #1 had been seen sitting in a car with a friend on 2/1/24 late at night. She said in the morning the staff called her and said the resident was acting differently. The staff said the resident was easier to get along with than she normally was, her pupils were dilated and her blood pressure and pulse were high. The IDON said the resident had a history of methamphetamine use while a resident and she refused a drug screen that day. The IDON looked at her laptop and said there was no follow up documented on the resident's status after 2/2/24. She said the staff should have assessed her for any changes for at least 72 hours. The IDON said the resident would be at risk for a heart attack or stroke with her elevated pulse and blood pressure. The IDON said she thought a nurse practitioner (NP) had come in to see the resident on 2/2/24. -However, she said there was no note from any provider. The IDON said the nursing staff should have been assessing the resident for any cardiac symptoms and checking her vital signs. She said if the resident had refused an assessment or vital signs that should be documented in the nursing notes. Licensed practical nurse (LPN) #1 was interviewed on 2/5/24 at 1:46 p.m. She said a resident should be monitored for 72 hours after a change of condition including vital signs. She said if a resident had an elevated pulse or blood pressure she would notify the provider and check the vital signs at least twice per shift. She said the licensed nurses were having difficulty tracking and following up on the changes of condition because the electronic medical record (EMR) system no longer flagged residents with a change of condition for follow up. The IDON walked up to the interview at that time. She said she would contact the third party provider of the EMR system for follow-up to correct the issue. Registered nurse (RN) #1 was interviewed on 2/5/24 at 1:56 p.m. She said if a resident's pulse was 130/110 and the pulse was high, the vital signs should be checked every 15 minutes until normal or otherwise directed by the provider. She said the resident should have been assessed for chest pain, shortness of breath, headache and diaphoresis (sweating). V. Facility follow up On 2/5/24 1:37 p.m., after the IDON was interviewed regarding the facility's failure to monitor the resident, a late entry was added to the progress notes. A late entry nurses note documented in the progress notes, on 2/4/23 at 8:26 a.m. the resident refused vital signs. The note documented the nurse did not notice any abnormal breathing or dilated pupils. -However, there were no further notes regarding the resident's health status or vital signs on 2/4/24. There were no notes regarding the resident's health status or vital signs on 2/3/24. There were no further assessments or vital signs of the resident on 2/2/24 after 5:26 p.m. On 2/6/24 at 3:53 p.m, after the survey, the NHA emailed a progress note from a nurse practitioner (NP) dated 2/5/24 at 3:53 p.m. The note documented the resident was a known illicit drug substance abuser and was witnessed being dropped off at the nursing home late at night. The note documented the resident pulse was significantly elevated otherwise her vital signs were acceptable. The note documented the resident remained asymptomatic. The NP note documented the elevated pulse was likely due to illicit drug use. -However, there was no ongoing assessment of the resident to determine if the resident was asymptomatic.

Based on observations, record review and interviews the facility failed to ensure two (#93 and #62) of three out of 51 sampled residents with a pressure ulcer received the necessary treatment and services according to professional standards of practice. Specifically, the facility failed to ensure: Resident #93, who was at high risk for developing pressure wounds and an increased risk for developing infections, developed a sacral skin wound on 5/25/23 that progressed to a stage 4 sacral pressure wound. The facility failed to ensure effective and timely interventions were in place to prevent Resident #63 from the development of pressure wounds. The facility failed to assess, monitor and document skin assessments and pressure wounds. The facility failed to place timely interventions in the prevention of the development and progression of the pressure wound. -Due to facility failures, the resident experienced a stage 4 sacral pressure wound that became infected and required hospitalization and a surgical washout and debridement. Resident #62, who was on hospice and had an increased risk of developing pressure wounds experienced the the following worsening wounds: A pressure wound on the left heel started on 6/22/23 that progressed to an unstageable wound, a stage 2 pressure wound on the left buttock started on 8/28/23, and a pressure wound to the right buttock on started on 10/18/23 which progressed to a stage 3 pressure wound. The facility failed to ensure effective and timely interventions were in place to prevent Resident #62 from the development of pressure wounds. The facility failed to accurately assess and monitor and document skin assessment and pressure wounds. The facility failed to communicate and coordinate with hospice in assessing, monitoring, documenting and treating the pressure wounds. -Due to the facility failures, the resident experienced a worsening of her pressure wounds and the formation of new pressure wounds. Findings included: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 11/29/23, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedure The Prevention of Pressure Injuries policy, revised April 2020, was provided by the nursing home administrator (NHA) on 11/15/23 at 4:34 p.m., read in pertinent part, Inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living (ADL). Select appropriate support surfaces based on the resident ' s risk factors, in accordance with current clinical practice. Evaluate, report and document potential changes in the skin. Review the interventions and strategies for effectiveness on an ongoing basis. The Pressure Ulcer/Skin Breakdown Clinical Protocol policy and procedure, last revised April 2018), was provided by the NHA on 11/15/23 at 4:34 p.m., read in pertinent part, The nursing staff and practitioner will assess and document an individual ' s significant risk factors for developing pressure ulcer; for example, immobility, recent weight loss, and a history of pressure ulcers. In addition the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; Pain assessment; Resident ' s mobility status; Current treatment, including support surfaces; and All active diagnoses. III. Resident #93 A. Resident status Resident #93, age 74, was admitted on [DATE] and readmitted on [DATE]. According to the November 2023 computerized physician ' s orders (CPO), the diagnoses included stage 4 sacral pressure ulcer acquired during stay, chronic leukemia and dementia. The 10/2/23 minimus data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. He was dependent, needing staff assistance with toileting and transfers, required substantial/maximal assistance with personal hygiene and bed mobility and was independent with eating. The MDS indicated the resident had an unhealed stage 4 pressure ulcer not present upon admission and was at risk for developing pressure ulcers. B. Observations On 11/15/23 at 1:30 p.m. licensed practical nurse (LPN) #6 was observed removing the old dressing on the sacral wound. The sacral wound bed was difficult to visualize due to the depth of the wound. There was no redness or drainage noted around the wound site. Resident #93 was observed on an air mattress. C. Record review The skin breakdown care plan, initiated on 5/10/23 revised on 9/12/23, documented Resident #93 had actual skin breakdown related to decreased mobility, morbid obesity, edema and respiratory failure. It documented Resident #93 had a stage 4 pressure wound to the sacrum (triangular bone in the lower back formed from fused vertebrae and situated between the two hip bones of the pelvis) with a history of infection and debridement. Interventions included preventative skin care, assist the resident to turning and repositioning frequently, encourage fluids, observe skin condition daily with ADL care, obtain dietician consult, pressure redistribution surface to bed and chair, wound treatment, weekly skin checks, weekly wound assessment to include measurements and description of wound. A comprehensive review of the care documented that not all of the care plan interventions were in place had not been initiated on the care plan until 7/27/23 after the resident returned from the hospital from sepsis and surgical debridement of an infected sacral stage 4 pressure wound that he developed in the facility prior to going to the hospital. The documentation failed to reveal personalized interventions that were in place prior to the development of the stage 4 pressure wound. The CPO documented an order for a pressure redistribution mattress to bed, ordered 4/6/23. The 5/25/23 nursing progress notes revealed a change of condition note with an open skin wound or ulcer noted on Resident #93 ' s lower back. The wound nurse assessed the area and cleansed with wound cleanser, medihoney (a wound dressing gel or paste treatment that promotes wound healing) was applied to the wound bed and covered with bordered foam dressing. No documentation of the resident ' s physician being notified. The 5/25/23 physician order documented to cleanse sacral skin tear with wound cleanser, pat dry with gauze, apply medihoney cover with foam border once a day, ordered 5/25/23. The 5/31/23 Braden score (an assessment tool used to predict pressure ulcers) was 12 out of 23 the lower score indicated Resident #93 was at high risk for developing pressure ulcers. The CPO documented an order for resident to be followed by the facility wound specialist, ordered 6/7/23. The 6/8/23 wound care physician note revealed the resident had a stage 4 pressure ulcer on the sacrum. The wound measurements were 6.8 x 9.4 x 2.5 centimeters (cm). with 20% slough and 80% eschar. The 6/12/23 nutrition progress note revealed resident was complaining of his butt being sore with the 6/7/23 and documented that Resident #93 ' s skin and wound had moisture associated skin damage (MASD). The 6/13/23 at 7:30 p.m. the change of condition nursing progress notes documented the resident ' s pressure wound had , foul smelling drainage coming from the sacral wound, the resident ' s skin was cold and clammy, and the resident ' s labs (bloodwork) showed an elevated white blood cell count (indicating a likely infection) The resident was transferred to the hospital. On 6/14/23 hospital admission and surgical records revealed Resident #93 was admitted to the hospital with septic shock secondary to an unhealed infected stage 4 pressure wound and a urinary tract infection (UTI). On 6/16/23 hospital records revealed Resident #93 underwent a surgical washout and debridement of sacral wound with application of wound vac (vacuum) therapy (a dressing connected to a vacuum pump to pull fluid, bacteria and debris out of the wound). The 6/22/23 wound care physician note revealed the wound measurements were 9.2 x 11.5 x 4.5 cm with 80% granulation and 20% slough and was documented as improved. The CPO documented an order for an air mattress, ordered on 6/28/23 discontinued on 7/3/23 The CPO documented an order for a low air mattress, ordered on 7/5/23. -A comprehensive review of the medical record revealed an order for an air mattress on 6/28/23, after the resident had been hospitalized for sepsis and underwent surgical debridement of his stage 4 sacral pressure wound. The 7/11/23 wound care physician note revealed the wound measurements were 6 x 8.5 x 2 cm with 100% granulation and was documented as improved. The 7/18/23 wound care physician note revealed the wound measurements were 6 x 8 x 1.7 cm with 60% granulation and 40% slough. The 8/7/23 wound care physician note revealed the wound measurements were 5.9 x 4.6 x 1.5 cm with 100% granulation and was documented as improved. The 8/25/23 wound care physician note revealed the wound measurements were 5.6 x 4.2 x 1 cm with 80% granulation and 20% slough and was documented as improved. The 8/29/23 wound care physician note revealed the wound measurements were 5.6 x 3.2 x 1.2 cm and was documented as improved . The 9/12/23 wound care physician note revealed the wound measurements were 4.5 x 3.5 x 0.8 cm and was documented as improved. The 9/19/23 wound care physician note revealed the wound measurements were 4.5 x 3.5 x 0.8 cm and was documented as improved. The 9/26/23 wound care physician note revealed the wound measurements were 3.9 x 3.1 0.8 cm and was documented as improved. A comprehensive review of the medical record revealed an order for the resident to be followed by a wound care specialist until 6/7/23, 12 days after the wound was identified on 5/25/23. A comprehensive review of the wound physician notes revealed no documentation by the wound care physician before 7/11/23. D. Staff interviews LPN #6 was interviewed on 11/15/23 at 1:30 p.m. LPN #6 said the wound had improved over the last several months. He said wound care has been following the resident and is seen weekly by the wound physician. He said Resident #93 had been on a different air mattress but had switched to a pump air mattress within the last two months. LPN #4 was interviewed on 11/16/23 at 10:00 a.m. LPN #4 said when a new skin condition was identified an incident report and a change of condition needed to be completed. She said nurses do a weekly skin condition assessment and documented the findings on the skin assessment form. She said after a skin issue was identified the wound nurse, the DON and the physician were notified. The wound care nurse (WD) was interviewed on 11/16/23 at 2:15 p.m. The WD said Resident #93 ' s stage 4 pressure wound had improved and had started as a skin tear that progressed to MASD then to a stage 4 pressure wound. She said she was unable to recall the timeline. She said the previous wound nurse had indicated that the resident had refused dressing changes and repositioning. She said she did not know what interventions were in place when the pressure wound started. She said the resident eventually had to be hospitalized for the pressure wound and had returned with a wound vacuum. She said he had improved since the wound vacuum was removed. The director of nursing (DON) was interviewed on 11/16/23 at 12:12 p.m. She said when a new skin condition was identified staff would notify wound care and the DON by phone or text. She said staff would then notify the physician to obtain orders. Nursing should do weekly formal skin checks and certified nurse aides do daily skin checks with daily care. IV. Resident #62 A. Resident status Resident #62, age 79. was admitted on [DATE]. According to the November 2023 CPO, the diagnoses included cerebral infarction (stroke), epilepsy and malignant breast cancer. The 8/15/23 MDS assessment revealed the resident had severe cognitive impairment with deficits in short and long term memory. She was dependent with bed mobility, toileting, personal hygiene, transfers and eating. The MDS documented that the resident was at risk of developing pressure ulcers and had no unhealed pressure ulcers. B. Observations On 11/15/23 at 3:00 p.m. LPN #6 was observed removing dressings from wounds on the left heel and over sacrum and right buttock. -Left heel had eschar noted on the medial (inside) aspect of heel. Heel boots were in place. -Right buttock was observed with an area covered in slough -Coccyx/sacral area with an abrasion and pink wound bed. Resident #62 was observed on a regular non air mattress. C. Record review The skin bruising and skin tear care plan, initiated on 7/18/18 revised 10/25/18, revealed Resident #62 was at risk for bruising and skin tears due to a seizure disorder. Interventions included observe skin daily with ADL care, provide skin tear treatment per physician order and report changes, and weekly skin assessment by licensed nursing personnel. The skin breakdown care plan, initiated 6/3/19 revised 3/23/23, documented Resident #62 was at risk for breakdown due to limited mobility and a splint to hand. Interventions included check frequently under splint, pat skin when drying, encourage resident to consume all fluids, observe skin for signs of skin breakdown, observe skin condition daily with ADL care and report abnormalities, off load/float heels while in bed, obtain dietician consult, pressure redistribution surface to bed and chair, provide supplements, weekly skin assessment by licensed nurse. The nutrition care plan, initiated on 7/31/18 revised 11/6/23, documented Resident #62 was on hospice services on 3/1/21 and hospice was following the resident for skin care. A comprehensive review of the care plan failed to document personalized interventions or coordination with hospice services for pressure ulcer monitoring, prevention or interventions. The 10/1/23 nursing weekly comprehensive skin evaluation assessment documented no new skin wounds or concerns. It documented no additional interventions were in place in the prevention of wounds. The 10/8/23 nursing weekly comprehensive skin evaluation assessment documented a pressure ulcer at left gluteal fold (crease under buttock). It did not document the appearance of the wound. It documented no interventions were in place. It documented notification was not required. The 10/15/23 nursing weekly comprehensive skin evaluation assessment documented a pressure wound on the left gluteal fold. It did not document the appearance, stage or size of the wound. It documented no additional interventions were in place. It documented no notification was required. The 10/22/23 nursing weekly comprehensive skin evaluation assessment documented a wound in the right gluteal area. It did not document the appearance, stage or size of the wound. It documented that hospice had a preventative treatment in place for sacral area for protection and that hospice was notified on 10/17/23. It documented that hospice was in to evaluate on 10/18/23. It documented dietary interventions were in place for treatment. The 10/29/23 nursing weekly comprehensive skin evaluation assessment documented an open area at sacrum and left heel. It did not document the appearance, stage or size of the wounds. It did not document additional interventions were in place. It documented no notification was required. The 11/6/23 nursing weekly comprehensive skin evaluation assessment documented a pressure wound on sacrum and left heel. It did not document the appearance, stage or size of the wounds. It did not document additional interventions were in place. It documented no notification was required. A comprehensive review of the nursing weekly comprehensive skin evaluation assessment did not consistently or accurately document the presence, location, appearance, interventions or notification of appropriate providers. The 11/8/23 Braden scale documented that Resident #62 had a score of 13 and was at a moderate risk for pressure ulcer injury. The hospice progress notes documented a left medial heel pressure wound. -On 6/22/23 it was documented as a new onset and the stage was not documented. was documented as red and the size was 4 x 3.75 centimeters (cm). -On 7/6/23 the stage and appearance was not documented and the size was 3.5 x 3.5 cm. -On 7/13/23 the stage and appearance was not documented and the size was 3.5 x 3.5 cm. -On 7/20/23 the stage and appearance was not documented and the size was 3.5 x 3.5 x 0.1 cm. -On 7/24/23 the stage, appearance and size were not documented. -On 8/2/23 the stage, appearance was not documented and the size was 3 x 3 x 0.1 cm. -On 8/7/23 the stage and size was documented and the appearance was black and necrotic. -On 8/15/23 the stage was not documented, the appearance was black and the size was 2 x 2.5 x 0.2 cm. -On 8/24/23 the stage and appearance was not documented and the size was 2 x 2 x 0.1 cm. -On 8/28/23 the stage, appearance and size was not documented. -On 9/5/23 the stage was not documented, the appearance was black and the size was 2 x 2 x 0.2 cm. -On 9/11/23 the stage and size was not documented, the appearance was black and necrotic. -On 11/3/23 the stage was not documented the wound bed was black and necrotic and the size was 3 x 3 x 3 cm. -There was no documentation of the left heel wound between 9/11/23 and 11/3/23. A comprehensive review of the residents medical record including available hospice notes failed to t reveal consistent or accurate documentation of the wound staging, appearance, measurements or response to treatments. The hospice progress notes documented a left buttock pressure wound. -On 8/28/23 it was documented as a new onset stage 2 pressure wound with the wound bed appearing pink and pale and the size was 1 x 0.75 x 0 cm. -On 8/31/23 it was documented as stage 2 with a red wound bed and 3 x 2 cm in size. -On 9/5/23 it was documented as stage 2 with a red and bloody wound bed and 4.5 x 1 x 0.2 cm in size. -On 11/3/23 the wound bed was documented as pink and healthy with a size of 1.5 x 0.75 x 0 cm. There was no further documentation of the left buttock pressure wound between 9/5/23 and 11/3/23. The hospice progress notes documented a right buttock wound. -On 10/18/23 it was documented as stage 1 and new in onset. The appearance and size was not documented. -On 10/25/23 it was documented as a stage 3 and the size was 2 x 2 cm. There was no further documentation of the right buttock pressure wound after 10/25/23. The 11/15/23 hospice wound care orders documented -Right gluteal fold (crease in buttock) twice weekly and as necessary cleanse with wound cleanser, pat dry, skin prep peri wound, apply medihoney to wound bed and cover with foam dressing. -Left medial heel apply betadine and cover with foam dressing every other day and as necessary for dislodgement. There was no documentation of wound care order for coccyx/sacral or left buttock area. The November 2023 CPO documented wound care and prevention orders -Pressure redistribution mattress, ordered 11/25/22. -Apply optifoam dressing over sacrum every other day and as needed for the prevention of skin breakdown, ordered 1/19/23. -Float heels and apply heel boots, ordered 6/24/23. -Betadine left heel for deep tissue injury every day and as necessary, ordered 6/24/23. There was no documentation of additional interventions put into place after the left heel was identified was identified as black and necrotic on 8/7/23, after a stage 2 left buttock or coccyx wound was identified on 8/28/23 and a right buttock pressure wound was identified on 10/18/23. D. Staff interviews LPN #6 was interviewed on 11/15/23 at 3:00 p.m. He said that hospice nurse had been rounding on Resident #62 for wound care and dressing changes. He said the staff changed the dressing over the sacrum every other day and also when it became dislodged. He said the staff changed the dressing change on the left heel every day. He said the resident wore heel boots at all times. He said that the resident was on a regular pressure reduction mattress. He said they had not tried any other mattress for the resident after she developed the current pressure wounds. He said that the facility nursing skin documentation should match the hospice wound documentation notes. He said hospice provider should upload their notes into the medical record for staging and measurements and should be documented on the facility skin tracking form. The hospice nurse (HN) was interviewed on 11/15/23 at 3:14 p.m. The HN said the Resident #62 ' s right buttock wound was healed on 11/3/23 and found again on 11/10/23 and was assessed and documented as unstageable. Wound care ordered medihoney and covered it with foam dressing. She said the left heel pressure wound had been present for a period of time but it was documented as improving. She said the wound care orders were to paint the left heel with betadine and cover with a foam dressing and application of heel boots. She said she was not aware of a coccyx/sacral or right buttock wound. She said that the hospice noted for the resident had to be requested by the facility. She said the resident had a history of previous pressure wounds and with the development of the current pressure wounds put the resident at a higher risk of developing pressure wounds. She said additional interventions such as an air mattress would be appropriate to help heal and prevent further formation of pressure wounds. She said she was unaware the resident was not on an air mattress. She said the resident should be on an air mattress and would order one for the resident. The WD was interviewed on 11/16/23 at 2:08 p.m. The WD said that she had not been aware of any pressure wounds for Resident #62. She said nursing staff and the hospice staff had not reported any to her. She said when any resident was identified with pressure wounds or skin issues it needed to be documented in the comprehensive skin assessment and reported to the wound care nurse and the appropriate provider. The DON was interviewed on 11/16/23 at 2:15 p.m. The DON said when a resident was on hospice with hospice doing the nursing skin assessments and wound care for a resident with pressure wounds or skin issues the facility skin assessment documentation should reflect the hospice documentation. She said that the facility and hospice should be in direct communication regarding the assessment and the care of the pressure wounds. She said that the communication between hospice and the facility about the pressure wounds was done informally with the nurses on the unit. The NHA was interviewed on 11/16/23 at 2:20 p.m. The NHA said there was not a good process between the facility and hospice regarding communication on the assessment and care of the pressure wounds for Resident #62.

Based on observations, record review and interviews the facility failed to ensure for four (#75, #79, and #111) of five residents reviewed received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being, out of 54 sample residents. Specifically, the facility failed to follow physician orders for significant weight loss, consistently put interventions in place and timely address Resident #75 nutritional needs. Specifically, the facility failed to follow physician orders for weight loss, consistently put interventions in place and timely address Resident #79 nutritional needs. Resident #75 experienced a significant, unplanned weight loss of 12 % in three months. Resident #79 experienced an unplanned weight loss of 5.56 % in one month. Record review and interviews revealed the facility failed to ensure supplements ordered by the physician were being provided to Resident #75 and Resident #79 and additional interventions were assessed for the resident ' s weight loss. Interviews confirmed the facility lacked a system to ensure supplements were being consistently given, change of condition for feeding assistance was being assessed, and potential swallowing difficulties were being evaluated related to significant weight loss. The facility's failure to have a system that ensured physician orders were followed, changes in resident ' s assistance needs and dietary needs were monitored contributed to Resident #75 and Resident #79's weight loss. Resident #111 who was identified as had increased nutritional risk related to dementia and dysphagia experienced a significant weight loss of 7.88% in a one months period of time; however the facility did not initiate timely interventions to prevent the resident from experiencing and additional significant weight loss o 16.55% weight loss in a three months time frame. The facility failed to ensure effective and timely interventions were in place to prevent Resident #111, initially when the resident triggered with significant weight loss. The facility failed to monitor weekly weights, failed to consistently monitor meal intakes, failed to increase a house supplement until after triggering a significant weight loss of 16.55% three months after the resident experienced a significant weight loss of 16.55%. Addidioally, the facility failed to consistently monitor the resident ' s intake of prescribed health nutritional shake supplements when intakes were mostly less than 50%; failed to monitor as necessary health shakes were provided by the nursing staff; and, failed to conduct weekly interdisciplinary (IDT) nutrition assessments. -Due to the facility failures, the resident experienced continued downward trending weight loss. Findings include: I. Facility policy and procedure The Nutrition/Unplanned Weight Loss policy and procedure, revised September 2017, was provided by the nursing home administrator (NHA) on 11/18/23 at 3:51 p.m. It revealed, in pertinent part, The physician will consider whether any assessment including additional diagnostic testing is indicated to help clarify the severity or consequences of weight loss and/or impaired nutrition. The physician will review and rule out medical causes of oral or swallowing problems before authorizing other consults or interventions to modify diet consistency. The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes II. Resident #75 A. Resident status Resident #75, age 92, was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO), diagnoses included unspecified dementia, anorexia, and dysphagia oropharyngeal phase (difficulty initiating swallowing). The 9/27/23 minimum data set (MDS) assessment documented the resident was unable to participate in the brief interview of mental status (BIMS) because the resident rarely understood conversation and communication. Staff interview section showed the resident had short and long term memory deficits and moderately impaired decision making abilities. The assessment documented that the resident was independent with eating and did not require assistance from staff. The resident was coded for being at risk for malnutrition with no swallowing issues. B. Observation Resident #75 was observed on 11/14/23 from 12:21 p.m. to 12:59 p.m. The resident was sitting in bed in her room when certified nursing aide (CNA) #7 brought in the meal tray. The CNA adjusted the resident ' s bed to a 135 degree angle and repositioned the resident so she was in front of the meal tray on the bedside table. The resident was not able to participate in repositioning. The CNA uncovered the resident ' s food but did not cut up the meal. After the CNA exited the room, Resident #75 took one of the whole meatballs on her plate and put the entire meatball in her mouth. She accompanied the meatball with fluids and began to cough and expressed difficulty breathing. After a minute, the resident stopped coughing but still had not swallowed the meatball in her mouth. Resident #75 finished chewing the meatball at 12:40 p.m. She then picked up a cup of peaches and attempted using her knife in the position of a chopstick to eat the peaches. The resident was able to consume the entire cup of peaches in this manner. The resident attempted to cut up the remaining meatball and put pieces in her mouth while still chewing on the peaches. She took sips of fluids while still chewing peaches and meatballs. At 12:54 p.m. the resident spit the pieces of meatball she had been trying to eat into her hand. She placed the pieces onto her plate. She attempted to drink her milk, but because of the angle of the bed, she spilled the whole cup of milk onto her bed. At 12:59 p.m. the resident tried to eat more of the meatball she had cut up but began coughing while eating. The resident spit out the meatball pieces into her hand and pushed the plate away. C. Representative interview Resident #75 ' s representative was interviewed on 11/13/23 at 3:34 p.m. She stated the resident did not have family involvement and she was a longtime friend of the resident. The representative stated the resident had not been eating well and the facility asked her to prepare and bring in Korean food for the resident but she was not able to come in often enough. The facility kitchen used to make more noodles and rice and Resident #75 would eat those. D. Record review Resident #75's weight record revealed she experienced a significant, unplanned weight loss of 12 lbs (pounds) and 12 % from 9/3/23 to 11/3/23 (a two month period). The weight and vital record revealed: The resident weighed 100 lbs on 9/1/23. The resident weighed 92 lbs on 10/1/23, a loss of 8% in 30 days. The resident weighed 88 lbs on 11/3/23, a loss of 12% in 60 days. The comprehensive care plan, revised 10/01/23, revealed the resident was at nutritional risk due to dementia and varying appetite. Interventions were to honor the residents' food preferences. The resident liked Korean food and the facility was to prepare preferred Korean food as capable. Provide supplements as ordered and monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss, and abnormal labs) and report to nutritionist and physician. The November 2023 CPO revealed the following physician orders: Regular diet with regular texture- ordered on 9/25/23; House supplement- two times a day for weight maintenance- ordered on 9/22/23 discontinued 11/3/23; House supplement- three times a day for weight maintenance- ordered on 11/3/23; Speech assessment with swallow study to ensure correct diet- ordered on 11/14/23 (during survey); and, Regular diet, dysphagia texture advanced texture- ordered on 11/14/23 (during survey). The September 2023 medication administration record (MAR) reviewed from 9/22/23 through 9/30/23 revealed: The resident drank 50% of the house supplement two times. The resident drank 25% of the house supplement one time. The resident drank 0% of the house supplement one time. The resident did not receive the house supplement two times. The October 2023 MAR reviewed from 10/1/23 through 10/31/23 revealed: The resident drank 50% of the house supplement two times. The resident drank 25% of the house supplement two times. The resident drank 0% of the house supplement five times. The resident did not receive the house supplement six times. The November 2023 MAR reviewed from 11/1/23 through 11/16/23 revealed: The resident drank 50% of the house supplement eight times. The resident drank 25% of the house supplement one time. The resident drank 0% of the house supplement three times. The resident did not receive the house supplement two times. A review of the progress notes dated 9/3/23 through 11/16/23 revealed: Nutrition narrative note dated 11/14/23 (during survey) at 6:20 p.m. revealed the registered dietitian (RD) spoke with speech therapy and requested resident being assessed with swallow study to ensure resident had the safest and most effective diet. Nutrition narrative note dated 11/14/23 (during survey) at 8:01 p.m. revealed the RD observed the resident during dinner with downgraded diet texture. The resident ate 75% of her meal independently with initial prompting. -There were no prior nutrition notes between 9/3/23 to 11/13/23. -According to medication administration notes reviewed from 9/3/23 through 11/16/23, the resident did not receive the house supplement nine times in September 2023 due to the supplement not being available. -The resident did not receive the house supplement six times in October 2023 due to the supplement not being available. -The resident did not receive the house supplement one time in November 2023 due to the supplement not being available. Nutritional assessments reviewed from 9/3/23 through 11/16/23 revealed: -No nutritional assessments conducted after 8/7/23. Weight variance assessment dated [DATE] documented the resident had a 8 % weight loss and was attributed by nursing to varying meal intake and dementia. The resident showed a preference to sugary food so the staff held the dessert from meals to encourage the resident to eat more of the regular meal. RD to trail Mirtazapine 7.5 milligram (mg) for thirty days to stimulate appetite. RD asked the resident ' s power of attorney (POA) to bring in Korean foods for the resident to increase intake.The Mirtazapine was discontinued after 10/31/23 without further information. Weight variance assessment dated [DATE] documented the resident had a 12% weight loss and was attributed by nursing to varying meal intake and refusing meals. The resident had increased sleeping and was refusing meals. Weight loss was determined to be due to furthering dementia. Residents POA was bringing in Korean food for the resident which the resident frequently refused. -However, record review showed the facility failed to put further interventions in place to mitigate weight loss beyond house supplement drinks which were provided inconsistently. The resident was not assessed for changes in feeding needs or changes in swallowing or chewing functioning until the survey observations were brought to staff's attention. III. Resident #79 A. Resident status Resident #79, age 70, was admitted on [DATE]. According to the November 2023 CPO, diagnoses included unspecified dementia. The 8/17/23 MDS assessment documented the resident was unable to participate in the BIMS because she was rarely understood. Staff interview section showed the resident had short and long term memory deficits and moderately impaired decision making abilities. She was assessed to be independent with eating and did not require assistance from staff. B. Observation On 11/14/23 at 11:40 a.m. Resident #79 was observed sitting in the memory care dining room. The resident sat at her table and did not have any drinks. Resident #79 was served her meal at 12:12 p.m. The resident did not eat or attempt to eat her meal. Resident #79 did not receive any encouragement from staff to eat. She was not offered an alternative since she was not eating her meal. At 12:39 Resident #79 still had not eaten any of her meals. At 12:51 CNA #7 came and took the resident ' s meal without offering any alternative. C. Record review Resident #79's weight record revealed she experienced an unplanned weight loss of six lbs and 5.56% from 9/1/23 to 11/3/23 (a two month period). The weight and vital record revealed: The resident weighed 108 lbs on 9/1/23. The resident weighed 102 lbs on 10/1/23, a loss of 5.56% in 30 days. The resident weighed 102 lbs on 11/3/23. The comprehensive care plan, revised 5/25/23, revealed the resident was at nutritional risk due to dementia. The resident had increased nutrient needs related to excess energy expenditure, constant wandering and pacing. Interventions were to provide nourishment as ordered, offer finger foods, staff assistance at meals to cut food into smaller pieces, supplements as ordered and monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss, and abnormal labs) and report to nutritionist and physician. The November 2023 CPO revealed the following physician orders: Regular diet with regular texture- ordered on 11/3/2020; House nourishment- two times a day for weight stability. Chocolate pudding or equivalent offered by kitchen- ordered on 10/6/23; House supplement- one time a day for weight stability- ordered on 10/7/23; Speech assessment for evaluation only- ordered on 11/15/23 (during survey). The September 2023 MAR reviewed from 9/1/23 through 9/30/23 revealed: The resident did not receive house supplements or house nourishments in the month of September 2023. The October 2023 MAR reviewed from 10/7/23 through 10/31/23 revealed: The resident drank 50% of the house supplement five times. The resident drank 0% of the house supplement two times. The resident did not receive the house supplement ten times. The resident consumed 25% of the house nourishment one time. The resident consumed 0% of the house nourishment four times. The resident did not receive the house nourishment nine times. The November 2023 MAR reviewed from 11/1/23 through 11/16/23 revealed: The resident drank 0% of the house supplement three times. The resident did not receive the house supplement three times. The resident consumed 50% of the house nourishment three times. The resident consumed 0% of the house nourishment four times. The resident did not receive the house nourishment four times. A review of the progress notes dated 9/3/23 through 11/14/23 revealed: -The resident did not receive the house nourishment fourteen times in September 2023 due to the nourishment not being available. -The resident did not receive the house nourishment four times in October 2023 due to the nourishment not being available. The resident did not receive the house supplement three times in October 2023 due to the supplement not being available. -The resident did not receive the house nourishment three times in November 2023 due to the nourishment not being available. The resident did not receive the house supplement two times in November 2023 due to the supplement not being available. Assessments reviewed from 9/3/23 through 11/16/23 revealed: -No nutritional assessments conducted after 8/14/23. Weight variance assessment dated [DATE] documented the resident had a 5.6 % weight loss in one month and was attributed by nursing to varying meal intake and falling asleep during meals. When the resident was offered a peanut butter and jelly sandwich for a snack, she would consume 100 %. The resident slept through breakfast so the RD ordered peanut butter and jelly sandwiches for a snack and supplement drinks. Nutritional risk review dated 11/6/23 documented the resident would eat sandwiches offered but not the entire sandwich. The resident liked cheeseburgers and the RD would add cheeseburgers to her meals once a week and change snacks from sandwiches to pudding. The RD had reviewed the care plan for the risk review. -However, record review showed the facility failed to put further interventions in place to mitigate weight loss beyond house supplement drinks and nourishment snacks which were provided inconsistently. The facility failed to follow the care plan interventions of cutting the resident ' s food and providing finger foods. IV. Staff interviews CNA #7 was interviewed on 11/14/23 at 1:30 p.m. She stated Resident #75 ate a regular diet. Resident #75 could be selective with the food she ate but if she liked the food she would eat a lot of it. She preferred rice and noodles. CNA #7 said Resident #79 wandered the unit frequently and sometimes would not sit down for a meal. If the staff provided her food inside of a cup with a utensil and allowed her to walk with it, she would eat the food. When the resident did sit down for meals, she preferred finger foods but did not receive these often from the kitchen. Licensed practical nurse (LPN) #5 was interviewed on 11/14/23 at 1:45 p.m. She said Resident #75 and Resident #79 were prescribed house supplement drinks for weight loss but the unit often did not get the supplements from the kitchen. When the nurse requested the supplements from the kitchen, they would be told the kitchen was too short staffed to bring any over or the kitchen had run out of supplements. The dietary manager (DM) was interviewed on 11/14/23 at 1:51 p.m. She stated the kitchen sent supplements to Resident #75 and Resident #79 ' s unit three times a day. She did not know if the nursing staff passed the supplements to the residents. The DM had been receiving the drink buckets with the unopened supplements sent back from nurses and let the RD know. The director of nursing (DON) was interviewed on 11/14/23 at 2:09 p.m. The DON said Resident #75 needed staff to set up her meals, with additional encouragement and reminders to eat. The facility had not requested a speech evaluation after the resident ' s significant weight loss because the resident ' s daughter did not want an evaluation. The resident ' s code status was do not resuscitate (DNR) or withhold cardiopulmonary resuscitation if found without a pulse or heartbeat. The daughter did not want any changes to her diet preferences or diet texture due to this. -However, there was no family involvement according to the resident's representative who was trying to help the facility find food the resident liked to eat (see interview above). The DON was not aware if the resident was at risk for choking or had difficulty swallowing. The DON said Resident #79 required set up for her meals. The resident was at nutritional risk but there had not been a speech evaluation ordered for possible changes in eating assistance or eating abilities. The resident preferred finger foods but there was no order to ensure the resident received finger foods. The DON had not heard from the nurses the residents had not been receiving house supplements consistently as ordered. If a resident had significant weight loss, the RD would complete an observation of the resident when eating to see if additional interventions were needed. The RD was interviewed on 11/14/23 at 2:36 p.m. The RD said Resident #75 was receiving a regular diet with regular textures. The resident was to receive supplement shakes three times a day, hot chocolate with milk, chocolate pudding and cookies to add calories. The RD did not observe residents while eating, instead she relied on feedback about the resident eating habits and ability from the nurses. The nurses had told the RD that Resident #75 sometimes consumed her supplements and meals and sometimes she did not and attributed this to her advancing dementia. The RD had not evaluated if the resident required more eating assistance and was no longer appropriate or able to be eating independently. The RD said Resident #79 was to receive house nourishments three times a day and these consisted of pudding or snacks. The resident was to be given a supplement shake for weight management. The RD had ordered the resident a burger once a week. She did not know why the resident was not being provided more finger foods and had not observed the resident eating. The RD said she relied on the nurses for feedback and had not followed up with any additional evaluations or assessments to address her weight loss. The RD was aware there was a discrepancy between the nursing and the kitchen staff over whether or not the kitchen was failing to send supplements or if the nurses were failing to pass out the supplements. This had been going on for two months and the RD had not taken any action to resolve the discrepancy. The RD said if a resident had weight loss with snacks and supplements ordered and it was not impacting their weight loss, the RD would look into changes in swallowing or cognitive ability to eat without increased assistance. -However, there was not record of these approaches being attempted with either Resident #75 or Resident #79. 47350 V. Resident #111 A. Resident status Resident #111, age 96, was admitted on [DATE]. According to the November 2023 CPO the diagnoses included cerebral infarction (stroke), heart failure and moderate protein calorie malnutrition. The 9/4/23 (MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of three out of 15. He was dependent on staff assistance for toileting, personal hygiene, transfers and required substantial to maximal assistance with bed mobility and eating. The MDS documented that Resident #111 had or was at risk for malnutrition. It did not indicate that he had a weight loss of 5% or more in one month or a weight loss of 10% in 6 months. B. Record review The nutrition care plan, initiated on 6/5/23 and revised on 11/7/23, indicated that Resident #111 had increased nutritional risk related to dementia and dysphagia, Interventions included fortified foods, honoring food preferences, weigh and alert the dietician and physician to any significant loss or gain, monitor for changes in nutritional status, including changes in intake and ability to feed self, monitor intake at all meals, offer alternate choices, alert dietician and physician to any decline in intake, total assistance required at meals (initiated 6/5/23), and offer alternative food choices if less than 50% consumed at mealtime. A comprehensive review of the care plan failed to reveal personalized interventions for weight loss for Resident #111 until 11/7/23 with a loss of 5.1% in one month. The resident ' s weights were documented as follows: -6/2/23 165 lbs (pounds) -7/11/23 152 lbs -8/1/23 142.7 lbs -8/4/23 142.4 lbs -9/1/23 137.7 lbs -10/6/23 136.8 lbs -11/3/23 130.1 lbs -11/13/23 131.4 lbs A comprehensive review of the resident ' s weights revealed a weight loss of 7.88% in one month (6/2/23-7/11/23) and a loss of 16.55% in three months (6/2/23-9/1/23). The November CPO indicated an order for weekly weights every Monday, ordered on 6/5/23 and reordered on 11/6/23. A comprehensive review of the CPO and the medical record failed to reveal documentation of weekly weights from 6/5/23 until 11/7/23. The November CPO indicated an order for the resident to be assisted with every meal, ordered on 8/10/23. The November CPO indicated an occupational therapy order for staff to continue to provide the resident feeding assistance for all meals, ordered on 8/11/23. The 9/1/23 quarterly nutritional risk review documented that Resident #111 had a weight loss trend and triggered significant weight loss of 16.5% in three months. A comprehensive review of the interdisciplinary team weight variance documentation did not indicate any further documentation before 9/1/23. A comprehensive review of the CPO revealed the following diet and supplementation orders: -House supplement once a day for weight loss for poor oral intake with weight loss, ordered 7/12/23 discontinued 9/1/23. -Med pass (fortified nutritional shake) twice a day for three months, ordered on 8/10/23, discontinued on 9/1/23. -Liquid protein supplement for low protein labs for two months ordered 9/1/23 -House supplement twice a day for weight loss for three months, ordered 9/2/23 -Health shake PRN (as necessary), Ensure provided by family, if resident consumes less than 50% of his meal, ordered on 9/1/23 discontinued 11/8/23. No documentation of it being given in October or November. -Two gram sodium dysphagia advanced texture diet, with large portions of protein ordered 9/26/23. The October 2023 medication and treatment administration record (MAR/TAR) indicated an order for a health shake as needed for weight loss, provided the resident consumes less than 50% of his meals. There was no documentation if a health shake was provided. The 10/6/23 interdisciplinary team weight variance assessment documented Resident #111 ' s weight of 136.8 pounds (lbs) with a previous weight of 152 lbs and indicated a weight loss of 10% in three months. The November 2023 MAR/TAR indicated an order for health shakes as needed for weight loss. There was no documentation to show if the health shake was provided. The 11/8/23 IDT (interdisciplinary team) weight variance assessment documented Resident #111 ' s weight of 130.1 lbs with a weight loss of 5.1% in one month. The 11/10/23 nutrition progress notes documented communication with the resident ' s daughter regarding updating the resident ' s food preferences and reviewing current supplementation. -There was no detail on the outcome of the communication. A comprehensive review of the nutrition progress notes did not indicate any further documentation before 11/10/23. A comprehensive review of meal intakes revealed inconsistent documentation of the resident food intake. There were several days when staff failed to record the resident's meal intake including: -On 10/17/23 no documentation of intake for breakfast -On 10/19/23 documentation of lunch refusal by resident -On 10/20/23 no documentation of intake for breakfast or lunch -On 10/25/23 no documentation of intake for breakfast or lunch -On 11/4/23 no documentation of intake for breakfast or lunch -On 11/5/23 documentation of 25% or less for breakfast, less than 50% for lunch -On 11/6/23 no documentation of intake for dinner -On 11/7/23 no documentation of intake for dinner -On 11/9/23 documentation of 25% or less for breakfast, no documentation of intake for dinner A comprehensive review of diet and supplementation orders and oral intake indicated that house supplementation was not increased to twice a day until 9/2/23 after Resident #111 had triggered a weight loss of 16.55% for three months. The medical record indicated no documentation of the health shake (Ensure) being provided or the amount when the resident refused meals or had an intake of 50% or less. It indicated that oral intake was not being consistently documented. C. Staff interviews Certified nurse assistant (CNA) #3 was interviewed on 11/16/23 at 9:50 a.m. She said residents with weight loss or significant weight loss have an order to be weighed weekly, other residents were weighed monthly. She said Resident #111 was a resident that required one to one assistance with meals. Licensed practical nurse (LPN) #4 was interviewed on 11/16/23 at 10:00 a.m. She said residents were usually weighed monthly. Residents with weight loss or significant weight loss had an order to be weighed weekly. The registered dietician (RD) was interviewed on 11/16/23 at 9:00 a.m. She said that Resident #111 was on a dysphagia advanced diet with additional portions of protein and required one to one assistance while eating. She said he had inconsistent intakes for meals. She said that he was on a house supplement twice a day, a Boost shake once a day, and his daughter brought in Ensure, which the daughter offered. She said that he had been on the Med Pass fortified shake, but was discontinued because he did not like it. She said he has had a significant weight loss of 20.4% over the past five months. She said his current supplements were started in September, with one being started in November. She said they discussed significant weight loss daily in morning meetings. She said weekly weights had not been done until they had been ordered in November. The corporate nurse consultant (CNC) was interviewed on 11/16/23 at 9:10 a.m. She said it was an expectation that all residents who triggered for significant weight loss were to be weighed weekly and the IDT was to conduct a weekly nutrition review and conduct a quarterly IDT review.

Based on observations, record review and interviews, the facility failed to prevent an accident involving hot liquid which caused a second degree burn with one (#1) of three out of 13 sample residents. On 1/21/23 at 2:45 p.m. Resident #1 was found to have a large blistered and reddened area on the right thigh. Nursing staff were unable to explain how the injury occurred. A physical assessment and investigation was initiated. Nursing staff revealed the resident was assessed to have two burn sites on the right thigh. The resident was experiencing pain at the burn site (see more information below). On 1/24/23, the resident was examined for an initial evaluation with a wound care physician. The physician diagnosed the resident with a second-degree burn to the upper right thigh. The physician measured the burn site. The total wound surface burn site with blistering, measured 3.0 centimeters (cm) by 9.3 by 0.1 cm (length by width by depth). There were two other burn site area one reddened and blistered and the other reddened and non-blistered the proximal (closer to the torso) area of redness measured 1.0 cm by 3.0 cm by 0.0 cm; the distal (furthest from the torso) area measured 2.5 cm by 2.8 cm by 0.0 cm. According to the investigative summary dated 1/29/23, documented that during incontinent care performed on 1/21/23 at approximately 2:45 p.m., Resident #1 was found with redness and blisters on the upper right thigh; staff providing care had no indication what had caused the injury. After further interviews with staff over the next couple of days, it was determined the injury was a burn caused by an unknown substance. The facility failed to provide appropriate supervision and ensure a safe environment for Resident #1 to prevent the resident from sustaining a second-degree burn with redness and blistering, to the thigh. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation from 3/1/23 to 3/2/23, resulting in the deficiency being cited as past noncompliance with a correction date of 1/27/23. I. Facility policy The Food Handling policy, revised on 6/15/18, was received from the nursing home administrator (NHA) on 3/1/23 at 1:24 p.m. It read in pertinent part: Hot beverages are to be served at a pleasing temperature, to the residents, but in a manner that reduces the risk for burns. Follow recommendations for reheating beverages in the microwave found in (Guidelines for Hot Beverages). Hot beverages such as coffee, tea and hot chocolate are held at high temperatures (160-185) degrees Fahrenheit (F). Brief exposures to liquids at these temperatures can cause significant scald burns. When serving hot liquids to residents, consider the following: -Dispense the beverage in a plastic mug; not a styrofoam cup. -Do not overfill the drinking cups. -Place the beverage away from the edge of the table and near the patient's dominant hand. -Explain to the patient that a hot liquid is being served. -Place the beverage in the patient's field of vision. -Transfer the hot beverage from the coffee urn to a serving container. II. Resident #1 A. Resident status Resident #1, under the age of 65, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO) the diagnosis included burns of unspecified degree to the right thigh, underweight, anemia, dementia, and major depressive disorder. The 2/6/23 minimum data set (MDS) revealed the resident was not able to be assessed with the brief interview for mental status (BIMS) due to short-term and long-term memory impairments. The resident had disorganized thinking and was not able to focus attention on conversations nor was the resident able to make herself understood or understand most conversations. The resident required extensive assistance with bed mobility, transfers, dressing, toilet use, hygiene, bathing, and moving back and forth on the unit. The resident was independent with eating once set up. B. Record review Burn incident investigation On 1/21/23 an internal investigation report documented Resident #1 received a second degree burn to the right upper thigh over 0.5 percent of the body. The initial proximal blistered wound measured 1.7 cm by 2.1 cm by 0.0 cm; the distal blistered wound measured 3.0 cm by 9.3 by 0.1 cm; the proximal non -listered reddened wound measures 1.0 cm by 3.0 cm by 0.0 cm; the distal non-blistered reddened wound measured 2.5 cm by 2.8 cm by 0.0 cm. The actual cause of the burn was undetermined. The burn injury was discovered on 1/21/23 at approximately 2:45 p.m., shortly after change of shift with incontinent care during first rounds. The certified nurse aide (CNA) working the prior shift denied any knowledge of how the resident could have sustained the second degree burn and denied observing any redness when the resident was last changed on the day shift (reportedly 11:00 a.m.). Initial wound care treatment included a cold compress followed by application of a non-stick bandage pending physician assessment and treatment recommendations. The investigation documented the facility was unable to determine the exact time the resident's burn was sustained. Incident note dated 1/21/23 at 7:20 p.m., documented the resident was assessed after staff observed reddened and blistering areas on the top of the resident's right thigh. During nursing assessment, the resident experienced moderate pain as evidenced by a score of 5 out of 10 (with 10 being the worst pain on the scale) on the pain assessment in advanced dementia (PAINAD) scale. Symptoms of pain included occasional moan or groan; low level of speech with a negative quality; facial grimacing; and, tense distressed pacing. Nursing note dated 1/21/23 at 7:29 p.m, documented: A change in condition reported: Evaluation are/were: Change in skin color or condition. Nursing observations, evaluation, and recommendations are: Attending nurse requested assistance with assessment of residents leg. Leg appeared reddened in areas, rounded. Several of the red areas had what appeared to be blisters. On call provider was notified; treatment orders were given. Physicians orders read Silvadene (silver sulfadiazine) external cream 1 percent. Apply to the right anterior thigh topically, two times a day for wound care. Gently cleanse the area with wound cleanser- apply silvadene-cover with a sterile bandage and kerlix. Order date 1/21/23. Physician's visit note read in part: Date of encounter: 1/24/23. Medical necessity of visit: follow up on burns. Chief complaint: Resident #1 has two different areas to her right upper leg, the distal area is second degree burn, no open or fluid filled blistering noted, the proximal burn area is a second degree burn, there was a fluid filled blister but this has opened. Staff report that they believe she poured hot coffee on her leg which caused the burn. Wound care physicians note dated 1/24/23 documented the resident was examined for initial assessment and treated for second degree burns to the upper right thigh, four days after the injury was sustained. The resident wounds were cleansed and an antimicrobial dressing was applied with a dry outer dressing. The resident experienced pain during care responding with occasional negative vocalizations, a sad frightened frown, tense body language but was consoled. The comprehensive care plan revised 1/24/23, documented Resident #1 was at risk for burns from hot beverages due to no safety awareness as evidenced by a history of wandering and grabbing cups and objects from tables and counters. The gaol was resident will have no further injuries from hot beverage spills onto lap. Interventions included: -Increase visual checks for safety during meals to aid in preventing Resident #1 from grabbing other items from the table that do not belong to her; -Seating arrangements to allow Resident #1 to sit with other residents that do not drink hot beverages; and, -Provide resident/patient with set-up and supervision with cues to extensive assist for eating. C. Observations On 3/1/23 at 5:24 p.m., Resident #1 was observed self propelling throughout the unit in a manual wheelchair reaching out to grab at staff and residents as they walked passed by. A CNA on the unit approached and assisted the resident to the dining room. The resident was seated away from others with hot liquids in front of a table tray and served the dinner meal. Resident #1 at the meal remaining in place until the meal was done. When the resident was finished eating, the CNA removed the table tray and the resident continued roaming around the unit touching every person who she passed. III. Staff interviews The dietary manager (DM) was interviewed on 3/1/23 at 1:30 p.m. The DM said the coffee was brewed in one machine in the kitchen and then transferred to a stainless steel thermos dispenser to be served to the residents. The coffee was tempted prior to being taken to the dining room and resident floors for service. The DM said the temperature of the coffee should be 160 degrees F or lower. If steam was coming off the poured coffee it was most likely too hot to serve. Staff were educated to monitor the coffee dispenser and inspect any resident attempting to operate the dispenser on their own. The DM said hot liquid at above 160 degrees had the potential to cause scalding burns. CNA #2 was interviewed on 3/2/23 at 10:20 a.m. CNA #2 said she was working from 6:00 a.m. to 2:00 p.m., on 1/21/23, the day this resident was burned. CNA #2 she had not observed the resident spilling any ot liquids and had not observed any signs that there was any hot liquid spilled around the resident; and Resident #1 never complained of pain throughout the day shift. CNA #2 said she provided incontinent care for Resident #1 just before lunch, at approximately 11:00 a.m. The resident's pants were wet around the brief but not on the resident's legs. Unit nurse manager (UNM) was interviewed on 3/2/23 at 11:10 a.m. The UNM said Resident #1 needed to be monitored because she was reaching to grab items from other residents' tables and the drink carts which caused a safety concern. The UNM said no staff knew what time the resident burn occurred on 1/21/23 or how the burn occurred, but it might be possible that the resident spilled some hot liquid on herself. The NHA was interviewed on 3/2/23 at 12:00 p.m. The NHA said Resident #1 had sustained a second degree burn to the right thigh, requiring the resident to start seeing the wound care physician to treat the burn. The wound was healing but still required ongoing wound care treatment and monitoring by nursing staff and the wound physician. Immediately following the discovery of the resident burn, the facility investigated for possible causes and preventative measures. The resident care plan was updated with new safety interventions and all staff were educated to follow the revised care plan to maintain the resident's safety. Licensed practical nurse (LPN) #4 was interviewed on 3/2/23 at 1:00 p.m. LPN #4 said Resident #1 was impulsive and was touching things all the time. LPN #4 said the resident was non-verbal so staff were unable to find out exactly how the resident was injured. CNA #3 was interviewed on 3/2/23 at 3:30 p.m. CNA #3 said she worked on 1/21/23, during the evening shift from 2:00 p.m. to 11:00 p.m. CNA #3 said she came on shift and started rounding and checking on resident needs. Resident #1's briefs were soiled upon checking in on the resident. CNA #3 provided Resident #1 incontinence care at approximately 2:45 p.m. and noticed redness and blisters on the resident's right thigh. CNA #3 reported the resident's injury to the nurse for further assessment. Because no staff on duty know how the injury occurred, CNA #3 called CNA #2, as that CNA had worked with the resident on the prior shift. CNA #3 said CNA #2 denied knowledge of Resident #1 injury and said the resident did not have any signs or symptoms of an injury or burn during the day shift. IV. Facility corrections Interview and record review during the complaint investigation revealed the facility investigated this singular event and implemented corrective actions to prevent reoccurance. The care plan was revised with interventions for staff to set Resident #1 up to be separated from other residents who drank hot liquids. Since Resident #1 did not consume hot liquids. The resident was not in jeopardy of being burned by her own drinks but was at risk from grabbing hot liquids from peers consuming such beverages. The care plan interventions included placing Resident #1 away from hot liquids at meals and monitoring the resident during the meal. Observations and interviews during the survey revealed staff were consistently following the care plan interventions and the resident had not experienced any further problems being injured by hot liquids. The facility determined all residents in the facility were at risk for being burned by hot coffee or any other hot beverage such as tea or hot chocolate, if not properly brought to a safe temperature for serving. The dietary department educated dining aides to make sure hot liquids did not exceed 160 degrees F when serving to a resident. Coffee for example was to be tempted properly, in the kitchen at each service, to make sure its temperature met the recommended 160 degrees F prior to taking it to the dining room or to the resident units for service to the residents. Additionally, staff were instructed that residents were not permitted to dispense coffee directly from the stainless dispensers. Signs were posted on the coffee and hot water dispensing containers warning residents to ask for assistance due to the risk of being burned. All nursing staff were educated to follow Resident #1's revised care plan intervention to prevent reoccurance of the resident being burned as of 1/27/23. Interviews with the NHA confirmed the corrective actions, and therefore the facility's substantial compliance, by 1/27/23, at the time of the survey conducted between 3/1//23 to 3/2/23. 42193

Based on observation, record review and interviews, the facility failed to provide treatment and care services in accordance with professional standards of practice for one resident (#3) of three residents reviewed for change of condition out of eight sample residents. The facility failed to ensure timely care and services were provided to Resident #3 following a change of condition. Resident #3 suffered three falls within six days in December 2020 after she recovered from COVID-19 with an increase in behavioral symptoms. The falls occurred during the night shifts on 12/14/2020, 12/16/2020, and 12/19/2020. The resident experienced new pitting [CONDITION(S)] to the lower left extremity and a noticeable increase in reported pain levels starting 12/21/2020. Although both the facility and medical provider documented the increased [CONDITION(S)] and resident complaints of leg pain, an x-ray was not ordered until 1/6/21, 18 days after the latest fall and 10 days after the pitting [CONDITION(S)] started, which revealed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . This contributed to the resident suffering unnecessarily from associated increased leg swelling and increased pain levels due to the delay in treatment and discovery of the fracture. Findings include: I. Facility policies and procedures The Falls Management policy, last revised 2/18/2020, was provided by the director of nursing (DON) on 4/22/21 at 4:58 p.m. via email, documented in pertinent part: Patients will be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Patients experiencing a fall will receive appropriate care and investigation of the cause. The Notification of Change in Condition policy, last revised 11/30/2020, was provided by the DON on 4/22/21 at 4:58 p.m. via email, documented in pertinent part: A center must immediately inform the resident/patient (hereinafter patient), consult with the patient's physician, and notify, consistent with his/her authority, the patient's Health Care Decision Maker (HCDM), where there is: -An accident involving the patient which results in injury and has the potential for requiring physician intervention (refer to); -A significant change in the patient's physical mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications); -A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or -A decision to transfer or discharge the patient from the Center. When making notification of above, the Center must ensure that all pertinent information is available and provided upon request to the physician. II. Resident status Resident #3, age 83, was admitted on [DATE]. According to the April 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/14/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of seven out of 15. She required extensive assistance with two person physical assistance with bed mobility, dressing, and toileting. She required extensive assistance with one person physical assistance for personal hygiene. She was totally dependent and required two person physical assistance for transfers. She was independent and required set up help only for eating. III. Resident observations On 4/21/21 at 10:20 a.m. Resident #3 was observed seated in her wheelchair in the atrium. She had her feet elevated on foot pedals and a blanket was placed over her lap and legs. She was socializing with another resident. -At 2:39 p.m. Resident #3 was again observed seated in her wheelchair in the atrium. She was drinking a soda. Her feet were elevated on foot pedals and she had a blanket covering the majority of her legs. There was a soft backing behind the foot pedals. No [CONDITION(S)] was observed in her right leg, however, the left leg was completely covered by the blanket. On 4/22/21 at 10:29 a.m. Resident #3 was observed in the atrium seated in her wheelchair. Registered nurse #1 (RN #1) lifted the blanket on the resident's legs which revealed the resident was wearing [CONDITION(S)]-embolic deterrent (TED) hose on her right leg and a controlled ankle motion (CAM) boot to the left leg. There were towels placed underneath the left foot in the CAM boot. IV. Record review A. Care plans The resident's behavioral care plan, last revised 1/14/21 revealed Resident #3 was resistive to care related to cognitive loss/dementia, would often refuse incontinence care when offered, would get upset stating she had not received incontinence care, would call family crying about not receiving incontinence care, would yell and bang on items when in bed, and was noted to have increased verbal behaviors after she had COVID-19. Pertinent interventions included: -Allow time for expression of feelings; provide empathy, encouragement, and reassurance; -Contact daughter to speak with the resident after behavior/during behavior episodes; -Provide a calm, quiet, well-lit environment; -Approach the resident/patient in a calm, unhurried manner; reassure as needed; and, -Explain all care, including procedures (one step at a time), and the reason for performing the care before initiating The resident's impaired cognitive function care plan, last revised 1/10/21 revealed Resident #3 had impaired cognitive function and thought processes related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Pertinent interventions included: -Encourage resident to elevate legs, rest in bed and call daughter for assistance; -Evaluate behavioral symptoms for underlying causes, e.g., toileting needs, pain, positioning; and, -Provide an environment that is conducive to the patient's ability to get adequate sleep and maintain resident's/patient's preferred sleep/wake schedule The resident's fall care plan, last revised 1/10/21, revealed Resident #3 was at risk for falls due to cognitive loss, impaired mobility, Hoyer (mechanical) lift transfers, and covid [CONDITION(S)]. New interventions were not added after the multiple falls sustained in December 2020, rather, several new interventions were added on 1/10/21 including: -Fall mats; - Medication evaluation as needed; - Implement the following safety precautions: offer check and change every 2-4 hours; and, - Psychiatrist involvement due to increased behaviors, believing resident can self transfer, covid [CONDITION(S)]. The resident's skin breakdown care plan, last revised 4/5/21, revealed Resident #3 had potential for skin breakdown related to incontinence of bladder and bowel and impaired mobility. The care plan section documented the 1/6/21 increased [CONDITION(S)] to bilateral lower extremities and fracture and that the cast of the left lower extremity was removed on 4/1/21 and a deep tissue injury was noted to the left heel. Pertinent interventions included: -L [left] heel wound treatment as ordered: Soft boot to left wheel when in bed and Cam boot when out of bed; -Monitor for pain, CMS (circulation, motion and sensation) and ROM [range of motion] to LLE [left lower extremity]. Elevate as needed to help prevent swelling. Resident #3's [CONDITION(S)] was mentioned in the nutrition section of the care plan in relation to a significant weight gain in January 2019 and April 2021, and the skin breakdown section of the care plan in relation to the 1/6/21 fracture and skin integrity after the cast was removed on 4/1/21, however, there were no interventions in place for [CONDITION(S)] prior to the falls in December 2020. -There was no care plan section specifically for lower extremity [CONDITION(S)] with interventions in place for [CONDITION(S)] prior to the falls in December 2020. B. Falls 1. Facility records for falls a.12/14/2020 fall The 12/14/2020 at 8:30 p.m. general note revealed Resident #3 was found in a prone position next to her bed after an unwitnessed fall. The resident was assessed by the nurse, neuro checks and vital signs were initiated, and the resident was found to be within normal limits. The resident stated she did not hit her head. She had no complaints of pain and no injuries were noted. The 12/14/2020 corresponding risk management survey (RMS) event summary revealed the root cause of the fall was that the resident appeared to be agitated and tried to get out of bed. The fall mat was in place and the resident was assisted into her wheelchair after the fall and later placed in bed when she became tired. b. 12/17/2020 fall The 12/17/2020 at 3:45 a.m. general note revealed Resident #3 had an unwitnessed fall out of her wheelchair at approximately 3:30 a.m. The resident was found laying on her stomach face down on the floor next to her nightstand. The resident stated she hit her head and a small quarter size redness was observed on the left temple. No other injuries were noted. The resident's night stand was knocked over. The resident appeared to be at her baseline, however, her right pupil was sluggish. No new orders were provided by the on-call physician, but it was recommended the resident be seen by her regular medical provider in the morning for possible recommendation of a head computerized tomography (CT) scan. The corresponding 12/17/2020 RMS event summary report revealed that prior to the fall the resident was restless and had not slept all day or night and would scream whenever she was alone. The note revealed the resident was trying to ambulate on her own in her room and had propelled herself out of her wheelchair. Her side table and dressers were tipped over. The on-call physician advised that if the resident's condition worsened or new symptoms developed to consider sending the resident to the hospital. The 12/17/2020 medical provider note revealed Resident #3 had dementia and had become increasingly agitated at night with nocturnal agitation and behaviors of yelling out. Resident #3 was discussed in the psychoactive pharmaceutical meeting during which it was decided to stop the resident's [MEDICATION(S)] (antipsychotic) and start her on [MEDICATION(S)] (antidepressant/sedative). Staff were to continue monitoring the resident's behaviors. c. 12/19/2020 fall The 12/19/2020 at 2:14 a.m. general note revealed Resident #3 had an unwitnessed fall out of bed at approximately 1:30 a.m. The resident was found laying on her stomach face down on the floor mat with her legs propped on the bed. The resident stated she did not hit her head. Discoloration was noted on her left elbow with moderate pain, but no other injuries were noted at the time. The resident was assisted back into bed with a hoyer lift. She appeared to be at baseline, however, her right pupil was sluggish. The corresponding 12/19/2020 RMS event summary report revealed that prior to the fall the resident's call light and personal items were within reach. The root cause section of the note listed resident had an unwitnessed fall. The 12/22/2020 medical provider note revealed Resident #3 was experiencing worsened dementia with behaviors since recovering from COVID-19. She had fallen from bed three times. Fall mats were on the floor and the bed was in the lowest position. She was reviewed in the psychoactive pharmaceutical meeting on 12/17/2020. An additional dose of [MEDICATION(S)] was added on this date with instructions for staff to continue to monitor the resident. The 12/28/2020 medical provider note revealed the increase in [MEDICATION(S)] had been ineffective in managing Resident #3's nocturnal agitation even after the dosage was increased on 12/22/2020. Resident #3 had been refusing to go to bed which resulted in prolonged time in her wheelchair. The prolonged time in the wheelchair had worsened Resident #3's [CONDITION(S)] resulting in increased lower extremity [CONDITION(S)] with the left being worse than the right. The 1/4/21 medical provider note revealed Resident #3 continued to refuse going to bed at night and her behaviors and [CONDITION(S)] had contributed to an increase in lower extremity [CONDITION(S)]. [MEDICATION(S)] (diuretic) was restarted due to persistent lower extremity [CONDITION(S)]. The 1/6/21 medical provider note revealed a nurse (RN #2) spoke to the medical provider and told her that he thought Resident #3's left foot [CONDITION(S)] might be caused by a fracture. The medical provider knew of no recent injury and the resident was unable to recall any injury. The resident had bilateral lower extremity [CONDITION(S)] with left being more edetemous than the right had improved some with the addition of [MEDICATION(S)]. Imaging of the foot, ankle and distal tibia/fibula were ordered and revealed a very obvious displaced distal tibia/fibula fracture on the left side. The 1/7/21 medical provider note revealed Resident #3 was sent to the emergency department the morning of 1/6/21 after the x-ray of the left foot and ankle revealed fractures of tibia and fibula. The resident's fracture was splinted by the orthopedic physician in the emergency department and she was returned to the facility in stable condition with orders for six [MEDICATION(S)] (narcotic) tablets and instructions to follow up in one week for casting. C. Lower extremity [CONDITION(S)] 1. Professional reference The Healthline, Everything You Should Know About Pitting [CONDITION(S)], last updated on 8/31/17, retrieved on 4/26/21 from: https://www.healthline.com/health/pitting-[CONDITION(S)] It read in pertinent parts, [CONDITION(S)] is swelling in the body caused by excess fluid. It often affects the lower body, such as the legs, feet, and ankles, but it can occur anywhere. If you press on a swollen area and an indentation or pit remains, it's called pitting [CONDITION(S)]. To determine the extent of the pitting [CONDITION(S)], your doctor will push on your skin, measure the depth of the indention, and record how long it takes for your skin to rebound back to its original position. They will then grade it on a scale from 1-4. -Grade 1; 2 millimeter (mm) depression, or barely visible; rebound time is immediate; -Grade 2; 3-4mm depression, or a slight indentation; rebound time is 15 seconds or less; -Grade 3; 5-6mm depression; rebound time is 10-30 seconds; and, -Grade 4; 8mm depression, or a very deep indentation; rebound time is more than 20 seconds 2. Documentation of Resident #3's [CONDITION(S)] Review of the CPO and December 2020 medication administration records (MAR) revealed Resident #3 was not on any medications for [CONDITION(S)] prior to the three falls in December 2020. Review of the resident's progress notes revealed the following: The medical provider note dated 11/3/2020 documented the resident was negative for peripheral [CONDITION(S)]; -12/1/2020 documented the resident was negative for peripheral [CONDITION(S)]. -12/17/2020 documented the resident was negative for peripheral [CONDITION(S)]. General progress note dated 12/23/2020 at 12:43 a.m. documented Resident #3's legs were noticeably swollen and the resident complained of pain to the legs. General progress note dated 12/26/2020 at 9:51 p.m. documented staff asked the resident if she would like to lay down as it would be beneficial to her swollen legs due to being in her wheelchair. The resident stated, not right now. General progress note dated 12/27/2020 at 5:22 a.m. documented the resident's legs were swollen with +2 pitting [CONDITION(S)] to the bilateral lower extremities, and the resident complained of leg pain when they were moved. The resident's legs were placed on foot pedals for elevation because the resident refused to lay down, however, the resident continued to take her legs off the foot pedals. -At 6:34 p.m. the resident had +4 pitting [CONDITION(S)] in bilateral lower extremities with the left side being more endemic than the right. The medical provider note dated 12/28/2020 documented the resident was positive for [CONDITION(S)] with +2 [CONDITION(S)] of the left and right pretibial, +4 [CONDITION(S)] of the left and right ankle, +4 [CONDITION(S)] of the left and right pedal. General progress note dated 1/1/21 at 3:12 p.m. documented that the resident's feet were especially edematous and shiny. -At 9:20 p.m. the resident refused to lay down and her legs were swollen and hurting. The medical provider note dated 1/4/21 documented the resident was positive for [CONDITION(S)] with +2 [CONDITION(S)] of the left and right pretibial, +3 of the left ankle and left pedal, +2 [CONDITION(S)] of the right ankle and pedal; this indicated that the left side showed more [CONDITION(S)] than the right side. General progress note dated 1/4/21 at 9:20 p.m. documented staff educated the resident on how important it was to rest her legs as they were causing her pain and were swollen with +3 pitting [CONDITION(S)]. General progress note dated 1/5/21 at 9:37 p.m. documented the resident was in bed and some of the leg swelling had gone down. The resident's legs were still swollen and the resident complained of pain when she moved her legs. The medical provider note dated 1/6/21 documented the resident was positive for [CONDITION(S)] with +3 [CONDITION(S)] of the left ankle and +2 [CONDITION(S)] of the right ankle; this indicated that the left side showed more [CONDITION(S)] than the right. The medical provider note dated 1/7/21 documented the resident was positive for [CONDITION(S)] with +3 [CONDITION(S)] to the left pedal and +2 [CONDITION(S)] to the right ankle and pedal. -According to progress notes and confirmed with interviews the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She did not have a history of pitting [CONDITION(S)] until after her fall, which would indicate a change in condition for her baseline status to her lower legs. The facility failed to identify pitting [CONDITION(S)] as a change for the resident and lower extremity pitting [CONDITION(S)] is not mentioned in the resident's progress notes between September 2020 and December 2020. It is not mentioned until 12/27/2020 which is after the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] D. Pain levels Review of the December 2020 and January 2021 MARs revealed the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ? every shift. The reported pain levels prior to and after the falls were as follows: 1.Before falls -12/1/2020 pain level of 2 on all three shifts; -12/2/2020 through 12/20/2020 pain level of zero on all shifts; 2. After falls -12/21/2020 pain level of 5 on all three shifts; -12/22/2020 pain level of 5 on afternoon shift; -12/23/2020 pain level of 6 on afternoon shift; -12/24/2020 and 12/25/2020 pain level of zero on all three shifts; -12/26/2020 pain level of 5 on afternoon shift and 8 on night shift; -12/27/2020 through 12/29/2020 pain level of zero on all three shifts; -12/30/2020 pain level of 5 on all three shifts; -12/31/2020 pain level of 0 on all three shifts; -1/1/21 pain level of 5 on all three shifts; and -1/2/21 through 1/5/21 pain level of 0 on all shifts. Review of the December 2020 and January 2021 MARs revealed the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 received as needed pain medication as follows: -12/11/2020 pain level 5; -12/12/2020 pain level 8; -12/14/2020 pain level 5; -12/16/2020 pain level 7; -12/21/2020 pain level 5; -12/22/2020 received pain medication twice for pain levels 8 and 6; -12/23/2020 pain level 6; -12/24/2020 received pain medication twice for pain levels 5 and 4; -12/25/2020 pain level 7; -12/26/2020 received pain medication three times for pain levels 6, 5, and 8; -12/28/2020 pain level 5; -12/29/2020 pain level 5; -12/30/2020 pain level 5; -1/3/21 received pain medication twice for pain levels zero and 5; and -1/6/21 pain level 5 V. Hospital documentation The 1/6/21 summarization of encounter note from the hospital revealed Resident #3 sustained a fall during transferring. She was diagnosed with a closed displaced comminuted fracture of the shaft of the left tibia and fibula. The hospital physician recommended a closed treatment with splint application followed by cast application in clinic with close radiographic followup in one week. The procedure and plan was fully reviewed with the patient and her daughter. VI. Interviews Registered nurse (RN) #1 was interviewed on 4/22/21 at 10:29 a.m. RN #1 said she was familiar with Resident #3. She said that lower extremity [CONDITION(S)] had been an ongoing concern for Resident #3 and she had been off and on diuretics and potassium supplements several times. She said she was not present when Resident #3 suffered multiple falls in December 2020 as those occurred on a different shift, however, she did state that the resident's lower extremity [CONDITION(S)] was significantly more noticeable after her falls. She said the resident had been combative with nursing staff after her falls and refused to lie down in bed or elevate her legs. The medical provider was interviewed via telephone on 4/22/21 at 11:57 a.m. She said she would not answer any questions about Resident #3 until after she spoke with her manager. She said she would call back after speaking with her manager. The medical provider called back on 4/22/21 at 12:37 p.m. The medical provider said Resident #3 had been one of her patients for a long time. She said Resident #3 had always had lower extremity [CONDITION(S)], however, it was not pitting and seemed to be fairly well controlled without medication. She said she had recommended having the resident wear compression stockings but the resident did not always tolerate them. She said the resident's [CONDITION(S)] did get worse after her falls in December 2020. She said she only knew what was reported to her and everything could be found in her notes. She confirmed that she did order an x-ray on 1/6/21 because a nurse suggested the resident may have a fracture. She said she was not aware of any other injuries Resident #3 may have suffered outside of the multiple falls. RN #1 was interviewed again on 4/22/21 at 1:22 p.m. RN #1 said when a change of condition occured for a resident, the nurse notified the medical provider and family right away, vital signs are taken, and a change of condition was initiated. She said with regards to Resident #3, she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she did not know of any other injury Resident #3 may have sustained that would have caused her left tibia/fibula fracture other than one of her falls. She said she did not know how it was ultimately determined that the resident may have had a fracture. RN #2, the nurse who suggested to the medical provider that Resident #3 may have had a fracture, was called on 4/22/21 at 3:02 p.m. A voicemail was left but no return call was received. The director of nursing (DON) was interviewed on 4/22/21 at 4:34 p.m. The DON said Resident #3 had COVID-19 prior to the falls in December 2020 and was diagnosed with COVID-19 [CONDITION(S)] when her behaviors became unmanageable. She said she had not heard of COVID-19 [CONDITION(S)] prior. The DON said the resident had always had behaviors, but they became much worse after she was diagnosed with COVID-19. She said the medical provider had changed the resident's medications, taken laboratory samples, and consulted with a psychiatrist but the resident continued to yell and try to get out of bed without staff assistance. The DON said after the three falls in December 2020, nothing was noted as an injury, but the resident's [CONDITION(S)] continued getting worse and the fracture was discovered on 1/6/21. The DON said she did not know if the fracture was caused by one of the falls, but she believed it was a possibility. She said she did not know why it took so long between the resident's falls and increasing [CONDITION(S)] before an x-ray was ordered.

Based on observations, interviews and record review, the facility failed to ensure two (#1 and #2) of four residents received adequate supervision to prevent accidents out of six sample residents reviewed. Specifically, the facility failed to ensure heated liquids were a safe temperature before giving those heated liquids to Resident #1 and Resident #2. Resident #1 requested for a cup of Ramen noodles to be heated up by a nurse. The nurse heated the cup of Ramen noodles for 90 seconds and then put it in the resident's lap while she was sitting in her wheelchair. The nurse failed to ensure the cup of Ramen noodles was at a safe temperature before giving it back to Resident #1. Resident #1 spilled the cup of Ramen noodles and sustained second [MEDICAL CONDITION] the right and left upper thigh and the right index finger. The facility failed to provide education to staff on the practice of heating up food and liquid items safely following the incident with Resident #1 to prevent the incident which occurred with Resident #2, two weeks later. Resident #2 requested for a cup of tea to be heated up by a certified nurse aide (CNA). The CNA heated up the cup of tea and gave it back to the resident. The CNA failed to ensure the cup of tea was a safe temperature before giving it to Resident #2. Resident #2 spilled the cup of tea and sustained a second degree burn to the forearm and a first degree burn to the abdomen. The facility's failure to ensure the liquids were at a safe temperature for both Resident #1 and Resident #2 caused both residents to sustain second degree burns. Cross-reference F684 for the facility failing to ensure a registered nurse (RN) conducted an assessment of Resident #2 second degree burn to the forearm and first degree burn to the abdomen. The licensed practical nurse (LPN) failed to notify the physician of the burn and obtain a treatment order. The LPN placed a dressing onto Resident #2 right forearm without obtaining a physician's orders [REDACTED].>Cross-reference F580 for the facility failing to notify the physician of Resident #2 sustaining a second degree burn to the forearm and first degree burn to the abdomen timely. Findings include: I. Facility policy and procedure The Safety with Hot beverages policy and procedure, undated, was provided by the nursing home administrator (NHA) on 11/4/2020 at 9:30 a.m. It revealed, in pertinent part, Beverages should be served at a palatable temperature while maintaining appropriate practices for resident safety. The preferred temperature for consuming coffee is 135 degrees F (Fahrenheit). The Microwave Ovens and Safety policy and procedure, revised November 2016, was provided by the NHA on 11/4/2020 at 9:30 a.m. It revealed, in pertinent part, Staff should microwave food for patients whenever possible. Allow food to sit uncovered for approximately two to seven minutes after the standing time before serving. Even after seven minutes post-microwaving, some food would still pose a burn injury risk if there was contact with an individual's skin. II. Professional references According to the American Burn Association, Scald Injury Prevention, April 2017, https://ameriburn.org/wp-content/uploads/2017/04/scaldinjuryeducatorsguide.pdf (retrieved 11/5/2020): Older adults have thinner skin so hot liquids cause [MEDICAL CONDITION] even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. First degree burns: the top layer of skin (epidermis) turns red/pink and is mildly painful. Some swelling may occur but no blisters form. Second degree burns: the top and middle layers of skin (dermis) are injured, causing blisters, pain and swelling. The blisters may break, and the skin underneath will be red/pink and wet. Time and temperature relationship to severe burns: 155 degrees F, 1 second; 148 degrees F, 2 seconds; 140 degrees F, 5 seconds; 133 degrees F, 15 seconds; 127 degrees F, 1 minute. Cooking-related scalds are common in all age groups, but are especially services for younger children, older adults and people with disabilities. Microwave foods and liquids may reach temperatures greater than boiling without the appearance of bubbling. Stir and test food thoroughly before serving or eating. III. Failure to ensure microwave heated liquids were a safe temperature A. Resident #1 Resident #1, age younger than 65, was admitted on [DATE] and readmitted on [DATE]. According to the October 2020 computerized physician orders [REDACTED]. The 9/10/2020 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status score of 12 out of 15. She required extensive assistance of one person with personal hygiene. She was independent with all other activities of daily living. She was independent with eating with set up assistance only. 1. Record review The activities of daily living care plan, initiated 6/1/15 and revised on 10/21/2020, revealed the resident required assistance with activities of daily living due to [MEDICAL CONDITION] which compromised the resident's functional ability with right sided weakness. The nutrition care plan, initiated 9/1/15 and revised on 7/2/2020, revealed the resident had limited food acceptance. The resident typically ate her own pre-packaged meals instead of the facility food. This had been part of her comprehensive care plan since 9/1/15. The 10/17/2020 situation, background, assessment and recommendation (SBAR) nursing progress note revealed the resident asked the nurse to heat up a cup of Ramen noodles in the microwave. The nurse heated up the Ramen noodles for 90 seconds and placed it in the lap of the resident while she was sitting in her wheelchair. The resident was given her medications by the nurse and then when she turned to leave the medication cart, the resident spilled the cup of Ramen noodles onto her lap. The nurse assisted the resident to her room and assessed the resident. She contacted the nurse practitioner (NP) who instructed the nurse to apply a cool compress for 20 minutes as needed for 24 hours. Upon updating the NP, she gave further orders to apply Silvaderm topically twice a day for two days. The nursing note did not indicate the nurse had stirred or obtained the temperature of the cup of Ramen noodles prior to giving it back to the resident. The nurse did not carry the heated cup of Ramen noodles for the resident, but instead placed it in her lap, while she maneuvered through the unit in her wheelchair. The 10/17/2020 change of condition evaluation revealed in the afternoon on 10/17/2020 the resident sustained [REDACTED]. It indicated the resident experienced acute pain at a level 8-10 to the right inner thigh, left inner thigh and the right hand. It indicated the resident requested a cup of Ramen noodles be heated up. It was placed in the microwave, by the nurse, for 90 seconds. It was then placed on the resident's lap while she sat in her wheelchair. The cup of Ramen noodles spilled on the resident. The nurse assisted the resident back to her room and assessed the resident for injury. The incident investigation revealed the root cause of the spill was the resident turning in her wheelchair. The corrective action indicated staff must carry hot food to the resident's room with no exceptions. The RN interview revealed, the nurse heated up the cup of Ramen noodles for 90 seconds in the microwave and placed it in the resident's lap. The nurse did not obtain the temperature of the heated item to ensure it was a safe temperature before placing it in the resident's lap while she was in her wheelchair. The resident then spilled the cup of Ramen on her lap, causing second degree burns. B. Resident #2 Resident #2, age 70, was admitted on [DATE] According to the October 2020 CPOs, the [DIAGNOSES REDACTED]. The 10/23/2020 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She required supervision with one person physical assistance with bed mobility, transfers, dressing and toileting. She was independent with set up help only with eating. 1. Record review The 10/23/2020 nursing progress note revealed a CNA reported the resident had popped a blister on the right forearm and wanted a Band-Aid. The LPN indicated she assessed the wound which was red with no drainage. She covered the wound with Xeroform [MEDICATION NAME] dressing and bordered gauze. It did not indicate the physician was notified and orders for a treatment were obtained. It did not indicate an RN was notified and performed an assessment of the blistered area. A review of the resident's medical record on 11/2/2020 at 11:15 a.m. did not reveal documentation of a skin check or assessment completed on 10/23/2020 following the notification made to LPN #1 by the CNA of the popped blisters to the right forearm. The 10/25/2020 nursing documentation note documented the resident had a burn injury to her right forearm. It was reported the resident sustained [REDACTED]. The 10/25/2020 SBAR documented approximately four days prior, the resident spilled hot tea on her arm causing blistering. It was noted in the resident's medical record on 10/23/2020, an LPN provided a dressing to the affected area. The physician assistant (PA) was notified on 10/25/2020 and gave new orders for wound care twice per day to cleanse with soap and water, then cover with antibiotic Xeroform. The 10/26/2020 wound round progress note revealed the resident was seen for a second degree burn to the right forearm. The wound measured 16 cm x 14 cm x 0.1 cm. The wound physician recommended treatment of [REDACTED]. The 10/29/2020 nursing progress note documented along with the second degree burn to the resident's right forearm, the resident also sustained a burn to the right upper quadrant of the abdomen. No open areas or blisters were noted. The 10/29/2020 skin check revealed the resident had a second degree burn to the right inner forearm and a first degree burn to the right abdomen. The incident investigation documented the resident requested a staff member heat up her tea. The resident said the staff gave her back the hot tea and she spilled the hot tea onto herself. She said it happened at night and she did not report it timely. She said the following day, the nurse had assisted her and put a dressing onto her forearm. The investigation indicated the spill of the hot tea must have occurred at night on 10/22/2020. LPN #1, in her interview during the incident investigation, said on 10/23/2020 around 10:00 p.m., a CNA asked her for aBand-Aid for Resident #2. She said she gave her a dressing for her forearm and assisted to put it on. She said she noted small blisters and the area with red but the blisters had not opened yet. She said she did not ask the resident what happened to her arm. LPN #1 received one to one training on 10/30/2020 on the facility policy and procedure for a resident with a change of condition, treatment orders, and ensuring to review the resident's medical record prior to providing a treatment. The facility failed to notify the physician timely when the skin trauma occurred, which caused a second degree burn to the right forearm and a first degree burn to the abdomen and obtain treatment orders. The facility failed to conduct a skin assessment upon the identification of the burn on 10/23/2020. C. Staff interviews CNA #1 was interviewed on 11/4/2020 at 9:33 a.m. She said liquid heated up in the microwave should be at 135 degrees F before giving it to the resident to ensure they do not get burned if they spill the liquid. She said staff should use the thermometer to check the temperature. She said Resident #1 had been eating pre-packaged food items for a long time. She said the staff heated up the items in the microwave and gave them back to the resident. She said since Resident #2 sustained the burns, they had to walk the items back to the resident's room for her and were not allowed to put them in her lap while she was in the wheelchair. RN #1 was interviewed on 11/4/2020 at 9:26 a.m. She said when heating up a food or liquid item in the microwave, the food item should be stirred after the heating was finished, let the food and/or liquid sit for a couple minutes, and then place the thermometer in the item to obtain the temperature. She said in order for the liquid to be safe for the resident, it should be 135 degrees F. She said Resident #1 had been eating pre-packaged food for as long as she had worked on the unit, which was over a year. She said Resident #1 often ate Ramen noodles or macaroni and cheese. She said the staff have always heated up the food item for the resident, given it back to her on her lap while she was in the wheelchair, and then she wheeled herself back to her room. She said since Resident #1 sustained burns, the staff must walk the food item to the resident's room. RN #2 was interviewed on 11/3/2020 at 3:56 p.m. She said the facility had recently placed thermometers in the kitchenette by the nursing station. She said it was put there during the survey process the previous week on 10/29/2020 (not after the two incidents occured to Resident #1 and Resident #2). She said she did not know the proper procedure to heat up food or a liquid for a resident. She said she probably would not heat the item up, but would get a CNA to do it. She said she did not know the safe temperature range. She said she thought some of the staff had been educated for the process of heating up items, but she had not attended the training. Upon walking into the kitchenette next to the nursing station, RN #2 identified the thermometer that was in a bin on top of the microwave. She said there were documents posted on the wall with the procedure on how to heat up a food or liquid item. She said she had never read the documents posted on the wall before. She said the documents on the wall did not identify a safe temperature for heated food and liquids. The director of nursing (DON) was interviewed on 11/2/2020 at 4:07 p.m. She said Resident #1 had been eating pre-packaged means such as cups of Ramen for a long time. She said usually, the staff heated up the item in the microwave and then placed it on the resident's lap while she sat in the wheelchair. Resident #1 would take it back to her room. She said she had received a call from the nurse to inform her Resident #1 had spilled the cup of Ramen on herself and sustained second degree burns. She said the nurse heated the cup of Ramen noodles for 90 seconds and put it in the resident's lap. She said the resident hit her wheelchair on the medication cart and spilled the cup of Ramen noodles. She said the resident sustained [REDACTED]. She said the nurse did not ensure the cup of Ramen noodles was a safe temperature before giving it to Resident #1. She said the facility provided education to staff to carry heated items for the resident back to her room instead of placing it in her lap in the wheelchair. She said following that incident, Resident #2 asked a staff member to heat up a cup of tea. She said the resident spilled it on her arm and abdomen. She said the resident sustained [REDACTED]. She said the LPN did not notify the RN to do an assessment of the resident's burn. She said the LPN put a treatment on the resident's forearm without ensuring there was a physician's orders [REDACTED]. She said the LPN did not notify anyone or communicate it to the oncoming shift of the resident's second degree burn to the forearm. She said it was not until 10/25/2020 that the nurse noticed the dressing and notified the physician. She said the RN then assessed the resident, obtained a treatment order and completed a change of condition assessment. She confirmed the resident had a delay of treatment from 10/23/2020 to 10/25/2020. She said the first degree burn on the resident's abdomen was not identified until another four days later on 10/29/2020. She said for both incidents with Resident #1 and Resident #2, the staff should have ensured the items were a safe temperature before giving them to each of the residents. VI. Failure to ensure staff were provided education to prevent the second burn incident A. Record review The 10/17/2020 in-service sign in sheet revealed education was provided to staff to bring Resident #1 food, when heated up in the microwave, to the resident's room, instead of handing it to her. The 10/26/2020 in-service training sign in sheet revealed education was provided to staff regarding safe temperature range and the process of heating up food and liquids. This in-service was completed nine days following the first burn incident with Resident #1 and after the burn incident with Resident #2. B. Staff interviews RN #1 was interviewed on 11/4/2020 at 9:26 a.m. She said the staff had recently been educated on the procedures of heating up food and/or liquid in the microwave. She said the education occurred after Resident #2 sustained a burn to the forearm and abdomen. The DON was interviewed on 11/2/2020 at 4:07 p.m. She said staff was not interviewed on the proper procedure to ensure safe temperatures of heating up food and liquids in the microwave until after the second incident occurred on 10/23/2020. The NHA was interviewed on 11/2/2020 at 4:38 p.m. She confirmed the safe temperature range and heating instruction in-service was not provided to staff on 10/17/2020 with the in-service related to the burn with Resident #1. She said the in-service completed on 10/17/2020 was specifically related to Resident #1 plan of care. She said staff were instructed to carry Resident #1 food item to her room instead of placing them on her lap. She said it was not until after the second incident, the facility began educating staff on the safe temperature range and the process of heating up food and liquids. She said the education was ongoing with the first date on 10/26/2020 and during the survey process on 11/2/2020.

Based on observations, record review and staff interviews, the facility failed to ensure one (#1) out of three residents received necessary care and services to prevent the development of pressure injuries to his left lower extremity (calf and heel). Specifically: The resident was at known risk for pressure injury due to his compromised medical condition. (Cross-reference F692). He developed deep tissue injuries (DTI) which progressed to unstageable, necrotic wounds, contributing to pain and infection. Interviews revealed that at the family's request, the facility had been using a non-formulary device to relieve pressure on the resident's left lower extremity for six months to a year. The device was a doughnut-type personal pillow with a hole in the middle, similar to a cervical collar used for the neck. The facility was aware the doughnut-type device was inappropriate for pressure relief. However, it failed to take steps to minimize the risk it posed for pressure injuries development. Specifically, although use of the device was mentioned on the Kardex and care plan, there was no evidence the device had been evaluated by therapy until after the resident's wound developed and neither the Kardex nor the care planned instructed staff how to properly place the device under the resident's left lower extremity. None of the staff interviewed stated they had received training on how to place the device to prevent complications. Further, there was no documentation the resident and/or family was educated regarding the use of a non-formulary positioning device and the risks versus benefits of its use. Findings include: I. Policy and procedures The Skin Integrity Management policy, last revised 1/31/2020, was provided by the director of nursing (DON) on 8/26/2020 at 2:30 p.m. The policy read in part, The implementation of an individual patient's skin integrity management occurs within the care delivery process. Staff continually observe and monitor patients for changes and implement revisions to the plan of care as needed. Notify Medical Director, Center Nurse Executive (CNE), and Center Executive Director (CED) if deviation from protocol is requested by physician/advanced practice provider (APP), managed care company, or others. II. Professional reference The National Pressure Ulcer Advisory Panel, NPUAP Pressure Injury Stages 2016, http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ (July, 2017) accessed on 8/30/2020, reveals the following pertinent information: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. III. Resident #1 A. Resident status - known risk for developing pressure injuries and use of a doughnut-type device to relieve pressure at family request that the facility did not recommend. 1. Record review Resident #1, age greater than 65, admitted on [DATE]. According to the August 2020 computerized physician orders [REDACTED]. The minimum data set (MDS) assessment dated [DATE], revealed the resident had moderate cognitive impairment with a brief interview of mental status (BIMS) of ten out of 15. He required extensive assistance with bed mobility and was total dependence with toileting. He was at high risk for pressure ulcers with no unhealed pressure ulcers during the assessment period. He had moisture. He had a pressure-reducing device in place. He had associated skin damage (MASD) and received ointments and medications other than to the feet. The Kardex (a flow sheet to direct resident care) created 10/18 and current as of 8/17/2020, documented in pertinent part under the section titled Other Devices, off load/float heels while in bed with doughnut ring provided by family. A care plan, created on 2/17/19, and revised on 7/13/2020, identified the resident at risk for skin breakdown related [MEDICAL CONDITION], decreased mobility, preference to stay in bed and family providing positioning devices that the facility does not recommend. The goal was the resident's wound/skin impairment will heal as evidenced by decrease in size, absence of [DIAGNOSES REDACTED] and drainage and/or presence of granulation x 30 days (revised 7/13/2020). Interventions included in part, off load/float heels while in bed with the doughnut ring provided by family (initiated 2/17/19; revised 7/14/2020), and provide wound treatment as ordered. 2. Observations and interview of doughnut-type device (pillow) to relieve pressure On 8/20/2020 at 2:05 p.m. and 2:20 p.m., observations with the director of therapy (DOT) revealed a doughnut-type pillow in Resident #1's room. Per the DOT, the pillow appeared to be a device used for immobilizing the neck and he called it a cervical collar. He stated the family wanted the resident to use this device for his left lower extremity (LLE); however, it was non-formulary and he said it was not the appropriate device for positioning/elevating feet. Review of Resident #1's record failed to disclose evidence, other than the Kardex and care plan dates above, when the facility began using the doughnut-type pillow provided by the family. The DOT, interviewed again on 8/20/2020 at 3:15 p.m., said he did not have any documentation in the therapy notes that the resident had the doughnut pillow provided by the family for positioning. He said they had recommended a different device which was part of their formulary and he did not know the staff were not using the recommended therapy device. B. Resident decline - development of pressure injuries 1. Family and hospice nurse interview A family member, interviewed on 8/17/2020 at 1:00 p.m., said she had recently had a [MEDICATION NAME] visit with the resident. She said she could see his left foot showing from underneath the blanket and she asked a staff member to lift up the blanket. She said she asked them to remove his bandage on his left leg and saw he had a very bad looking, black wound. A hospice nurse said that since she began seeing the resident, he had not had any wounds on his left lower extremity (LLE), only some excoriation to his sacral area. However, said when she saw him again on 7/21/2020, he had a soft blue colored boot on his LLE for a deep tissue injury (DTI). She said licensed practical nurse (LPN) #1 told her she believed the doughnut-type pillow the family provided caused the DTI. She said the resident had been stable for quite some time, up until the wounds appeared and then he began to decline. She said she never saw a pressure-relieving device on his foot before 7/21/2020, and only saw his feet elevated on pillows. 2. Observation and interview revealed a black, necrotic wound on the resident left foot (calf and heel) that caused the resident pain. On 8/20/2020 at 1:30 p.m., a wound care observation was conducted with unit manager (UM) #1. She said the resident had been medicated with [MEDICATION NAME] 10 milligrams 20 minutes ago; however, Resident #1 said the pain medication was not working on the pain in his foot. UM #1 lifted the blankets off his lower legs and revealed he had a blue, soft boot over his left lower extremity. His feet were exposed which revealed the toes on his left foot were black and necrotic. The resident winced with pain when his left leg was touched and slightly repositioned. The UM said she was going to contact hospice to see if there was anything else that could be given to him for pain before she attempted to do the dressing change. On 8/20/2020 at 4:40 p.m., wound care observations were conducted with UM #1 and certified nurse aide (CNA) #8. The UM said the resident was pre-medicated with [MEDICATION NAME] sulfate 10 milligrams 25 minutes earlier. She asked the resident how his pain was and he said it was no good. As the UM began to position his left leg to remove the old bandage, the resident winced with pain. After removing the dressing, dated 8/19/2020, the left ankle and calf area was exposed. The skin was black and necrotic extending from the ankle and three quarters of the way up his calf, just below the back of the knee. The resident winced and grimaced. The UM confirmed there was no drainage and that the tissue was non-viable. She said the left toes were gangrenous. After cleansing the wound, she applied [MEDICATION NAME] to the area, let it dry and then wrapped it with a clean gauze dressing. She then reapplied the protective soft boot and placed his leg in a comfortable position. 3. Record review and interview confirmed Resident #1 developed new pressure injuries mid-July 2020. a. Interview The director of nursing (DON), interviewed on 8/17/2020 at 4:50 p.m., said Resident #1 was admitted to skilled care with post-surgical wounds to the LLE. He had vascular issues and had a stroke. She said he was mostly bed bound and would get up for showers or to be weighed. She said the wounds on the LLE from admission had healed up until he acquired the new wounds. b. Record review confirmed new pressure injuries developed mid-July, associated with pain and infection. June 2020: -A 6/24/2020 skin note documented in pertinent part that a skin check was performed and there were no skin injuries or wounds noted. July 2020: -A skin check dated 7/13/2020 documented a new skin injury, DTI (deep tissue injury), to the left posterior ankle. The wound type was described as pressure. -An IDT (interdisciplinary) wound round note dated 7/13/2020 by the wound nurse documented a left distal posterior calf/ankle DTI wound measuring 7cm(centimeters) by 8.5cm (centimeter) x UTD (unable to determine). The wound was 100 percent dark purple and the skin was intact. The wound was treated with sure prep and was offloaded. -A wound care progress note dated 7/20/2020 written by the wound doctor, documented in part, the following information regarding new wounds: Context three DTI's -Wound #6 left, distal posterior calf/ankle is a DTI persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 5.2cm(centimeters)x5.5cm(centimeters) with no measurable depth with an area of 28.6 sq (square) cm (centimeters). Wound bed had 100 percent [MEDICATION NAME]. -Wound #7 left heel is a DTI persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 4cm(centimeters)x2.5cm(centimeters) with no measurable depth with an area of 10 sq(square) cm(centimeters). Wound bed has 100 percent [MEDICATION NAME]. A wound care progress note dated 7/27/2020 by the wound doctor documented the following: -Wound #6 left distal posterior calf/ankle, unstageable obscured full-thickness skin and tissue loss. Measurements: 8cm(centimeters)x6.7cm(centimeters), no measurable depth, 56.6 sq(square) cm(centimeters) moderate amount of drainage noted. Wound bed 80 percent eschar, 20 percent granulation. -Wound #7 left heel unstageable obscured full-thickness skin and tissue loss. Measurements: 5cmx6cm, no measurable depth, 30 sq cm. Wound bed has 100 percent eschar. August 2020: - An IDT wound round note dated 8/3/2020 by the wound nurse documented in part, left distal posterior calf/ankle, unstageable. 9.7cm x10cmxUTD (unable to determine) depth. Left heel, unstageable. Measurements: 6cm x3.3cm xUTD (unable to determine) depth. -A 8/3/2020 wound doctor progress note documented the resident's measurements as follows: Wound #6, left distal posterior calf/ankle-8cmx6.7cm no measurable depth Wound #7, left heel-6cmx3.3cm no measurable depth -An 8/7/2020 hospice nurse note documented in part the facility called for the hospice nurse to assess the resident. The resident reported pain to his lower left extremity saying It hurts a lot. The resident was noted to have increased necrotic areas and green drainage to his left outer shin. The shin area measured 13cm(centimeters)x8.7cm(centimeters). The left heel wound was measured at 6cm x7cm. The resident was placed on an antibiotic for ten days. -An IDT wound round note dated 8/17/2020 documented in part, left distal posterior calf/ankle, unstageable. Measurements: 17cm x10cmxUTD (unable to determine) depth. Wound appears 100 percent eschar. Treatment recommended with [MEDICATION NAME] and kerlix (gauze wrap) dressing daily and as needed. Left heel, unstageable. Measurements: 5.5cm(centimeters)x6cm(centimeters)xUTD (unable to determine). Wound appears 100 percent eschar(dead tissue). Treated with [MEDICATION NAME] and kerlix and off loading of foot. Left toes, DTI/arterial. Measurements: 7cm(centimeters)x10cm(centimeters), (circumference of toes) xUTD (unable to determine. Wound appears 100 percent eschar(dead tissue). C. Failure to take steps to prevent the development of the resident's LLE unstageable, necrotic pressure injuries. Record review and interviews revealed the facility responded to Resident #1's pressure injuries above beginning on 7/13/2020, with a physical therapy evaluation, orders for a soft boot, protein supplement, wound consultants, wound rounds, and revised treatments. However, the facility failed to take steps to prevent the development of the unstageable, necrotic pressure injuries despite knowledge that the doughnut-type device was inappropriate and belief the device contributed to the resident's pressure injuries. Specifically: Record review and interview revealed the facility was aware the resident was using a doughnut-type device prior to the development of his pressure injuries and considered its use inappropriate. See Kardex (created 10/2018 and current as of 8/17/2020) above, which read, off load/float heels while in bed with doughnut ring provided by family. See care plan (created 2/17/2019 and revised 7/13/2020) above which read, family providing positioning devices that the facility does not recommend. Interventions included in part, off load/float heels while in bed with the doughnut ring provided by the family. Interview revealed the facility believed the doughnut-type device contributed to the resident's pressure injuries. -The DOT, interviewed on 8/20/2020 at 2:05 p.m. and 2:20 p.m., said that depending on how the cervical collar pillow was being placed/positioned on the resident's LLE/ankle, if placed inappropriately, it could cause pressure on the ankle. He said if staff were placing the pillow around the ankle and then securing the Velcro, the ankle would sit on top of the cushion and the heel would dangle in the middle, touching the mattress. -The nursing home administrator (NHA), interviewed on 8/17/ :40 p.m., said the resident's calf wound was caused by the positioning device (doughnut pillow) that the family had brought in and insisted the facility use. She said the left heel wound was due to the way the cushion was positioned under the resident's left ankle and the heel dropped through the hole in the middle causing the left heel to rub against the sheet. Yet, the facility failed to take steps to minimize the risk the doughnut-type device posed for pressure injury development. Specifically: 1. Although use of the device was mentioned on the Kardex and care plan, there was no evidence the device had been evaluated by therapy until 7/15/2020, after the resident's pressure injuries developed. -Record review revealed an order for [REDACTED]. And a PT clarification : Evaluation only, pressure relief interventions updated and revised 7/15/2020. -A PT evaluation dated 7/15/2020 documented the resident was referred due to impaired skin integrity to the left posterior distal calf/ankle DTI. The outcome of the evaluation was the resident had a heel pressure device in place and it was replaced with the resident's prior soft boot. 2. Although the use of the doughnut-type device was mentioned on the Kardex and care plan, neither the Kardex nor the care planned instructed staff how to properly place the device under the resident's left lower extremity. Staff interviews revealed none had received training on how to properly place the doughnut-type device. The DOT, in his interview on 8/20/2020 at 2:05 p.m., said he did not know if staff were educated on the proper placement of the cervical collar pillow. CNA #1, interviewed on 8/20/2020 at 1:58 p.m., said the resident did not have wounds on his left leg up until a month ago or so and now all of a sudden he did and they were pretty bad. She said she usually elevates the resident's feet with regular pillows. She said she had not received any training on how to use any positioning device for Resident #1. Licensed practical nurse (LPN) #1, interviewed on 8/20/2020 at 4:10 p.m., said the resident did not have any leg wounds until a month ago. She said the family wanted them to use the doughnut pillow they brought in about six months ago for the left leg. She said the resident did not like the boot that therapy provided. She said she believed it was the pillow that caused the wound due to not being placed around the leg properly. She said she did not receive any training on how to place the pillow properly on his LLE. UM #1, interviewed on 8/20/2020 at 5:00 p.m., said the family brought the doughnut pillow in a while back, maybe longer than a year ago. She said the family wanted the pillow used instead of the one we recommended. She said she did not receive any training on how to use the personal pillow properly. CNA #8, interviewed on 8/20/2020 at 5:00 p.m., she said that she had been taking care of Resident #1 for the past couple of months. She said she usually props resident's feet up on several pillows to help avoid pressure. She said she had used the pillow provided by the family on the LLE but did not receive any instructions on how to properly place it. The DON, interviewed a second time on 8/20/2020 at 5:15 p.m., she said they were using the doughnut pillow per the family's request. She said she did not know how long the pillow was in use and did not know if staff had been instructed on how to properly place the pillow. She said she would look for documentation on both issues. The wound nurse (WN), interviewed on 8/24/2020 at 5:00 p.m., said the resident did not have any unhealed wounds to the LLE until she was notified to look at the newly acquired wounds. She said when she first saw the wound behind the ankle/calf area it was purple and the skin was intact. She said she did not know if the facility had care planned the use of the pillow before using it. She said the resident DTI was caused by the improper use and application of the doughnut pillow, stating one of the CNAs placing the device provided by the family incorrectly. The shape of the DTI wound on the back of the ankle/calf area was the shape of the doughnut pillow, round. She said the wound kept getting worse and unfortunately was not going to heal due to his already compromised state. She said she did not personally provide any education to the staff about the use of the doughnut pillow. 3. There was no documentation to show the resident and/or family had been educated regarding the use of a non-formulary positioning device and the risks versus benefits of its use. The DON, in an interview on 8/17/2020 at 4:50 p.m. and in another interview on 8/20/20 at 5:15 p.m. said the facility had recommended a soft protective boot for Resident #1 and his heels were always elevated. She said the family had brought a pillow from home and wanted it used instead of the boot for offloading his LLE. She said staff had tried to educate the family about using the soft boot instead of the one they brought from home. She further said they had tried educating the family many times but did not know if there was any documentation to support that. The NHA, interviewed on 8/17/2020 at 4:50 p.m. with the DON said Resident #1's family insisted the facility use the doughnut pillow (see above). She said the facility documented in the resident's record the risk of using the cervical collar pillow and the wound nurse had spoken to the spouse about the risks. The WN, interviewed on 8/24 at 5:00 p.m., confirmed she talked to the family to let them know the pillow could cause issues and recommended that a facility soft boot be used. However, there was no documentation in Resident #1's record to show the resident or his family was thoroughly educated on the use of the doughnut-type pillow and the risk for harm versus benefits of its use. (See care plan above) D. Physician interviews The primary care physician (PCP) for the resident, interviewed on 8/25/2020 at 2:29 p.m., said that it had been difficult to get in to see the resident due to the COVID-19 restrictions. He said there was a care conference held with the hospice team, the family and the facility representatives. He said they discussed many concerns including the wounds caused by pressure. He said the resident had very serious vascular disease (circulation) and had a dry gangrene on his left toes due to poor circulation. He said the resident had underlying ischemia (insufficient blood flow) which predisposed him to skin breakdown. He said he was not aware the resident had been using a non-formulary positioning device. The wound doctor (WD), interviewed on 8/27/2020 at 1:49 p.m., said the resident had sustained a DTI from pressure. He said wounds could be caused by immobility, lack of sensation or improper placement of a positioning device. He said he did not remember what type of a device was used to elevate the resident's LLE. He said that doughnut cushions are not good to use for elevating an extremity because it puts pressure on one area and did not spread the pressure out evenly. He said if a resident had predisposing complications, proper care and interventions should be put into place; otherwise, if things are not being done correctly, problems could arise and then become worse. He said the resident's wounds started out as DTIs and then worsened. He said he had not seen the resident in about two weeks and did not know the status of the wounds at this time.

Based on observation, record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for nutrition out of three sample residents received the necessary care and services to maintain acceptable parameters of nutritional status. Specifically, the facility failed to ensure: -A formal nutritional assessment was completed following a significant weight loss for Resident #1; -Monitoring of nutritional interventions and intakes was adequate and completed; and, -Additional measures and interventions were considered and put into place to ensure adequate meal intake and prevent further weight loss. The facility failures contributed to the resident experiencing a significant weight loss. Findings include: I. Facility policy The director of nursing (DON) provided the facility's Nutrition/Hydration Management policy, revised 1/31/2020, on 8/25/2020 at 12:35 p.m. The policy documented in part, The implementation of an individual patient's nutrition/hydration management occurs within the care delivery process. Staff will consistently observe and monitor patients for changes and implement revisions to the plan of care as needed. The purpose was to provide safe and effective care to manage patients ' nutrition and hydration needs. -Address any changes in condition that affect or potentially affect the patient's nutritional status with Dietician when indicated; -Observe oral intake of meals, supplements and snacks and complete the meal monitor data collection sheet when ordered or indicated; -Monitor patient's weight as ordered; -Review Dietitian's progress notes to identify ongoing progress and recommendations; -Revise patient's care plan as needed; -Document: percentage of food/fluid intake, administration of oral supplements, enteral feedings, or total [MEDICATION NAME] feedings; -Intake and output as ordered/indicated. II. Resident #1 Resident #1, age greater than 65, admitted on [DATE]. According to the August 2020 computerized physician orders [REDACTED]. (Cross-reference F686) On 8/17/2020 at 1:00 p.m., a family member stated she had recently visited the resident. She said it had been awhile since she had seen Resident #1 and he looked much thinner and weak since the last time. She was concerned staff were not assisting him to eat. On 8/20/2020 at 1:15 p.m. the resident was lying in bed and slightly turned to his right side facing the over the bed table. He was trying to reposition his upper body using the bed cane. The resident appeared thin and frail. The cheeks of his face were sunken in. His upper body and arms appeared thin and bony. He had an opened bottle of water on his bedside table. He said he did not like the facility food brought to him. He said he had not had much of an appetite lately and missed his family coming in to see him. A. Resident status The minimum data set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment with a brief interview of mental status (BIMS) of ten out of 15. He required extensive assistance with eating of one person. His height was 64 inches and weight of 163 pounds and had no or unknown weight loss or gain during the review period. He was not assessed to have a swallowing disorder. A care plan initiated 11/8/18 with a target date of 9/20/2020 identified the resident required assistance at times for eating related to paralysis/weakness affecting the left upper extremity. (LUE). Interventions included to provide set-up, supervision assistance for utilizing suitable utensils needed for eating. A care plan initiated 12/17/19 and revised on 1/9/2020 revealed the resident had a strong preference for Hispanic foods, often did not eat facility meals but would eat food brought in by family members. The goal was the resident would have intake of food and fluids as desired for comfort and pleasure x90 days. Interventions included to warm up food provided by family as needed, honor food preferences within meal plan, weight per facility protocol and monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition to physician as indicated. A nutritional assessment dated [DATE] documented there were no concerns identified. The resident's weight was 165 pounds on 3/5/2020. His BMI (Body Mass Index) was 28.3. He was on a regular liberalized diet and had a strong preference for Mexican food. He was considered overweight by BMI standards, however; appropriate for age. He had selective food preferences and primarily liked sweets, baked goods and Mexican foods. He had generally poor intake of facility foods. The family typically brought in food and supplements, however; they were currently unable to visit. The note further read that the importance of eating facility foods was discussed with the resident. His average intake was 60 percent and breakfast was usually his best. The resident was not assessed to have a significant weight loss or gain. The summary documented the resident remained on Hospice services with the goal of nutrition being comfort oriented while attempting to minimize preventable weight loss and skin breakdown as able. As needed interventions included fortified pudding twice a day with meals, fortified oatmeal, two bowls with banana and use of a scoop plate with meals and assistance with meals. A nutritional assessment dated [DATE] also documented in pertinent part there were no concerns identified. The resident's weight was 162.6 on 6/3/2020 and his BMI was 27.9. He remained on the same regular, liberalized diet. The resident ate in his room per infection control protocol and needed set up assistance at minimum and additional assistance as needed. He received a scoop plate to encourage independent eating. He continued to exhibit poor intake of facility foods and did well with the fortified oatmeal at breakfast. The family had provided food and snacks that were kept in the resident's room. Under the section entitled skin integrity, the resident did not have any skin injuries per skin check of 6/3/2020. The RD attempted to contact the resident's power of attorney (POA) and left a voicemail. (There was no further documentation the RD attempted to follow up with the POA.) The plan was to continue current interventions (see above). B. Record review revealed weight loss in July 2020, followed by further, significant weight loss in August 2020, as well as poor intake. 1. The weight record over the last six months revealed the following: 3/5/2020 -165.0 pounds 5/3/2020 - 163.8 pounds 7/2/2020 - 155.8 pounds 8/6/2020- 140.8 pounds The weight record revealed a 14.67 percent weight loss from 3/5/2020 to 8/6/2020; a 14.05 percent weight loss from 5/3/2020 to 8/6/2020; and a 9.40 percent weight loss from 7/2/2020 to 8/6/2020. 2. Intake A 30-day (7/27/2020 to 8/25/2020) look-back record of the resident's daily meal intakes revealed he consumed between 25 to 50 percent. There were 20 days out of 30 with only two meals recorded for the day and two out of 30 days where only one meal was recorded for the day. There was zero percent consumed recorded on: 7/31/2020 (breakfast, lunch, dinner); 8/3/2020 (breakfast, lunch dinner); 8/15/2020 (breakfast and dinner); 8/16/2020 (breakfast and dinner); 8/17/2020 (breakfast, lunch, dinner); 8/19/2020 (breakfast, lunch, dinner); 8/20/2020 (breakfast, lunch, dinner); 8/22/2020 (breakfast, lunch, dinner). Five refusals were recorded on 7/27/2020 (lunch), 8/11/2020 (breakfast), 8/12/2020 (breakfast), 8/15/2020 (lunch) and 8/16/2020 (lunch). C. Facility response to Resident #1's poor intake, weight loss 7/2/2020 and significant weight loss 8/6/2020 - failures in facility response. 1. Facility response A 7/14/2020 nutrition note documented the resident had wounds and a protein supplement was recommended to promote wound healing (Proheal 30 milliliters every day).Other interventions included cheddar omelet and fortified oatmeal at breakfast, fortified pudding at lunch and dinner and food and supplements brought in by family. A care plan meeting note dated 7/29/2020 documented the resident's diet was reviewed and noted that he refused facility foods and Ensure supplement was provided. The daughter requested that someone assist him with meals to ensure he was eating properly. The resident's Kardex (a flow sheet to direct resident care) created 10/18 and current as of 8/17/2020, similar to the resident's care plan, read to encourage resident to consume all fluids of choice during meals, please warm up food provided by family for resident as needed, provide fortified foods per RD (registered dietitian) recommendations, provide Mexican foods within facility's ability as resident requests and provide set-up assist at meals, additional assistance as needed. A progress note by the nurse practitioner, dated 8/3/2020, documented the resident was seen for a change of condition related to left foot necrosis. The note revealed the resident had abnormal weight loss, appeared chronically ill, his cheeks were sunken and he had temporal wasting. In addition, the note revealed the resident appeared to have lost more weight with more temporal wasting. There were no recommendations made during the visit to address the additional weight loss. A nutrition note dated 8/19/2020 documented the RD recommended increasing supplement to three times a day due to weight loss and the 8/2020 CPO documented the following order in pertinent part: -Regular, liberalized diet, regular texture. Start date 11/4/19. -Protein liquid 30ml (milliliters) two times a day. Start date 7/29/2020 -Ensure three times a day. Start date 8/18/2020 -Multi Vitamin/Minerals. Start date 7/29/2020 -[MEDICATION NAME] (appetite stimulant) 7.5mg (milligrams). Start date 7/23/2020. Finally, progress notes reviewed for the past 45 days revealed staff encouraged the resident to eat and offered supplemental shakes with little to no success. 2. Failures in facility response Record review revealed no evidence found in the clinical record the RD calculated Resident #1's caloric (Kcal), fluids or protein needs to sustain and maintain optimal nutritional health and wound healing based on his age, height, weight and medical condition following his significant weight loss 8/6/2020. (Cross-reference F686; the resident currently has an acquired, unstageable, necrotic wound to his left lower extremity.) Record review revealed a new MDS assessment was not completed following the resident's significant weight loss of 15 pounds in one month. Record review revealed there were no additional interventions implemented or care planned when the significant weight loss was identified. Record review of the 7/14/20 nutrition note (see above) documented the family was bringing food and supplements but the note did not specify how often to offer the food items or the supplements to the resident or how this should be monitored. Moreover, the DON, interviewed on 8/24 at 6:20 p.m., was asked to provide any documentation to show that the monitoring was occurring. The DON did not provide any additional documentation. Record review of intake records revealed no documentation the facility reapproached the resident to offer nourishment when he refused his meals or had zero intake (see above) . Finally, while review of progress notes for the past 45 days revealed staff encouraged the resident to eat and offered supplemental shakes with little to no success, there was no documentation found staff attempted additional interventions such as calling the family to discuss other suggestions or to talk to the resident to encourage him to eat. D. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 8/20/2020 at 1:55 p.m. She said she had been taking care of the resident for the past three months. She said he was declining and had lost weight. She said he often refuses to eat. She said his family would send in Mexican food and he really liked tamales; however, he was not always eating the food the family brought in. She said she offered to feed him but he wanted to do it himself. The director of nursing (DON) was interviewed on 8/24/2020 at 6:20 p.m. She said the interdisciplinary team (IDT) had at risk meetings on Tuesdays and weight loss was addressed. She said the RD was involved in the meetings and gave updates and input. If there was a significant change in weight then a change of condition was documented. She said the family had been bringing food for the resident that he liked and the daughter would call to check and see if he received the food. She said that nursing was told to document in the clinical record when food from the family was offered. She said they had a designated IDT person assigned to check in with the resident to encourage him to eat. The RD was interviewed on 8/25/2020 at 10:50 a.m. He said he had started working at the facility in June 2020. -He said he completed a nutritional assessment on residents quarterly with the MDS schedule. He said if a resident triggered for weight loss, he would take a look at them. He said if a resident has a weight loss, they try to provide items that the residents prefer to prevent any further weight loss. He said nursing was responsible for updating the physician regarding weight loss issues. He said if the nurse practitioner was in the building he would speak to them. He said the IDT met every morning and they would discuss any residents that had nutritional concerns and they also have at risk meetings. He said they discuss as a team what would be beneficial to the resident. He said he was responsible for updating the nutrition care plan. He said if there was weight loss identified with a resident, he would try and follow up with a note, otherwise, he would capture it in the next quarterly MDS assessment. He said he tried to provide oversight to residents with weight loss concerns to observe at least one meal, however; he could not make it to every resident. He said he reviewed meal intake records and talked with staff regarding concerns. -He said Resident #1 did have a significant weight loss and they offer him the food the family brings in and offer liquid supplements. He said the resident did not like the facility food but seemed to do well with breakfast items such as oatmeal. He said he tried calling the resident's wife and left a message but did not hear back from her. He said he did not attempt to reach back out to her. -He said that collaboration with hospice was done through care conferences. He said that when a resident was on hospice care it was about comfort and that food and fluids were provided for comfort and for pleasure. He said Resident #1 also recently started on an appetite stimulant. He said the family used to come in frequently before the COVID-19 pandemic visitor restrictions were put into place. He said the impact of this, having wounds (cross-reference F686) and not having his family around, could potentially be a factor in his significant weight loss. The primary care physician (PCP) was interviewed on 8/25/2020 at 2:30 p.m. He said the resident was thin with poor intake. He said that his [DIAGNOSES REDACTED]. He said the impact of not being able to see his family on a regular basis may also be a contributing factor to his weight loss.

Based on observations, record review and interviews the facility failed to ensure the resident environment remained as free of accident hazards as possible, and that each resident received adequate supervision and assistive devices to prevent accidents. This failure affected one (#33) of 56 total sample residents. Specifically: Falls -The facility failed to protect Resident #33 from numerous falls which resulted in major injuries. Equipment -The facility failed to ensure space heaters were not used in resident areas. -The facility failed to ensure medical devices were not plugged into non-medical grade power strips. Findings include: I. Falls [NAME] Immediate jeopardy 1. Situation of Immediate Jeopardy Resident #33, age 57, was admitted on [DATE] with a readmission date of [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 9/18/19 minimum data set (MDS) assessment revealed the BIMS interview could not be conducted because the resident was rarely to never understood. He required extensive assistance from one person for bed mobility, dressing, toilet use, and personal hygiene, extensive assistance from two people for transfers, was totally dependent with eating, and was not walking (used a wheelchair). On 12/17/19 at 11:46 a.m., the nursing home administrator (NHA) was notified Resident #33 sustained 26 falls within five months with major injury, which included, numerous major injuries which included, head trauma, bone fractures, lacerations, and black eyes. Resulting in a significant cognitive and mobility decline with a recent [DIAGNOSES REDACTED]. These failures created a situation of immediate jeopardy. The facilities response was as follows: Resident (#33) was placed on 1:1 for monitoring of intervention effectiveness on 12/17/19 at 11:50 a.m. 1:1 to use call light and or ask floor staff for coverage when a break is needed. These interventions were implemented on (MONTH) 17, 2019. - Physician order [REDACTED].>-Restorative Nursing Plan ordered/implemented, stand pivot transfer assist to promote upright functional mobility. Assist with ambulation as tolerated using walke-6 times/week for 15 min. Restorative Nursing Program to be completed by CNA (certified nurse aide) and monitored by DON (director of nurses). -Vitamin D B-12 Level (Drawn 12/17/2019 WNL (within normal limits) -Motion Lights placed in room to improve lighting and behaviors due to impulsivity on 12/17/2019 -Binder with the following information has been presented to staff with education. The binder is kept in the residents room. Behavior Modification Techniques Likes/Dislikes pulled from care plan: -Likes: Reading the newspaper, walking, [MEDICATION NAME] oil, hip hop on his phone, going outside, watching TV, snacks, enjoys comedies and National Geographic -Dislikes: close supervision, group activities, helmet -New staff will be educated during orientation to the floor. Education initiated by the DON on 12/17/19 to include but not limited to floor staff. Training to include residents fall mitigation efforts to reduce injury. Continue to participate in Pet visits as scheduled and resident allows, at least weekly. -Knee pads, elbow pads and a variety of helmets for the resident to choose from offered and accepted. Residents requests items to be removed and they are removed when requested. Offer to resident every shift. CNA will document in P[NAME] refusal or acceptance under the Task tab. -Use a soft approach soft tone of voice, talk slowly in short simple sentences re-approach later -Monitor and track hours of sleep -Room de-cluttered, padding added to the sink and bed board. Excess furniture removed and TV hung on the wall to attempt to reduce major injury with fall. -Monitor and report changes in alertness, attention, sleep patterns, behavior, or mood to physician, DON and CED (center executive director/ nursing home administrator). -Basil plant given to resident with scheduled watering times. Interviews initiated by DON or designee with staff on the resident's unit. Questions targeted to assess the effectiveness of interventions, gain information related to residents needs for direct care staff and to implement appropriate newly suggested interventions. 1. What interventions do you feel are working to prevent falls? 2. What fall interventions are not working. 3. What suggestions do you have to prevent falls. 4. Have you received enough education related to fall interventions. -Physicians will continue to evaluate the need for additional interventions to assist in preventing falls with major injury. -On (MONTH) 17, 2019 the team held an Immediate QAPI meeting to identify any root cause or trends for resident falls. Incidents reviewed to include activity during fall, staff interviews, time of day and number of falls and effectiveness of current interventions. Trend identified for two times frame, scheduled timed toileting was added at 1400, 2200, 0600. Scheduled water times for plan on Tuesday/Friday at 1600. CNA Fall Care communication tool was developed 12/17/2019. -Nurses will monitor completion of documentation, intervention appropriateness/effectiveness each shift, to be reviewed by the IDT (interdisciplinary team) . 2. Based on review of the facility's removal plan, observations and record review, the NHA was informed the Immediate Jeopardy situation was removed on 12/18/19 at 11:00 a.m. However, deficient practice remained at a G level. The NHA said the abatement plan interventions had been implemented as of 12/17/19 after the immediate jeopardy was called. B. Facility Policy The fall policy dated 3/15/16 documented in pertinent parts, .Patients will be assessed for fall risks as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Patients experiencing a fall will receive appropriate care and investigation of the cause Communicate patients fall risk status to caregivers, Develop individualized plan of care, Review and revise care plans regularly Conduct Interdisciplinary team meeting with 72 hours of falls The Center Executive Director (NHA) and Center Nurse Executive (director of nurses) will conduct a post fall review . II. Resident #33's- multiple falls with major injury The nurse's notes, interdisciplinary team (IDT notes) event summaries and care plan were reviewed. The medical record documented the resident had fallen at least 25 times between 7/11/19 and 12/15/19. The facility failed to protect the resident from multiple falls, and two falls resulted in major injuries, and ten with minor injuries and 13 falls with no injuries. Although an event summary report was completed on the falls, the facility failed assess and implement effective fall interventions and re-evaluate the fall interventions after a fall for effectiveness. The facility failed to investigate to identify root cause of falls to determine trends then modify the fall interventions and failed to provide adequate supervision to prevent further falls and/or further injury from frequent falls. As a result the resident sustained [REDACTED]. Resulting in a significant cognitive and mobility decline with a recent [DIAGNOSES REDACTED]. Although, the 25 (no event summary completed for 8/20/19) event summary reports were completed, and had a root cause conclusion, the reports documented the events of the falls and poor safety awareness and did not have a root cause. On 9/4/2019 at 4:39 p.m. the physician progress notes [REDACTED]. the resident was alert, with no acute distress, his jaw wired shut, and he was unable to verbalize and has a bruise over the left eye. ([MEDICAL CONDITION]) TBI without L[NAME] of unspecified duration sequelae. Given the patient's fall history over the past year, I think he has sustained enough head trauma and accumulated enough injury to be consistent with [MEDICAL CONDITION]. His personality and decision-making capacity certainly is impaired compared to 6-12 months ago. I discussed this with the NP as well as nursing and the patient's mother. I think the patient has sustained significant brain trauma that has led to at least a mild cognitive deficit . Prior to the falls with major injuries which occurred on 8/20/19 the resident experienced two falls with minor injuries, and three falls with no injury. The resident experienced six falls with minor injuries and five falls prior to the second fall with major injury on 9/19/19. The falls with major injuries were as follows: 1. Major injury fall #1 -On 8/20/19 the IDT progress note documented, social services director (SSD) received call from a nearby medical office that Resident #33 stopped in the medical office and did not feel well. The medical office said called the facility to report that Resident #33 had fainted face first to the floor, and as a result suffered a laceration to the front and back of his head and appeared to have broken teeth. The resident was sent to the emergency room . -On 8/24/19 the progress note documented the resident was readmitted to the facility after a stay in the hospital for post/trauma/accident. The resident had a fracture of mandible fracture and a subdural hematoma. His jaw was wired shut. The medical record failed to show an event summary report was completed in relation to this fall in order to identify root cause, and to evaluate interventions. 2. Major injury fall #2 On 9/19/19 at 9:26 p.m., the resident experienced a fall with the one to one sitter. The progress note documented the resident was agitated. On 9/19/19 at 7:05 p.m., the event summary report documented, the agency CNA stated that she stood up to call a facility aide to relieve her, and the resident stood up to follow her and fell forward onto the floor. The resident injured his knees and elbows bilaterally. The report documented the interventions which were in place prior to the fall were as follows: - Medications reviewed by NP and dose adjustments were made to his insulin and B/P medications. -Monitor vital signs, including orthostatic B/P as needed and report to MD as indicated. -NP reviewed medications and made adjustments with his insulin and B/P medications. -Offer/assist resident with urinal/commode as requested/needed. -Staff continue to remind him to ask for assistance. -Utilize night light in the room/bathroom. -Medication evaluation as needed. -Place call light within reach when in bed or close proximity to bed. -Resident had one on one supervision. After the fall an x-ray was ordered, as the resident was complaining of pain. The report documented, the resident refused all the imagining to be completed and he was sent to the emergency room for evaluation. 3. A summary of the falls with minor injuries were as follows: --On 7/11/19 at 1:30 p.m., the event summary report documented, the resident was in the lobby, he stated he was sitting for about 15 minutes, stood up and started walking. He got dizzy and fell to his knees. The resident's blood glucose (BG) level was 358. He was assisted back to his room. The neurological check (neuro checks) and assessment were completed. The report documented the preventative measures which were in place prior to the fall were call light and personal items were within reach, and room was clutter free. The resident experienced an abrasion to bilateral knees. The corrective action was the resident had a history of [REDACTED]. The resident was impulsive. The progress note at 3:07 p.m. read in pertinent part, Orders obtained include: assist resident to his room and encourage him to use call light for assistance . -On 7/26/19 (no time indicated), the event summary report documented, the resident was noted to be walking outside the facility this shift. Resident traveled to Target shopping center where two employees discovered the resident. Resident returned to the facility via employee transportation. Resident #33 stated the scraps and cuts on his right knee and right palm of hand, came from a fall in the parking lot. -On 7/26/19 at 1:35 a.m., the event summary report documented, the resident was observed on the floor next to bed. The resident received a 3 cm laceration to the back of the resident's head and abrasion on his left elbow. Resident had regular socks on at the time of the fall. The resident was educated to use the call light when trying to go to the bathroom. Non-slip socks were placed on the resident. Preventative measures were put into place prior to the fall included, call light and personal items within resident's reach and clutter free environment. - On 9/2/19 at 1:00 p.m., the event summary report documented, the resident was found on the floor face down. The resident was assisted into a chair then assessed by the licensed nurse. The resident had hit the back of his head (soft bump noted). The report documented a meeting was to be scheduled with the family to discuss his multiple falls. -On 9/5/19 at 2:15 p.m., the event summary report documented, the primary nurse reported that the resident had a fall in his room and sustained lacerations on his forehead. The nurse practitioner ordered STAT x-ray of the c-spine and skull. Resident #33 said he was trying to pick up the TV remote and he fell . --On 9/5/19 at 4:25 p.m., the event summary report documented, NP had just finished speaking to the resident regarding increased recent falls and she was standing at nurse's cart when NP and RN heard a loud crash from the resident's room. When they entered his room they found him lying face up on the floor, unresponsive. Resident had a heartbeat with agonal breathing. Staff assisted the resident with breathing via ambu bag and called 911. Resident was responsive, breathing independently and able to answer questions when emergency medical services (EMS) arrived. Resident transported to ER for further evaluation. -On 9/11/19 at 12:28 a.m., the event summary report documented, the resident was wheeling himself around the unit, he stood up, resulting in a fall and landed on his right elbow. Resident reported pain in his elbow and it was red. He was able to move all extremities. A STAT x-ray of elbow was ordered due to pain. Resident continued to try and stand even when educated that he was too weak. The license nurse and certified nurse aide (CNA) were taking turns with 1:1 attention for the resident. -On 9/18/19 at 1:30 a.m., the event summary report documented, the resident was found on the floor of his room. He had bleeding to his upper eye from the previous fall. The resident had fallen the previous day on 9/17/19 at 9:15 a.m., by rolling out of bed. He said he wanted to get into his wheelchair. -On 9/19/19 at 6:30 p.m., the event summary report documented, the resident was transferring from his wheelchair to bed, and threw himself backwards onto the bed, striking his head on the door handle of the door. The incident was witnessed and he had a bump on the upper back of his head. -On 12/10/19 at 5:00 a.m., the event summary report documented, the resident was noted to be on the floor in his room. Resident said he hit the back of his head. The report documented, the care plan was followed. The interventions put into place was to attempt to assist the resident out of bed as early as possible when he awakes. IV. Resident fall history after 9/13/19 Abbreviated survey On 9/13/19 during an abbreviated survey, the facility was cited for F 689 at a harm level; upon exit (9/13/19) until compliance (10/7/19) Resident #33 also sustained two falls (see above). After the facility was back in compliance the resident sustained [REDACTED].>- On 10/19/19 at 2:00 p.m., the event summary report documented, the resident was sitting in his geri-chair when he told the sitter he had to go to the bathroom. The sitter was positioned in front of the chair, she turned slightly to unplug the tube feeding (TF), he then stood and slid to the floor. He did not hit his head. - On 10/28/19 at 7:15 p.m., the event summary report documented, the sitter informed the nurse while the resident attempted to ambulate independently after sitting up in bed; the resident was unsteady and fell back onto the bed. - On 11/28/19 at 4:00 p.m., the event summary report documented, the resident had an unwitnessed fall and was found on the floor in the library room. The report documented no injury. - On 12/6/19 at 4:00 p.m., the event summary report documented, the emergency bathroom light came on in the residents room. The resident was found in the bathroom between the toilet and the wheelchair (w/c). The w/c brakes were locked. The resident was sitting on the floor facing the wall with his pull-ups and pants just above his knees. He was not able to tell the nurse what had happened. He had rapid respirations and was wide eyes as if very frightened. The resident experienced a second fall on 12/6/19 at 8:15 p.m., the resident fell while trying to stand up in the dining room. Resident #33 became agitated with staff when attempting to redirect. - On 12/10/19 at 10:50 a.m., (second fall for the day) the event summary report documented, the resident was in the hallway, and was seen holding onto the rails with buttocks on the floor, w/c behind him. A CT-Scan was ordered for his head. -On 12/15/19 at 8:40 p.m. the event summary report documented, the resident self propelled in w/c, closely monitored by nursing staff. During the end of shift reported the resident rolled around the corner to another hallway away from nurses. Residents in the atrium hollered to get the nurses attention that the resident was on the floor. Resident noted on the floor with mild twitching [MEDICATION NAME] approximately 30 seconds. Once eyes opened, they were slow to respond. Pupils sluggish and unchanged. V. The facility failed to implement effective fall interventions and re-evaluate the fall interventions after a fall for effectiveness. The director of nurses (DON) was interviewed on 12/17/19 at 9:45 a.m. The DON said that after each fall the care plan was updated. She said the care plan was updated to include, how and when the resident fell , then the interventions were listed. She said the resident had experienced so many falls, that the program had a difficult time with keeping all of the information. The care plan last updated, on 12/10/19 identified the resident was at risk for falls related to experiencing dizziness, diabetes mellitus (DM) with uncontrolled blood sugars (BS). The resident was ambulatory with poor safety awareness and impulsiveness. The care plan was updated with dates and interventions after each fall included: -Utilize night light in the room/bathroom. 7/29/19 -Medication evaluation as needed. 7/29/19 -Place call light within reach, anticipate resident's needs as he may not use the call light related to the decline in cognitive status. 7/29/19 -Maintain a clutter-free environment in the resident's room and consistent furniture arrangement. 7/29/19 -When the resident is in bed, place all necessary items within reach. 7/29/19 -Monitor for and assist with toileting needs. 7/29/19 -Encourage resident to attend all activities that maximize their full potential while meeting their need for socialization. 7/29/19 -Monitor vital signs including orthostatic blood pressure as needed and report to MD. 7/29/19 -Offer/assist the resident with the urinal/commode as requested/needed. 7/29/19 -Assess for changes in medical status, pain status, mental status and report to MD.7/29/19. -NP reviewed medications and made adjustments to his insulin and B/P medications. 8/12/19 -Medications reviewed by nurse practitioner (NP), dose adjustments made to insulin and blood pressure (B/P) medications. 8/18/19 -Resident has a history of dizziness and falling, staff continue to remind the resident to ask for assistance. The resident is impulsive and continues to transfer on his own. 9/6/19 -Resident was placed in a recliner in the atrium for closer supervision. 9/10/19 -Resident has refused therapy, will try again and see if he will participate. 10/19/19 -Soft helmet related to recent fall and impulsiveness. Therapy to address fall. 10/29/19 -The wheel chair cushion was re-evaluated with the second fall.12/10/19 The facility failed to show that the interventions were evaluated for effectiveness, and were timely. The interventions in the event summary report, had listed, he was reminded to use the call light and to wait for assistance, however, this intervention proved to not be effective as he continued to fall 23 more times since the intervention was put into place. The intervention of encourage resident to attend all activities, was added to the care plan however, according to the interview with the nursing home administer on 12/17/19 at 3:45 p.m., the resident did not like to attend group activities. Review of the activity participation records for (MONTH) and (MONTH) 2019 showed he did not attend activities that he preferred in room activities. The regional nurse consultant said on 12/17/19 at 3:45 p.m., he was being evaluated for pet therapy as he liked dogs. The resident was observed on 12/10/19 at 3:21 p.m. in his room with a 1:1 CN[NAME] They were sitting in the room, not engaged in any interactions, i.e talking or other activities. The resident began moving his feet back and forth, the CNA got up and took him to the bathroom. Afterwards, they returned to where they were sitting previously. They remained in the room until 4:06 p.m. The CNA took the resident out of his room and walked around the unit. The intervention of resident refused therapy was added on 10/19/19 and that they would attempt again if he would participate. However, the facility was aware he was not wanting to participate in therapy according to the interview with the NHA on 12/17/19 at 3:45 p.m. The NHA said the resident was referred to therapy 13 times and he refused nine times and worked with therapy five times. The intervention with soft helmet was added on 10/29/19, however, he had 20 falls prior to the soft helmet addition on the interventions. The summary event reports showed he had eight unwitnessed falls, and eight falls which resulted in a head injury or report that he hit his head. The remaining four falls were witnessed and staff reported he did not hit his head. The NP was interviewed on 12/17/19 at 12:50 p.m. The NP said the resident did not like to wear the soft helmet and he would throw it across the room. The event summary reports were reviewed and none of them reported the soft helmet was on when the resident sustained [REDACTED]. The NHA was interviewed on 12/17/19 at 3:45 p.m. The NHA said the resident was always walking, and enjoyed going outside to walk. She said he was difficult to keep sitting, as he always enjoyed walking. The facility failed to include the resident in a restorative walking program. The medical record showed no evidence the resident was on a restorative program which would have allowed the resident to safely engage in an activity he enjoyed. The care plan failed to include, from the event summary report on 12/10/19 showed the interventions put into place after the fall was to attempt to assist the resident out of bed as early as possible when he awakes. VI. The facility failed to ensure the certified nurse aides and the licensed nurses were aware of the plan of care Observations On 12/16/19 at 9:45 a.m., the registered nurse (RN) #3 was observed to keep the resident near the nurses cart. She was observed to pass medications to other residents. When she would leave the cart to go to another resident room, she would push the resident to the room and have him sit outside the room while she cared for the other resident. On 12/16/19 at approximately 4:00 p.m., the certified nurse aide was sitting with the resident. The CNA said he was on a one to one sitter with Resident #33. VII. Interviews RN #3 was interviewed on 12/16/19 at 9:43 a.m. she stated she was pretty much 1:1 with him. She said she wasn't sure if there was an order or not but he would get up and fall. RN #3 said she tried to keep him close. She said she had him sit at the cart while she went into other rooms so he could be close to her The director of nurses (DON) was interviewed on 12/17/19 at 9:45 a.m. The DON confirmed the resident had fallen 26 times since (MONTH) 2019. She said an event summary and fall investigation should be completed after each fall. She said interventions should be implemented and added to the care plan after each fall. She said when the IDT reviews the falls then the IDT team will add more interventions as needed. She said she keeps a log of all falls, however, she does not have any information from (MONTH) 2019 to (MONTH) 2019. She said a unit manager was keeping the log and she could not find the information. She said she took over monitoring the falls in (MONTH) 2019. She said a fall investigation should have been completed when he fell outside of the facility. The DON said Resident #33 had a sitter since (MONTH) 2019, however, she said it was discontinued in early (MONTH) 2019 as the criteria to use a one on one sitter was to prevent falls, however, he had three falls with the one on one sitter, and the IDT reviewed the falls and determined to remove the one on one sitter, and just keep an eye on him. She said the NP reviewed the medication on 8/14/19. She said the soft helmet was added to the care plan 10/29/19. The DON said in (MONTH) 2019, he was alert and oriented, and he has now had a significant change in his cognitive status. She said it was a combination of falls and diabetes. The DON said the NP said that he had a [MEDICAL CONDITION]. The DON said the logs were used to track and trend, however, she confirmed she only had the logs since September. She said most of his falls were in his room, but she was not sure of the times he fell . The medical director was interviewed on 12/17/19 at 12:50 p.m. The MD said earlier in the resident's stay at the facility he had been the primary physician. He said he was aware the resident had sustained numerous injuries, which included bone fractures and head trauma. He said Resident #33 had been discussed at the quality assurance performance improvement (QAPI) meeting and the falls were unresolvable until his condition worsened. He said the sitter was unsuccessful as the resident became angry. He said the resident had lost all muscle tone and when he stood up he fell . He said there was nothing more they could do to keep him from falling. He said if there was anything that could prevent him from falling, it would of been added a year ago. The MD said the facility could not be held accountable for keeping people safe when they made poor decisions. The primary physician (PP) was interviewed on 12/17/19 at 12:50 p.m. The primary physician heard the medical director's reasons for the falls and then replied the resident had type one diabetes and he also had a condition that his blood pressure dropped when he stood. The [MEDICAL CONDITION] contribute to passing out. He said the resident was extremely brittle diabetic. His blood sugar was difficult to regulate. The primary physician confirmed the resident had sustained subdural hematomas as a result of hitting his head. He said the resident had poor judgement. The primary physician said the resident had fallen when he resided at an assisted living prior to moving to the facility. The PP said short of chemically restraining the resident he was not sure what else could be done. The NHA was interviewed on 12/17/19 at 3:45 p.m. The NHA said while he had the sitter, he would become agitated and did not like the sitter. She said the resident was not on a one to one sitter prior to the immediate jeopardy at 11:50 a.m. She said the staff take it upon themselves to keep him on a one to one, because they know he has had multiple falls. He liked to go outside and he wears a wander guard as he did not sign out like he should. She said the only resort they had to keep him safe was restrain him. She said the family was pleased with the care and had no suggestions. IX. Space heaters [NAME] Observations On 12/9/19 at 12:00 p.m., residents were observed in the main dining room awaiting their meal. The dining room had three space heaters which were spread across the dining room. The space heaters were currently being used. On 12/9/19 at 2:00 p.m., room [ROOM NUMBER] had a space heater. The resident was in her room lying in bed. B. Interviews The MTD was interviewed on 12/9/19 at 4:50 p.m. The MTD said that the space heaters had been in the building since the day after Thanksgiving. He said the circle pump on the was being replaced as it was not pumping hot water through the furnace. He said the parts had been ordered, but the space heaters four in the dining room were being used and one in 801 and one in 1202. He said that the main dining room was cold and therefore the space heaters were requested to assist in warming the dining room. The MTD said the space heaters did not have breakers on them, so the nurses were responsible to turn them off and on. He said he knew the facility was prohibited from using space heaters. The nursing home administrator (NHA) was interviewed on 12/9/19 at 5:07 p.m. The NHA said she knew she could not use space heaters in the facility, however, she would rather use the space heaters, then have the resident ' s be cold or to infringe on their rights to move. She said she would rather take a citation then let the residents be cold. The NHA said she would not have the space heaters removed. C. Follow-up On 12/9/19 at approximately 7:00 p.m., theNHA had the four space heaters in the dining room and three space heaters removed from resident rooms, including room [ROOM NUMBER]. X. Failed to ensure medical devices were not plugged into non-medical grade power strips. [NAME] Environmental tour and staff interviews On 12/12/19 at 9:00 a.m. and on 12/16/19 at 2:30 p.m. the following observations were made of medical equipment being plugged into non-medical grade power strips: - Rooms #1105, #1208, #1204 and #1510 the oxygen concentrators were plugged into power strips. - room [ROOM NUMBER] the continuous positive airway pressure ([MEDICAL CONDITION]) machine was plugged into a power strip. - room [ROOM NUMBER] the bed and oxygen concentrator were plugged into a power strip. - room [ROOM NUMBER] the gastric tube feeding dispensing machine was plugged into a power strip. The environmental tour was conducted with the maintenance director (MTD), his assistant the maintenance worker (MW) and the housekeeping manager (HM) on 12/16/19 at 2:30 p.m. The MTD said medical equipment could not be plugged into power strips and only plugged into the wall. He said some of the rooms needed more power outlets installed and since there were not enough outlets some of the families and residents were plugging the medical equipment in the power strips. The MTD, MW and HM were observed unplugging the medical equipment and plugging it into the walls in rooms #1105, #1208, #1204, #1402, #1509 and #1510 as they were being shown the concerns during the tour. In room [ROOM NUMBER] the MTD said he wanted to communicate with the floor nurse for a safe ti (TRUNCATED)

Based on record review and interviews, the facility failed to ensure a safe environment and adequate supervision to prevent accidents for two (#8 and #3) of three residents reviewed for falls of the 14 sample residents. Specifically, the facility failed to ensure Resident #8 was properly assessed and received the necessary supervision and assistance required during cares. The resident had multiple falls resulting in a [MEDICAL CONDITION] and [MEDICAL CONDITION]. Furthermore, the facility failed to utilize care planned interventions to prevent Resident #3 from rolling out of bed. Findings include: I. Facility policy and procedure The Falls Management policy and procedure, last revised 3/15/16, provided by the nursing home administrator (NHA) on 9/13/19 at 12:28 p.m. revealed in pertinent part, Patients will be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. If a patient falls: perform neurological assessment for all unwitnessed falls and witnessed falls with head injury. Update care plan to reflect new interventions. II. Resident #8 status Resident #8, age 65, was admitted on [DATE] on respite care and was discharged [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. No minimum data set (MDS) assessment was completed for the resident's stay. According to general progress notes, the resident was alert and confused. Record review According to a general progress note on 8/24/19, the resident arrived at the facility at 6:30 p.m. The wife reported the resident had multiple falls prior to admission and walked into a wall and hurt his face and leg. Bruising was noted to his face. Review of the record revealed no comprehensive assessment of the resident including a fall risk assessment was completed upon admission to the facility. According to the (MONTH) 2019 CPO, an order was obtained on 8/25/19 for non-skid footwear for safety. Review of the record revealed no other fall prevention interventions were identified and implemented. The care plan that identified the resident at risk for falls was not created and initiated until 8/28/19. It revealed the resident was admitted with a [DIAGNOSES REDACTED]. Interventions included: -Place call light within reach while in bed or close proximity to the bed; -Maintain a clutter free environment in the resident's room and consistent furniture arrangement; and -When resident is in bed, place all necessary personal items within reach. According to an 8/29/19 general progress note, at approximately 7:00 p.m. the resident was witnessed to be crawling out of his wheelchair onto the floor. The resident was assisted up and back to bed. No registered nurse (RN) assessment was completed. No risk management for a fall was completed. No interventions were implemented to prevent the resident from crawling onto the floor. No neurological checks were completed. The resident's care plan was not updated. According to an 8/30/19 Change of Condition at 5:08 p.m., the resident had an abrupt onset of severe pain secondary to a fall. Pain was located at the right iliac crest. The resident was found on the floor in the bathroom by the certified nurse aide (CNA) in the doorway on his buttocks. He stated he was going to the bathroom and fell . The resident stated no injury upon initial assessment then complained of low back pain. The physician was notified and x-rays of the lumbar spine were ordered. Review of the 8/30/19 x-ray report of the lumbar spine revealed no acute findings. According to the 8/30/19 risk management event summary report, the resident had an unsteady gait and was supposed to be non-weight bearing (NWB) on one foot (the resident did not have an order for [REDACTED]. He was not always able to be redirected and would get aggressive at times. The resident was assessed for pain and injury and orders were obtained related to complaint of back pain. The resident was assisted back to his wheelchair and taken to the nurse's station for supervision. The care plan was updated on 8/30/19 to include: place walker/wheelchair within reach. Resident's gait was unsteady and he had a boot on his left foot (the resident did not have an order for [REDACTED]. According to an 8/31/19 Change of Condition note the CNA found the resident on the floor. The resident denied he was on the floor but thought he was on the bed. The resident had no injuries and no complaints of pain. According to the risk management event summary report for this fall, the resident was walking around his bed holding on to the bed and kept circling the bed, not using his walker. Staff reported the residents gait was unsteady and he had a boot to the left leg. The resident was found lying on the floor close to the bed. The resident was non-compliant with care, transfers and ambulates without the use of his walker at times. He had a brace to his left foot and was supposed to be non-weight bearing (NWB) but the resident had dementia and did not remember his weight bearing status. The resident was difficult to redirect. His needs were to be anticipated. Review of the record revealed no new interventions were implemented to prevent the resident from falling again and the care plan was not updated with any new interventions. According to a 9/1/19 nursing note the resident was seen crawling and sitting upright on the floor by the staff that shift. No registered nurse (RN) assessment was completed. No risk management for a fall was completed. No interventions were implemented to prevent the resident from falling. No neurological checks were completed. The resident's care plan was not updated. According to a 9/3/19 care plan evaluation progress note, the interdisciplinary team (IDT) reviewed the fall on 8/31/19. The resident was found on the floor in his room without injury and was able to move all his extremities. The resident was ambulatory, on [MEDICAL CONDITION] medications, on respite stay and discharging that day. Review of the record revealed no IDT review for the fall on 8/30/19. According to 9/3/19 emergency department provider notes, the patient was brought in from a nursing home by family with claims of abuse and neglect. The family's main concern was a subacute fall sometime in the last week with multiple pain complaints. Significant trauma was seen on the patient's right hand and in his hip. The hand did show evidence of a fifth metacarpal (finger) mid-shaft fracture which was mildly displaced. Pelvis and hip x-rays confirm a right femoral neck (hip) fracture which was displaced. III. Resident #3 status Resident #3, age less than 65, admitted on [DATE], discharged to the hospital on [DATE] and re-admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 8/6/19 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. The resident had no falls since last assessment. Record review The care plan, last revised 8/28/19, revealed the resident was at risk for falls related to poor safety awareness. Interventions included: -Landing mat for safety; -Wide bed with perimeter mattress for boundary awareness; -Assist getting in and out of bed with assistance; -Provide verbal cues for safety and sequencing when needed; -Maintain a clutter free environment in the resident's room and consistent furniture arrangement; -When in bed, place all necessary person items within reach; and -Anticipate resident needs. According to an 8/27/19 Change in Condition note the resident had a fall. According to the 8/27/19 risk management event summary report, at 11:00 a.m. the resident was found lying on the mat on the floor beside the bed, wrapped in blankets. The resident said she rolled out of bed. A body pillow was offered for boundary awareness. According to an 8/28/19 general progress note, IDT reviewed the fall from 8/27/19. The resident was found lying on the floor mat next to the bed, wrapped in blankets. The resident stated she rolled out of bed. The resident had no injuries or complaints of pain. A body pillow was offered for boundary awareness. The care plan was updated on 8/28/19 to include: body pillow offered for boundary awareness. According to an 8/28/19 Change in Condition the resident had a fall in the morning. According to the risk management event summary report, at 10:00 a.m. the resident was heard hollering and was found lying face down on the mat beside the bed with blankets wrapped around her. The resident stated she rolled out of bed. The resident was assessed for injury then assisted back into bed. The body pillow was placed on the left side of the resident to deter rolling out of bed. There was no documentation to indicate the body pillow was in place prior to the resident rolling out of the bed to prevent the fall. A medication review was requested and medication changes were made however the resident's care plan was not updated with this intervention as a fall prevention. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 9/13/19 at 11:19 a.m. She said a resident was considered to have fallen any time they were on the ground. She said if a resident was seen crawling on the ground it would not be considered a fall if that resident had a care plan stating they crawled on the ground. She said whenever a resident fell , an RN needed to assess the resident before they were moved. If the resident did not have any injuries, they used a mechanical lift to get the resident off the floor and back into their bed or wheelchair. She said if the resident hit their head or if the fall was unwitnessed, neurological checks were initiated and continued for 72 hours. She said a change of condition form and risk management form were completed with each fall. She said they tried to figure out why the resident fell and implement interventions to prevent the resident from falling again and updated the care plan. She said she was not sure if Resident #8 was care planned to crawl on the floor or not. The unit manager (UM) was interviewed on 9/13/19 at 11:43 a.m. She said whenever a resident fell the primary nurse was notified and an RN was called to assess the resident. If the resident was injured, 911 was called. If the resident did not have any injuries and it was unwitnessed, neurological checks were started. She said neurological checks would also be started any time the resident hit their head. She said anytime the resident was found on the ground it should be considered a fall whether they were guided to the ground or found crawling on the ground, witnessed or unwitnessed. She said the IDT reviewed all falls after the initial investigation was completed to determine why the resident fell and what interventions need to be implemented to prevent the resident from falling again. She said the care plan should be updated after each fall. She said the assistant director of nursing (ADON) and director of nursing (DON) were responsible for updating the care plan. The ADON was interviewed on 9/13/19 at 12:33 p.m. She said a fall was whenever a resident ended up unintentionally on a lower plane surface. She said crawling out of a wheelchair and on the floor was considered a fall and should be investigated as a fall. She said when a resident fell , they were to be assessed by an RN prior to being moved. She said if the fall was unwitnessed or the resident hit their head, neurological checks needed to be initiated immediately. She said a change in condition and a risk management form needed to be completed and the family and physician needed to be notified. She said all falls were discussed by IDT in the morning meeting to determine the cause of the fall and implement new interventions to prevent another fall. She said the care plan was updated at that time by herself or the DON. The DON was interviewed on 9/13/19 at 1:25 p.m. She said any time a resident fell the nurse needed to do a change in condition, investigate the fall and implement interventions immediately if needed. She said neurological checks should be initiated any time the resident hit their head or if the fall was unwitnessed. She said a fall occurs anytime a resident changes levels. She said if a resident was witnessed crawling on the floor and it was care planned as a behavior then it would not be considered a fall. She said crawling from the wheelchair to the floor would be considered a fall. She said new interventions should be put into place after each fall and the care plan updated. She said the IDT reviewed all falls in the morning meeting to discuss new interventions, care plan the interventions and update the kardex (a brief description of the resident's needs) for the CNAs.

Based on record review and staff interviews, the facility failed to ensure the environment for two (#100 and #33) of six out of 43 sample residents remained as free of accident hazards as possible, and the residents received adequate supervision to prevent accidents. Specifically, the facility failed to: - Implement and develop new fall interventions, complete a comprehensive interdisciplinary team review to prevent a fall with injury and continued falls after the injury, and update the fall care plan for Resident #100. -Failed to complete a comprehensive analysis post fall to identify and implement person-centered interventions for Resident #33. -Failed to ensure a registered nurse (RN) assessed Resident #100 and #33 post falls. -Failed to notify the physician and/or family post fall for Resident #33. As a result of the facility failing to complete a comprehensive analysis of Resident #100 ' s falls and implement person-centered interventions to reduce her risk for future falls, the resident sustained [REDACTED]. The findings included: I. Facility policy and procedure The Accidents/Incidents policy, revised 11/28/16, was provided by the nursing home administrator (NHA) on 12/12/18 at 4:00 p.m. It read in pertinent part; -The staff will use the Risk Management System (RMS) to report, review, and investigate all accidents/incidents which occurred on property and involved a patient who is receiving services. - The nurse will enter the accident/incident into the RMS within 24 hours of the occurrence; document the accident/incident in the patient ' s chart that will include all pertinent information, date, time, place, notifications, and initial and ongoing assessments; document the accident/incident on 24-Hour Report. -The NHA, director of nursing (DON) or designee will review all accidents/incidents to determine if: required documentation has been completed; and interventions to prevent further accidents/incidents have been identified and implemented. - When conducting an investigation, the NHA, DON, or designee will: make every effort to ascertain the cause of the accident/incident; initiate actions to prevent further accidents/incidents; use the RMS Witness Interview Form to conduct witness interviews from all staff who may have knowledge of the accident/incident; complete the investigation within five working days; root cause analysis will be completed within 30 days of the occurrence. - The NHA or designee will monitor that results of investigations/root cause analysis are forwarded to the Quality Assurance Performance Improvement Committee for follow-up. II. Resident #100 A. Resident status Resident #100, over the age of 65, admitted to the facility on [DATE] and readmitted on [DATE]. According to the computerized physician orders [REDACTED]. The 11/9/18 minimum data assessment (MDS) revealed the resident was not interviewable due to short- and long-term memory impairments and impaired daily decision-making skills. The resident required extensive assistance with bed mobility, transfers, toileting and ambulation. The resident used a walker and wheelchair for mobility and was incontinent of bowel and bladder. The MDS revealed the resident had one fall without injury. B. Record review 1. Fall care plan The fall care plan, initiated on 11/10/17 and revised 12/2/18, documented the resident was at high risk for falls related to cognitive loss, lack of safety awareness, history of falls, poor vision and hearing and she would not lock the wheels of the walker with transfers. The goal was no falls with major injury. The interventions included: assess for changes medical status, the bed moved against the wall, staff were to perform frequent checks, restorative program to maintain range of motion and assist with ambulation, request appropriate footwear from the family, toileting schedule with frequent reminders to use call light for assistance, medication evaluation as needed, verbal cues for safety and sequencing when needed, place call light within reach when in bed or close to bed, maintain clutter-free environment, when in bed provide necessary personal items within reach and therapy evaluation as needed. 2. Falls prior to the fall with major injury a. Fall #1 - 11/9/17 The RMS event summary report documented the resident had a fall on 11/9/17 at 4:45 p.m. The resident was witnessed trying to sit in a chair in the dining room and missed the chair. She was sitting on the floor when the nurse arrived and helped the resident back to her room. The 11/9/17 SBAR (situation, background, assessment, recommendation) communication form documented by the registered nurse (RN) revealed the resident had no medical changes, no injury, and the physician and responsible party was notified. Review of the resident ' s clinical record failed to reveal a comprehensive analysis of the fall was completed or person-centered interventions were implemented to reduce her risk for future falls. b. Fall #2 - 1/15/18 The RMS Event Summary Report documented the resident had a fall on 1/15/18 at 3:00 p.m. The resident was at the nurses station sitting in the chair of her walker when she attempted to stand and the wheels were not locked and she fell to her knees. The 1/15/18 SBAR communication form completed by the licensed practical nurse (LPN) documented the resident had no medical changes, no injury, and the physician and responsible party were notified. The orders obtained from the physician were continued monitor for safety. Review of the of the resident ' s clinical record failed to reveal the resident was assessed by a RN post fall. Review of the resident ' s clinical record failed to reveal a comprehensive analysis of the fall was completed. The fall care plan documented interventions of physical therapy (PT) and occupational therapy (OT) evaluation and treatment for [REDACTED]. The 1/18/18 OT initial evaluation documented in part, Patient ambulates mod (modified) I (independent) with rollator walker and recently sustained a fall. Patient presents with impairments in balance, mobility and strength resulting in limitations and/or participation in the areas of general tasks and demands, mobility and self care. The 2/5/18 OT discharge summary documented in part, Precautions include: fall risk, [MEDICAL CONDITION], incontent of bowel/bladder, primary language is Korean. Provided instruction to patient with restorative nursing staff specifically in order to facilitate improved performance during functional activities, in order to increase safety and reduce the risk of further medical complications [REDACTED]. c. Fall #3 - 3/11/18 The RMS event summary documented the resident had a fall on 3/11/18 at 5:00 p.m. The resident was walking down the hallway and fell . The 3/11/18 SBAR communication form documented by the LPN revealed no medical changes, no injury and the physician and responsible party were notified. The physician order [REDACTED]. Review of the of the resident ' s clinical record failed to reveal the resident was assessed by a RN post fall. Review of the resident ' s clinical record failed to reveal a comprehensive analysis of the fall was completed or person-centered interventions were implemented to reduce her risk for future falls. The fall was not documented on the resident ' s care plan. d. Fall #4 - 3/22/18 The RMS event summary documented the resident had a fall on 3/22/18 at 9:45 a.m. The resident was ambulating back to her room from the nurses station utilizing her walker when she suddenly fell backwards. The resident hit her head and she did not have non-skid tread on the soles of her shoes at the time of fall. The resident had a lump to the back of her head and complained of headache when as needed Tylenol was administered. The 3/22/18 SBAR communication form documented by the LPN revealed a lump to the back of the resident ' s head and complaint of pain the back of head. A neurological evaluation was completed. The physician and responsible party were notified, with no new orders. Review of the of the resident ' s clinical record failed to reveal the resident was assessed by a RN post fall. Review of the resident ' s clinical record failed to reveal a comprehensive analysis of the fall was completed or person-centered interventions were implemented to reduce her risk for future falls. The fall was not documented on the resident ' s care plan. The 3/26/18 physician progress notes [REDACTED]. It documented in part, She has a small lump on the left side of her parietal bone. Blood pressure is well controlled at this time. Continue to monitor. The 3/26/18 PT initial evaluation summary document in part, Patient requires skilled physical therapy services at the prescribed frequency and duration to address the following functional areas: ambulation and functional activities in standing. These functional deficits are the result of the patient ' s impaired strength and imparied balance. Due to the documented physical impairments and associated functional deficients, without skilled therapeutic intervention, the patient is at risk for falls and hospitalization s. The 5/4/18 PT discharge summary documented in part, Skilled services provided are functional ROM (range of motion)/strength to BLE (bilateral lower extremities), standing balance and safety awareness with use of rollator walker during gait training to achieve highest functional mobility in SNF (skilled nursing facility) setting. e. Fall #5 - 8/25/18 The RMS event summary documented the resident had a fall on 8/25/18 at 1:00 p.m. The resident was being assisted by her family seated in the chair on her walker. The walker was being pushed with resident on the seat of the walker on uneven pavement in the front of the building and the resident tipped over with the walker and hit her head. A neurological evaluation was completed and resident complained of mild pain with Tyleonol administered. The family insisted on going out of facility for lunch after the fall occurred. The 8/25/18 SBAR communication form documented by the LPN revealed no medical changes, injury noted with no description, and new pain to hematoma on the back of the head. The physician and responsible party was notified. The physician order [REDACTED]. Review of the of the resident ' s clinical record failed to reveal the resident was assessed by a RN post fall. The resident ' s fall care plan was documented intervention of educated family member not to push resident using the walker and offered a wheelchair instead. 3. Fall with major injury a. Fall #6 - 10/27/18 The RMS event summary documented the resident had a fall on 10/27/18 at 7:04 a.m. A certified nurse aide (CNA) observed resident sitting on the edge of her bed while obtaining her roommate's vitals. The resident ambulated without her walker and staff assistance to the bathroom. The resident lost her balance and fell on her right side. The nurse heard the fall and reported to the resident ' s room. The resident held her right hip and was grimacing. Staff assisted the resident to her bed. Physician was notified and ordered an x-ray of her right hip. The family was notified. The 10/27/18 SBAR communication form documented initially by the LPN and then by the RN revealed resident had new pain in her right hip. No other medical changes were documented, the physician was notified with new orders of as needed Tylenol and an x-ray of right hip and pelvis. The family was notified. The resident was sent to the hospital after the facility x-ray results were communicated to the physician. The 10/27/18 hospital paperwork documented Resident #100 admitted with closed displaced intertrochanteric fracture of right femur. The resident had surgery on 10/28/18 to nail her right [MEDICAL CONDITION]. The resident was discharged from the hospital and readmitted to the facility on [DATE]. Review of the resident ' s clinical record failed to reveal a comprehensive analysis of the fall was completed or person-centered interventions were implemented to reduce her risk for future falls until 11/5/18, after the resident fell again on 11/3/18. 4. Falls after major injury a. Fall #7 - 11/3/18 The RMS event summary documented the resident had a fall on 11/3/18 at 9:30 a.m. The resident was trying to stand from sitting position from her bed, was wearing sandals and fell . The nurse found the resident on her buttocks and was assessed and assisted back to her bed and asked to stay in bed and use call light when she needed assistance. The 11/3/18 SBAR communication form documented by the LPN revealed no medical changes, injury noted and new pain to hematoma on the back of the resident ' s head. A neurological evaluation was completed. The physician and responsible party was notified. The physician ordered an x-ray of her right hip and pelvis. Review of the of the resident ' s clinical record failed to reveal the resident was assessed by a RN post fall. The 11/5/18 IDT meeting progress note documented the resident was reviewed for fall on 10/27/18 and 11/3/18. The 10/27/18 fall, resident was ordered therapy when she readmitted from the hospital from the right [MEDICAL CONDITION]. It documented resident had increased behaviors of spitting on the floor and pouring water on the floor. The intervention for the 11/3/18 fall was to request alternative shoes from her family. The interventions added to the care plan were: requested appropriate footwear from family, anticipate needs related to dementia, toileting schedule, and frequent checks/reminders to use the call light for assistance. b. Fall #8 - 11/11/18 The RMS event summary documented the resident had a fall on 11/11/18 at 11:55 a.m. The nurse was alerted the resident had fallen by her roommate. The resident was on the floor on the left side of her bed without footwear and the call light was behind her headboard. The resident complained of generalized pain and requested to return to bed. The nurse assisted the resident to bed and incontinence care was provided, vital signs checked, and as needed [MEDICATION NAME] was administered. The 11/11/18 SBAR communication form documented by the LPN revealed no medical changes, no injury noted, and resident had worsened pain. A neurological evaluation was completed.The physician and family were notified. The physician order [REDACTED]. Review of the of the resident ' s clinical record failed to reveal the resident was assessed by a RN post fall. The 11/12/18 IDT meeting progress note documented the resident was reviewed for fall on 11/11/18 and documented, .pending PT/OT evals. Poor safety awareness. On restorative nursing program for ambulation. Anticipating needs. The interventions added to Resident #100 ' s care plan were to continue with frequent checks, referral to therapy, bed moved against the wall (implemented previous to this fall but not documented on the care plan until 11/14/18), and restorative program to maintain range of motion and assist with ambulation. The 11/12/2018 physician progress notes [REDACTED]. There were no changes to the resident ' s blood pressure medication by the physician. It documented in part, fell again this WE (weekend). She has a tendency to get OOB (out of bed) without requesting assistance. The 11/13/18 orthopaedic clinic follow up visit documented in part, (Resident #100) presents to clinic today for evaluation. She is 2.5 weeks status [REDACTED]. The patient had fallen 3 times at her care facility. Review of the therapy records documented the resident received PT and OT services starting 11/20/18. The resident received PT services until 12/4/18, with OT treatment continued. The OT initial evaluation documented in part, Continued OT services are necessary in order to assess safety and independence with activities of daily living, assess and modify environmental hazards and design and implement restorative nursing program. c. Fall #9 - 11/30/18 The 11/30/18 at 8:38 p.m. nurse progress note indicated the resident had fallen onto her bedside mat on the floor, trying to ambulate to bed from sitting in her wheelchair. The call light was in place and no injuries noted. The 11/30/18 SBAR communication form documented by the LPN revealed no medical changes, no injury noted. A neurological evaluation was completed. The physician and responsible party were notified. There were no new orders obtained. Review of the of the resident ' s clinical record failed to reveal the resident was assessed by a RN post fall. Review of the resident ' s clinical record failed to reveal a comprehensive analysis of the fall was completed or person-centered interventions were implemented to reduce her risk for future falls. C. Staff Interviews LPN #2 was interviewed on 12/13/18 at 8:59 a.m. She said when a resident had fallen the nurse on the floor evaluated the condition of the resident and completed an assessment. She said if the fall was witnessed and the resident hit their head or unwitnessed fall, a neurological evaluation and continued checks were initiated. She said the neurological checks were done in a series of four checks every 30 minutes, four checks every hour, and then every four hours for 24 hours. She said the nurse evaluated the resident ' s condition, then assisted either by a mechanical lift or staff so their skin could be evaluated for injuries. She said she would alert the RN, to evaluate the severity of the injuries. She said the physician and family would be notified and new orders would be obtained from the physician depending on the severity of the fall. She said then the nurse initiated a SBAR communication form, which triggered a change of condition follow up charting for up to nine shifts. She said then nurse completed a RMS event summary in the electronic medical record system, separate from the resident ' s medical record, where the nurse documented the investigation of how the fall occurred with causal factors, environmental concerns, and fall interventions. She said the nurse on the floor implemented interventions for the fall and then documented on the resident ' s care plan. She said the IDT team had involvement with those residents that had multiple falls to review and implement interventions. LPN #2 said Resident #100 had multiple falls and interventions that included fall mat on the right side of her bed since the left side was against the wall, her bed in the lowest position, and she was working with therapy since her baseline for mobility was a walker and she was now confined to a wheelchair. She said the resident had falls because of her footwear and the family was to bring in non-skin footwear but brought sandals and slippers for the resident to wear. She said the staff sometimes will put on non-skid socks since there was not appropriate footwear available. She said the resident today was wearing her slippers without non-skid socks. She said when the resident returned from the hospital on [DATE] with a fracture to her right hip, she was on [MEDICATION NAME] as needed for her pain which had contributed to her falls when she returned. She said her pain had become more managed recently so that may have helped with her not falling most recently. CNA #2 was interviewed on 12/13/18 at 9:15 a.m. She said she knows how to take care of residents by report from the nurse on shift and the nurse also reported any changes with residents. She said she accessed the resident ' s information on the kardex in the electronic medical record but she asked the nurse if she had specific questions about taking care of the resident. CNA #2 said for Resident #100, she ensured the bed was in the lowest position and fall mat in place when she was in bed because she tried to get herself up. She said when she provided assistance to the resident with transfers to use the restroom, she used a gait belt and checked to make sure the wheelchair breaks were locked. The DON was interviewed on 12/13/18 at 12:25 p.m. She said when a resident had fallen witnessed or unwitnessed, change of condition was initiated by the floor nurses. She said LPN or RN completed the change of condition assessment of the fall and evaluation. She said she was not aware the LPN could not complete an evaluation and assessment after a fall. She said the following day after a fall nursing management checked to ensure fall investigations were completed by the nurses and vital signs were obtained. The DON said the IDT met once a week on Mondays to review the falls that happened throughout the previous week and the team consisted of herself, the assistant director of nursing, dietary manager, and social service director. She said in the meeting, the team did a comprehensive check to ensure everything was completed from the fall investigation and made sure the interventions were on the resident ' s fall care plans and if there were any additional recommendations. She said the information discussed from the meeting was recorded in a progress note in the resident's medical record. She said that the IDT notes provided 11/5/18 and 11/12/18 because they recently initiated reviewing the recents with falls in (MONTH) (YEAR). She acknowledged the SBAR communication form and RMS event summary most often did not identify the root-cause analysis of the falls. She confirmed there was not timely follow up by IDT for falls that happened in the previous week. The DON said Resident #100 had multiple falls due to her dementia and her trying to get up and transferring herself. She said even after safety reminders like reinforcing the resident to use the call light for assistance, the resident will forget in minutes. She said the resident was checked and changed since she was incontinent of bladder and bowel and scheduled toiling was initiated since she had fallen trying to go to the bathroom. She said the resident had frequent checks, therapy was working with her on ambulation and transferring, and she was often placed in the common area by the nurses station to watch her more closely. She said the falls indicated on Resident #100 ' s care plan were from the IDT meeting discussions. She said she did not know why the falls from 11/9/17, 3/11/18, and 3/22/18 were not Resident #100 ' s care plan. She said the IDT reviewed and discussed residents that had fallen but there was no formalized meeting or documentation until (MONTH) (YEAR) so that may be the reason the corresponding falls were not the resident ' s care plan or interventions put into place. She said that currently no representative from therapy was attending the IDT meeting. PT #1, the therapy manager, was interviewed on 12/13/18 at 1:29 p.m. He said the resident was currently receiving OT therapy services and she had recently worked with PT. He said she had not reached her baseline of using a walker for mobility prior to her right [MEDICAL CONDITION]. He said PT had worked with the resident in (MONTH) and worked on improving her strength and balance with using a walker due to her cognitive deficits. He said with OT, the resident ' s progress was slow. He said OT was working on transfer safety since the resident was impulsive. He said the resident ' s level of assistance with transfer varied from stand by to contact guard assistance. He said she would need assistance from staff for transfers due to her dementia and current medical status. III. Resident #33 A. Resident #33 status Resident #33, over the age of 65, was admitted [DATE]. According to the (MONTH) (YEAR) CPO, [DIAGNOSES REDACTED]. The 9/25/18 MDS assessment revealed the resident ' s mental status was severely impaired with a BIMS score of three out of 15. She required extensive assistance of one person with transfers and toilet use. She had two or more falls without injury since the last assessment. B. Record review Care plan The fall care plan, initiated 9/17/18 (six days after her admission) and last revised on 12/2/18, revealed she was at risk for falls due to cognitive loss, lack of safety awareness, repeated falls, impaired cognition and weakness. She had falls on 9/13/18, 9/14/18, 9/19/18, 9/20/18, 10/29/18, and 11/5/18. The interventions included: - Anticipate residents needs (initiated 11/6/18). - Keep bed in lowest position (initiated 9/27/18). - Bed moved against the wall to optimize living space (initiated 9/21/18). - Fall mats in place for safety (initiated 9/21/18). - Keep wheelchair locked next to bed. Schedule toileting (initiated 11/3/18). - Restorative program to maintain ROM (range of motion) (initiated 11/3/18). - Safety teaching with son (initiated 11/26/18). - Medication evaluation as needed (9/17/18). - Place call light within reach while in bed or close proximity to the bed (initiated 9/17/18). - Remind resident to use call light when attempting to ambulate or transfer (initiated 9/17/18). - Maintain a clutter-free environment in the resident ' s room and consistent furniture arrangement (initiated 9/17/18). - When resident is in bed, place all necessary personal items within reach (initiated 9/17/18). - Monitor for and assist toileting needs (initiated 9/17/18). - Encourage the resident to attend all activities that maximize their full potential while meeting their need to socialize (initiated 9/17/18). The CNA Kardex revealed the safety interventions were for staff to keep the wheelchair locked next to her bed and to provide scheduled toileting. She required extensive assistance with transfers and toileting. The care plan and the Kardex failed to specify the residents specific toileting schedule or needs. Admission nursing assessment The 9/11/18 admission nursing assessment revealed the resident was at risk for falls and had a fall within the past month prior to her admission and she had sustained falls in the last two to six months prior to her admission. C. Fall documentation and failures 1. Fall 9/13/18 The 9/13/18, 7:00 a.m. SBAR communication form, completed by an LPN, revealed the resident was found on the floor near the bathroom door lying on her left hip and arm. The assessment noted the resident had poor safety awareness and the staff were going to observe the resident for injuries. - Review of the of the resident ' s clinical record failed to reveal the resident was assessed by a RN post fall. The facility was unable to provide evidence of a comprehensive analysis of the fall or the implementation of person-centered interventions to reduce her risk for future falls (See NHA interview below). 2. Fall 9/14/18 The 9/14/18, 5:30 a.m. SBAR communication form revealed the resident had fallen. The form failed to provide details about the fall and neither the physician or family were notified of the fall. - The NHA was interviewed on 12/12/18 at 3:30 p.m. She reported the facility had not completed an RMS event summary or investigation for the fall on 9/13/18 or 9/14/18. 3. Fall 9/19/18 The 9/19/18 RMS event summary report revealed, at 2:40 a.m., the nurse heard a banging on the resident ' s door. Upon opening the door, the resident was found lying in front of the door on her left side. The resident was unable to recall if she fell or crawled out of bed. The form failed to reveal the completion of an investigation and no interventions were identified. The 9/19/18 SBAR communication form revealed the resident was assisted with two assist from the door to the bed and her neurological checks and vital signs were normal. No interventions were identified. - Review of the resident ' s clinical record failed to reveal a comprehensive analysis of the fall was completed or person-centered interventions were implemented to reduce her risk for future falls. 4. Fall 9/20/18 The 9/20/18, 2:15 a.m. SBAR communication form revealed the resident was found laying on her left side in her room on the floor near the bathroom. The resident was unable to state what she was attempting to do. The 9/20/18 RMS event summary report revealed the resident had been toileted by the CNA 15 minutes prior to the fall. The resident was re-educated on the need to use the call light. - Review of the resident ' s clinical record failed to reveal a comprehensive analysis of the fall was completed or person-centered interventions were implemented to reduce her risk for future falls. 5. Fall 10/29/18 The 10/29/18, 2:00 a.m. SBAR communication form, completed by a RN, revealed the resident stated she was going to the bathroom and fell . She was unable to reach the call light so she crawled to the room door and called for help. Call light was within reach. The 10/29/18 RMS event summary revealed the resident was incontinent of both bowel and bladder. She was re-educated, again, on the use of the call light. Call was within reach of resident when she was in her bed light was again placed within reach of resident. - Review of the resident ' s clinical record failed to reveal a comprehensive analysis of the fall was completed or person-centered interventions were implemented to reduce her risk for future falls. The resident was re-educated on the use of the call light even though she had demonstrated memory problems. The care plan revealed on 11/3/18 a new intervention was added for scheduled toileting, however neither the care plan nor CNA Kardex provided specific toileting times or intervals. 6. Fall 11/5/18 The 11/5/18, SBAR communication form, completed by an LPN, revealed the resident ' s roommate reported this resident was on the floor. The resident was observed by the LPN, sitting up on the floor between her bed and her roommates bed. The 11/5/18, RMS event summary, completed by an LPN, revealed the resident attempted to transfer self without assistance, lost her balance and fell backwards landing on her buttocks. The call light was within her reach but was not used. Reminded resident each time to press call light. - Review of the of the resident ' s clinical record failed to reveal the resident was assessed by a RN post fall. The resident ' s clinical record failed to reveal a comprehensive analysis of the fall was completed or person-centered interventions were implemented to reduce her risk for future falls. She was again reminded to use the call light despite her memory difficulties and repeated failure to use the call light. C. Staff interviews CNA #1 was interviewed on 12/13/18 at 8:53 a.m. She stated the resident ' s fall interventions included to assist her with toileting every two to three hours and just check on her frequently. She said the fall interventions were located on the CNA Kardex. She said the facility did not routinely include CNAs in the fall investigation process or the implementation of interventions post fall. LPN #1 was interviewed on 12/13/18 at 9:00 a.m. She stated, immediately after the fall, she would complete

Based on record review, observation and interview, the facility failed to ensure 15 of 60 sample residents (#11, #20, #23, #47, #72, #76, #78, #82, #93, #107, #155, #160, #256, #302, #304) received the care and services necessary to attain and/or maintain their highest practicable level of well being. Specifically: -Diabetic management: The facility failed to have systems in place to manage diabetic residents, some of whom had a history of [REDACTED]. of diabetic residents (omissions in blood sugar testing, medication administration, and physician notification) despite knowledge of management failures. The facility's multiple system failures in managing diabetic residents created a situation of immediate jeopardy with the potential for serious harm. -Pain management: Staff failed to timely assess the site of resident #107's pain and failed to promptly intervene to minimize the pain. Resident #107, observed three days in her wheelchair, reported buttocks pain, rating it at a level 8 out of 10 on the third day. A certified nurse aide (CNA) confirmed the resident complained of pain on her bottom "a lot." -[MEDICAL TREATMENT] management: The facility failed to maintain consistent communication with the [MEDICAL TREATMENT] center for resident #76. The findings include: I. Immediate Jeopardy - Diabetic Management A. Findings of Immediate Jeopardy 1. Record Review A list of residents receiving insulin was received on 2/21/14 at 9:30 a.m. from the Director of Nursing (DON) and the Nursing Home Administrator (NHA) along with copies of the 1/14 and 2/14 MARs (medication administration records). Review of resident list revealed insulin dependent diabetics resided on a number of different units, including the Rehab unit, Cheyenne unit and Columbine unit. Review of the residents' MARs revealed blood sugar levels below 60 mg/dl with documented evidence insulin (which further lowers blood sugar) was administered without notification of the physician, blanks for blood glucose levels, blanks for insulin administration, examples when the blood glucose levels were high and the physician was not appropriately notified, and a lack of nursing assessment documentation corresponding with the abnormal blood glucose levels. See details below for residents #11, #20, #23, #47, #72, #78, #82, #93, #155, #160, #256, #302, #304. Resident #78, an insulin dependent diabetic, was found unresponsive. Her blood sugar was not checked before she was transferred to the hospital where, per family report, it was very low (23). Resident #302, an insulin dependent diabetic, did not have insulin orders on admission and, despite continued high blood sugar readings, no physician consultation was obtained for three weeks. Resident #23, an unstable insulin dependent diabetic, had both several high and low blood sugar readings; there was no evidence the physician was notified. Review of the Consultant Pharmacist's 1/17/14 Monthly Facility Review revealed the pharmacist identified and reported on "concerns with omissions "holes" on the MAR (medication administration record), identified during the pharmacist's 10/13, 11/13 and 12/13 reviews. 2. Observations a. Rehab unit observations were conducted on 2/21/14 at approximately 10:45 a.m. with a nurse on the unit. Observations revealed: -The 300 hall medication (med) cart contained one box of glucoburst (delivers 15 gm glucose orally) and no IM [MEDICATION NAME]. The nurse confirmed she took care of residents who received insulin with this cart. -The Rehab unit medication room was observed and contained no oral glucose or IM (intramuscular) [MEDICATION NAME], as confirmed by the nurse. -The 400 hall cart was observed with the nurse and contained no oral glucose or IM [MEDICATION NAME], as confirmed by the nurse, who also said she took care of residents who received insulin with this cart - and one resident had oral glucose gel that was wasted this morning because the resident almost needed to use it, so it was wasted. Neither nurse knew where to locate IM [MEDICATION NAME], in case of an emergency when a resident was not conscious and could not swallow oral glucose. The 400 hall nurse thought IM [MEDICATION NAME] might be available on the Cheyenne unit in the "Omnicell" machine, but she was not sure. b. Cheyenne unit Observation of the Cheyenne unit was conducted on 2/21/14 at approximately 11:05 a.m. with the nurse. -The 700/800 hall med cart contained no oral glucose or IM [MEDICATION NAME], and the nurse confirmed she took care of residents who received insulin with this cart. The nurse said there should be glucose and [MEDICATION NAME] on the cart, but she did not find any and said she would have to ask for some. -The Cheyenne unit medication room was observed with the nurse and contained one box of oral glucose and no IM [MEDICATION NAME], as confirmed by the nurse. The Cheyenne Unit Manager who was subsequently interviewed did not know where to find IM [MEDICATION NAME], thought it may be in the "Omnicell" machine, and verified there was no list of contents for what was in the machine. The Unit Manager said the Director of Nursing (DON) would have a list of what was in the machine. -The 500/600 hall med cart was observed with the nurse. The cart contained one IM [MEDICATION NAME] and no oral glucose. The nurse did not know where to locate additional IM [MEDICATION NAME] or oral glucose gel. c. Columbine unit (1) Observation on 2/21/14 beginning at 10:52 a.m. revealed four medication (med) carts and two med rooms on the Columbine unit. No emergency kits (e-kits) were observed on the unit. The med cart observations revealed that medication (IM [MEDICATION NAME], oral glucose) for rapid response to low blood sugars was not readily available on all med carts or all med rooms on the unit. Specifically: -Cart 1 - Contained no [MEDICATION NAME] (IM) or glucose gel. The nurse revealed on 2/21/14 at 10:52 a.m., [MEDICATION NAME] and glucose gel were in the emergency (e) kit (but see above, an e-kit was not observed on the unit). -Cart 2 - Contained 3 glucose gels and one [MEDICATION NAME] (with a resident name on it). -Cart 3 - Contained 3 glucose gels and no [MEDICATION NAME] IM. -Cart 4 - Contained no glucose gel or [MEDICATION NAME] IM. -Med room [ROOM NUMBER] - Contained no glucose gel or [MEDICATION NAME] IM -Med room [ROOM NUMBER] - Contained no [MEDICATION NAME] IM or glucose gel (2) Staff interviews revealed some staff was not aware of the availability or location of medication (IM [MEDICATION NAME], oral glucose) for rapid response to low blood sugars. -During an interview on 2/21/14 at 12:05 p.m., a licensed nurse on the Columbine unit said she had five diabetics on insulin assigned to her cart. She said she 'probably' had IM [MEDICATION NAME] on her cart, but knew there was one [MEDICATION NAME] IM in another med cart. -A second nurse on the Columbine unit stated on 2/21/14 at 12:10 p.m. that most facilities have [MEDICATION NAME] IM in the e-kit so she assumed it was in the e-kit. -A third nurse on the Columbine unit revealed on 2/21/14 at 12:15 p.m. that she had three residents with insulin assigned to her cart. She did not know if [MEDICATION NAME] IM was in the e-kit but there was a new pyxis system (system that stores medication orders, medications and dispenses medication in a single dose form). A fourth nurse on the Columbine unit was interviewed on 2/21/14 at 1:10 p.m. She was not sure if [MEDICATION NAME] IM was available. d. On 3/5/14 at 12:52 p.m., the consultant pharmacist was interviewed via phone. Regarding diabetic management, he said [MEDICATION NAME] should be in every cart. B. Imposition of Immediate Jeopardy On 2/21/14 at approximately 4:15 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were notified by the Colorado Department of Public Health and Environment (CDPHE) that the facility's management of diabetic residents created a situation of immediate jeopardy for serious harm. The facility's management failures included: Administering insulin to residents with blood glucose levels below 60; not notifying the physician when blood glucose levels were below 60 or over 400 or over or under ordered parameters; nurses not knowing where to find oral glucose and IM [MEDICATION NAME] as well as not knowing when to appropriately use them; and lack of documentation of monitoring blood sugars and administering insulin as ordered to diabetic residents. C. Plan to Remove Immediate Jeopardy The NHA and DON subsequently submitted a short-term plan to correct the immediate jeopardy situation. It read: "1. Residents who are insulin dependent are having baseline blood sugars (BS) taken today by nurse management. 2. Nurse management oversight will occur in each instance of insulin administration and blood sugar level evaluation. Scheduled times are 0600 (6 a.m.), 1100 (11 a.m.), 1600 (4 p.m.), and 2200 (10 p.m.). 3. All licensed staff will be educated regarding [DIAGNOSES REDACTED] and blood sugar monitoring. 4. 15 boxes of [MEDICATION NAME] gel will be available by 6PM this evening." Observations of diabetic residents' records on 2/22/14 and 2/23/14 revealed the facility had substantially complied with the above short-term plan. The NHA and DON were interviewed on 2/24/14 at approximately 1:50 p.m. -The DON said management oversight was provided for every BS and insulin administration since the evening of 2/21/14 and they "did not miss one." The DON said documentation expectations were clarified with the nurses and it was the same for all units. -The DON said oral glucose and IM [MEDICATION NAME] were now on every med cart in the facility, the nurses could "grab and go - no hunt" for oral glucose or IM [MEDICATION NAME]. The DON confirmed there were now at least 10 IM [MEDICATION NAME] and 28 oral glucose gel packets in the facility. -The DON said the facility/company policy on signs/symptoms of hypo/[MEDICAL CONDITION] was "now" on every MAR, there was an audit book, inservices were provided, competency testing was performed on how to check a BS and how to administer insulin; she added it was a really good weekend and staff appreciated the oversight. On 2/24/14 at approximately 2:00 p.m., the NHA submitted a second plan to remove immediate jeopardy to CDPHE. A revised plan was submitted at approximately 4:00 p.m. The plan dated 2/24/12 read: "The center identified each resident with physician's orders [REDACTED]. 2014. Each resident with insulin orders has been reviewed, to ensure that a physician's orders [REDACTED]. -A baseline blood sugar has been obtained for each Insulin diabetic resident - this has been completed by February 21, 2014. -[MEDICATION NAME] has been ordered and had been received on February 21, 2014. The [MEDICATION NAME] is now being stored in each medication cart. Two remain in the Omni Cell. -Glucose gel has been obtained and is on every med cart and in the med rooms by 2/21/14. -The amount of Glucose gel and [MEDICATION NAME] IM to remain in the house at any given time is 10 [MEDICATION NAME] IM and 24 Glucose gel. This will be minimum amount at any time. One time a week the carts and med rooms will be audited to maintain this amount. -Beginning on February 21, 2014 residents receiving insulin have been supervised by management including the Director of Nurses, Regional Registered Nurse, Nurse Practice Educator and the Division Nurse Educator, to ensure that accurate doses are being administered and the insulin orders are transcribed and administered accurately. -Beginning on February 21, 2014, the nurse management is reviewing the MARs daily to ensure that the insulin, blood sugars, and sliding scales have been documented and administered accurately. The daily review also includes monitoring for residents who may refuse their insulin, to ensure that appropriate physician notification has occurred. -Education has been provided for the Licensed Nurses, beginning on February 21, 2014 regarding the use of sliding scale insulin, obtaining parameters for physician notification, notifying the physician for refusals of care/treatment and obtaining and reporting blood sugars as indicated by the physician ordered parameters. Per [DIAGNOSES REDACTED] protocol located in front of the MAR indicated [REDACTED]. -Education has been provided for the certified nursing assistants, facility staff have been educated regarding the Hyper and [DIAGNOSES REDACTED] protocol and notifying the nurse on duty should they suspect any of those symptoms. -Beginning on February 24, 2014 the licensed nurses will have a 2nd nurse verify the blood sugar and insulin have been administered and documented accurately. This will be initialed on the MAR indicated [REDACTED]. As stated in the protocol. Beginning on 2/22/2014 residents' diabetic MARs are kept together with the current MARs. -Beginning on 2/23/2014 the injection site diagram was added to the MAR. -Beginning on February 24, 2014 the licensed nurses will have a 2nd nurse verify the blood sugar and insulin have been administered and documented accurately. -The DNS/Designee will do daily monitoring to determine that the insulin, blood sugars, and sliding scale have been documented accurately and Physician notification as necessary." Documentation of the in-services was provided. D. Removal of Immediate Jeopardy On 2/24/14 at 4:55 p.m., the NHA was notified that the facility's plan for removal of immediate jeopardy had been accepted and the immediate jeopardy had been removed. However, deficient practice remained at an E level (pattern with the potential for more than minimal harm). II. Failure in Diabetic Management A. Effects of [DIAGNOSES REDACTED] C.V. Desouza, G. B. Bolli, and V Fonseca, "Diabetes Care," June 2010, volume 33, no. 6 pp 1389 - 1394 write in pertinent part: "The modern definition of [DIAGNOSES REDACTED] is plasma glucose <70 mg/dl. At plasma glucose below this threshold (60 - 65 mg/dl), the brain becomes neuroglycopenic and promotes secretion of counterregulatory hormones ... which have relevant cardiovascular effects. If (even mild) [DIAGNOSES REDACTED] episodes recur often over time (e.g. once a day), the brain adapts to [DIAGNOSES REDACTED] with symptom responses at a lower-than-usual plasma glucose concentration. This shifting of brain glucose thresholds to higher levels ... is dangerous because it masks most of the mild [DIAGNOSES REDACTED] episodes until blood glucose decreases to (equal to or < 50 mg/dl. In turn, failure to sense symptoms of [DIAGNOSES REDACTED] in an early phase ([DIAGNOSES REDACTED] unawareness) increases the risk of prolonging duration and increasing frequency of [DIAGNOSES REDACTED] with [MEDICAL CONDITION] ..." B. Facility Policies for Diabetic Management in Effect Prior to Immediate Jeopardy 1. The 1/2/14 Diabetic Care Protocol was received and reviewed on 2/21/14. It included in pertinent part: -Upon admission, initiate [DIAGNOSES REDACTED] Protocol Physician order [REDACTED]. -Develop care plan to include the patient's usual symptoms indicating low or high blood glucose and the patient's usual or ordered regimen for diet, blood glucose monitoring, and exercise. -Perform fingerstick blood glucose (blood sugar/BS) monitoring as ordered. -Administer insulin/oral hypoglycemic medication as ordered. -Evaluate for and respond to any change in condition. -Treat hypoglycemic episode according to "[DIAGNOSES REDACTED] Protocol" (refer to [DIAGNOSES REDACTED] procedure) or per order. -Report blood glucose results to physician/mid-level provider according to ordered parameters. -If parameters are not ordered, report (the) following to physician/mid-level provider: --Urgent: Notify immediately if blood glucose is greater than 400 or less than 70 (and not corrected with interventions according to "[DIAGNOSES REDACTED] Protocol"). --Routine: Notify as soon as possible during normal business hours if blood glucose greater than 350 or greater than 300 on two consecutive readings. --Activate emergency medical services (EMS) according to health care directives and notify physician/mid-level provider immediately for presentation of signs of either ketoacidosis or Hyperglycemic Hyperosmolar Non-Ketoti[DIAGNOSES REDACTED] (HHNKS): -Document: --Insulin/oral hypoglycemic medications; --Blood glucose readings; --Nursing interventions; --Notification of physician/mid-level provider and response, as indicated ..." 2. The 1/2/14 [DIAGNOSES REDACTED] Protocol revealed: "Prompt intervention is provided for patients experiencing hypoglycemic reaction. Signs and symptoms of [DIAGNOSES REDACTED], usually a sudden onset, include: Irritability, bizarre change in behavior; *altered sleep pattern (* most common signs in elderly); pale, cool, moist skin; confusion; numbness of tongue, lips; weakness, dizziness, faintness; stupor, convulsions; excessive hunger; unconsciousness; *change in function; *headache; *slurred speech; blurred or impaired vision; trembling, restlessness; coma; and [MEDICAL CONDITION]" a. PRESENTATION/SYMPTOMS - Asymptomatic Low blood glucose (less than 70 or physician ordered low parameter) TREATMENT -Hold all diabetic medications, including insulin and oral meds. -Administer rapidly absorbed simple carbohydrate such as 4 oz juice, or 5 or 6 oz regular soda pop or tube of glucose gel per patient's routine. -If meal time, have resident eat meal. -Repeat blood glucose measurement in 10-15 minutes; if above 70, or ordered parameter, give diabetic meds. -If below 70, repeat juice and blood glucose measurement x1. If no improvement, notify physician. Obtain specific follow-up orders regarding diabetic medications and glucose monitoring. -Follow with meal or snack within one hour. NOTIFICATION Notify physician per ordered parameters; report: Patient's age and sex; events, interventions, and patient's response; vital signs; neurological observations; mental status observations; blood sugar over past 48 hours; usual pattern (fluctuations, trends) of blood sugars over recent months; approximate I&O (intake and output) last 24 hours; current diabetic medications; all active diagnoses; all other current medications; and recent labs. DOCUMENTATION -Assessment of patient's condition -Fingerstick glucose levels -Interventions and patient's response -Physician notification and response -Follow-up, if indicated -Include patient on 24-Hour Summary Report ... b. PRESENTATION/SYMPTOMS - Symptomatic, Conscious, Able to swallow TREATMENT -Perform fingerstick blood glucose measurement. -If less than 70 or physician ordered low parameter, immediately administer rapidly absorbed simple carbohydrate such as 4 oz juice or 5-6 oz regular soda pop or tube of glucose gel per resident's routine. -Remain with resident and monitor vital signs. Put patient in safe environment such as bed or chair. -Repeat blood glucose measurement in 10-15 minutes. -If below 70, repeat juice and blood glucose measurement 10-15 minutes after juice administration. -Hold all diabetic medications, including insulin and oral meds. -As patient responds, provide meal or snack of protein and starch. -Notify physician. Obtain specific follow-up orders regarding diabetic medications and glucose monitoring. NOTIFICATION Notify physician per ordered parameters; report: Patient's age and sex; events, interventions, and patient's response; vital signs; neurological observations; mental status observations; blood sugar over past 48 hours; usual pattern (fluctuations, trends) of blood sugars over recent months; approximate I&O (intake and output) last 24 hours; current diabetic medications; all active diagnoses; all other current medications; recent labs. Notify family/responsible party. DOCUMENTATION -Assessment of patient's condition -Fingerstick glucose levels -Interventions and patient's response -Physician notification and response -Follow-up, if indicated -Include patient on 24-Hour Summary Report ... c. PRESENTATION/SYMPTOMS - Symptomatic, Extremely drowsy, Cannot swallow TREATMENT -Perform fingerstick blood glucose measurement. -If less than 70 or physician ordered low parameter, immediately administer glucose - [MEDICATION NAME] 1 mg IM (intramuscularly) or subcutaneously (SQ). -If no response to [MEDICATION NAME] in 15 minutes, repeat [MEDICATION NAME] 1 mg IM or subcutaneously. If no response to second [MEDICATION NAME] injection, activate EMS (according to patient's health care directives). -Hold all diabetic medications, including insulin and oral meds. -As patient responds and is able to swallow, provide meal or snack of protein and starch. -Notify physician. Obtain specific follow-up orders regarding diabetic medications and glucose monitoring. NOTIFICATION Notify physician per ordered parameters; report: Patient's age and sex; events, interventions, and patient's response; vital signs; neurological observations; mental status observations; blood sugar over past 48 hours; usual pattern (fluctuations, trends) of blood sugars over recent months; approximate I&O (intake and output) last 24 hours; current diabetic medications; all active diagnoses; all other current medications; recent labs; and obtain specific follow-up orders regarding diabetic medications and glucose moitoring. Notify family/responsible party DOCUMENTATION -Assessment of patient's condition -Fingerstick glucose levels -Vital signs -Interventions and patient's response -Physician notification and response -Follow-up, if indicated -Include patient on 24-Hour Summary Report ... d. PRESENTATION/SYMPTOMS - Symptomatic, Unconscious TREATMENT -Perform fingerstick blood glucose measurement. -If less than 70 or physician ordered low parameter, immediately administer glucose - [MEDICATION NAME] 1 mg IM or subcutaneously. -Notify physician immediately. -If no response to [MEDICATION NAME] in 15 minutes, repeat [MEDICATION NAME] 1 mg IM or subcutaneously and activate EMS (according to patient's health care directives). -Remain with patient and monitor vital signs. -Hold all diabetic medications, including insulin and oral meds. - Obtain specific follow-up orders regarding diabetic medications and glucose monitoring. NOTIFICATION Notify physician per ordered parameters; report: Patient's age and sex; events, interventions, and patient's response; vital signs; neurological observations; mental status observations; blood sugar over past 48 hours; usual pattern (fluctuations, trends) of blood sugars over recent months; approximate I&O (intake and output) last 24 hours; current diabetic medications; all active diagnoses; all other current medications; recent labs; Notify family/responsible party. DOCUMENTATION -Assessment of patient's condition -Fingerstick glucose levels -Vital signs -Interventions and patient's response -Physician notification and response -Family notification -Follow-up, if indicated -Include patient on 24-Hour Summary Report ... C. Resident Failures 1. Resident #78 Review of the face sheet revealed [AGE] year-old resident #78 was admitted to the facility on [DATE] (around 5 p.m. per nurses' note) with [DIAGNOSES REDACTED]. a. Resident Status The physician's 1/6/14 progress note revealed the resident had "Type 2 diabetes mellitus. The patient's home medications have been resumed and we will keep her on sliding scale." The physician's 1/13/14 progress note revealed the resident had "Type 2 diabetes mellitus. I would like to continue to monitor her Accu-Cheks (blood glucose levels). She is currently on a sliding scale (for insulin administration)." Review of the 1/14 All Active Orders revealed: -Humalog 100 unit/ml solution SQ - before meals (AC) and at HS (bedtime) everyday: If FS (fasting sugar) less than 60, call MD: 60-150 = 0 units, 151-200 = 2 units, 201-250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 351-400 = 10 units, if over 400 call MD (physician). -[MEDICATION NAME] 100 unit/ml solution SQ 10 units everyday at lunchtime. -[MEDICATION NAME] 100 unit/ml solution SQ 5 units everyday at breakfast time. Review of the 1/14 MAR indicated [REDACTED]. b. Record Review - Facility Failures According to the Skilled Charting Guidelines Tool, diabetic residents were to be assessed for and documented on the following: level of consciousness, thirst, weakness or diaphoresis, elevated temperature, blood sugar results, dietary intake, status of wounds, insulin/oral hypoglycemic dosage, and response to treatment/teaching. Record review revealed the resident's dietary intake was not documented, her BS levels were not consistently monitored as ordered, insulin was not consistently administered as ordered and there was no documentation staff appropriately intervening when the resident was found unresponsive. Specifically: (1) There were no corresponding nurses' notes or physician notification regarding the following documentation on the resident's 1/14 MAR: -1/4/14 before supper BS and Humalog were omitted without documentation. -1/4/14 bedtime BS and Humalog were omitted without documentation. -1/6/14 BS before lunch was 285; however, the lunchtime [MEDICATION NAME] was omitted without documentation. -1/7/14 BS before breakfast and Humalog were omitted without documentation. -1/8/14 BS bedtime and Humalog were omitted without documentation. -1/10/14 BS before breakfast and Humalog were omitted without documentation. -1/10/14 BS bedtime and Humalog were omitted without documentation. -1/12/14 BS before breakfast and Humalog were omitted without documentation. -1/13/14 BS before lunch was 99; however, the lunchtime [MEDICATION NAME] "hold/see nurse note" without documentation in the nurses' notes. (2) Review of the meal and fluid intake documentation revealed no documented evidence the resident received: -1/5/14 breakfast or fluids -1/5/14 lunch or fluids -1/5/14 fluids with supper -1/6/14 breakfast or fluids -1/6/14 lunch or fluids -1/7/14 breakfast or fluids -1/7/14 lunch or fluids -1/8/14 breakfast or fluids -1/8/14 lunch or fluids -1/9/14 supper or fluids -1/10/14 supper or fluids -1/12/14 supper or fluids -1/13/14 breakfast or fluids -1/13/14 lunch or fluids (3) Change of condition - failure to assess BS level The resident's interested party (IP) was interviewed on 3/6/14 at 9 a.m. She said the resident went to the hospital on [DATE] in a "diabetic coma, after they pumped her full of sugar she came to and told us she had not been fed or given water for four days ... no one answered her call light the night before (on 1/13/14) for a long time ..." The IP said she was with the resident in the hospital on [DATE] when they called an emergency alert; resident #78's blood sugar was 23 and the resident's responsible party/power of attorney was also there (at) about 5 p.m. in the emergency room . Review of the 1/14/14 Physician/NP (nurse practitioner)/PA (physician assistant) Communication and Progress Note for New Symptoms, Signs and Other Changes in Condition at 6:55 a.m. revealed: -Situation: The symptom/sign/change I'm calling about is "Pt unresponsive saturation down in the 60's c (with) transfer from bed to chair using Hoyer..." this started "0500 (5 a.m.) ... this has gotten better since it started ... things that make the condition worse are "anxiety, manipulation esp(ecially) transport ..." things that make the condition better are "O2 (oxygen), turn up O2 ..." other things that have occurred with this change are "none ..." -Progress note: "Pt wanted to be put back in lazy boy chair. D/T (due to) being uncomfortable in bed & legs & back hurt at an 8 (on a scale of 0-10) per resident. Initially pt given 2 pain pills d/t pain reported, Pt cont(inued) to complain of discomfort and adamantly requested to be put back in lazy boy at 0500 (5 a.m.). After reminding the pt of increased fall risks and skin breakdown, pt stated 'I don't care.' ... Pt was transferred using Hoyer lift, sling on correctly, O2 via NC on @ 8 L, no incident c (with) mechanical device. Pt became unresponsive while being placed in lazy boy. O2 sats @ 68%, pt given O2 non-rebreather for 10 min until recover O2. Sates (up) to 99%. NC (nasal cannula) on at 6L Sats @ 98%. Pt completely alert & oriented x3. Pt made aware of all event, primary contact notified, DON aware & ADON (Assistant DON) and unit manager. MD called notified of event - order to monitor and call c (with) changes, with the possibility of ER eval if any other change occur." The DON was interviewed on 2/21/14 at approximately 3:15 p.m. The DON said when a resident is unresponsive the blood sugar should be checked if the resident was a diabetic. The DON put together a timeline of the resident's stay. The DON's timeline did not explain the lack of blood sugar testing when the resident was unresponsive or the reason the resident was not transferred immediately to the hospital. 2. Resident #302 Resident #302, an [AGE] year-old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. Record Review Record review revealed the facility failed to obtain insulin orders on admission from a physician and, despite continued high blood glucose reading, no care conference or physician consultation was conducted to regulate insulin effectively for 24 days. In addition, blood sugar testing was not completed accurately or as ordered. Specifically: (1) History and physical A history and physical dated 2/3/14 by the resident's attending physician stated, under Medication History as follows: "The order for [MEDICATION NAME] on the chart is for [MEDICATION NAME] (antihypertensive) 50 milligrams three times daily three times a week, but the nurses appear to be giving it daily. He came to us on [MEDICATION NAME] 70/30 b.i.d. (twice daily); the insulin was placed on hold 2/1/14 and we ordered blood sugars before meals and at hour of sleep. Today is 2/3/14 and the a.c. (before meal) and h.s. (hour of sleep) blood sugars are not done accurately. In view of the record, it appears he was on [MEDICATION NAME] and sliding scale prior to coming here; I don't know how he got switched to [MEDICATION NAME] 70/30 and the nurses are unable to explain where they are getting their orders." (2) Nursing Progress notes -On the date of admission 2/1/14, the note read (in part) that the physician gave orders to resume all medications except insulin. The nurse indicated she called the resident's previous nursing home to get orders; resident had been receiving "[MEDICATION NAME] 70/30 100 units Insulin bid (twice daily) confirmed per (Name), the nurse." -On 2/2/14 at 10 a.m. stated the resident's blood sugar was 199, "Insulin on hold until we get a new order." -On 2/2/14 at 2:30 p.m., "No call returned for a new order. A new call made to the physician's office," and a report was given to the office nurse. -On 2/2/14 at 10 p.m., a call was made to the nurse practitioner for new orders to restart insulin. No return call was received, and the resident's blood sugar was recorded as 264. -On 2/7/14 at 9 a.m., the nurse noted she called the nurse practitioner regarding insulin orders. -On 2/11/14 at 11:15 p.m., the resident's blood sugar was 424 and a call was made to the nurse practitioner. [MEDICATION NAME] 25 units were given but no new orders were given. -On 2/21/14 at 12:42 p.m., the resident's blood sugar was recorded as 475 and the physician's office was notified. The office nurse called back at 3:05 p.m., and no new orders were received. -On 2/21/14 at 6 p.m., the physician's office was notified of a blood sugar of 487. Nursing was instructed to recheck the blood sugar at hour of sleep and if over 350, to give an additional dose of 5 units of [MEDICATION NAME] with [MEDICATION NAME]. At 8 p.m., the resident's blood sugar was 510. Five units of [MEDICATION NAME] was given per the doctor's office nurse. -Undated progress note but written in different ink and handwriting stated "Resident's blood sugar was 421, the nurse practitioner was notified. Sta

Based on observations, interviews and record review, the facility failed to ensure one (#52) of 60 sample residents received timely and comprehensive care and services to prevent the development and progression of pressure ulcers. Specifically: Resident #52 did not receive ordered measures for pressure wound care. This failure contributed to the development of new pressure ulcers and failed to prevent the progression of an existing pressure ulcer. Findings include: Resident #52, an [AGE] year old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had impaired hearing and vision, as well as mildly impaired expressive and receptive speech. She required extensive assistance with all activities of daily living (ADLs) including toileting. She scored 3 out of 15 on the Brief Interview for Mental Status (BIMS), indicating significant cognitive impairment. 1. Record Review Record review revealed the resident entered the facility with skin breakdown and was assessed at high risk for skin breakdown. Record review further revealed a number of ordered interventions as the resident's existing wound worsened and she developed other areas of skin breakdown. An admission note by the physician 1/8/14 noted the resident had a "fairly extensive" closed pressure ulcer on the heel of her right foot and 2 centimeter (cm) red, open area medial talus area. The left foot had red areas under the 2nd and 5th metatarsal heads on the plantar surface. An admission nursing assessment dated [DATE] indicated the resident had Stage II pressure ulcer, a wound on the right foot at that time. No treatment orders were recorded on the date of admission until 1/23/14 (see below). The Braden Scale for predicting pressure ulcers dated 1/7/14 was scored at 12, indicating the resident was at high risk for skin impairment. An attending physician progress notes [REDACTED]. Physician orders [REDACTED]. -1/23/14 Float heels with pillow in bed every shift every day, -1/23/14 Wound to right inner foot to be left open to air. Float heels with pillows in bed per wound care physician, -2/17/14 Multi-podus boots to right foot and soft boot on left foot at all times, -2/18/14 Discontinue multi-podus boot to right foot, discontinue soft bootie to left foot. Prevelon boots to the right and left feet to be worn in bed and when up in wheelchair, and -2/19/14 Prevalon boots to both feet to be worn in bed and when up in wheelchair. Start when boots are available. February orders from the wound care physician were as follows: -2/16/14 Order for air mattress and wheelchair pad, and -2/20/14 Order for skin prep to wound daily Wound care physician progress notes [REDACTED]. -On 1/22/14, the physician documented the resident's right heel pressure ulcer was 2 x 5.3 cm and 100% eschar. A second right inner foot pressure ulcer was .7 x .6 and 100% eschar. The left foot had a wound 3 x .5 cm. -On 2/13/14, the physician documented "all are 100% eschar." At that time, he noted the resident had three wounds. Those wounds were documented as left inner foot 1.3 x 0.6 centimeters (cm), left heel 3.6 x 6.0 cm, and right plantar area .5 x .5cm. -On 2/14/14, the physician listed left inner foot, left heel and right plantar wounds. - On 2/20/14 the physician noted the right heel was 6 x 4 cm, right lateral foot distal to inner malleolus 1.5 x 1.1 cm, a left Achilles tendon area was 2.1 x .6 cm with 100% eschar, and a right anterior plantar foot wound .5 x .5 cm with 100 slough that was described as soft, but no moisture in a dried area. Two areas were noted to be the same size. Review of the resident's care plan for foot ulcer dated 1/20/14 (13 days after admission when she was identified as high risk for pressure sores) revealed care approaches that included elevating the lower extremities on a pillow and using an air mattress. Handwritten notations on the care plan for additional approaches were as follows: -1/23/14 - skin prep to bilateral heels and feet twice daily -2/6/15 - sure prep to "all areas" -2/17/14 - blue multi-podus boots to right lower extremity and heel -2/18/14 - Prevalon boots to right and left feet while in bed or up in wheelchair -2/20/14 - foot cradle to bed -2/20/14 - float heels while in bed -2/20/14 - lotion to lower extremities and feet every day. Review of the resident's record revealed no weekly tracking by facility staff of the resident's pressure areas. 2. Observations and Interviews Observations and interviews revealed ordered interventions to prevent further skin breakdown and to promote healing were not being implemented. a. Observations On 2/27/14 at 11:15 the resident was observed in bed. Her feet were not supported by pillows and had direct contact with the bottom sheet. She was not wearing any boots on her feet. Her right medial foot showed a black, closed wound approximately 1.5 x .5 cm. Her left heel showed a small (.5 x .5 cm) closed black wound. On 2/28/14 at 2:30 p.m. the resident was observed in bed. Her feet were uncovered and were not supported for off-loading pressure. She said her feet were cold. She did not have boots on her feet. The wounds were visible as described above. On 2/29/14 at 9 a.m., the resident was observed in bed. Her feet were not off-loaded and there were no pillows under her feet. She was not wearing boots. b. Interviews On 2/19/14 at 11 a.m., the unit nurse said the resident had an unstageable pressure on her right foot. She did not indicate the resident had any other pressure wounds. On 2/25/14 at 11:40 a.m., the unit nurse on the resident's hall said the resident had a pressure sore on her right foot; however, she required no special treatments. She said the only thing they put on the wound was skin prep. After checking the MAR, the nurse said, "I guess she's supposed to have boots, but I haven't seen them yet." On 2/27/14 at 11:50 a.m., a second nurse from the adjacent hall said, "I heard you asking about the resident's foot care - she's supposed to have special boots on at all times. I've called several times, but they are not available yet (see above order on 2/18/14). I don't know what's holding it up." On 2/27/14 at 9:37 a.m., the certified nurse aide (CNA) said he didn't know of any special treatments the resident received except an air mattress. On 2/28/14 at 3 p.m., the central supply clerk said that obtaining the resident's boots was a problem because the boots ordered were not in the corporation's formulary. She said the facility had changed ownership that year and she had been unaware the ordered boots were not available. She said she had contacted the corporation's supply contact and placed an order for [REDACTED]. On 2/28/14 at 3:15 p.m. the Director of Nursing said the facility conducted wound rounds weekly and on a monthly basis, the dietician and therapy supervisor attended those rounds as well. She said the ordered Prevalon boots were back-ordered and not available. She said the MDS coordinator was usually responsible for skin-related care plans. She said she expected pressure wound orders to be followed as written.

Based on record review, observations and interviews, the facility failed to provide appropriate care and services to ensure that three of 44 sample residents (#243, #10, #27) environment remained as free from accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically: The facility failed to provide adequate supervision and assistive devices to prevent the residents from falling. Resident #243 fell [DATE] and sustained fracture of her right hip, and residents #27 and #10 fell and sustained head lacerations. The findings include: 1. Resident #243 Resident #243, age 88, originally was admitted to the facility from home (per admission documents) on 11/30/11. Her [DIAGNOSES REDACTED]. She was readmitted , per the face sheet, on 1/16/12 from the hospital. The 1/23/12 Significant Change in Status Minimum Data Set (MDS) revealed additional [DIAGNOSES REDACTED]. The resident's MDS dated [DATE] also revealed a Brief Interview of Mental Status (BIMS) score of 7/15, indicating impaired cognitive abilities. This was a decline from MDS dated [DATE], which revealed a BIMS score of 10/15. a. Known Fall Risk on Admission The Nurses' Notes, dated 11/30/11, revealed that the resident had been admitted to the facility from home with [DIAGNOSES REDACTED]. The four-page Nursing Assessment for admission date of [DATE] revealed that she was admitted from home, could transfer with one-person assist, and was at risk for falls. b. Falls Following Admission - Facility Response - Failures in Facility Response From her admission on 11/30/11 through the end of February 2012, resident #243 had four falls. The third fall on 1/9/12 resulted in a hip fracture that required surgery. (1) First Fall on 12/18/11 On 12/18/11 Nurses' Notes revealed that the housekeeper witnessed the resident stand up and slide on the floor. The resident denied any pain and the nurse found no apparent injury. The physician and family were notified. Review of the resident's record revealed the facility failed to develop a care plan on admission or before this fall that addressed the resident's history of falls, identified the resident's specific fall risks, and established planned interventions to minimize these risks. Moreover, the facility did not complete a post-fall investigation or complete an event report for this fall in order to evaluate and consider interventions to keep the resident safe during self-transfers. (2) Second Fall on 12/20/11 On 12/20/11, Nurses' Notes read the certified nurse aide (CNA) found resident #243 sitting on floor in her room with her back against the bed, socks on, one shoe off. The resident stated that she was trying to transfer herself from bed to wheelchair and slid to the floor. The nurse found no injuries. The physician and family were notified. Neurological checks for 72 hours were started. An Event Report/Fall Investigation regarding this fall was completed almost two weeks later on 1/3/12. This document confirmed the nurse's note of 12/20/11. This report also revealed that the resident was attempting to transfer self from bed to wheelchair unassisted and she was non-compliant with asking for assistance. This report revealed a recommendation to prevent further falls was that she needed a bed alarm and did not have one at the time of the fall. A care plan to address the resident's risk for falls was initiated 12/20/11. The focus of this care plan included extensive assist with ADLs (activities of daily living) and bed and wheelchair alarms in use. The interventions initiated on 12/20/11 included encourage her to request assist if needed for transfer, use call light prior to transfer. However, record review failed to reveal any documentation of bed or wheelchair alarm placement or function prior to the physician's orders [REDACTED]. (3) Third Fall on 1/9/12 with Fracture On 1/9/12 Nurses' Notes read the resident was found on the floor by the bathroom door. The resident stated she slipped on a wet spot while ambulating unassisted; however, a wet spot was not noted by the nurse. The resident was lying on her back with her right leg rotated outwards, complaining of pain to her right hip and unable to move her right leg. The physician was called and ordered transport to hospital. The transfer summary from the hospital revealed that the resident was admitted on [DATE] and discharged on [DATE]. She had right hip intertrochanteric and sub-trochanteric fractures and underwent surgery for [REDACTED]. She was discharged back to the facility on [DATE] with a physician's orders [REDACTED]. An Event Report/Fall Investigation dated 1/9/12 was completed for this unwitnessed 1/9/12 fall. This document confirmed the nurse's note of 1/9/12. This report also revealed that the fall occurred during unassisted ambulation. This report revealed a recommendation to prevent further falls was to encourage the use of the call light and do not attempt to ambulate unassisted. This Event Report/Fall Investigation indicated that there were no alarms being used for this resident even though a bed alarm had been recommended after the second fall and had been noted on the care plan since 12/20/11. Moreover, while recommendations were made (see above), these interventions were shown by the resident's previous falls to be ineffective. There was no indication the facility considered new interventions or factors that might be prompting the resident to self-transfer without assistance. Review of the resident's care plan for falls revealed no updates upon the resident's readmission to the facility on [DATE] until the 2/10/12 revision (see below). (4) Fourth Fall on 2/26/12 On 2/26/12 Nurses' Notes revealed that the resident was found lying on her back on floor in her room. The nurse noted a two centimeter lump on the back of the resident's head. Neurological checks were initiated and found to be within normal limits, range of motion was also within normal limits. There were no signs or symptoms of injury noted. Neurological checks were continued for 72 hours. An Event Report/Fall Investigation dated 2/26/12 was completed for this unwitnessed 2/26/12 fall. This document confirmed the nurse's note of 2/26/12. The report revealed that the fall occurred when the resident attempted to transfer herself without assistance. She stated she slipped and fell backwards, hitting back of head. She was found lying on her back, without shoes on, and had not called for assistance. This report indicated that an alarm was being used for this resident, but that it was not in place, and it was not turned on, and it did not sound. The report indicated that the alarm battery was in working order. This report included a recommendation to prevent further falls was that the resident needed constant instruction to use the call light when she needs assistance. However, the resident had shown, through previous falls, that she did not use the call light when she needed assistance. There was no plan to increase supervision of the resident or for supervision of the resident at regular intervals. Review of the care plan for falls revealed it was revised on 2/10/12, to direct staff to check for placement and function of bed and wheelchair alarms every shift and as needed. Review of the Treatment Administration Records (TAR) for 2/12 revealed documentation of bed and wheelchair alarms on appropriately on day shift for 19 of the 29 days beginning 2/1/12 through 2/29/12, and on night shift for 23 of the 29 nights beginning 2/1/12 through 2/29/12. c. Observations Observations of the resident on 2/28/12 in bed and in wheelchair, 2/29/12 in bed and in wheelchair, and 3/1/12 in bed and in wheelchair, revealed no bed alarm or wheelchair alarm in use. d. Staff Interviews In an interview, on 3/1/12 at 9:20 a.m., the Unit Manager/Nurse stated that she would have to check if this resident had bed and wheelchair alarms. In the resident's room, she confirmed that there were no bed or wheelchair alarms in place, or located anywhere in the resident's room. In another interview, on 3/1/12 at 12:15 p.m., the Unit Manager/Nurse stated that the floor nurses should be signing off on the TAR when they check for the bed and wheelchair alarms. She could not explain why the bed and wheelchair alarms were not in place today, and she did not know for how long there had been no alarms. She stated that she had told the nurses that they should not sign off on the TAR if they do not personally check for both alarms. In a third interview, on 3/1/12 at 4:00 p.m., the Unit Manager/Nurse stated that from now on, she would make sure that the alarms are on. (Observations on 3/6/12 revealed that the wheelchair and the bed alarm were in place and in use.) e. Resident Interview In an interview, on 3/1/12 at 10:30 a.m., the resident stated that her memory was not very good anymore, and that the nurses want her to wait for help to go to the bathroom. She stated that she did not remember having a wheelchair alarm or a bed alarm. She stated that she could transfer herself from the wheelchair to the bed without assistance. The resident was not able to state the plan that she needed assistance from the staff for any transfer. Her statements indicated she was confused about this expectation. 2. Resident #27 Resident #27, age 70, was admitted to the facility on [DATE]. According to the 1/12 Computerized Physician order [REDACTED]. According to the initial MDS, dated [DATE], the resident had moderate cognitive impairments. The MDS indicated the resident required extensive assistance with activities of daily living. The resident did not have a fall history and had not fallen in the past six months. a. Fall Risk Although the resident's fall evaluation, dated 10/25/11, documented the resident had not had a fall in the past 30 days, it also read that the resident had a change in mobility, gait and transfer mobility. The resident's care plan, dated 12/4/11, identified the resident was at risk for falls related to psychotropic medications, impaired balance, pain and visual deficit. Denies history of falls. The goal was for the resident to remain free from falls. The approaches were to assist of two for mechanical transfers, evaluate effectiveness and monitor for side effects of psychotropic drugs. b. Fall 1/9/12 According to the Interdisciplinary Progress Notes, dated 1/9/12, "...pt (patient) fell in the shower while in her w/c (wheelchair). Pt was witnessed fall by CNA (certified nurse aide). Pt had 3 cm (centimeter) laceration to her forehead with 50 ml blood loss. Pt and CNA deny any LOC (loss of consciousness). Neuro check, vital signs were done. DON (director of nurses), medical power of attorney and Dr (name of physician) notified and pt departed to (name of hospital) ... " The fall investigation, dated 1/9/12, documented, "patient was in the shower chair, was attended by CNA who turned to grab the hair dryer. Patient slipped out of chair and hit her forehead on the floor. CNA then asked for help to get the pt back in the chair. Pt had a 3 cm laceration to her forehead with about 50 ml blood loss.." The investigation documented the resident's mental status prior to the fall was lethargic. The fall investigation recommendation was for the resident to have two CNAs available and ensure the resident did not lean forward in the wheelchair. The investigation documented the resident was lethargic and that may be due to the dose of Gabapentin and maybe it needed to be reduced. The resident returned to the facility on [DATE]. The medical record failed to show that the recommendation above regarding evaluating the resident's Gabapentin was implemented. c. Staff Interviews The CNA who was assisting the resident in the shower on 1/9/12 was interviewed on 3/1/2 at approximately 1:00 p.m. The CNA said that while the resident was in the shower chair, she moved her close to the sink. The CNA left the resident unattended and walked away approximately four feet to get the hair dryer and the resident then fell face first on to the floor. She stated that the resident was lethargic during the shower. She stated the resident bled a lot. The director of nurses (DON) was interviewed on 3/1/12 at 1:30 p.m. The DON stated the resident should not have been left unattended if she was lethargic. She confirmed after reviewing the medical record that the medication Gabapentin had not been evaluated. The DON stated the resident's fall evaluation should have been updated after the fall. 3. Resident #10 Resident #10, age 90, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. a. Resident Status The Minimum Data Set (MDS), dated [DATE], described resident #10 as cognitively intact. Functionally, the resident required extensive assistance of at least two people for bed mobility, transfers, dressing, toileting and personal hygiene. The MDS described the resident as not steady in moving from seated to standing position, moving on and off the toilet and transfer between bed and chair or wheelchair. There was impairment on one side of both the upper and lower extremities affecting limitation in range of motion. The resident was identified as always incontinent of both bladder and bowel. The resident had one fall with no injury and two falls with minor injuries during the look-back period. A new admission Resident Fall evaluation (RFE) was done on 9/23/11. Ten of 21 factors were answered "yes." Each "yes" indicated a fall risk factor. A RFE dated 11/24/11 listed six of 21 factors as fall risk factors. The evaluation stated the resident had no falls in the past 30 days. A care plan addressing the problem of risk for falls, initiated 10/5/11, included the following interventions in pertinent part: When resident (is) in bed, have all necessary personal items within reach. Place call light within easy reach of resident. Resident has wheelchair alarm, transfer pole and large call button. Ensure safety devices in place and functioning q (every) shift and PRN (as needed). Assist resident getting in and out of bed with one or two person assistance. b. Falls On 3/1/12 at 1:49 p.m., an interview was conducted with the Director of Nursing (DON). The DON said (Resident) Fall Evaluations (RFEs) are done quarterly, after a fall, and after a change in condition. The DON stated that care plans were revised after a fall. A new Care Plan was initiated on 12/8/11 which addressed manipulative behaviors related to falls and self transferring. (1) 12/2/11 An Interdisciplinary Progress note (IDT PN) dated 12/2/11 at 9:15 a.m., read that the resident had been found on the floor. The resident stated she had been attempting to get into bed. There were no injuries noted. The facility's fall investigation of the resident #'s 12/2/11 fall documented the resident was instructed not to transfer alone and staff was instructed not to leave (resident) in bathroom unattended. The investigation form stated a fall evaluation was completed post fall. The investigation form noted that the care plan had been updated. No RFE was completed following the 12/2/11 fall and there was no revision or update following the 12/2/11 fall, directing staff to not leave the resident in the bathroom unattended. (2) 12/7/11 An IDT PN dated 12/7/11 at 2 p.m., documented staff had heard "yelling" and a chair alarm sounding and found the resident sitting (on the floor), holding onto the wheelchair in the bathroom doorway. No injuries were noted. The facility's fall investigation for the 12/7/11 fall recommended the resident be instructed in the use of the call light and every one hour check sheet put into place. The investigation form stated a fall evaluation had been done post fall. The investigation form stated the care plan had been updated. No RFE was completed following the 12/7/11 fall. Care plan review revealed a care plan for manipulative behaviors was initiated on 12/8/11. The care plan alleged the resident was attempting to self-transfer without calling for staff assistance and falls. The resident then called her son and told him that the staff left her alone and didn't help her transfer. Interventions listed included reminding resident to use call light and wait for staff arrival prior to transferring, staff to assist with all transfers/mobility for safety, anticipate needs for safety and tab alarm when in bed and wheelchair. There was a hand-written entry, not dated, that read "2 person assist with all CNA (certified nurse aide) cares and answering of call light." However, there was no revision to the resident's fall care plan, directing staff to not leave the resident in the bathroom unattended. (3) 12/20/11 An IDT PN dated 12/20/11 at 8:05 a.m. noted a CNA calling for nursing help stating, "A resident has fallen." The note documented a 1 cm laceration of the resident's forehead with no other apparent injuries. The physician was notified and the resident was sent to the hospital for evaluation. A physician telephone order, dated 12/20/11, ordered the resident sent to the hospital emergency room for evaluation and treatment for fall and laceration to forehead. The facility's fall investigation for the 12/20/11 fall noted the care plan was updated. The investigation form noted the resident had three falls in the past 31-180 days. The investigation form listed interventions in place as "resident encouraged to use call light and to request assistance, continue chair alarms and every hour checks." A RFE dated 12/20/11, indicated the resident had falls in the past 30 days. Five of 21 factors were listed as fall risk factors. There were no updates to the resident's fall care plan regarding new or revised safety interventions. c. Observations and Family Interview On 3/1/12 at 3:46 p.m., resident #10's son was overheard telling the nursing staff at the Cheyenne nursing station that he had just found resident #10 half in and out of bed and that staff had not assisted the resident. An interview with resident #10's son was conducted on 3/1/12 at 3:55 p.m. Resident #10's son stated he had come into the resident's room and found her lying on her side at the edge of the bed; her head was hanging off the side of the bed. He said that a staff member had come in, walked past his mother (who has the bed closest to the door), to help the resident's roommate but did not attempt to reposition the resident in bed. He said that was when he went to the nurses' station and reported that staff had not assisted resident #10. d. Staff Interview and Record Review A staff interview was conducted with a Licensed Practical Nurse (LPN #1) on 3/1/12 at 4:10 p.m. LPN #1 acknowledged that resident #10 was a fall risk. LPN #1 said the interventions put in place to keep resident #10 from falling were the use of a low bed. The LPN did not think the resident had an alarm and stated, "At this point, I think that is all that we have for an intervention." LPN #1 did not remember why resident #10 had fallen in the past. Review of the CNAs' ADL book 3/1/12 at 3:50 p.m., revealed a notation about not leaving resident #10 in the bathroom alone. However, after reviewing the resident's care plans, LPN #1 agreed that she could not find this intervention on the resident's care plan. She then added this intervention to the plan. LPN #1 said that a fall evaluation should be completed after a fall. LPN #1 said resident #10 was checked on every two hours. These checks were charted on an IDT progress note kept in the nursing station that recorded the date and time as well as what had been done for the resident. However, a review of the IDT progress note on the clipboard on 3/1/12 at 4:30 p.m., showed the last entry as 2/12/12. CNA #1 was interviewed on 3/6/12 at 4:37 p.m. CNA #1 was asked if there were any special instructions in caring for resident #10 and stated that staff was to remain with the resident when she was toileted. CNA #1 said that every hour checks were done by the CNAs and documented on a clipboard at the nurses' station. "We are supposed to check on her every hour whether he/she calls or not. If there are any concerns we report to the nurse." A review of the IDT progress note on the clipboard for 3/6/12 was done 3/6/12 at 4:50 p.m. The only entry for 3/6/12 was at 3 a.m. which was acknowledged by CNA #1.

Based on observation, resident and family interviews and record review, the facility failed to ensure that two (#2 and #3) of three sample residents were given the necessary services to maintain good grooming and personal hygiene. Specifically: -Resident #2 was left in a bed soaked with urine and not given appropriate peri-care for over six hours. Observations revealed the resident's room smelled strongly of urine, her bedsheets were soaked with urine, and the resident's buttocks were excoriated. -Resident #3 was not given appropriate assistance with eating. Cross Reference F252 Findings include: 1. Resident #2, a [AGE] year-old female, was originally admitted to the facility on [DATE]. She had diagnoses, according to her face sheet, that included [MEDICAL CONDITION], obesity, [MEDICAL CONDITION], and multiple joint contractures. According to her most recent full Minimum Data Set (MDS), an annual assessment completed on 9/30/10, resident #2 was totally dependent on staff for extensive assistance with all Activities of Daily Living (ADLs). She was incontinent of both bladder and bowel and the staff were responsible for toileting, providing peri-care, repositioning and skin monitoring. She was also noted to be alert and oriented with only modified independence in decision-making. Complaints had been received by the Colorado Department of Public Health & Environment (CDPHE) in reference to resident #2's room being very odorous (specifically urine smells) from a frequent facility visitor, and from the family of another resident. There were also allegations that the resident was not being checked and changed for incontinence and was left to lie in her own waste. Resident Interview/Observation: On 7/12/11 at approximately 12 o'clock noon, a brief interview with resident #2 was conducted in her room. Prior to entering her room, a very strong urine smell was evident 10 feet away from her closed door. Upon entering the room, the smell of urine was overwhelming and pungent. During the interview, the resident was asked if she was aware of the strong odor of urine. She stated she was not and that she didn't "smell very well" anymore. Resident #2 further stated that she knew she was wet and had mentioned it to the nurse that gave her medication at nine o'clock that morning. The nurse told her she would "tell her aide (certified nurse aide). She said that three hours had passed and no one had come in to give her incontinence care. The resident stated "that happens all the time." Observations revealed there were two brown rings of dried urine on the bottom sheet and the sheet was soaked. The resident then pointed to her right buttocks area and stated that "it burns." Staff Interviews: The Director of Nursing (DON) and the Charge Nurse assigned to resident #2 were interviewed on 7/12/11. he Charge Nurse (a Registered Nurse/RN) was interviewed in the presence of the DON at approximately 12:15 p.m. When asked if resident #2 had told her she was wet that morning at 9 a.m., the RN confirmed that. She stated that she told the CNA assigned to resident #2. A few moments later, the RN stated that she meant to tell her, but perhaps in the business of the day she had forgotten. The CNA was interviewed in the presence of the DON and the RN at approximately 12:30 p.m. She stated the RN did not tell her that resident #2 was wet. -The CNA stated that "(resident #2) refuses (care) all the time" and that "according to her care plan, (resident #2) only needed to be changed once a shift." -When asked when she had last seen the resident that day, she acknowledged she had not seen her at all yet. She stated her shift started at 6:00 a.m. The CNA confirmed that resident #2 required a lot of care but maintained that she had not yet seen resident #2 in 6 + hours since she had come on duty. The DON, RN and CNA were informed of the surveyor's observations above. All three staff was asked to accompany the surveyor to resident #2's room. Upon inspection of the resident's bed, the DON and RN confirmed the dried brown rings on the resident's sheet were urine. Observation of Peri-Care: Following the above observation, the CNA donned gloves, raised the bed, and with the assistance of the RN, had the resident turn to her left side. The CNA then dug into the resident's trash can for a clean bag (the extra trash bags were down in the receptacle under the currently used bag). She then started to resume the peri-care without changing her gloves. (The surveyor asked that she remove those gloves and put clean ones on.) The resident had two blue chux (disposable incontinence pads) underneath her, as well as a pillow between her legs. The resident had contractures in her legs and the right leg was especially drawn up. -There was an area of excoriation on the resident's right outer buttocks. The CNA used disposable wipes and cleansed the residents skin. When she used a wipe to clean in the right inguinal area, the wipe was noted to have bright red blood on it. As the CNA wiped there, resident #2 stated, "Oh, don't do that - it bleeds." Due to the resident's contractures, it was very difficult for the CNA to open the resident's thighs and observe the source of the bleeding. -The pillow that had been between the resident's legs was noted to be wet with urine and yellow in overall color. The RN stated she had not been aware of any bleeding or excoriation in the peri area. -After completing the resident's peri-care, the CNA reached for the soiled pillow she had removed and started to put a fresh pillow case on it. The CNA was asked (by the surveyor) to get a clean pillow for the resident. The RN left the room to get some barrier cream to apply all over the resident's peri-area. There was also noted to be excoriation under her breasts, which had clumps of powder ([MEDICATION NAME] Powder) under them. As the RN and the CNA rolled resident #2 back on to her left side, standing urine was observed on the mattress. The DON and RN were both shown the standing puddle of urine under resident #2. Resident #2 had a pressure-relieving mattress on her bed and the DON instructed the CNA that two chux should not be used on this type of mattress. Post Peri-Care Interviews: The DON and RN acknowledged that the CNA should have been checking on resident #2 at least every two hours and offering to assist her with peri-care. They stated that the resident was often non-compliant but that the state she was found in was not acceptable. They stated the CNA would be counseled and re-educated. The DON later stated that she had spoken to the overnight shift and determined the last time resident #2 had been changed was approximately at 5:30 a.m., just prior to change of shift. The Care Plan for resident #2 read, in pertinent part: -FOCUS: "(Resident #2) has urinary incontinence, is bedbound most of the time, will use bedpan at times. Impaired mobility, physical limitations." -GOALS: "To be clean, dry and odor-free." -INTERVENTIONS: "Thorough peri-care after each incontinence. Observe for redness ...Incontinent Program: Containment: Check for wetness ac (after meals), pc (before meals), qhs (every night at bedtime) and on rounds during the night. She does agree to be changed at times, but has agreed to be changed at midnight, 1:30 p.m. and 9 p.m. ...." The DON was asked if she felt changing and providing peri-care as care planned above was acceptable (1:30 p.m., then 8.5 hours later at 9 p.m., then three hours later at midnight ...then not again for 13.5 hours until 1:30 p.m.) and she stated it was not adequate. 2. Resident #3, an [AGE] year-old male, was admitted to the facility on [DATE]. He had diagnoses, according to his face sheet and physician progress notes [REDACTED]. According to his most recent Minimum Data Set (MDS), a quarterly assessment completed on 5/3/11, resident #3 was totally dependent on staff for extensive assistance with all Activities of Daily Living (ADLs). He was incontinent of both bladder and bowel and the staff were responsible for toileting, providing peri-care, repositioning and skin monitoring. (Since the MDS above, the resident had a Foley catheter inserted due to [MEDICAL CONDITION] bladder and hopes of healing skin breakdown.) Record review revealed the resident had experienced weight loss; however, according to his physician, the weight loss was unavoidable due to a decline in the resident's functional ability, . Interview/Observation: A complaint filed with the CDPHE alleged the resident was not receiving assistance with eating as necessary. On 7/12/11 at approximately 1 o'clock noon, resident #3 was observed in his room. There was a sign posted above the resident's bed that stated HOB to remain at 90 degrees when he was eating. The resident was lying back in bed with the HOB (head of bed) at 30 degrees (confirmed by a facility Physical Therapist who measured the elevation of the HOB). There was a lunch tray on the resident's overbed table (it was pureed food) and it appeared that only a few bites of food had been eaten. One of resident #2's family members, who visited frequently, came in during the visit. She stated that the resident did not get assistance when eating alone in his room, and that they were worried about choking or continued poor oral intake. Physician Interview: On 7/12/11 at approximately 2:00 p.m., the resident's physician stated he was not sure where the order (if there was one) had come from regarding the "HOB to be up at 90 degrees while eating" and that the resident had no history of aspiration. He stated the resident had no diagnoses that would prevent him from eating anything he would like (i.e. diabetes) and he was fine with encouraging high calorie Ensure shakes, made with ice cream, to supplement his current poor oral intake. The physician then wrote the following orders: -Ensure milkshake with ice cream (to try and get a higher caloric intake) three times a day every day. -CNA to stay with pt @ all meals-with Breakfast, Lunch and Dinner every day. -Weekly weights (he had only been monitored monthly prior). -PT (physical therapy) to re-evaluate and treat for mobilization and for strengthening. -ST (Speech Therapy) to evaluate, for questionable dysphagia (difficulty swallowing), position of HOB etc., complex dysphagia. The physician stated that he was going to re-approach the family in regard to considering comfort care or hospice for resident #3, as he continued to decline.