Every finding on record at Mountain Vista Health Center

Based on observations and interviews, the facility failed to remove medications and biologicals that were stored and labeled properly according to professional standards in three of five medication carts and two of four medication storage rooms.Specifically, the facility failed to:-Ensure expired medications were discarded; and,-Ensure a drug buster was not stored next to medications. Findings include:I. Professional referencesThe United States Food and Drug Administration (USFDA) Don't Be Tempted to Use Expired Medicines (revised 10/31/24), was retrieved on 5/1/26 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It read in pertinent part, Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth, and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed, there is no guarantee that the medicine will be safe and effective. If your medicine has expired, do not use it.I. Facility policy and procedureThe Storage of Medication policy, undated, was received from the nursing home administrator on 5/1/26 at 3:41 p.m. It revealed in pertinent part, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control and security. All medication rooms are routinely inspected by the consultant pharmacist or discontinued, outdated, defective or deteriorating medications with worn illegible or mislabels.II. ObservationsOn 4/28/26 at 3:45 p.m. the medication cart #2 on the 100 unit was observed with licensed practical nurse (LPN) #1. The drawer on the medication cart for Resident #54 contained the following:-Mirtazapine (medication used to treat depression) oral tablet 7.5 milligram (mg). The order was discontinued on 4/17/26.-Levothyroxine (medication used to treat hypothyroidism) oral tablet 25 micrograms (mcg). The order was discontinued on 1/15/26.The drawer on the medication cart for Resident #24 contained the following:-Xarelto (medication used as a blood thinner) oral tablet 15 mg. The order was discontinued on 2/20/25.The drawer on the medication cart for Resident #64 contained the following:-Albuterol Ipratropium-Albuterol Inhalation solution 0.5-2.5 mg/3 milliliter (ml) (Ipratropium-Albuterol) The medication did not have an expiration date.On 4/28/26 at 4:35 p.m. the medication cart #1 on the 200 unit was observed with LPN #2. The drawer on the medication cart for Resident #2 contained the following:-Benzonatate (medication used as a cough suppressant) oral tablet 100 mg. The order was discontinued on 4/9/26.The drawer on the medication cart for Resident #66 contained the following:-Ondansetron (medication used to prevent nausea and vomiting) oral tablet 4 mg) The medication expired on 3/31/26.On 4/29/26 at 10:12 a.m. the medication storage room for the secured unit was observed with registered nurse (RN) #2. The cabinets in the medication storage room for the secured unit contained the following:-Twenty-two pre-filled normal saline 0.9% flush syringes 10 ml that expired on 5/13/18.-Three pre-filled normal saline 0.9% flush syringes 10 ml that expired on 7/31/21.-Three vials of ceftriaxone (medication used to treat infections) for injection 1 gram (gm) that expired 1/30/23. The emergency medication, non-narcotic, supply box, for the secured unit expired in March 2026. The supply box contained the following medications:-Humulin R (Short acting regular) insulin-Humulin N (intermediate acting) insulin-Humulin 70/30 (premixed) insulin -Humalog (lisprio) insulin-Cathflo Activase (alteplase)-Lantus (glargine) InsulinOn 4/29/26 at 11:00 a.m. the medication storage room on 200 unit was observed with LPN #3. The medication refrigerator for the 200 unit for Resident #11 contained the following:-Two boxes that contained five pens each of Basaglar KwikPen (insulin glargine) 100 units/ml pen that expired on 9/23/25.-One box that contained five pens of Basaglar KwikPen (insulin glargine) 100 units/ml pen that expired on 10/13/25.The medication refrigerator for the 200 unit for Resident #16 contained the following:-Lumigan 0.01 % (eye drop) that expired on 11/30/25. On 4/29/26 at 11:30 a.m. the medication cart #1 on the rehabilitation unit was observed with RN #1. The following items were found.-A 16-ounce bottle of Drug Buster (activated charcoal-based disposal system designed to quickly deactivate and destroy unwanted pills, capsules, liquids, creams) was in the same drawer as liquid medications. III. Staff interviewsLPN #1 was interviewed on 4/28/26 at 3:30 p.m. LPN #1 said all medications should have been discarded immediately upon reaching the medication expiration date. LPN #1 said any nurse who was assigned to this medication card should be checking the expiration dates on the medications. LPN #2 was interviewed on 4/28/26 at 4:40 p.m. LPN #2 said it was the responsibility of all of the nurses to check the expiration dates on medications during their shift and before medication administration. RN #2 was interviewed on 4/29/26 at 10:20 a.m. RN #2 said she did not work on the secured unit very often. RN #2 said she was unsure as to who was responsible for monitoring expired medications in the medication room.LPN #3 was interviewed on 4/29/26 at 11:10 a.m. LPN #3 said it was the nurses responsibility to ensure all expired medications were removed from the medication storage refrigerator. The director of nursing (DON) was interviewed on 4/30/26 at 1:30 p.m. The DON said the nurses were responsible for checking the expiration dates before administering medication to the residents. The DON said medications should be discarded immediately if it was discontinued, or the nurses should verify with the doctor that the medication was no longer needed. The DON said the night supervisor should be checking medication storage rooms once a week. She said she would advised the night supervisors to check the cabinets and drawers in the medication storage rooms for expired medications. The DON said the night supervisors did not understand the explanation of her instructions. The DON said she would initiate education and training with the supervisors today regarding when and how to check the medication rooms The DON said she also started education and training RN's and LPN's to check the medication carts for expired and mislabeled medications. The DON said it was important to keep the medication storage rooms and medications carts free from expired and mislabeled meds to prevent resident harm and to maintain the efficacy of the medication.

Based on observations, record review and interviews, the facility failed to ensure 16 residents on a mechanical soft diet received food and fluids prepared in a form designed to meet his or her needs per speech therapy recommendation, physician orders and the residents care plan.Specifically, the facility failed to ensure residents who were prescribed a mechanical soft diet had food prepared according to their diet orders of mechanical soft as indicated on their meal tray cards. Findings include:I. Facility policy and procedureThe Mechanical Soft Food Preparation policy, undated, was provided by the registered dietitian (RD) on 4/28/26 at 5:52 p.m. The policy read in pertinent part, The facility will prepare mechanical soft foods in a manner that sustains the nutritional value and taste. The foods will be ground to assure the desired consistency. Mechanical soft foods will be made from regular menu items to assure similar taste and nutritional quality. Recipes for regular menu items will be followed during production. Mechanical soft foods must be ground to the proper consistency per resident's needs/requests.II. Meal service observation and staff interviewsDuring a continuous observation of the dinner meal service on 4/28/26, beginning at 4:11 p.m. and ending at 5:42 p.m., the following was observed:The posted menu documented the dinner meal was a tuna melt grilled sandwich, sweet potato rounds, ambrosia salad (creamy fruit salad) and banana pudding. The mechanically soft altered menu items were a ground grilled tuna melt sandwich and sweet potato rounds.Cook (CK) #1 was interviewed on 4/28/26 at 4:13 p.m. (during meal service). CK #1 said the sweet potatoes in the pan in hot holding were frozen sweet potato rounds and were fried.At 4:26 p.m. CK #1 assembled four meal plates for residents. The plates were placed on a tray for residents whose meal tickets documented they were prescribed mechanical soft diets. The four meal plates included a whole grilled tuna melt sandwich cut in half (triangles) and the fried sweet potato rounds.-The menu extensions provided by the facility documented the mechanical soft modification for the tuna melt sandwich was a ground grilled tuna melt sandwich (see menu extensions below).CK #2 was interviewed on 4/28/26 at 4:28 p.m. (during meal service) CK #2 said he put the raw onions in the food processor before putting them into the tuna salad, but he did not add celery because the facility did not have celery.-The facility was notified the item served was different from the item listed on the extensions. The tuna melt sandwich was served grilled and cut in half instead of ground grilled tuna melt sandwich.CK #2 was interviewed on 4/28/26 at 4:49 p.m. (during meal service). CK #2 said the recipe book for dinner (on 4/28/26) was somewhere, but he made the tuna salad so many times he did not use the recipe.At 4:52 p.m. CK #1 assembled a meal plate of a whole grilled tuna melt sandwich cut in half and sweet potato rounds for a resident whose meal ticket documented a mechanical soft diet order. At 4:53 p.m. CK #1 assembled two meal plates for residents whose meal tickets documented mechanical soft diet orders. The two meal plates included a whole grilled tuna melt sandwich cut in half and fried sweet potato rounds.At 4:54 p.m. the dietary manager (DM) pulled the week five recipe binder. The tuna salad recipe was not present in the binder for the dinner meal on 4/28/26.At 4:55 p.m. CK #1 assembled a meal plate of a whole grilled tuna melt sandwich cut in half and sweet potato rounds for a resident whose meal ticket documented a mechanical soft diet order. At 4:58 p.m. CK #1 assembled a meal plate of a whole grilled tuna melt sandwich cut in half and sweet potato rounds for a resident whose meal ticket documented a mechanical soft diet order. At 5:24 p.m. CK #1 assembled a plate of diced chicken tender, sweet potato rounds and gravy for a resident whose meal ticket documented a mechanical soft diet order. The chicken was diced in one quarter to one half inch pieces.-However, the facility's mechanical soft diet description failed to indicate the appropriate size mechanical soft meat should be cut into (see description below).At 5:33 p.m. CK #1 assembled three meal plates for residents whose meal ticket documented mechanical soft diet orders. The three meal plates included a whole grilled tuna melt sandwich cut in half and mashed sweet potato.CK #1 was interviewed on 4/28/26 at 5:33 p.m. CK #1 said the facility ran out of sweet potato rounds during meal service. He said the facility substituted canned sweet potato for a mechanical soft diet as a backup.-The facility failed to serve a ground grilled tuna melt sandwich item as part of the mechanically altered diet. The facility failed to chop foods to the desired consistency (see record review below).On 4/28/26 at 6:04 p.m. a test tray for a mechanical soft diet, which was served at the same time as resident room trays, was evaluated by four surveyors during the dinner meal service. The test tray was assembled in the kitchen at 5:41 p.m., arrived on the unit at 6:04 p.m. and was tested for texture.The test tray meal consisted of a whole grilled tuna melt sandwich cut in half and canned sweet potato. The edges of the tuna melt sandwich were hard and crumbly.III. Record reviewThe mechanical soft diet description from the facility's diet manual was provided by the RD on 4/28/26 at 5:52 p.m. The diet manual documented the following modifications for the mechanically altered food items served during dinner meal service on 4/28/26:Remove desired number of servings to chop for the mechanical soft diets.Use a knife/fork or processor to chop foods to the desired consistency.-The mechanical soft diet description failed to include the residents could have grilled bread or fried items.The mechanical soft menu extensions were provided by the nursing home administrator (NHA) on 4/27/26 at 9:10 a.m. The extensions documented the following modifications for food items served during the dinner meal service on 4/28/26:Three ounces (oz) ground grilled tuna melt sandwich;Four oz sweet potato rounds;Four oz cup of fruit (soft); and,Four oz banana pudding.The recipe for grilled tuna melt was provided on 4/27/28 at approximately 11:00 a.m The grilled tuna melt recipe documented for tuna salad include recipe card #4141. After assembling the sandwiches, heat a large skillet/flat top grill to medium heat, place the sandwich margarine side down, brush the other side with melted margarine. Let bread get crisp and carefully flip the sandwiches. [NAME] to 145 degrees Fahrenheit (F) and serve promptly. Mechanical soft steps: remove the desired number of services to chop for the mechanical soft diets. Use a knife, fork or process to chop foods to the desired consistency.-However, the recipe did not specify what the desired consistency was.IV. Additional staff interviewsThe DM was interviewed on 4/28/26 at 4:43 p.m.(during meal service) The DM said he was trained by the assisted living food service director to make and serve the grilled tuna melt sandwiches and serve the potato rounds (see observations above). The DM said the facility did not use the international dysphagia diet standardisation initiative (IDDSI) diets. The DM pointed to a paper on the table titled IDDSI Menu EC7 (easy to chew level seven) and said that was the facility's mechanical soft diet.The DM and the RD were interviewed on 4/29/26 at 10:45 a.m. The DM said when the facility had mechanical soft sandwiches the staff ground the meat and not the bread. The DM said because the tuna was ground already the staff did not grind the bread. The DM said the staff assembled the tuna melt sandwiches and then toasted the sandwich.-However, the menu extensions documented ground grilled tuna melt sandwiches (see record review above).The RD said some residents had the modified texture diet for dentition (condition of teeth) because they were missing teeth or they had chewing issues. The director of rehabilitation was interviewed on 4/29/26 at 3:45 p.m. The director of rehabilitation said speech pathology staff conducted the resident swallowing assessments and recommended the diet order based on the assessment. She said the speech therapist was notified if a resident refused a modified texture diet and it was the discretion of the speech therapist to do anOTHER evaluation if needed. The director of rehabilitation said they documented all resident refusals of a diet. She said if a resident refused a texture of a food item on their diet the facility could offer a different option of the same texture. The director of rehabilitation said the risk of not following a prescribed diet was aspiration (food, liquid, saliva, or stomach contents enter the airway and lungs instead of the esophagus, causing coughing, wheezing, or silent choking for the resident).CK #2 and the DM were interviewed together on 4/29/26 at 4:30 p.m. CK #2 said he had a full training on food texture when he was hired a year ago. CK #2 said he had some texture coaching with the DM. CK #2 said he referred to the facility's menu program for any mechanical soft modified texture. He said for any alternate menu, he modified the texture based on what the DM taught him.The DM said he taught the cooks how to prepare the texture for any alternate menu as there was no reference in the facility's menu program. The DM said he had to create any modification texture for the alternate menu based on his experience.

Based on interviews and record review, the facility failed to ensure two (#71 and #86) of four residents out of 51 sample residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to effectively resolve Resident #71 and Resident #86's written grievances (complaints) about call lights previously. Findings include:I. Facility policy and procedureThe Grievances/Complaints Filing policy, dated [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 3:41p.m. The policy read in pertinent part, The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and or representative.The Answering the Call Light policy, dated [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 3:41p.m. The policy read in pertinent part, The facility uses a silent call light system that requires residents to wear a pendant around their neck or on their wrist. The call light system is monitored via electronic devices that alerts staff. General guidelines included: Report all defective call lights to the Nurse Supervisor promptly. Answer the resident's call as soon as possible. Be courteous in answering the resident's call. Steps in the procedure included: Turn off the call light by claiming and clearing on the tablet. Identify yourself and listen to the residents request for assistance. Do what the resident asks of you. If you have promised the resident you will return with an item or information, do so promptly. The following information should be documented through the grievance process or incident report, or medical record as it pertains: If the resident refused the treatment/solution, and the reasons why. If an issue is identified that prevents a resident from using their all light or the system is not able to clear, the nursing supervisor will implement and document 15 minute checks for the resident affected. Documented checks will be turned in to the director of nursing (DON) or designee.II. Resident #71A. Resident statusResident #71, age [AGE], was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus (a chronic condition where the body resists insulin or fails to produce enough causing high blood sugar), necrotizing fasciitis (bacterial infection that destroys tissue under the skin and spreads rapidly), and depression. The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) of 13 out of 15.B. Resident interviewResident #71 was interviewed on [DATE] at 3:11 p.m. Resident #71 said he filed a grievance about long call light wait times on [DATE]. Resident #71 said he continued to have issues with long call light wait times. C. Record reviewA grievance form, dated [DATE], was provided by the DON on [DATE] at 6:05 p.m. Resident #71 wrote that the date of incident/concern was over the past few weeks. The grievance form description of concern revealed call lights had gone unanswered for long periods of time. The grievance description revealed Resident #71 had gone out of his room to get assistance from certified nursing aides (CNA) who were on their phones. The grievance description revealed that the CNAs who were available to assist Resident #71 pushed assisting the resident onto a different CNA, instead of helping Resident #71 themselves. The grievance description revealed that the CNAs who were available to assist Resident #71 did not offer to assist him. The grievance description revealed Resident #71 did not feel his CNAs were being professional and he did not feel that he was being treated with dignity and respect. A follow up section was included in the grievance form documentation. The follow up documentation revealed the following items were reviewed and discussed with staff and Resident #71. The form documented the staff were instructed to answer all call lights timely even if the resident calling for help was not assigned to them. The call light iPads were assessed and it was confirmed that they were working properly. -However, Resident #71 said there continued to be long call light wait times (see resident interview above).On [DATE] at 6:14 p.m. call light logs for Resident #71 were provided by the DON. According to the logs, the call light response times for [DATE] were as follows:Review of Resident #71's call light response log from [DATE] to [DATE] revealed the following call light response times:The call light was activated and not answered for 20 to 39 minutes, 16 times.The call light was activated and not answered for 40 minutes to one hour, seven times.The call light was activated and not answered for one hour and one minute to one hour and 30 minutes, four times.The call light was activated and not answered for over one hour and 30 minutes, six times.III. Resident #86A. Resident statusResident #86, age [AGE], was admitted on [DATE]. According to the [DATE] CPO, diagnoses included hyertensive heart disease (heart damage caused by long term untreated high blood pressure), peripheral vascular disease (a circulatory disorder involving narrowed or blocked blood vessels often causing painful leg cramps), polyneuropathy (a malfunction of multiple nerves causing numbness tingling and pain of the feet or hands), personality disorder (one's way of thinking, feeling and behaving deviates from the expectations of the culture, causes distress or problems functioning, and lasts over time), and bipolar disorder (a chronic mental health condition characterized by intense fluctuating mood shifts). The [DATE] MDS assessment revealed the resident was cognitively intact with a BIMS of 15 out of 15.B. Resident interviewResident #86 was interviewed on [DATE] at 4:36 p.m. Resident #86 said she had filled out a grievance form on [DATE] about a call light wait time issue. Resident #86 said that she had used her call light and no one came. Resident #86 said that she then used her hand bell to call for help and no one came. Resident #86 said she had been incontinent and was waiting for help for an extended period.Resident #86 said call light wait times were longer at night because the facility only had two people working on nights. Resident #86 said that sometimes she had to wait for her designated CNA to come help her because the other CNAs would not assist her. Resident #86 said the other CNAs would not assist her, because she was not on their list of residents to assist. Resident #86 said there had been times where she would intermittently ring her bell multiple times and no one would answer. Resident #86 said that she would then get so frustrated that she had to go to the door and yell down the hall for help and that she was not the only one doing it. Resident #86 said that she tried to ask for help when staff were not doing rounds or shift change. Resident #86 said that staff wouldn't come when she was wet and sometimes dirty for hours and hours. Resident #86 said that even after receiving the pendant button, she had to wait in wet and soiled briefs. Resident #86 said that, that morning ([DATE]), she had pressed the call light and no one came. Resident #86 said that she saw someone coming to assist another man across the hallway. Resident #86 said that she waited and waited. Resident #86 said that she had to go to the bathroom and was waiting and waiting. Resident #86 said that she tended to slide down in her wheelchair. Resident #86 said that when she pressed the call light she also needed help getting pulled up in the chair because her lower back was hurting. Resident #86 said that some staff did as little as they could to help. Resident #86 said that she got really frustrated because she was in pain and her back hurt.C. Record review A grievance form, dated [DATE] was provided by the DON on [DATE] at 6:05 p.m. Resident #86 filled out a grievance form for an incident that occurred on [DATE]. Resident #86 wrote that at 4:40 p.m. she was feeling cramps indicating that she needed to get to the bathroom and have a bowel movement. Resident #86 wrote that she pressed the call button and pulled the string by the bed and received no response. Resident #86 wrote that she had hoped someone would come before dinner was brought. Resident #86 wrote that she called a few minutes before 5:00 p.m., when staff were usually getting trays and was told they're coming. Resident #86 wrote that no one showed up and her tray was brought in some time after 5:00 p.m. Resident #86 wrote that she finished her meal, rolled to the sink to clean up, and still no one came. Resident #86 wrote that it was 7:29 p.m., and her tray was still there. Resident #86 wrote that by then, the night shift was there and getting set up to care for the residents for the evening. Resident #86 wrote that she got tired of waiting for someone to respond and it was too late to call the operator. Resident #86 wrote that she began ringing the bell, hoping someone would respond. Resident #86 wrote that as always, CNA #10 was the only staff member who really worked during the night shift, completed her duties, and usually asked to help with the residents of other employees. Resident #86 wrote that CNA #10 was busy putting people to bed. Resident #86 wrote that a CNA finally came into her room and she advised the CNA of the situation, sitting in her soiled brief since before dinner. Resident #86 wrote that the CNA tried to clear the call light alert from the iPad system. Resident #86 wrote that after a while, she told the CNA that the CNA was busy on the iPad, instead of attending to her needs with a burning bottom and a solid brief. Resident #86 wrote that she told the CNA to tend to her soiled brief instead of trying to clear the call light notification on the iPad. Resident #86 wrote that the CNA told her that the CNA needed to clear the iPad. Resident #86 wrote that she raised her voice at the CNA and the CNA told her not to yell at her. Resident #86 wrote that she told the CNA that she would yell because the CNA was playing with her tablet instead of taking care of her. Resident #86 wrote that she finally told the CNA to leave and the CNA did. Resident #86 wrote that she began ringing the bell again and a tall male CNA came in and said someone would be there. Resident #86 wrote that the staff were busy putting people to bed. Resident #86 wrote that apparently that was more important than attending to someone rotting in their brief. Resident #86 wrote that the male CNA left. Resident #86 wrote that it was 7:44 p.m. and still no one had come to assist her. Resident #86 wrote that she was tired of being the last consideration for response. Resident #86 wrote that there was always someone else who would come first. Resident #86 wrote that that was why she was sleeping in her wheelchair the past few weeks. Resident #86 wrote that it had been more than a year since anyone had come to assist her in the morning. Resident #86 wrote that it was 7:49 p.m. and she was still sitting in her soiled brief, burning and getting very sore. Resident #86 wrote, someone please do something about the situation. Resident #86 wrote that she felt like the red-headed stepchild and her butt hurt.The actions taken section of the grievance form revealed the facility pulled call light logs and verified times with the times of the grievance. The grievance form revealed the facility planned to get the resident a new call pendant to ensure call lights would go through to the system.Call light logs for Resident #86 were provided by the DON on [DATE] at 6:14 p.m. The grievance form revealed the resident/complainant was satisfied on [DATE]. -However, the call light log for Resident #86 revealed the following call light wait times after the grievance form had been marked as the resident/complainant being satisfied on [DATE].Call light logs for Resident #86 were provided by the DON on [DATE] at 6:14 p.m. Review of Resident #86's call light response log from [DATE] to [DATE] revealed the following call light response times:The call light was activated and not answered for 20 to 39 minutes, 21 times.The call light was activated and not answered for 40 minutes to one hour, six times.The call light was activated and not answered for one hour and one minute to one hour and 30 minutes, four times.The call light was activated and not answered for over one hour and 30 minutes, 16 times.IV. Staff interviewsCNA #8 was interviewed on [DATE] at 3:50 p.m. CNA #8 said she knew a call light was going off because she looked at her iPad. CNA #8 said the iPad's battery frequently died and it did not jingle or alert her when a call light was going off. CNA #8 said at one point the facility used a television (TV) screen to show when call lights were going off. CNA #8 pointed to the TV screen above her computer which was blank and had no call light information on it. CNA #8 said that in order to turn the call light off, she had to take the iPad into the resident's room and get close to the resident to clear the iPad notification. CNA #8 said that unless you were actively looking at the iPad, you were going to miss a call light going off. CNA #8 said that if the resident pulled the cord, or call light, and no one came to help them, the resident could use the hand bell to get the attention of the staff. CNA #8 said that when residents used the bell, she did not know exactly where the ringing was coming from at first, so she had to go look around to help the resident.CNA #9 was interviewed on [DATE] at approximately 10:35 a.m. CNA #9 said he was an agency nurse and was new to the facility. CNA #9 said when a resident pushed their call light the light above the door went off and you could see their light.CNA #9 was interviewed on [DATE] at 4:08 p.m. CNA #9 said that he had been a CNA for 10 years and that he did not receive any training before starting at the facility because the facility assumed he knew what he was doing. CNA #9 said no one told him how the call light system worked at first and that he did not get a tour of the facility. CNA #9 said previously in the day he thought the call lights were the lights above the doors of the residents'rooms. CNA #9 said he was mistaken about how the call lights worked and that someone showed him that the iPads actually showed when a resident called for assistance. CNA #9 said that in order to clear the call light, the staff had to bring the call light within close proximity of the resident's call light pendant. CNA #9 said you had to bring the iPad up to the resident wrist band to turn the call light off. The social services director (SSD) was interviewed on [DATE] at 5:17 p.m. The SSD said as soon as she received a grievance she made a copy for herself and gave the person responsible for responding to the grievance a copy as well. The SSD said she also spoke about the grievance in the next morning meeting. The SSD said that she ensured the responsible person received the grievance and followed up with that resident. The SSD said that once the grievance was marked as satisfied by the resident, she gave the grievance to the nursing home administrator (NHA) and also kept a copy for her records. The SSD said she would expect the grievance issue to be solved after the grievance process was completed. The SSD said that sometimes extra things came up and the facility had to do additional follow up later on. The DON was interviewed on [DATE] at 5:30 p.m. The DON said that the call light system worked through the residents pushing a button/pendant on their wrist or necklace or by the residents pulling the call light cord on the wall. The DON said that this would trigger the iPad to bring up the resident's name and room number which told staff the was calling. The DON said that staff had to then take the iPad into the resident's room and clear the call light by placing the iPad close to the pendant, if the resident used the pendant to call staff. The DON said that normal staff members showed the agency staff how the call light system worked. The DON said that the CNAs would tell the agency staff how to clear the iPad alerts and would go into the residents room to clear it for them.The DON said that some residents used hand bells because the facility was having trouble with skynet which was the service that was used to work the tablets. The DON said that sometimes, the call bell service would go down and the call light notifications would not pop up on the iPads, so the facility gave the residents hand bells to alert staff that they needed assistance. The DON said that the facility got a backup battery for their generator so that the system wouldn't go down. The DON said that when the Skynet system went down, call light notifications did not get to the iPads. The DON said that the call light log records only reflected call light wait times from when the iPad system was up and running, not when the system was down.The DON said that she read through the grievance forms and saw what the resident complained about. The DON said that she pulled the call light logs and interviewed staff to find out whether or not a call light was unable to be cleared, which would be documented in the grievance form. The DON said that when residents complained about call lights not being answered timely, the facility did call light audits. The DON said that Resident #86 would not let staff come into her room or would kick them out of her room and would ring her call bell because she was mad. The DON said that she expected call lights to be answered within five to 10 minutes. The DON said that staff could poke their head into the room and say they were tied up if that were the case, and that they would go help the resident when they could. The DON said that she expected the night shift staff to answer call lights within 15 minutes if they were tied up in a room. The DON said that the facility implemented tablets on the medication carts for the nurses so that if a CNA was tied up in a room, the nurses could help the CNAs and assist the resident if they were able to do so. The DON said that the nurses could not clear the call light notification themselves unless they were truly able to take care of what that resident needed. The DON said that it was important to answer call lights timely so that the resident felt safe and so that the residents were comforted knowing they could get someone's help remotely or in a time of distress.The DON said that it sounded like the facility needed to implement better onboarding with agency staff. The DON said that she would tell regular staff that when agency staff first got to the facility that they needed to tell agency staff where things were in the facility and how the call lights work. The DON said that the facility would need to make sure that all staff understood the education. The DON said that the facility would do call light audits and go room to room to ensure proper names and room numbers were coming up for each resident. The DON said that the facility would have to do a daily audit of call lights to assess call light wait times.

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 for two of four units.Specifically, the facility failed to:-Ensure staff donned (put on) personal protective equipment (PPE) when providing care for a resident who was on enhanced barrier precautions (EBP);-Ensure housekeeping staff followed proper cleaning procedures for disinfecting resident rooms and high frequency touched areas; and,-Ensure staff wore personal protective equipment (PPE) when providing care for Resident #56 who was on transmission based precautions (TBP), which included contact and droplet precautions. Findings include: I. EBP failures A. Facility policy and procedure The Enhanced Barrier Precautions policy was provided by the nursing home administrator (NHA) on 5/1/26 at 3:41 p.m. The policy read in pertinent part, It is the policy of American Baptist Homes of the Midwest to reduce transmission of multidrug-resistant organisms through an infection control intervention designed that employs targeted gown and glove use during high contact resident care activities known as Enhanced Barrier Precautions (EBPs). EBPs are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBPs are indicated for residents with wounds or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO. Indwelling medical device examples include urinary catheters. For residents whom EBP are indicated, EBPs are employed when performing the following high contact resident care activities: Dressing, bathing or showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, care of a catheter, or wound care. The Infection Prevention and Control Program policy, dated September 2025, was provided by the NHA on 5/1/26 at 3:41 p.m. The policy read in pertinent part, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted by national standards and guidelines. All staff are responsible for following all policies and procedures related to the program. The facility will use standard approaches, as defined by the CDC for transmission based precautions, airborne, contact, and droplet precautions. The category of transmission based precautions will determine the type of personal protective equipment (PPE) to be used. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. High touch objects and environmental surfaces ( bed rails, over-bed table, bedside commode, lavatory surfaces in resident bathrooms) should be cleaned and disinfected with an EPA-registered disinfectant for healthcare use at least daily and when visibly soiled. B. Observations On 4/28/26 at 10:38 a.m. certified nursing aide (CNA) #4 and CNA #5 went into Resident #52's room. A bin with PPE was present inside the room. There were signs on top of the bin which read Enhanced Barrier Precautions. CNA #5 and CNA #4 provided catheter care to Resident #52. They also cleaned his face and placed his belongings within reach. Then both CNAs left Resident #52's room. -CNA #4 and CNA #5 failed to put on gowns prior to providing care to Resident #52 who was on EBP. C. Staff interviews CNA #5 was interviewed on 4/29/26 at 1:01 p.m. CNA #5 said management placed bins with PPE outside a resident's room when the resident was placed on precautions. CNA #5 said she knew which residents were on precautions because management told them and there were also signs up with bins in front of the resident's door. CNA #5 said if staff were going into a room which required EBPs to change a resident they should wear a gown and gloves. The infection preventionist (IP) was interviewed on 4/30/26 at 2:31 p.m. The IP said isolation precautions were typically set up with new admissions. The IP said the admissions coordinator found out whether or not the resident needed precautions to be in place prior to the resident being admitted and then would inform the IP. The IP said she then would prepare the isolation equipment (bin and signs) for the resident's arrival to the facility. The IP said if the resident arrived over the weekend, the weekend supervisor would arrange for the bin and signs to be set up. The IP said residents could have isolation equipment in their rooms if that was their preference. The IP said staff should still have been donning PPE before performing direct care activities with the resident. The IP said it was important for staff to wear proper PPE for EBPs because it protected both the staff and the resident. The IP said if a resident had an open line into their body such as a catheter, it was possible to transfer organisms from staff to the resident. The IP said it was also possible to transfer organisms from the resident to staff and then be transferred onto other residents. II. Housekeeping failures A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures retrieved on 5/5/26 from from:https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html?CDC_AAref_Val=https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html Common high touch surfaces include bedrails, sink handles, call bells, bedside tables, doorknobs, and light switches. According to the Centers for Disease Control and Prevention (CDC) When and How to Clean and Disinfect a Facility on 5/5/26 from https://www.cdc.gov/hygiene/about/when-and-how-to-clean-and-disinfect-a-facility.html#:~:text=During%20use,make%20sure%20germs%20are%20killed. After you apply the disinfectant to the surface, leave the disinfectant on the surface long enough to kill the germs. This is called the contact/wet time. The surface should stay wet during the entire contact time to make sure germs are killed. B. Facility policy and procedure The Routine Cleaning and Disinfection policy was provided by the NHA on 5/1/26 at 3:41 p.m. The policy read in pertinent part, The facility will follow manufacturer recommendations regarding appropriate contact time to ensure adequate disinfection. Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch areas to include but not limited to tray tables, bed rails, door knobs and levers and light switches. C. Record review The housekeeping manufacturer guidelines for each chemical spray was received from the maintenance director on 4/30/26 at 10:19 a.m. The manufacturer guidelines revealed the blue rapid multi surface disinfectant cleaner spray used by housekeeping personnel had a kill time of 10 seconds for COVID-19 and a 30 second kill time for the norovirus, influenza A virus, rhinovirus, murine norovirus, and hepatitis B and C. D. Observations On 4/29/26 at 11:26 a.m. housekeeper (HK) #1 was cleaning room [ROOM NUMBER], which was a double occupancy room. HK#1 used a blue rapid multi surface disinfectant solution to spray green rags four times each. HK #1 used the green rags to the door knobs, light switches, and bedside tables. The surfaces were not visibly wet for ten seconds.HK #1 did not clean the call bells present in room [ROOM NUMBER]. On 4/29/26 at 10:48 a.m. HK #2 was observed cleaning room the double occupancy room [ROOM NUMBER]. HK #2 did not clean the call bells present in room [ROOM NUMBER]. E. Staff interviews HK #1 was interviewed on 4/29/26 at 11:46 a.m. HK #1 said if they did not have so many rooms to clean, they would spray the surface and let it sit for longer. Housekeeper #1 said instead, they sprayed cloths and used cloths to wipe surfaces instead, because they had the whole unit to get to. HKr #1 said if all the rooms were filled on the unit, there would be about 70 rooms to clean. HK #1 said there were only four vacant rooms on the unit during the time of survey. HK #1 said call lights were cleaned when performing deep cleans. HK #1 said deep cleans were performed once a week if they had time or when a resident was discharged out of the room. HK #1 was interviewed on 4/30/26 at 12:10 p.m. HK #1 said the dwell time for the blue rapid multi-surface disinfectant spray was 10 seconds. HK #1 said they had noticed the surface drying quicker than 10 seconds and they would start putting more sprays onto the rag so the disinfectant didn't dry as fast. HK #2 was interviewed on 4/30/26 at 1:35 p.m. HK #2 said the training process was three days long and they were trained by another housekeeper who was no longer at the facility. HK #2 said he sprayed the blue rapid multi-surface disinfectant spray straight onto surfaces and let it sit for 30 seconds before wiping it off. The maintenance director was interviewed on 4/30/26 at 1:44 p.m. The maintenance director said the blue rapid multi-surface disinfectant cleaner spray used by housekeeping staff had a dwell time of 10 seconds for certain viruses and a 30 second dwell time for others. The maintenance director said housekeepers should be wiping all surfaces off except for fabric. The maintenance director said staff should work in a clockwise direction and clean any high touch surface. The maintenance director said surfaces should remain wet for 10 seconds when using the blue rapid multi surface disinfectant cleaner spray. The maintenance director said housekeepers had different techniques when cleaning the rooms. The maintenance director said some housekeepers have a bucket with disinfectant in the top of their cart and others use the spray and rags. The maintenance director said no matter what technique housekeepers used, they needed to ensure the dwell time was being met. The maintenance director said he was going to implement buckets with disinfectant solution for all housekeepers to use in order to ensure surfaces were staying wet for the proper dwell time. The maintenance director said staff needed to ensure the dwell times were being met and if their rags were not wet enough, they were not meeting the dwell time and weren't disinfecting. The maintenance director said he would start watching each housekeeper to ensure proper cleaning was performed. A. Professional reference According to the Centers for Disease Control and Prevention (CDC) on Infection Control: Transmission-Based Precautions for Health Care Providers, dated 4/3/24 and retrieved on line 5/7/26 from https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html It read in pertinent part, Transmission-Based Precautions are the second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. Use contact precautions for patients with known or suspected infections that represent an increased risk for contact transmission. Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. Use droplet precautions for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking. Use personal protective equipment (PPE) appropriately. [NAME] mask upon entry into the patient room or patient space. B. Facility policy and procedure The Transmission-Based (isolation) precautions policy was provided by the nursing home administrator (NHA) on 5/1/26 at 3:41 p.m. The policy read in pertinent part, It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission. Droplet precautions refers to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Facility staff will apply transmission based precautions in addition to standard precautions to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. The facility staff will apply Transmission based precautions in addition to standard precautions to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. Signage that includes instructions for use of specific PEE will be placed in a conspicuous location outside the resident's room wing, or facility wide. Additionally, either the CDC category of transmission based precautions (contact droplet or airborne) or instructions to see the nurse before entering will be included in the The facility will have PPE readily available near the entrance of the resident's room and will don appropriate PPE before or upon entry into the environment of a resident on transmission based precautions. Droplet precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions (respiratory droplets that are generated by a resident who is coughing, sneezing, or talking). A private room is preferential but if not available the resident can be cohorted with a resident with the same infectious agent. Healthcare personnel will wear a facemask for close contact with an infectious resident. Based upon the pathogen or clinical syndrome, if there is risk of exposure of mucous membranes or substantial spraying of respiratory secretions is anticipated, gloves and gown as well as goggles or face shield should be worn. C. Observations On 4/28/26 at 9:20 a.m. two signs on Resident #56's door indicated the resident was on TBP for contact and droplet precautions. Resident #56 was on droplet precautions initiated for positive rhinovirus (a highly contagious, common virus and the primary cause of the common cold). The sign of contact precautions read in pertinent part, Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also put on gloves and gown before room entry. Discard gloves and gown before room exit. The sign of droplet precautions read in pertinent part, Everyone must clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Remove face protection before room exit. On 4/28/26 at 9:23 a.m. CNA #6 entered Resident #56's room to deliver a breakfast meal. -CNA #6 failed to perform hand hygiene, apply a gown, gloves and face protection when entering Resident #56's room. On 4/28/26 at 12:30 p.m. CNA #6 entered Resident #56's room to deliver a lunch meal. -CNA #6 failed to perform hand hygiene, apply a gown, gloves and face protection when entering Resident #56's room. D. Resident interview Resident #56 was interviewed on 4/29/26 at 2:30 p.m. Resident #56 said staff told her she tested positive for rhinovirus when she came back from the hospital. She said that was the reason she was under isolation precautions. Resident #56 said it was just a cold and she did not understand why people were wearing all that stuff. She said sometimes staff did not put it on. E. Staff interviews CNA #7 was interviewed on 4/30/26 at 11:27 a.m. CNA #7 said if there was a sign on the resident's door that indicated the resident was on droplet precautions, the staff had to wash their hands, put on a gown, gloves, protective glasses, and a face mask prior to entering the resident's room. CNA #7 said staff had to remove PPE prior to exiting the resident's room after completing the tasks and clean their hands once outside the room. CNA #7 said Resident #56 was on droplet precautions for rhinovirus infection. She said staff had to use PPE even when they were delivering meals. CNA #7 said not implementing those precautions staff could catch whatever the resident had and pass it to someone else. LPN #3 was interviewed on 4/30/26 at 1:20 p.m. LPN #3 said the staff should wash their hands and put on a face mask, gloves, and gown before entering a resident's room with a sign that indicated the resident was on TBP. LPN #3 said Resident #56 was on TBP due to rhinovirus infection. She said there was a box of supplies outside of Resident #56's room. LPN #3 said staff should implement all the precautions even though staff were delivering meals. She said not using PPE was wrong. LPN #3 said CNA #6 could get infected with rhinovirus and spread it to the building. The IP and the DON were interviewed together on 4/30/26 at 2:49 p.m. The IP said Resident #56 was on droplet and contact precautions for rhinovirus. The IP said precaution signs were posted outside Resident #56's room door and PPE supplies stored outside the room. She said staff were supposed to put on a gown, gloves, and face mask prior to entering Resident #56's room. The IP said CNA #6 should have used PPE to prevent the spread of the disease in the facility. The DON said CNA #6 should have put on the gown and applied all the precautions in place.

Based on record review and interviews, the facility failed to ensure certified nurse aides (CNA) received the required 12 hours of annual in-service training for continued competence.Specifically, the facility failed to ensure two CNAs (#2 and #3) of five CNAs received 12 hours of annual training. Findings include:I. Facility policy and procedureThe Required Training, Certification and Continuing Education of Nurse Aides policy and procedure, undated, was received from the nursing home administrator (NHA) on 5/1/26 at 3:41 p.m. It revealed in pertinent part, It is the policy of this facility to comply with state and Federal regulations and requirements as they pertain to the training, certification and continuing education of its nurse aides. The facility will provide at least 12 hours of inservice training annually, based on employment date, not calendar year. Documentation of inservice training will be maintained by the Staff Development Coordinator and retained in an employee personnel or education file in accordance with facility policy. It is the responsibility of the employee to attend required in-service training to maintain employment status with the facility. The required 12 hours of annual in-service training include online education completed through the facility designated learning platform. Employees are assigned online training modules on a quarterly basis and completion of these modules within the designated timeframe is mandatory. II. Training reviewA review of CNA training was reviewed on 4/30/26 at 1:24 p.m. CNA #2 was hired on 3/13/24 and had only completed three hours of the required 12 hours of continuing education units (CEU). CNA #3 who was hired on 5/16/24 and had only completed seven hours of the required 12 hours of CEUs on the platform for education. The facility provided other in-service documentation for CEU however there was no way to determine the contact hours for them as the documentation did not include contact time.III. Staff interviewsThe staff development coordinator was interviewed on 4/30/26 at 3:15 p.m. She said CNAs were required to complete 12 hours minimum of CEU per year. The staff development coordinator said the facility used a platform for education along with inservice training they held. The staff development coordinator said the facility held all staff meetings and had staff signed in to show they were present. The staff development coordinator said she was unable to locate/provide contact hours for the in services provided during all staff meetings.The director of nursing (DON) was interviewed on 4/30/26 at 3:26 p.m. She said it was important for CNAs to complete their 12 hours of CEUs for job safety and residents safety. The DON said starting on May 11th the facility will be having all staff complete 12 hours of CEU prior to their first shift on the floor.

Based on record review and interviews, the facility failed to investigate and document incidents of physical abuse involving two (#2 and #3) of three residents reviewed out of eight sample residents. Specifically, the facility failed to conduct a thorough investigation of physical abuse involving Resident #3 and Resident #2. Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy, dated October 2024, was provided by the nursing home administrator (NHA) on 10/8/25 at 9:52 a.m. via email. It revealed in pertinent part, An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include: identifying staff responsible for the investigation; investigating different types of alleged violations; identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and, providing complete and thorough documentation of the investigation. Analyzing the occurrence(s) to determine why abuse, neglect, occurred, and what changes are needed to prevent further occurrences; Training of staff on changes made and demonstration of staff competency after training is implemented; Identification of staff responsible for implementation of corrective actions; The expected date for implementation; and, Identification of staff responsible for monitoring the implementation of the plan.II. Incident of physical abuse between Resident #2 and Resident #3 on 8/8/25A. Facility investigationThe 8/8/25 facility investigation documented Resident #2 and Resident #3 kicked each other while in the dining room. The investigation documented the residents were separated. The investigation documented Resident #2 had a history of aggressive behaviors with three prior incidents in the facility. The investigation documented staff and a resident witnessed the incident.-The investigation failed to document what staff were involved in the incident and failed to interview staff. The investigation documented there was no cause of the altercation discovered in the initial investigation. The investigation documented that witness statements were requested.-However, there was no documentation that indicated who the witnesses were or the statements. The investigation documented Resident #2 and Resident #3 returned to their rooms after the altercation and were placed on 15-minute checks. The final report from the facility substantiated the physical abuse.Review of the investigation did not reveal Resident #2 or Resident #3 were interviewed after the incident.B. Resident interviewResident #8 was interviewed on 10/8/25 at 12:50 p.m., who was identified as alert and oriented through facility and assessment. Resident #8 said she witnessed Resident #2 and Resident #3 kicking each other. Resident #8 said Resident #2 was the bully of the facility. Resident #8 said she was seated at the dining room table where the incident occurred at approximately 8:30 a.m. while she was waiting for breakfast. Resident #8 said someone from the dietary staff was there to help and stop the situation. Resident #8 said no one from the facility asked her what happened even though she witnessed the altercation. Resident #8 said the police did talk to her about what happened. Resident #8 said even after the police spoke with her, no one from the facility talked to her about what she saw happen. She said she would have told the administrator that Resident #2 was a bully in the facility.-However, the facility failed to interview Resident #8, who witnessed the resident-to-resident abuse on 8/8/25 (see investigation above). C. Staff interviewsThe social service director (SSD) and the social service assistant (SSA) were interviewed together on 10/8/25 at 12:20 p.m. The SSD said she was not involved with the altercation with Resident #2 and Resident #3. The SSA said she spoke with Resident #3 after the incident but she did not speak to Resident #2. The SSA said she did know that a dietary staff member separated the residents. The SSA was interviewed again on 10/8/25 at 1:30 p.m. The SSA said after further research, she determined Resident #8 witnessed the altercation on 8/8/25. The SSA said she did not interview Resident #8 after the incident as part of the investigation. Licensed practical nurse #1 was interviewed on 10/8/25 at 12:45 p.m. LPN #1 said Resident #2 and Resident #3 did not like each other. LPN #1 said the staff needed to keep an eye on them if they were in the same room to ensure the residents were not fighting. Dietary aide #1 (DA) was interviewed on 10/8/25 at 1:35 p.m. DA #1 said she worked the morning the two men (Resident #2 and Resident #3) had an altercation. DA #1 said Resident #3 liked to tease other residents in a playful manner. DA #1 said Resident #3 was teasing Resident #2 and Resident #2 began yelling shut the (obscenity) up repeatedly. She said Resident #2 came up to Resident #3 and kicked him over and over, and then both residents were kicking each other. DA #1 said she witnessed the altercation and separated the residents. DA #1 said she told both residents to stop as she pulled them apart from kicking each other. DA #1 said no one from the facility interviewed her about the incident. DA #1 said the former NHA did not speak to her about the situation. The nursing home administrator (NHA) was interviewed 10/8/25 at 1:50 p.m. The NHA said the former NHA only worked at the facility for two weeks. The NHA said during that time, the incident on 8/8/25 between Resident #2 and Resident #3 occured. The NHA said after an investigation the facility should interview eyewitnesses, including staff and residents. The NHA said he was unaware Resident #8 was a witness to the situation. The NHA said from now on all witnesses would be interviewed during the investigation.

Based on observations, record reviews, and interviews, the facility failed to properly prepare and store food and to maintain sanitary conditions in the main kitchen. Specifically, the facility failed to: -Ensure the main kitchen was clean and sanitary; -Ensure damaged cans were disposed of; and, -Ensure food was labeled and dated. The findings include: I. Ensure the main kitchen was clean and sanitary A. Professional reference The Colorado Retail Food Establishment Regulations (3/14/24), retrieved on 6/18/25 read in pertinent part, Nonfood-contact surfaces shall be constructed of approved materials, in good repair, and be easily maintained in a clean and sanitary condition. Equipment food-contact surfaces and utensils shall be clean to sight and touch. Food contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other solid accumulations. Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. (Chapter 4) Receptacles and waste handling units for refuse, recyclables, and returnables used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors, or covers. (Chapter 5) B. Observations The initial main kitchen tour was conducted on 6/11/25 at 11:00 a.m and the following was observed: -The vents above the stove were greasy and dusty, there was a sticker on the vents that indicated they were serviced on 2/27/25; -There was a yellow puddle of an unidentifiable liquid under the shelf in the dry storage room; - The used aprons were stored next to clean glassware and dishes; -The shelves were covered with light, white dust and felt sticky upon touch; -There was a dark grey trashcan in the preparation area that had no lid and the outside of the trashcan was covered with unknown white splatters and dried on food; -The shelf under the preparation table had dried on food and it was greasy; -The radio, paper towel dispenser, waffle maker, food cart and the food processor had caked on food and were sticky to the touch; -The preparation sink tap was dripping and the sink was leaking underneath. There was a towel put under the sink to trap water; -The outside of the deep fat fryer was greasy and there was dried oil streaks on its side; -The reach-in drink refrigerator had different colored, dried splatters inside on the bottom; -The juice machine vents were sticky and covered in juice. The drip tray had stagnant and crusted liquid inside; -The coffee machine had dried on dark splatters on the sides and there was dried black crud in the corners of the machine; -There was a dark substance on the baseboard throughout the kitchen; -The drain by the ice machine had dirty, dark gunk dried on it; and, -The ice machine lid had fingerprints inside and it had calcified streaks on its side. C. Staff interviews The dietary manager (DM) was interviewed on 6/11/25 at 3:20 p.m. She said the staff cleaned the kitchen after meal preparations. The DM said the staff also had daily cleaning tasks to complete. She said the walk-in refrigerator was cleaned daily and all surfaces of the kitchen were wiped down. She said the staff deep cleaned the kitchen once a week, including the reach-in fridges. She said the deep cleaning included scrubbing the floor to get rid off the dark build up on the floor and baseboard. She said deep cleaning also included the deep fryer, drains, vents and all equipment. She said the vents were cleaned by an outside company every two months. She said she had no information on the dripping tap and sink. The dietary director (DD) was interviewed on 6/11/25 at 3:40 p.m. He said the facility lost their utility staff who was responsible for deep cleaning two months ago. He said the kitchen staff was doing deep cleaning now. He said they would start deep cleaning the kitchen right away. He said the vents were cleaned quarterly by an outside company. II. Ensure damaged cans were disposed of A. Professional reference The Colorado Retail Food Establishment Regulations (3/14/25), retrieved on 6/18/25, read in pertinent part, A food that is unsafe, adultered, or not honestly presented shall be discarded or reconditioned according to an approved procedure. (Chapter 3) Products that are held by the permit holder for credit, redemption, or return to the distributor, such as damaged, spoiled, or recalled products, shall be segregated and held in designated areas that are separated from food. (Chapter 6) B. Observations The kitchen was observed on 6/11/25 at 11.00 a.m and the following was observed on a shelf in the dry storage area: -Two unopened, dented cans of tuna; and, -One unopened, dented can of mushroom. C. Staff interviews The DM was interviewed on 6/11/25 at 3:20 p.m. She said the kitchen staff should have removed the dented cans to the side and then discard it. She said keeping the cans on the shelf was an improper food handling procedure. The DD was interviewed on 6/11/25 at 3:40 p.m. He said that staff should have removed the dented cans from the shelf and moved it to his office. He said the vendor did pick up dented cans and reimbursed the facility for it. III. Ensure food was labeled and dated A. Professional reference The Colorado Retail Food Establishment Regulations (3/14/24), retrieved on 6/18/25, read in pertinent part, 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. Label information shall include the common name of the food. (Chapter 3) B. Observations The initial kitchen tour was conducted on 6/11/25 at 11:00 a.m. and the following was observed: -There was a round, white, plastic container in the dry storage that contained a dark brown food, the container was not labeled or dated; -There was a jar of opened jalapenos on the shelf in the walk-in refrigerator that was not labeled or dated; -There was an opened bag of pancake mix in the dry storage that was not labeled or dated;. -There was a plate of carrots in the walk-in refrigerator that was not labeled or dated; -There was a container of taco shells in the walk-in refrigerator that was not labeled or dated; -There was an opened package of pepperoni in the walk-in refrigerator that was not labeled or dated; and, -There was a tray of lettuce in the reach-in fridge in the preparation area, that was not labeled or dated. C. Staff interviews The DM was interviewed on 6/11/25 at 3:20 p.m. She said all produce should have a receiving date indicated on them. She said repackaged food should have a label. She said the label should indicate the name of the item and a date it was. She said all food items without a label should have been discarded by staff. She said nobody would know when to discard spoiled items without proper labeling. She said it was important to ensure food was labeled and dated correctly to prevent foodborne illnesses. She said spoiled food could attract pests to the kitchen. She said she would discard the unlabeled food.

Based on record review and interviews, the facility failed to ensure facility resources were administered in a manner that allowed its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in the facility. Specifically, the facility failed to: -Provide sufficient leadership to address and or avoid multiple concerns; -Prevent, report and fully investigate allegations of abuse timely to provide immediate protections to residents at risk of being victimized and re-victimized; -Report an injury of unknown origin in a timely manner so that an accurate timeline of events could be established and the injury could be effectively treated and monitored; and, -Implement effective interventions to prevent a female resident with severely impaired cognitive and an inability to consent to a sexual relationship from wandering into a male resident's room to watch him masturbate. Findings include: I. Abuse and neglect During the abbreviated survey from 3/19/25 to 3/24/25, it was identified that there were concerns over the timely reporting of an allegation of abuse so that the resident could be immediately protected from a repeat incident of abuse. While staff immediately separated the assailant from his victims in an incident of sexual abuse, the staff did not immediately alert facility leadership so that immediate interventions could be implemented to prevent repeated attempts of abuse by the assailant. Facility leadership were not immediately notified of the incident of sexual abuse occurring. Additionally, the staff's late notifications and failure to identify the incident of sexual abuse as a reportable incident of abuse led to delays in reporting the incident to the proper entities (facility administration, the State Agency and the local police). In this instance of sexual abuse, once the incident was reported to the local police, the resident was arrested and taken to jail for his abusive actions. Cross-reference F609: failure to report an allegation of abuse in a timely manner. II. Injury of unknown origin During the abbreviated survey from 3/19/25 to 3/24/25, it was identified that there were concerns over the timely reporting of a discovered injury of unknown origin to Resident #7. On 3/2/25, the resident's family member reported swelling, bruising and pain to the nurse on duty. While the injury was documented in the resident's electronic medical record (EMR), the injury was not reported to facility leadership until the injury worsened three days later. There was no record that the injury was monitored for proper healing. The investigation and assessment of the injury started late; it was discovered through the assessment that the resident's fingers were found to be broken (cross-reference F609: failure to report an injury of unknown origin and F658: failure to monitor an injury per professional standards). III. Leadership efforts The facility nursing home administrator (NHA) had been out on administrative leave since 1/31/25 (seven weeks as of 3/20/25), leaving the facility without a state-licensed administrator to manage the facility's day-to-day operations, particularly the management of incident reporting and investigations. The NHA had the responsibility to lead investigations for allegations of abuse to ensure compliance with identifying potential abuse; responding to an allegation of abuse; preventing ongoing abuse; and reporting abuse to the proper authority, all in a timely manner. IV. Staff interviews The director of nursing (DON) was interviewed on 3/19/25 at 12:05 p.m. The DON said the NHA was on administrative leave and she did not know if he was coming back to his position. The DON said the corporate consultants had been providing additional guidance in his absence, but she had taken on the role of abuse incident coordinator. The DON said it was difficult to manage the role of abuse incident coordinator, with all of her other duties. The DON and the corporate nurse consult (CNC) were interviewed on 3/20/25 at 3:11 p.m. The CNC said there was not currently an interim NHA with a state license filling in in the absence of the facility's NHA; however, the corporate office was looking for an interim NHA. The CNC said in the meantime, the CNC and other corporate leadership offered the DON and facility staff support onsite and remotely. The DON said she was acting as the facility abuse coordinator in the absence of the NHA, with assistance from the unit managers and social services staff, to determine needed interventions and complete abuse investigations. The DON said she would be glad to have someone take over the role of abuse coordinator because it was a lot to manage with her clinical duties. The DON said she did not report Resident #7's injury of unknown origin because she knew the resident and even though no one witnessed the injury occur, she assumed the injury was self-inflicted. The DON said she was not well-versed in the regulatory requirements for reporting and investigating abuse and was not able to give details on all types of incidents that needed to be reported. The DON said she did not know that injuries of unknown origin needed to be reported when the source of the injury was not observed, the injury could not be explained, and the injury was suspicious because of the extent of the injury or the location of the injury. V. Follow up The facility hired a full-time interim nursing home administrator (INHA) on 3/24/25. The INHA had an active State NHA license and prior experience in the industry -An interview with the INHA revealed that she and the CNC had already started training with leadership staff on the components of compliance for abuse identification, reporting, prevention and investigating.

Based on observation, record review and interviews, the facility failed to promote dignity and respect for one (#12) of three residents out of 14 total sample residents. Specifically, the facility failed to promote dignity and respect by sitting with the Resident #12 at the dining table and providing meal assistance in a dignified manner. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADL's) policy and procedure, dated 2024, was provided by the corporate nurse consultant (CNC) on 3/25/25 at 12:28 p.m. It read in pertinent part, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: eating to include meals and snacks . II. Resident #12 A. Resident status Resident #12, over the age of 65, admitted [DATE]. According to the March 2025, computerized physician orders (CPO), diagnosis included dementia with behavioral disturbance, protein-calorie malnutrition and bilateral cataracts. According to the 1/18/25 minimum data set (MDS) assessment, the resident was severely cognitively impaired and was unable to participate in the brief interview for the mental status (BIMS) assessment. Staff reported the resident had short and long-term memory problems with severely impaired daily decision-making skills and required daily cuing and supervision to make sound decisions. The resident was able to express her needs and had some ability to understand basic conversations. The MDS assessment indicated the resident needed set-up assistance. -However, the resident's medical record revealed the resident needed assistance with meals (see record review below). B. Observations During a continuous observation on 3/19/25, from 11:25 a.m. to 12:24 p.m., Resident #12 was observed at the lunch counter on the unit. The resident was served lunch and had eaten some of her meat but had not eaten anything else. Resident #12 sat not eating her meal for 45 minutes before certified nurse aide (CNA) #3 approached Resident #12 initially to pick up her tray. Without talking with the resident, CNA #3 started to spoon-feed the resident in a rushed manner. CNA #3 was standing in front of the resident and not talking to the resident as she assisted her to eat. After assisting the resident with a couple of bites of food, she called over CNA #4 to finish feeding the resident. CNA #4 approached the resident and sat beside her to finish feeding her. During a continuous observation on 3/20/25, from 11:15 a.m. to 11:43 p.m., Resident #12 was observed during lunch. CNA #3 approached Resident #12 from the front and started to spoon feed her in the same rushed manner as during the observation the day prior (see above). 3. Record review The resident's nutrition care plan, initiated 10/5/21, indicated the resident had a potential nutrition deficiency. Pertinent interventions included: continuing to encourage food and fluid for comfort, honoring the resident's food preferences, providing cueing and supervision during meal service (up to maximum assist on occasion), maintaining eye contact when assisting with meals, offering the resident utensils for self-feeding and offering the resident a meal alternative if she was not eating and informing the kitchen of what she wanted. The physician's assistant (PA) note, dated 2/26/25, documented: continue to assist Resident #12 with eating assistance and nutrition, as needed. The nutrition assessment, dated 1/15/25, documented Resident #12 was eating her meals in the assisted dining room with moderate to maximum assistance and was occasionally independent. The resident had weight gain over the last two quarters despite remaining underweight. Although the weight loss was not desirable, measures to combat weight loss in hospice residents might be ineffective. The staff continued to encourage foods and fluids as the resident desired for comfort. III. Staff interviews CNA #3 was interviewed on 3/20/25 at 11:22 a.m. CNA #3 said they delivered Resident #12's meal to her and let her eat as much independently as she was able. CNA #3 said once the staff noticed the resident stopped eating, they offered verbal prompts and then offered feeding assistance. CNA #3 said the staff should sit at the table with the resident and engage her in conversation about her meal to encourage food and drink intake. Licensed practical nurse (LPN) #2 was interviewed on 3/24/25 at approximatly 5:00 p.m. LPN #2 said when a resident needed feeding assistance, the staff needed to sit with them and encourage the resident to eat as much as possible independently. LPN #1 said the staff increased the level of assistance as needed so that the resident would get enough to eat. The director of nursing (DON) was interviewed on 3/20/25 at 3:55 p.m. The DON said staff should sit and communicate with the resident while assisting them to eat their meal.

Based on record review and interviews, the facility failed to report alleged violations of potential abuse, neglect, exploitation or mistreatment and injuries of unknown origin to the state oversight agency in accordance with state laws for two of five alleged abuse violations. Specifically, the facility failed to: -Timely report an allegation of sexual abuse by Resident #6 towards Resident #4, Resident #5, Resident #2 and Resident #3 to the State Agency; and, -Report Resident #7's injury of unknown origin to the State Agency. Findings include: I. Facility policy and procedure The Abuse, Neglect, and Exploitation policy and procedure, dated October 2024, was received from the director of nursing (DON) on 3/19/25 at 12:45 p.m. It read in pertinent part, Abuse is defined as the willful infliction of injury with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Alleged violation is a situation or occurrence that is observed or reported by staff, residents, relatives, visitors, or others but has not yet been investigated and, if verified, could be an indication of noncompliance with the federal requirements related to abuse. Possible indicators of abuse include but are not limited to physical injury of a resident of unknown source. Sexual abuse is a non-consensual sexual contact of any type with a resident. The facility will develop and implement written policies and procedures that establish policies and procedures to investigate any such allegations. An immediate investigation is warranted when suspicion, or reports, of abuse occur. Reporting of all alleged violations to the administrator, State Agency, adult protective services and to all other required agencies within the specified timeframes. If the event that caused the allegation involves abuse or resulted in serious bodily injury or no later, report within two hours. If the event that caused the allegation does not involve abuse or result in serious bodily injury, report within 24 hours. II. Allegation of sexual abuse A. Facility investigation of sexual abuse on 2/23/25 The investigation report revealed the date of the incident was 2/23/25. The incident report documented on 2/24/25 at 6:30 a.m. a certified nurse aide (CNA) reported to the unit manager that Resident #6 exposed his genitals on two different occasions to several residents. Video footage was reviewed and confirmed his indecent exposure on three separate occasions. The incidents were on 2/21/25 at 6:52 p.m., on 2/23/25 at 11:26 a.m. and on 2/23/25 at 11:34 a.m. The alleged incident happened on 2/23/25 at 11:26 a.m, on the east unit in the kitchenette area, where he exposed his genitals to two female residents (Resident #4 and Resident #5). The second incident happened immediately after the first incident on 2/23/25, at 11:34 a.m. Resident #6 wheeled himself to the main dining room. He sat at the same table as two female residents (Resident #2 and Resident #3). He touched Resident #2's arm and then proceeded to expose his genitals. Resident #2 turned her head away from Resident #6. During the facility's investigation, the facility reviewed additional video footage. The facility reported on 2/21/25 at 6:52 p.m. Resident #2 sat at a table in the main dining room alone. Resident #6 wheeled himself to Resident #2's table. Resident #6 lifted his shirt and pulled his pants down. He made motions as if he was fondling himself in front of Resident #2. Resident #6 took Resident #2's hand and tried to place her hand in his genital region. Resident #2 pulled her hand back and Resident #6 grabbed her hand again and made a fondling movement with their hands together. The behavior was repeated several times for over 20 minutes. On two occasions, Resident #6 made motions to his mouth, then to Resident #2's mouth, and then Resident #6 pointed to his genitals in a manner indicating he wanted her to perform oral sex. -The facility did not report the incident until 2/24/25 at 6:53 p.m., which was over 24 hours after Resident #6 exposed his genitals to Resident #4, Resident #5, Resident #3 and Resident #2. B. Resident #6 - assailant 1. Resident status Resident #6, age greater than 65, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included alcoholic cirrhosis of the liver with ascites (chronic liver disease caused by alcohol and fluid accumulates in the abdominal cavity), dementia, psychotic disturbance, mood disturbance and anxiety. The 2/14/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) assessment score of 12 out of 15. He was independent in eating, oral hygiene, toileting, showering and dressing. He used a manual wheelchair. C. Resident #4, Resident #5, Resident #2 and Resident #3 - victims 1. Resident #4 Resident #4, age greater than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included atherosclerotic heart disease, hypertension, contracture of muscle and peripheral vascular disease. The 1/12/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. 2. Resident #5 Resident #5, age 72, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included Alzheimer's disease, anxiety disorder, mood disturbance and anxiety disorder. The 1/12/25 MDS assessment revealed a BIMS assessment was not conducted because the resident was rarely or never understood. According to the staff assessment for mental status, the resident had short and long-term memory problems and her cognitive skills for daily decision making were severely impaired. 3. Resident #2 Resident #2, age 88, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included dementia, psychotic disturbance, mood disturbance and anxiety. The 3/3/25 MDS assessment revealed a BIMS assessment was not conducted because the resident was rarely or never understood. According to the staff assessment for mental status, the resident had short and long term memory problems and her cognitive skills for daily decision making were severely impaired. 4. Resident #3 Resident #3, age greater than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included dementia, psychotic disturbance, anxiety disorder and mood disturbance. The 1/4/25 MDS assessment revealed the resident was cognitively impaired with a BIMS score of three out of 15. III. Injury of unknown origin A. Resident #7 B. Resident status Resident #7, age 85, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included Alzheimer's disease, dementia with agitation, transient ischemic attack (small stroke), cerebral vascular disease (stroke) and depression. The 12/30/24 MDS assessment revealed a BIMS assessment was not conducted because the resident was rarely or never understood. According to the staff assessment for mental status, the resident had short and long term memory problems and her cognitive skills for daily decision making were severely impaired. She required maximum assistance with personal hygiene and showering. C. Resident's representative interview Resident #7's representative was interviewed on 3/20/25 at 11:09 a.m. The representative said he visited the resident frequently. He said when he visited Resident #7 on 3/1/25 he noticed her hand was swollen when he tried to hold her hand and she said ow. He said when he noticed her hand, he told the nurse to ask the doctor to take a look at her left hand. He said an x-ray was completed and she had a crack (fracture) in her hand. He said Resident #7 moved frequently throughout the unit in her wheelchair. He said she probably got her hand stuck in between the handrail and wall because he had seen her do that in the past. He said the facility did not say what they did to prevent the injury from happening again. B. Facility investigation of injury of unknown origin The investigation report revealed the date of the incident was 3/5/25. The investigation documented Resident #7 had a fracture of the third metacarpal (the third bone of the hand) on the left hand. The investigation documented that CNA #1 reported the resident went to bed between 7:30 p.m. or 8:00 p.m. CNA #1 said she checked on the resident at 9:00 p.m. because she heard a disturbance. The resident was sitting on the edge of the bed, trying to get out of bed. The resident's bedding was on the floor, the resident took off her brief and was in emotional distress. The investigation included the 3/7/25 provider progress note which revealed Resident #7 had edema to her fingers and the left dorsal (the back) aspect of hand. The x-ray on 3/5/25 revealed the resident had an acute (new) fracture involving the left third metacarpal with mild displacement. The resident was able to bend her finger and used her hand at baseline. She denied pain. The note documented options were discussed with the resident's representative, such as, buddy taping the fingers, an orthopedic consult, elevation and ice. The representative was understanding of the resident's dementia and her goals of care. The representative wished for comfort treatment only at that time and to continue to monitor. The investigation documented, based on the interviews the nurse manager had with the staff and based on the resident's impulsive movement, it was deemed that the fracture happened due to the resident hitting the wall or bed in her room, flailing her arms or any other type of sudden impulsive movement. -The facility was unable to provide documentation that the incident of unknown origin was reported to the State Agency. IV. Staff interview The director of nursing (DON) was interviewed on 3/20/25 at 3:57 p.m. The DON said she was the acting abuse coordinator. She said she did not know Resident #7's representative told the unit nurse about the swelling on 3/1/25. She said she did not know the nurse on 3/2/25 noticed swelling on Resident #7's left hand and the nurse did not report the swelling promptly. The DON said the nurse should have followed the injury of unknown source protocol. The DON said the protocol included completing a skin assessment, asking the other staff on the unit what happened and notifying the physician, abuse coordinator and the family. The DON said she did not report the injury because the resident had a history of hitting the walls. Licensed practical nurse (LPN) #2 was interviewed on 3/24/25 at 6:02 p.m. LPN #2 said if a resident had an injury, he would assess the injury and talk with the resident and staff to determine what happened. He said he would report the injury to the resident's physician and the nurse supervisor for further assessment and treatment recommendations. He said if the cause of the injury could be determined, it would be reported to facility leadership for an immediate investigation. LPN #2 said incidents involving abuse were to be reported immediately to the nursing home administrator (NHA) and the DON for investigation. He said if he observed an allegation of abuse, he was responsible for implementing an immediate intervention to protect the resident from further harm. The interim nursing home administrator (INHA) and the clinical nurse consultant (CNC) were interviewed together on 3/24/25 at 5:10 p.m. The INHA said she was the abuse coordinator as of today (3/24/25). She said the staff had two hours to report possible abuse to the abuse coordinator. The INHA said if a resident had an injury of unknown origin, the injury should be reported as possible abuse. She said when there was an injury of unknown origin, a risk management incident was completed, to include an investigation of interviewing staff, residents and family. The CNC said the nurse who noticed the swelling on 3/2/25 should have notified the physician and the abuse coordinator on 3/2/25.

Based on record review and interviews, the facility failed to ensure one (#1) of two residents out of five sample residents received treatment and care for optimal skin condition of a pressure wound and injury of unknown origin, in accordance with professional standards of practice. Specifically, the facility failed to: -Develop a care plan for treating Resident #1's moisture-associated skin damage (MASD) and preventing pressure injury due to immobility; -Reassess alternative methods of providing Resident #1's pressure-relieving interventions when the resident refused offers to be repositioned; and, -Reassess treatment methods and implement alternative interventions when Resident #1 developed a skin tear and his MASD worsened. Findings include: I. Professional reference According to Wound UK, volume 13, Number 4, 2019, Back to Basics: Understanding Moisture-Associated Skin Damage, retrieved online 4/4/25 from: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.wwic.[NAME]/uploads/files/documents/Professionals/New%20Articles/MASD.pdf Moisture-associated skin damage (MASD) is the umbrella term for four clinical manifestations, namely incontinence-associated dermatitis (IAD), intertriginous (skin folds) dermatitis (ITD), periwound moisture-associated dermatitis and peristomal moisture-associated dermatitis. Excess moisture and the associated chemical irritants cause MASD. The difference between the four conditions is the type of moisture that induces the skin damage. Urine and faeces cause IAD, and ITD is caused by perspiration. IAD is a form of contact dermatitis. The substances responsible for causing IAD are urine and/or feces. Feces contain enzymes that damage the stratum corneum (outer layer of skin). Liquid feces causes more damage than solid feces as the enzymes are more destructive in the liquid form. The enzymes in feces also exacerbate the effects of urine on the skin, hence, incontinence of urine and feces is more damaging to the skin than either type of incontinence on its own. Skin damage is normally found in the perianal area, although it can extend further depending on the degree of the incontinence and speed with which the contaminants are removed from the skin. According to the All [NAME] Tissue Viability Nurse Forum, Best Practice Statement on the Prevention and Management of Moisture Lesions, September 2023, retrieved online 4/4/25 from:chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.wwic.[NAME]/uploads/files/documents/Professionals/Clinical%20Partners/AWTVNF/All_Wales-Moisture_Lesions_final_final.pdf To address the issues associated with the development of moisture lesions and the unacceptable consequence of inadequate continence care, the individual's skin and continence status should be assessed regularly. Early recognition and use of appropriate interventions can prevent moisture lesions from occurring in the first place. Skin should be cleansed after each episode of incontinence using pH-friendly skin cleaners and avoiding traditional soap and water, which can strip the skin. A barrier product should be used to protect vulnerable skin from contact with urine and feces. Appropriate devices to divert incontinence should be considered in patients at high risk of developing moisture lesions. Although the treatment for pressure ulcers and moisture lesions is different, patients with moisture-associated skin damage still require pressure relief. This is because the presence of moisture increases the risk of pressure damage occurring. Individuals with incontinence may also have problems with mobility and, as a result, be at risk of developing pressure ulcers as well as moisture lesions. Consequently, when inspecting an individual's skin, it may be difficult to tell if the damage to the skin is caused by moisture alone or moisture in combination with pressure. If the skin is subjected to moisture and pressure, then the treatment strategy will have to overcome both of these insults to the skin. Therefore, along with guidance on how to prevent and manage moisture on the skin, pressure relief will be an important part of care for the individual. Repositioning together with the use of pressure-relieving equipment are the main methods of preventing pressure damage caused by extended periods of localized pressure on the skin. The use of repositioning should be considered in all at-risk individuals as a prevention strategy and should be undertaken to reduce the duration and magnitude of pressure over vulnerable areas of the body. The repositioning schedule should take into account the daily activities of the individual, their ability to tolerate pressure when in the seated and lying positions and the support surfaces in use. If a moisture lesion does not respond to interventions to minimize the effects of moisture alone, then the clinician should consider whether pressure is contributing to the damage and introduce repositioning and pressure relief into the individual's care. II. Facility policy and procedure The Pressure Injury Prevention Guidelines policy, dated 2024, was provided by the corporate nurse consultant (CNC) on 3/25/25 at 1:00 p.m. It read in pertinent part, To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. Policy Explanation and Compliance Guidelines: Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment (moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). The goal and preferences of the resident and/or authorized representative will be included in the plan of care. The Skin Assessment policy, dated 2024, was provided by the CNC on 3/25/25 at 1:00 p.m. It read in pertinent part, A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. III. Resident #1 A. Resident status Resident #1, age 72, was admitted on [DATE] and discharged [DATE]. According to the February 2025 computerized physician's orders (CPO) diagnosis included Parkinson's disease (a disease that causes tremors), diabetes and protein deficiency. The 2/2/25 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident needed substantial to maximal assistance with bed mobility (helper does more than half the effort; and the helper lifts or holds the trunk or limbs and provides more than half the effort). The resident was dependent on staff for all transfers and position changes. The MDS assessment documented that the resident did not have any pressure injury and was not at risk for pressure injury. -However, the resident's electronic medical record (EMR) documented that the resident had MASD upon admission. B. Resident#1's representative interview Resident #1's representative was interviewed on 3/13/25 at approximately 10:00 a.m. The representative said Resident #1 did not have any open pressure injuries upon admission to the facility, but soon after admission, developed an open pressure wound that continued to worsen. The resident's representative said she did not believe that the facility was treating the resident's pressure injury properly and removed the resident from the facility after suspecting that the wound had become infected. The representative said she had the resident sent to the hospital, where the resident received treatment for a stage 3 pressure wound with a suspected infection. C. Record review The resident's comprehensive care plan initiated 1/28/25 failed to document a care focus for treating the resident MASD or potential for pressure injury. Hospital discharge records, dated 1/28/25 and the 1/28/25 facility admission assessment, documented that the resident was admitted to the facility with MASD to the coccyx (base of the tailbone). The admission assessment, dated 1/28/25, revealed that the facility nursing staff assessed the resident's wound within hours of the resident's admission. The MASD measured 11 centimeters (cm) by 10 cm with no measurable depth. The wound was reddened with no open areas. The resident needed assistance with frequent repositioning as well and a pressure-reducing device was placed on the resident's bed and wheelchair. The initial skin assessment, dated 1/29/25, the resident's skin was reassessed within 24 hours of the first assessment by nursing. The nurse documented the resident had MASD on the lower coccyx region with no changes in measurement or condition. The nursing staff continued to monitor, assess and treat the resident's MASD. The skin evaluation note, dated 2/4/25, revealed the resident was assessed for a new skin issue. The nursing staff documentation revealed the resident had a skin tear with no skin loss on the coccyx at the site where MASD existed. There was no sign of infection; however, the resident expressed he had burning pain at the wound site. The note documented the resident had redness to the coccyx and a skin tear down the medial aspect of the intergluteal cleft (the groove between the buttocks). Up to this time, the resident's MASD was being treated with barrier cream and he was being encouraged to participate in frequent turning and repositioning. -There was no assessed measurement for the initial discovery of the resident's skin tear and no indication of what might have caused the skin tear. The nurse practitioner's note, dated 2/6/25, documented the resident was seen for new skin breakdown that was observed as excoriation with a small open area to the coccyx. The note revealed the resident had been refusing to turn and reposition and said it was too hard to be on him due to his Parkinson's diagnosis. The nurse practitioner recommended that the facility consider providing the resident an air mattress to help offload pressure on the resident's coccyx area. The wound care note, dated 2/6/25, documented the resident presented for a follow-up for their wound and an evaluation of MASD on the sacrum/coccyx. The note documented modifying factors included aging and impaired mobility. The MASD wound measured 2.5 cm in length by 0.3 cm in width with no measurable depth. The resident had no pain at the time of the exam. The wound bed had 100% epithelialization (development of new tissue). The periwound (skin surrounding the wound) skin texture was normal. The periwound skin moisture and color were normal. The 2/6/25 wound note also documented the resident's wheelchair cushion was evaluated and the treatment orders provided included: Cleanse and protect the wound; apply Triad cream twice a day (specialized wound care ointment to promote healing); monitor for signs and symptoms of infection; apply moisturizing cream twice a day for dry skin; and provide calorie and protein supplements per registered dietician, as needed to promote wound healing. -The wound care note failed to show evidence that the physician assessed the appropriateness of the resident's mattress for proper pressure relief. The skin evaluation note, dated 2/7/25, documented that the resident's wounds had not been assessed but included measurements of the resident's coccyx wound being 11 cm by 10 cm with no depth and no pain. -These measurements were inconsistent with the wound care specialist note dated 2/6/25 as well as the nurse practitioner notes dated 2/6/25 which revealed they had assessed the resident wound with different results (see above) The nurse practitioner's note, dated 2/7/25, documented the resident was seen in bed. The NP observed the excoriation and the resident had a small open area on the coccyx area. Barrier cream (Triad) was applied to the area. The resident had requested lidocaine ointment (a topical pain relief medication) for gluteal breakdown pain. A new order was entered for lidocaine topical cream -apply a small amount to the affected area once a day for pain to the superior gluteal fold. The nursing note, dated 2/9/25, documented lidocaine 2% external gel was applied to the coccyx for pain at the site of skin breakdown. The CNA alerted the nurse that the coccyx and buttocks seemed to have increased redness. A skin assessment was done. It was suspected that the resident had an adverse reaction to lidocaine. It was reported to the on-call provider and the lidocaine was discontinued. The nurse practitioner note, dated 2/12/25, documented the resident was assessed for skin breakdown. The resident continued to refuse repositioning but was encouraged to reposition. The resident now has an alternating pressure mattress for coccyx excoriation/breakdown. The note documented the resident had skin breakdown to the gluteal fold with peripheral erythema upon admission, however the breakdown had worsened related to the skin's continued exposure to moisture. It was recommended for the wound care team to evaluate. Nursing was to continue to apply barrier cream to the resident wound twice a day, however the resident was resistant to being moved for skin care. -It took the facility approximately 14 days to place an alternating pressure mattress on the resident's bed despite his wound worsening and refusing turning and repositioning for pressure relief and wound care. The wound care note, dated 2/13/25, documented the resident's coccyx wound was deteriorating. It measured 3 cm length by 0.4 cm width by 0.1 cm depth with a moderate amount of serous drainage (yellowish fluid that is thicker than water). New treatment orders included daily application of calcium alginate (an absorbent dressing that preserves proper moisture level) with a bordered dressing to keep the wound protected. An alternating pressure mattress in place. The wound care note, dated 2/18/25, documented the resident's wound was not healed but was improving. The wound measured 2.0 cm length by 0.4 cm width by 0.1 cm depth. Assessment: Healing is expected to be delayed due to identified factors, including impaired mobility, inevitable effects of aging, and non-compliance. The physician note, dated 2/18/25, documented the resident's buttock/gluteal wound was assessed today, peripherally expanded, with increased central breakdown. The wound was exacerbated by the resident's urinary incontinence, refusal to allow staff to change him after incontinent episodes or provide repositioning assistance to prompt offloading of pressure points of the coccyx at the wound site. The resident said he was unable to use the urinal and could not control voiding at times. The nursing note, dated 2/22/25, documented the CNA was trying to reposition the resident on his side to offload pressure on his coccyx. The resident refused and said he did not ever need to be on his side. The nursing note, dated 2/23/25, documented the resident had a coccyx wound that did not seem to be getting better. The note documented a message was left for the on-call nursing supervisor and wound care nurse. The wound care nurse said she would follow up with the physician in the morning. The family was concerned that the resident's wound was infected and requested that the resident be transported to the hospital for further assessment. IV. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 2/24/25 at 5:35 p.m. LPN #2 said residents who were bed-bound or in bed a lot and were at risk for pressure injury should be repositioned every two hours to relieve pressure and promote healing. LPN #2 said residents who refused this type of intervention could benefit from an alternating air mattress. LPN #2 said the air mattress would continuously inflate and slightly deflate the air pressure to offload continuous pressure on one point of the body and promote some circulation throughout the body. The director of nursing (DON) was interviewed on 3/20/25 at 2:15 p.m. The DON said Resident #1 was resistant to the care that was recommended to treat his MASD, despite providing the resident education to reposition. The DON said the wound specialist and the nurse practitioner (NP) were monitoring his skin and other health needs. She said he was also being followed by therapy and nursing. The DON said the resident had a standard pressure-relieving mattress but also needed to be willing to reposition. She said, despite his refusal to reposition and accept wound care on a routine basis, the staff were expected to continue to offer him repositioning as that was most important for pressure relief and healing.

Based on observations, record review, and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practical physical, mental, and psychosocial well-being for two (#7 and #14) of three residents reviewed for dementia care out of 14 sample residents. Specifically, the facility failed to develop and implement effective dementia management-focused interventions to prevent Resident #7 and Resident #14 from wandering into other residents' rooms. Findings include: I. Facility policy and procedure The Dementia Care policy and procedure, undated, was provided by the clinical nurse consultant (CNC) on 3/25/25 at 4:31 p.m It read in pertinent part, It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of, or is diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being. The facility will assess, develop, and implement care plans through an interdisciplinary team (IDT) approach that includes the resident, their family, and/or resident representative, to the extent possible. Care and services will be person-centered and reflect each resident's individual goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. II. Resident #7 A. Resident status Resident #7, age 85, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia with agitation, transient ischemic attack (heart attack), cerebral vascular disease (stroke) and depression. The 12/30/24 minimum data set (MDS) assessment revealed a brief interview for mental status (BIMS) assessment was not conducted because the resident was rarely or never understood. According to the staff assessment for mental status, the resident had short and long term memory problems and her cognitive skills for daily decision making were severely impaired. She required maximum assistance with personal hygiene and showering. The assessment revealed the resident wandered on one to three days during the seven day assessment look-back period. -The assessment did not reveal if the resident's wandering placed the resident at significant risk of getting to a potentially dangerous place or intruded on the privacy of others. B. Resident's representative interview Resident #7's representative was interviewed on 3/20/25 at 11:09 a.m. The representative said he visited the resident frequently. He said Resident #7 was initially on a non-secured unit at the facility. He said Resident #7 wandered into another resident's room and did not give the other resident privacy. He said the facility suggested the resident move to the secured unit because the facility was concerned the resident could leave the facility or wander into areas she did not know where she was. The representative said Resident #7 wandered in the secure unit. C. Resident observations During a continuous observation on 3/2025, beginning at 12:51 p.m. and ending at 1:46 p.m., the following observations were made: On the north side of the unit, four out of the eight residents' room doors were open. On the south side of the unit, one out of the six residents' room doors was open. At 12:51 p.m. Resident #7 was in the dining area in her wheelchair in front of a dining table. Resident #7 was surrounded by other residents who sat at the communal dining table. From 12:51 p.m. to 1:08 p.m. Resident #7 used her right hand to brush back and forth in a repetitive motion on top of the dining table. She did not have any activities to engage her. From 1:04 p.m. to 1:19 p.m., an unidentified staff member arrived at the unit. The unidentified staff member offered activities to the residents at the communal dining table. The activities included a utensil organization activity, a laundry sorting activity and a coloring activity. Each activity was offered to several residents at the communal dining table. -However, staff did not offer any of the activities to Resident #7. At 1:36 p.m., licensed practical nurse (LPN) #1 closed the open doors on the north side of the unit. During a continuous observation on 3/24/25, beginning at 10:05 a.m. and ending at 11:36 a.m., the following observations were made: On the north side of the unit, six out of the eight residents' room doors were open. On the south side of the unit, four out of the six residents' room doors were open. At 10:11 a.m. Resident #7 went into the first room on the north side of the unit. At 10:15 a.m., LPN #2 redirected Resident #7 out of the room. At 10:20 a.m., LPN #2 offered coloring to the residents sitting at the communal dining table. -However, she did not attempt to engage Resident #7 in the coloring activity. From 10:15 a.m. to 10:34 a.m. Resident #7 continued to wander in and out of the first room on the north side of the unit. At 10:38 a.m., LPN #2 closed the door to room [ROOM NUMBER]. At 10:46 a.m, LPN #2 asked Resident #7 if she wanted to listen to a guitarist. LPN #2 pushed Resident #7 down to the area where a guitarist was setting up to perform. At 10:54 a.m. LPN #2 and CNA #1 took Resident #7 to her room for toileting care. At 11:02 a.m. Resident #7 was taken back to listen to the guitarist. She listened to the guitarist with her eyes closed off and on. At 11:35 a.m. LPN #2 escorted Resident #7 to the communal dining table for lunch. -During the continuous observation, LPN #2 did not attempt to offer coloring to Resident #7 and did not attempt to redirect Resident #7 out of the first room on the north side of the unit after 10:15 a.m. D. Record review Review of Resident #7's wandering care plan, revised 3/21/25, revealed the resident was at risk for wandering due to dementia and anxiety. The behavior could be triggered in the afternoon after her family left the facility. Interventions included encouraging the resident to attend activities in the morning, ensuring the area was safe, addressing wandering by walking with the resident, redirecting the resident away from inappropriate areas, offering ice cream, sitting with the resident, closing the doors of other resident's rooms and administering and monitoring the effectiveness and side effects of medications ordered. The 2/15/25 nurse progress note revealed Resident #7 wandered into another resident's room and was slightly tearful and restless but she was unable to express what was distressing her. The behavior decreased after the certified nurse aide (CNA) changed her brief. The 2/16/25 nurse progress note revealed the resident was tearful and wandered up and down the unit. The resident talked to the nurse or other residents for a while. The resident sobbed but was unable to verbalize what was bothering her or how she could be helped. The resident did not have severe agitation like yesterday (2/15/25) when the resident pushed tables, ran into residents, and knocked things down. Soft redirections were mildly effective. The resident was able to sit at the table for dinner. The 2/18/25 nurse progress note revealed Resident #7 was wandering through the unit in a wheelchair very quickly. The resident cried out, showing signs and symptoms of anxiety. The resident was inconsolable, stated she was tired and refused to lie down. The resident displayed this similar pattern daily after lunch until about 2:00 p.m. The 2/21/25 nurse progress note revealed Resident #7 was wandering the unit in a wheelchair, crying, and said she needed to go to the library. The resident attempted several times to push the door open. The resident was tearful. The resident was able to be redirected for only ten minutes at a time. The resident was offered food, fluid, folding clothes and washing tables. The resident returned to being inconsolable. The 2/28/25 nurse progress note revealed the resident wandered throughout the unit in a wheelchair. The 3/1/25 nurse progress note revealed Resident #7 had a weary expression and was tearful and wandering. The resident could not explain why she was distressed. The resident did not respond to attempts to redirect or distract. The resident was allowed to wander and given tissues when weepy. When dinner arrived, the resident was able to be redirected and ate and drank well. The 3/3/25 nurse progress note revealed the resident was exit seeking and wandering in a wheelchair. The resident was inconsolable with tears, attempting to stand by herself. The resident was able to be redirected for short periods of time. The resident was changed, offered fluid and food, and one-on-one time. The interventions worked intermittently to redirect the resident but the behavior returned. The 3/7/25 nurse progress note revealed Resident #7 was tearful, worried and wandered the unit up and down the hallway in a wheelchair. The resident was able to be redirected for short periods with fluid, food and one-on-one attention. The resident was not aware of other's space, ran over other residents' feet and toes and into their wheelchairs. The 3/9/25 nurse progress note revealed the resident started restless wandering in the afternoon, which was a common behavior for the resident. The 3/14/25 nurse progress note revealed Resident #7 was kept safe when wandering by keeping doors closed and the resident within line of sight. The 3/15/25 nurse progress note revealed the resident wandered in her wheelchair with a distressed look on her face and was tearful. She was unable to coherently verbalize what was bothering her. The resident had a pattern of tearful and distressed behavior almost every day between the hours of 12:30 p.m. to 4:30 p.m. Staff was generally unable to provide comfort, distraction or redirection. Toileting would occasionally calm her behavior but not consistently. -Review of Resident #7's progress notes revealed there was no consistent documentation regarding what interventions were used and which interventions were effective when the resident's wandering was observed. The behavior monitoring and intervention task record revealed Resident #7 was known to have anxiety after her family visited. She was known to respond well to a serving of ice cream after family visits. The resident responded well to sensory activities. The resident responded well to weighted blankets around her shoulders. If the other residents' room doors were closed, Resident #7 did not wander as much and did not try to leave the unit. -There was no documentation in the behavior task record from 3/1/25 to 3/24/25 to indicate if wandering was observed, if interventions were used, and if the interventions were effective. III. Resident #14 A. Resident status Resident #14, age greater than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included Alzheimer's disease, dementia with agitation and anxiety disorder. The 1/4/25 MDS assessment revealed a BIMS assessment was not conducted because the resident was rarely or never understood. According to the staff assessment for mental status, the resident had short and long term memory problems and his cognitive skills for daily decision making were severely impaired. He required supervision for oral hygiene and moderate to substantial assistance with dressing, personal hygiene, toileting and showering The assessment revealed the resident wandered daily during the seven day assessment look-back period. -The assessment did not reveal if the resident's wandering placed the resident at significant risk of getting to a potentially dangerous place or intruded on the privacy of others. B. Resident observations During a continuous observation on 3/24/25, beginning at 10:05 a.m. and ending at 11:36 a.m., the following observations were made: On the north side of the unit, six out of the eight residents' room doors were open. On the south side of the unit, four out of the six residents' room doors were open. At 10:12 a.m. Resident #14 went into room [ROOM NUMBER]. He sat off and on the first bed and held the bed's remote control in his hand. At 10:18 a.m., Resident #14 looked through room [ROOM NUMBER]'s window and played with the vertical blinds on the window. -No staff observed Resident #14 in room [ROOM NUMBER] playing with the vertical window blinds of the bed controller. At 10:20 a.m., LPN #2 offered coloring to the residents sitting at the communal dining table. -However, LPN #2 did not attempt to redirect Resident #14 out of room [ROOM NUMBER] to participate in the coloring activity. At 10:21 a.m. Resident #14 left room [ROOM NUMBER] with one of the window blind slats in his hand (an individual strip once combined with others makes a window blind). He walked to the nurse's station and left the window blind slat at the nurse's station. At 10:33 a.m. Resident #14 walked in and out of the second-to-last room on the south side of the unit. At 10:34 a.m. Resident #14 walked in and out of room [ROOM NUMBER]. At 10:38 a.m. LPN #2 closed the door to room [ROOM NUMBER]. At 10:50 a.m. Resident #14 sat on the couch where the guitarist was setting up to perform. He sat on the couch and listened to the with his eyes closed. At 11:27 a.m. Resident #14 joined the other residents at the communal dining table for lunch. -During the continuous observation of Resident #14, LPN #2 did not attempt to offer coloring to the resident, did not redirect Resident #14 out of room [ROOM NUMBER]and did not ask Resident #14 if he wanted to listen to the guitarist. C. Record review Review of Resident #14's behavior care plan, revised 7/4/24, revealed the resident wandered. The interventions included eliciting family input for the best appropriate approaches. The 2/13/25 social services note revealed Resident #14 pushed on the door trying to leave the unit after a visitor left the unit. The resident was easily redirectable. The 2/14/25 nurse progress note revealed the resident attempted to push, pull and shove doors open on the unit to the outside hallway and outside patio. The 2/18/25 nurse progress note revealed Resident #14 pushed on doors with his hands and used his hands to push against the door. The 2/25/25 nurse progress note revealed the resident pushed and pulled on doors and was able to be redirected with snacks. The 3/3/25 nurse progress note revealed Resident #14 wandered the unit and pushed and pulled on doors. The 3/7/25 nurse progress note revealed the resident pushed and pulled on doors to the outside and was exit-seeking consistently throughout the day. The 3/11/25 nurse progress note revealed Resident #14 pushed and pulled on doors, wandered the unit and checked doors. The 3/14/25 nurse progress note revealed the resident pushed and pulled on doors, wandered to multiple doors, trying them over and over. The 3/18/25 nurse progress note revealed Resident #14 pushed and pulled on doors and wandered up and down the unit, trying each door. -Review of Resident #14's progress notes revealed there was no consistent documentation regarding what interventions were used and which interventions were effective when the resident's wandering was observed. Review of Resident #14's behavior monitoring and intervention task record revealed the resident had wandering behaviors and had exit-seeking behaviors. -There was no documentation in the behavior task record from 3/1/25 to 3/24/25 to indicate if wandering was observed, if interventions were used and if the interventions were effective. IV. Staff interviews LPN #2 was interviewed on 3/24/25 at 2:50 p.m. LPN #2 said she worked mostly in another unit. She said if a resident wandered, she kept an eye on the resident, tried to keep the resident out of other residents' rooms and provided activities to the resident. She said it was important to have interventions for residents who wandered because it helped the residents stay out of other residents' rooms and provided the residents with a purpose. She said one intervention was keeping the resident rooms' doors closed. She said it was an intervention because it prevented one resident from going through another resident's belongings. She said residents who wandered could take another resident's belongings and the items went missing. LPN #2 said she knew if a resident was a wanderer through verbal shift change reports, looking at the resident's care plan, utilizing the Kardex (an abbreviated care plan) and reading report sheets. LPN #2 said she did not document every time a resident wandered into the unit. She said she documented if the resident went into other residents' rooms and if the resident exhibited anxiety or agitation when they wandered. She said she documented her observations as a progress note. LPN #2 said she was familiar with Resident #7. She said night shift staff reported to her that Resident #7 wandered at night and offering ice cream was an effective intervention. LPN #2 said she did not know Resident #14 very well. She said he was wandering today (3/24/25). She said he sat down and watched television after lunch and that helped him not to wander. The CNC was interviewed on 3/24/25 at 5:10 p.m. The CNC said if staff saw a resident wandering into another resident's room, the staff should redirect the resident who was wandering out of the room. She said it was important to redirect the resident because the resident did not have the right to go into another resident's room without an invitation. She said interventions for residents were person-centered and included keeping other residents' doors closed if they were in the communal area, offering activities, walking with the resident and redirecting the resident. She said interventions were important because they kept the resident from going into other residents' rooms. The CNC said nursing knew if a resident wandered during their orientation period and by looking at the resident's care plan and the Kardex. The CNC said if the resident was in the secured unit, there was a level of wandering for all residents who lived in the unit. She said staff also knew if a resident wandered by reviewing a 24-hour report and when they received a verbal report from the previous shift nurse. She said if the resident exhibited new wandering or if the resident went into another resident's room, the nurse should document it as a progress note. The CNC said the interdisciplinary team (IDT) discussed residents' wandering behaviors in order to develop a person-centered intervention for residents. She said she was not familiar with Resident #7. She said she did not know the residents' room doors were left open on the secure unit, and she did not know activities were not offered to Resident #7. She said she was not familiar with Resident #14. She said the staff should have redirected Resident #14 when he was in other residents' rooms. She said the facility was working on additional dementia training in the future for the nursing staff.

Based on record review and interviews, the facility failed to investigate an allegation of physical abuse for two (#10 and #11) of six residents reviewed out of 11 sample residents. Specifically, the facility failed to thoroughly investigate alleged abuse between Resident #10 and Resident #11. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy, dated October 2024, was provided by the director of nursing (DON) on 2/25/25 at 1:48 p.m. via email. It read in pertinent part, Abuse is defined as the willful infliction of injury with resulting physical harm, pain or mental anguish, which can include resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking. Alleged violation is a situation or occurrence that is observed or reported by staff, residents, relatives, visitors or others but has not yet been investigated and, if verified, could be indication of noncompliance with the federal requirements related to abuse. The facility will develop and implement written policies and procedures that establish policies and procedures to investigate any such allegations. An immediate investigation is warranted when suspicion, or reports, of abuse occur. Written procedures for investigations include identifying staff responsible for the investigation, identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, focusing the investigation on determining if the abuse occurred, the extent, and cause and providing complete and thorough documentation of the investigation. II. Resident #10 - assailant A. Resident status Resident #10, age greater than 65, was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease and dementia with behavioral disturbance. The 12/9/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of one out of 15. She required set-up/clean-up assistance for dressing, oral hygiene, and eating, and supervision for toileting and personal hygiene. She used a manual wheelchair for mobility. B. Record review A nursing progress note, dated 2/17/25, revealed Resident #10 was involved in an altercation with another resident over a pack of wet wipes. Resident #10 grabbed the other resident's hand hard and dug her nails into the resident. Both residents were free of harm and injury and were separated. An interdisciplinary team note (IDT), dated 2/19/25, revealed Resident #10 was aggravated by another resident. The other resident (Resident #11) had a pack of wet wipes and Resident #10 wanted them. The other resident (Resident #11) pulled away and Resident #10 grabbed her arm, digging her nails into her arm. Staff immediately removed Resident #10 and kept the two residents separated for several hours. -The 2/17/25 nursing progress note, the 2/19/25 IDT note and the facility investigation revealed conflicting information regarding the incident, whether it was the resident's hand versus her arm that was grabbed (see facility investigation below). III. Resident #11 - victim A. Resident status Resident #11, age greater than 65, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included Alzheimer's disease and dementia with behavioral disturbance. The 2/3/25 MDS assessment revealed the resident had short term and long term memory problems and had severely impaired cognition and decision-making skills per staff assessment. She required substantial assistance from staff for most activities of daily living (ADL), set-up/clean-up assistance with eating and moderate assistance with toileting. She used a manual wheelchair for mobility. B. Record review A nursing progress note, dated 2/17/25, revealed Resident #11 was in a resident to resident altercation that afternoon (2/17/25). Resident #11 had a pack of wet wipes that another resident (Resident #10) wanted. Resident #11 did not give up the wipes, so the other resident (Resident #10) grabbed Resident #11's arm and dug her fingernails into her arm. The two residents were okay and separated. There were no new skin issues. The family and unit manager were aware of the altercation. -However, the investigation had revealed Resident #11's hand was grabbed (see investigation below). A skin check, completed on 2/19/25, revealed no new skin concerns. IV. Facility investigation The investigation of the altercation was provided by the DON on 2/20/25 at approximately 3:00 p.m. The investigation documented that on 2/17/25 at 2:28 p.m. Resident #10 grabbed Resident #11's hand and dug her nails into her skin. The two residents were immediately separated by certified nurse aide (CNA) #1 and were closely monitored. A skin check was performed on Resident #11 with no injuries noted. The residents' providers, resident representatives and the local police department were notified of the incident. Registered nurse (RN) #1, licensed practical nurse (LPN) #1 and CNA #1 were interviewed. -The facility was unable to provide documentation of interviews with other residents who may have witnessed the altercation. The conclusion of the investigation revealed that Resident #10 and Resident #11 were friends who socialized often. The altercation occurred because both residents were cognitively impaired and could not verbalize their needs. D. Staff interviews CNA #1 was interviewed on 2/24/25 at 4:20 p.m. CNA #1 said she was in the dining room near the residents when the altercation occurred. She said she was talking to other residents when she heard Resident #11 yell, No! CNA #1 looked over to see Resident #10 had grabbed Resident #11's left arm. She said afterwards, the two residents were separated. She said Resident #10 was agitated and said, that was horrible. CNA #1 said Resident #10 rarely got agitated and she had never seen her do anything like that before. She said she thought Resident #11's yelling triggered Resident #10. RN #1 was interviewed by phone on 2/24/25 at 5:04 p.m. RN #1 said she saw video footage of the altercation. She said Resident #10 was originally at another table. She said a resident was shaking Resident #10's wheelchair wheels and agitating her. She said Resident #10 was then moved to a table with her friend, Resident #11. RN #1 said she thought because Resident #10 was already agitated, she lashed out and grabbed Resident #11's right arm. -However, the investigation revealed Resident #11's hand was grabbed, while the 2//17/25 nursing progress revealed the resident's arm was grabbed. RN #1 said she did not think Resident #10's behavior was directed at Resident #11. RN #1 said that when she left work on 2/19/25 (two days after the altercation), Resident #11 had no evidence of injury. The DON was interviewed on 2/24/25 at 5:42 p.m. The DON said she had been temporarily taking over the position of nursing home administrator (NHA), since their NHA was on leave. The DON said she normally started investigating a resident to resident altercation immediately. She said she would interview others and get statements. She said this particular investigation was very short because Resident #10 and Resident #11 were friends and there was no injury.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents out of 10 sample residents was free from neglect. Resident #1 suffered an injury of unknown origin to the left forehead, a hematoma (a localized swelling of pooled blood due to injury or trauma), on [DATE] following a shower provided by hospice certified nurse aide (CNA) #1. The resident's son was notified of the forehead hematoma at 3:06 p.m., but the staff did not conduct a full skin assessment on the resident afterward to determine if other injuries were present. Resident #1 sustained a fall three days later, on [DATE]. No injuries were reported. -However, the staff did not conduct a full skin assessment to determine if other injuries were present. On [DATE], a progress note revealed that the resident had a faded yellow bruise to the left shoulder, hip, and a yellow, faded bruise to the left eye. On [DATE], a weekly skin assessment was conducted following a shower. It revealed a green/yellow bruise to the left side of the face, shoulder and breast. An abnormal protrusion to the clavicle (collarbone) was noted. -However, since there were no weekly skin assessments conducted since the original incident on [DATE], the date and origin of the clavicle injury were not identified. Due to the facility's failure to ensure a complete assessment after identifying an injury of unknown origin on [DATE], Resident #1 experienced a delay in care for her clavicle injury which was not discovered until an x-ray was performed on [DATE] and revealed a fracture. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on [DATE], resulting in the deficiency being cited as past noncompliance with a correction date of [DATE]. I. Incident and injuries of unknown origin between [DATE] and [DATE] Resident #1 sustained an injury of unknown origin on [DATE] and a fall on [DATE]. A full skin assessment documenting the resident's injuries was not performed until [DATE] (nine days later). Due to the facility's failure, the resident's injuries between [DATE] and [DATE] were not identified and treated immediately. Resident #1 experienced a delay in care which resulted in increased pain. -On [DATE], hospice increased the resident's pain medication. -On [DATE] an x-ray was ordered, which, on [DATE], revealed a clavicle fracture. II. Facility's plan of correction The corrective action plan implemented by the facility in response to Resident #1's unknown incident investigation failure between [DATE] and [DATE] was provided by the nursing home administrator (NHA) on [DATE] at 12:16 p.m. The plan revealed the following: A. Corrective action The facility notified the hospice company that the hospice CNA (CNA #1) and the hospice social worker were suspended from entering the facility pending the investigation. The investigation revealed hospice notes documented Resident #1 had a fall on [DATE], but the facility was never notified. On [DATE], the facility terminated their contract with the hospice company due to their lack of communication with the facility and lack of cooperation with the investigation. Education was provided to 23 staff members on [DATE] and included the following: -After a resident fall, call the physician and power of attorney (POA); -Complete neurological checks, fall assessment, post-fall evaluation, skin evaluation and risk management form; and, -Obtain witness statements if applicable. On [DATE] and [DATE], the remaining care staff obtained fall prevention education at the skills fair. Fall binders were created and placed at every nurses station as a reference for the staff and discussed by the unit manager.On [DATE], the facility began an investigation of Resident #1's injuries between [DATE] and [DATE]. The facility interviewed all staff on duty who were involved in care for the resident on the day of the fall on [DATE] and a few days prior to the fall. The interviews with the facility staff were noted to be consistent with facility documentation. Facility and hospice documentation was reviewed for dates [DATE] to [DATE]. On [DATE], Resident #1 had a bruise on the left forehead that was reported by CNA #1 after she gave the resident a shower. No other injuries were noted at that time. Facility staff reported that the bruise was not seen before the shower. CNA #1 denied any incident while in the shower. The facility's director of nursing (DON) notified the hospice DON of the bruise after the DON and registered nurse (RN) #1 saw the resident's hematoma and noted that it was visibly growing. -Hospice documentation stated there was a fall on [DATE]. The facility was not notified of the fall. The fall documentation was found after the facility requested hospice documentation and began the investigation on [DATE]. On [DATE], the staff reported that Resident #1 sustained a fall. She was found sitting in her room on the floor. Interventions were to review the resident's medications and check her neurological status every 15 minutes for 72 hours. Hospice staff increased her pain medication. On [DATE], Resident #1 had bruising to the left shoulder, hip and a yellow, faded bruise to the left eye. The injuries were being attributed to the fall on [DATE]. On [DATE], a nurse practitioner note (NP) stated the resident had bruising to the left shoulder. -No reported abnormality to the clavicle was noted. -Hospice documentation did not report any abnormality with the resident's clavicle until after the facility documented it on [DATE]. On [DATE], the facility requested interviews with hospice staff and they were never received. The facility was unable to identify the cause of the clavicle fracture after camera footage was obtained. The facility attributed it to either the alleged fall on [DATE] that was reported by CNA #1 (but not reported to the facility) or the documented fall on [DATE]. All documentation and facility staff interviews indicated that if the fracture was sustained on [DATE] or [DATE], it was not known to the facility or hospice staff until it was displaced and noticed on [DATE] (when the skin assessment was performed). B. Identification of others The facility terminated their contract with the hospice company on [DATE] and there had been no additional residents using that company. The facility made an update to their post-fall management procedures, which included documentation in a root cause analysis form which helped identify causes and potential preventive measures for future falls. C. Systemic changes The NHA sent an email on [DATE] at 12:16 p.m. that documented that all risk management (incident reports) were reviewed daily in the interdisciplinary team meetings. He said that completion of all required assessments after a fall were part of the review process. D. Monitoring The incident was brought to the facility quality assurance and process improvement (QAPI) meeting on [DATE] and involved discussion of the investigation, the findings and actions taken. Falls were reviewed monthly at QAPI and ongoing review of all risk management/incident reports was conducted. III. Facility policy and procedure The Integrated Fall Management policy, undated, was provided by the DON on [DATE] at approximately 5:36 p.m. It read in pertinent part, Purpose: fall risk assessment, identification and implementation of appropriate interventions as necessary, to maintain resident safety, prevent falls and reduce further injury from falls. Post Fall Procedure: When a resident falls the licensed nurse is notified. The nurse completes an assessment of the resident's condition including an interview, if possible, completion of vital signs and a body assessment. The environment of the fall is evaluated for possible contributing factors and addressed. The interdisciplinary team reviews the fall and care plan changes and may, if needed, implement additional interventions. Documentation of the above items is completed. IV. Resident #1 A. Resident status Resident #1, age 76, was admitted to the facility on [DATE] and expired on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included bladder cancer and Alzheimer's disease. The [DATE] staff assessment for mental status revealed the resident had short term and long term memory deficits and was severely impaired in making daily decisions. Resident #1 did not use any assistive devices for walking. The resident required partial/moderate assistance with dressing and personal hygiene, supervision or touch assist with shower transfers, and set-up/clean-up assistance for bathing and showering. The MDS assessment indicated she had had one fall with no injury since the last assessment. assessment. B. Record review On [DATE] (before the unknown incident), a weekly skin assessment documented that Resident #1 had no skin issues. On [DATE] a progress note revealed that the bruise to the resident's head was reviewed in the interdisciplinary team (IDT) meeting and that the facility continued to monitor the resident's neurological status. The note indicated a skin evaluation was still to be done. -However, a review of the resident's electronic medical record (EMR) did not include documentation indicating how the bruise to the resident's head occurred. On [DATE] at 3:47 p.m. a post-fall assessment revealed the resident had an old bruise on the left forehead that was fading. On [DATE] at 5:45 p.m. a weekly skin assessment revealed there were no skin issues. -However, this documentation conflicted with the earlier assessment on [DATE]. On [DATE] a progress note revealed that the resident had a faded yellow bruising to the left shoulder, hip and a yellow, faded bruise to the left eye. -However, a review of the resident's EMR did not include documentation indicating how the bruise to the resident's shoulder, hip or left eye occurred. On [DATE] at 11:27 a.m. a weekly skin assessment revealed a green/yellow bruise to the left side of the resident's face, shoulder and breast. An abnormality to the clavicle was noted. The assessment documented the resident's clavicle abnormality was not reported from the previous nurse. The resident's unwitnessed fall last week was reported. Resident #1's social services care plan, initiated [DATE], revealed the resident was a vulnerable adult due to loss of independence and cognition, visual impairment, depression and anxiety, was hard of hearing, received hospice services, had poor impulse control, wandered and was difficult to redirect at times and frequently refused medication. Interventions included administering medications as ordered, providing ancillary services as needed, monitoring and reporting any new changes to the provider and utilizing approaches that maximize her involvement in daily decision making and activity. The fall risk care plan, initiated [DATE], revealed the resident was at risk for falls. Interventions included anticipating and meeting the resident's needs and following facility fall protocol. Care plan revisions on [DATE] included reviewing information on past falls and attempting to determine the cause of falls, recording possible root causes, altering or removing any potential causes if possible, and educating the resident/family/caregivers/IDT as to the causes of the fall. Revisions on [DATE] included offering a chair when leaning or fatigued to avoid potential falls. -Resident #1's fall care plan was revised on [DATE] after a fall. New interventions included a pain management patch, 15-minute checks for 72 hours to better capture her personal and physical needs, staff maintaining heightened awareness for the resident and offering assistance as needed and for hospice staff to perform a medication review. Resident #1's hospice care plan, initiated [DATE], indicated the resident was on hospice services with terminal diagnoses of bladder cancer and dementia. Interventions included establishing and coordinating the plan of care and services between the facility and the hospice team, maintaining communication and informing of changes, hospice staff documented provisions of care for the facility staff, updated and reviewed as changes occurred. V. Staff interviews The DON was interviewed on [DATE] at 5:28 p.m. The DON said she was new at the time of the incident on [DATE] and was on vacation when it happened. She said the SBAR (situation, background, assessment and recommendation) assessment was the standard nursing assessment documented after a fall and included questions about the resident's range of motion, pain level, and neurological status. She said it was not a full head-to-toe assessment. She said when Resident #1's forehead hematoma was first noted by facility staff, a full skin assessment should have been done. RN #1 was interviewed on [DATE] at 5:36 p.m. RN #1 said she was a unit manager. RN #1 said Resident #1 had a big lump on her head after a shower with CNA #1 on [DATE]. RN #1 said she was not sure if the resident fell or if she hit her head while being combative. She said the resident had a history of being combative during care. She said she saw the resident the morning of [DATE] before the shower and she did not see any injury to her forehead. The DON and RN #1 were interviewed together on [DATE] 5:36 p.m. RN #1 said that a few processes had changed since the incident. RN #1 said the facility developed a root cause analysis form. RN #1 said a fall binder was developed as a reference for the nurses and supervisors and RN#1 said she had conversations with the nurses about the new binder. She said the facility did more audits and checklists now. RN #1 said she saw the resident after the incident and the hematoma was the size of an egg, growing, and looked new. RN #1 said she, the previous DON and the nursing home administrator (NHA) assessed Resident #1. RN #1 said neurological checks were started at 7:00 p.m. that night ([DATE]) because nobody was sure how she got the injury to her head. RN #1 revealed part of the facility's procedures after a fall included leaving the resident where they were found and having a RN assess the resident before moving them. She said the resident's provider and family would be notified of the fall, and a post-fall evaluation and RN assessment would be documented. She said RN assessments were documented under risk management. She said neurological checks were conducted on the resident for three days, even if no injuries were noted or the fall was unwitnessed. RN #1 said huddles were conducted with the CNAs so they could discuss the fall and future prevention methods. RN #1 said the hospice company would not let the facility talk to CNA #1 who gave Resident #1 the shower and had originally reported the hematoma. RN #1 said that because of the confusion and uncertainty, and because they could not get timely information from the hospice company, the facility implemented cares in pairs for the resident's safety. She said normally staff would have done a full skin check after noticing the hematoma on the resident's head, but the resident would not let anyone perform a skin assessment. RN #1 said the resident resisted a lot of care. She said if staff had done a full skin assessment, at least on [DATE] after the resident's other fall, it would have helped them determine the timeline of the resident's injuries, but the resident refused to let staff do full skin assessments. She said as a standard, skin checks were done weekly. RN #1 said it was the facility's mistake that they did not chart the resident's history of refusals of care. RN #1 said the facility received hospice notes well after the incident but did not receive CNA notes, and that the facility did not know if the documentation was in real-time or post-dated. She said they still did not know for sure how Resident #1 sustained a clavicle injury.

Based on observations, record review and interviews, the facility failed to two (#87 and #92) of three residents reviewed received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being level out of 34 sample residents. Resident #87 was admitted on [DATE]. Her admission weight was 113.8 pounds (lbs). The resident maintained a weight between 113 lbs and 118 lbs between January 2023 and January 2024. The resident lost 12.3 pounds between 1/4/24 and 2/15/24. The facility did not weigh the resident monthly despite a physician's order for monthly weights. The registered dietitian (RD) recommended weekly weights and weights were not consistently obtained on a weekly basis. The resident had poor meal intake and refused meals. There were no preventative measures implemented to address her eating patterns to ensure her intake was adequate. Due to the facility's failure to implement nutritional interventions, Resident #87 sustained a severe weight loss of 10% or 11.7 pounds in six months. Resident #92 was admitted on [DATE]. Her admission weight was 152 lbs. The resident maintained a weight between 147.3 lbs and 153.2 lbs between 5/12/23 and 2/6/24. Weekly weights and weights were not consistently obtained on a weekly basis. There were no nutritional interventions implemented between 2/6/24 and 3/3/24 when she sustained a 15.1 lbs weight loss. Due to the facility's failure to implement nutritional interventions, Resident #92 sustained a severe weight loss of 17.36% or 26.6 pounds in six months. Findings include: I. Facility policy The Nutritional Assessment policy, revised October 2017, was received by the nursing home administrator (NHA) on 3/20/24 at 12:42 p.m. It read in pertinent part, The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident's risks for nutritional complications. Such interventions will be developed within the context of the resident's prognosis and personal preferences. The Weight Assessment policy, revised March 2022, was received by the NHA on 3/20/24 at 12:42 p.m. It read in pertinent part, Resident weights are monitored for undesirable or unintended weight loss or gain. Residents are weighed upon admission and at intervals established by the interdisciplinary team. The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. II. Resident #87 A. Resident status Resident #87, age [AGE] years old, was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included prediabetes, osteoporosis, abnormal weight loss, major depressive order, vascular dementia with behavioral disturbance, atherosclerosis of native artery, chronic obstructive pulmonary disease and gastro-esophageal reflux disease (GERD). The 1/17/24 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The resident required set up assistance for eating. She required substantial assistance with oral hygiene, personal hygiene, toileting and showering. The assessment documented the resident required set up assistance with eating and the resident had not experienced weight loss. Her height was 4 feet 11 inches and she weighed 116 pounds. Her diet was a mechanically altered diet. B. Observations and interview The resident was in the dining area of the secured unit on 3/13/24 from 12:11 p.m until 12:46 p.m. She required complete assistance with her meal. She consumed less than 25% of her meal. On 3/18/24 the resident was in her room due to contact isolation measures. The nurse brought the resident lunch at 12:41 p.m. The nurse left the room at 1:09 p.m. The nurse said the resident ate about 25 percent of her meal. The nurse said the resident did well with a nutritional supplement shake and liquids but not the actual meal. The meal intake record documented she consumed less than 25% of her meal. C. Record review Resident #87's weight loss history revealed significant weight loss as follows: -On 10/5/23, the resident weighed 116.3 pounds; -On 11/6/23, the resident weighed 118.3 pounds; -On 12/2/23, the resident weighed 117.8 pounds; -On 1/4/24, the resident weighed 116.3 pounds; -On 2/15/24, the resident weighed 104 pounds; -On 2/23/24, the resident weighed 103.6 pounds; -On 3/1/24, the resident weighed 108.3 pounds; -On 3/18/24, the resident weighed 103.2 pounds; and, -On 3/19/24, the resident weighed 104.6 pounds. Resident #87's medical record revealed she experienced a significant unplanned weight loss of 10% or 11.7 pounds in six months from 10/5/23 to 3/19/24. The nutrition care plan, revised 1/22/24, revealed the resident had nutritional risks and potential for nutrition risks related to weight loss, dementia, psychotic disturbance, anxiety, hypothyroidism, prediabetes, osteoporosis, glaucoma, poor mobility and elevated LFT's (liver function tests). Interventions included encourage food and fluids at and between meals, honor food preferences, offer snacks daily, occasionally could feed self but usually required increased cueing and assistance at meals, monitor labs, weights, fluid volume status and skin integrity, provide supplements as ordered and monthly weights. The malnutrition care plan, revised 1/29/24, revealed the resident was at risk for malnutrition. The interventions included a complete mini nutritional evaluation, if malnourished consult dietitian and if mini nutritional evaluation results indicate risk, consult dietitian. The dementia care plan, revised on 1/27/23, revealed the resident would likely experience progressive decline in intellectual functioning characterized by deficit in memory, judgment, decision making and thought process related to dementia. Interventions included a BIMS at each review or as needed to monitor for changes in cognition. The self care deficit, revised 1/29/24, revealed the resident was at risk for feeding. The interventions included to provide meal support per resident's need The 2/22/24 dietitian progress note revealed she was not sure the 2/15/24 weight was accurate and changed monthly weights to weekly weights. The 2/28/24 dietitian progress note revealed the resident's weight was down significantly since December 2023. It read in pertinent part, The resident's intake declined. Increased frequency of Ensure supplement. Possible effect by norovirus? Noticeable decrease intake and nausea. Continued weekly weights and relay concerns to nursing and social services. The 3/7/24 dietitian progress note revealed the resident was on weekly weights. The note documented in pertinent part, Weight on 2/23/24 was 103.4 pounds. Variable intake through February (2024). No nausea, vomiting or diarrhea per progress notes. Follow weekly weights. The 3/8/24 nurse progress note for weekly weights said that weight was not obtained because weight was not due. -There was no documentation that the physician or dietitian were notified that the weight was not obtained. The 3/18/24 nurse progress note revealed the provider was notified about a new weight. The resident was already on Ensure (nutritional supplement), modified diet, recent illness and poor appetite. The provider ordered labs. The dietitian was notified and followed up once labs were completed. The resident was not experiencing difficulty with swallowing or a modified diet. -The 3/19/24 dietitian progress note (during the survey) revealed the resident had significant weight loss since December 2023. The note documented in pertinent part, She declined medically since January 2024. She had increased temperature. Pneumonia was ruled out with chest x rays. Fluids were encouraged. She was in isolation due to an outbreak of norovirus but remained asymptomatic. Resident was weak, poor intake and temperature. Concerned with the resident's overall medical decline, advanced age, severe dementia and weight loss. Body mass index (BMI) decreased from 23.9 to 20.8. May consider hospice consultation if warranted. Continue weekly weights and supplements. The March 2024 CPO revealed the following: -Regular puree textured diet -Ensure plus, three times a day for poor intake. Offer after meals, 237 mls. Start 2/28/24. -Ensure plus, one time a day for poor intake and weight loss. Start 10/20/23, discontinued 2/28/24. -Give snacks at bedtime. Start 3/15/23. -Weigh weekly, one time a day every 7 days. Start 2/23/24. -The facility did not follow the weekly weight order between 3/1/24 and 3/17/24. -The Ensure supplement was not changed until 2/28/24, after the resident had lost 12.7 lbs since 1/4/24. The March 2024 meal intake records documented the resident consumed the following from 2/19/24 to 3/20/24. The records revealed the resident ate 76-100 percent on 20 occasions, 51-75 percent on seven occasions; 26-50 percent on 21 occasions, zero-25 percent on 20 occasions and refused five meals (3/11/24, 3/13/24, 3/15/24 and 3/19/24). The resident had less than three meals in a day recorded for several days from 2/19/24 to 3/20/24. The record revealed the resident ate two meals on six days (2/20/24, 3/6/24, 3/9/24, 3/14/24, 3/16/24 and 3/19/24) and only one meal on five days (2/22/24, 2/29/24, 3/1/24, 3/7/24 and 3/17/24). III. Resident #92 A. Resident status Resident #92, age [AGE] years old, was admitted on [DATE]. According to the March 2024 CPO, the diagnoses included dementia, Alzheimer's, psychotic disturbance, mood disturbance, general anxiety disorder and osteoarthritis. The 2/15/24 MDS assessment documented that the resident had severe cognitive impairment with a BIMS score of zero out of 15. The resident required partial assistance for oral hygiene, toileting, showering, dressing and personal assistance. The assessment documented the resident required partial assistance with eating and the resident had not experienced weight loss. and had experienced weight loss. Her height was 5 feet 4 inches and she weighed 147 pounds. She was on a mechanically altered diet. B. Observations and interviews The resident was observed on 3/13/24 from 12:11 p.m until 12:54 p.m. An unidentified certified nurse aide (CNA) and an unidentified nurse talked at 12:28 p.m. The CNA said the resident lost 20 pounds. The nurse went to the medication cart and came back to the resident with a shake in a plastic cup. The resident tried to drink the shake independently. Her hand was shaking and she almost spilled the shake. The shake was not reoffered. The CNA provided juice in a plastic cup and left the resident. The resident spilled the juice when the CNA walked away. C. Record review Resident #92's weight loss history revealed significant weight loss as follows: -On 9/7/23, the resident weighed 153.2 pounds; -On 10/5/23, the resident weighed 151.6 pounds; -On 11/6/23, the resident weighed 152.7 pounds; -On 12/7/23, the resident weighed 150.6 pounds; -On 1/4/24, the resident weighed 151.5 pounds; -On 2/6/24, the resident weighed 147.3 pounds; -On 3/3/24, the resident weighed 132.4 pounds; -On 3/13/24, the resident weighed 126.6 pounds; and, -On 3/19/24, the resident weighed 131.4 pounds. -Despite the 15.1 pounds (10.12%) weight loss demonstrated in one month between 2/6/24 and 3/3/24, the facility did not add any nutritional interventions until ten days after the significant weight loss was documented. Resident #92's medical record revealed she experienced a significant unplanned weight loss of 17.36% or 26.6 pounds from 9/7/23 to 3/13/24. The nutrition care plan, revised 2/19/24, revealed the resident was at risk related to dementia, seasonal allergies, B12 vitamin deficiency, constipation and vitamin D deficiency. Interventions included encourage food at and between meals, Ensure twice a day, honor food preferences, offer snack daily, weekly weights, monitor labs and could sometimes eat independently but may need full assistance. The dementia care plan, revised 5/24/23, revealed the resident would likely experience progressive decline in intellectual functioning characterized by deficit in memory, judgment, decision making and thought process related to dementia. Interventions included simplify tasks by breaking tasks into one step at a time and utilize approaches to maximize involvement in daily decision making and activity. The ADL self care performance deficit care plan, revised 5/25/23, revealed the resident had a deficit related to dementia. She was able to hold the cup, feed herself and eat foods independently. The eating care plan, revised 8/28/23, revealed the resident had her own teeth with some missing teeth. She was able to feed herself independently, follow staff set up, encouragement and cueing. Interventions included staff to provide set up assistance with feeding. Staff were to provide verbal cues, set up tray, pour liquids, cut foods and apply condiments with each meal. The 3/18/24 provider note documented Resident #92 was seen for gradual weight loss of 25 pounds over the past 12 weeks and six pounds over the past three weeks. Staff reported she often did not eat well, took two to three Ensures daily and took fluids with encouragement. Her weight loss was expected and unavoidable as her dementia advanced. The dentist was following for a tooth that periodically became abscessed, though it did not seem to interfere with her eating or cause pain. The staff should continue oral intake and supplementation as tolerated. -The provider had called the weight loss unavoidable, however, there were no interventions added when she had a significant weight loss from 2/6/24 to 3/13/24. In addition, the resident had an abscessed tooth that did not interfere with eating, however according to the dietitian's note (see below) she had poor appetite due to the abscessed tooth. The 3/16/24 nurse progress note revealed the resident was losing weight and had declined. The resident ate 100% at breakfast, lunch and dinner. The 3/15/24 nurse progress note revealed the resident was physically declining and failed to thrive. It documented in pertinent part, Resident stayed in bed and encouraged fluids. Ensure ordered for two times a day. Resident was weak and left message for provider for labs. The 3/15/24 dietitian progress note (during the survey) documented the resident was treated for weight loss. It documented in pertinent part, Resident started on Ensure twice a day. Resident refused to drink. Resident has poor appetite due to abscess on right side of face. The 3/13/24 dietitian progress note said the resident was treated for tooth abscess with oral antibiotics. The resident had decreased in oral intake over the last week. Requested resident was reweighed because weight was significantly down. Added oral supplement for calories and fluids. Resident did well with finger foods and needs cueing and encouragement with intake. Follow weights weekly. The 3/12/24 provider notes revealed the staff reported right sided facial swelling due to an abscessed tooth. The resident did not open her mouth. She had a slight right sided facial swelling with palpation. She refused to open her mouth for an oral exam and did not show any signs of pain when palpating. The plan was to continue with antibiotics and probiotics. The 3/8/24 social services note revealed a request for a dental appointment as soon as possible. -There was no documentation that a dentist saw the resident. A request for dental records was made and the previous dentist visit from 11/14/23 was provided. The medication administration record (MAR) was reviewed for March 2024. It revealed the following orders: -Monthly weights on the third of every month. Start 3/3/24. -Weekly weights; one time a day every seven days for weekly weights. Start 3/14/24. -Ensure plus three times a day. Offer three times a day. Offer after meals. Start 3/14/24. -Give snack at bed time. Document percent eaten. Start 5/12/23. -Clindamycin 150 mg. Take one capsule by mouth every six hours for abscess for five days. Take one tablet every six hours for five days followed by dentist visit. Start 3/7/24. The March 2024 meal intake records documented the resident consumed the following from 2/19/24 to 3/20/24. The records revealed the resident ate 76-100 percent on 45 occasions, 51-75 percent on eight occasions; 26-50 percent on 13 occasions, zero-25 percent on two occasions and refused four meals. The resident had less than three meals in a day recorded for several days from 2/19/24 to 3/20/24. The record revealed the resident ate two meals on seven days (2/20/24, 3/6/24, 3/9/24, 3/14/24, 3/16/24, 3/17/24 and 3/19/24) and only one meal on four days (2/22/24, 2/29/24, 3/1/24 and 3/7/24). IV. Staff interviews CNA #3 was interviewed on 3/19/24 at 3:56 p.m. She knew when to weigh a resident when the nurse provided a list and verbally told the CNA. She said the list was for residents who lost weight. Once she weighed the resident she told the nurse. She documented the weight in the resident's electronic medical record. She asked the nurse what the resident weighed the last time the resident was weighed. She said it was important to weigh a resident because it showed the resident's health status. CNA #3 said she was familiar with Resident #87. She did not know why the resident lost weight because she ate her pureed meal and she required assistance with meals. CNA #3 said she was familiar with Resident #92. She said the resident ate a lot at dinner but she did not eat as much at breakfast and lunch because she was sleeping. The director of nursing was interviewed on 3/20/24 at 12:49 p.m. She said she was not familiar with Resident #87 and Resident #92. She said all residents should be weighed at least monthly. She said it was important to monitor the resident's weight because if the resident lost weight it could indicate the resident was depressed or the resident did not like the food or consistency. She wanted to pay more attention to the resident and add interventions to prevent weight loss. She said the nursing staff collaborated with the dietitian to ensure weights were completed. The nurse told the CNA to weigh the resident. The nurse was responsible to notify the dietitian when the resident had weight loss. The dietitian was notified in a daily meeting. The DON was unable to say what defined significant weight loss. The unit manager (UM) was interviewed on 3/20/24 at 12:59 p.m. She said there was an issue with staff weighing residents as ordered. She said some staff did not like the scale in the unit where Residents #87 and #92 lived. She said there was not oversight to ensure weights were obtained based on the physician orders. She said the facility corrected the issue. The dietitian shared a list of residents who required weekly weights. The registered dietitian (RD) was interviewed on 3/20/24 at 10:06 a.m. She was responsible for completing the nutritional assessment and they were completed at time of admission, quarterly and if there was a change in condition. She was notified when a resident lost weight during a morning clinical meeting, if a provider notified her and she independently looked through a dashboard connected to the resident's weights on a weekly basis. She said significant weight loss was five percent in 30 days, seven and half percent in a quarter and more than ten percent in six months. She said interventions depended on the resident. If they did not like fluids, she would not add a liquid supplement. She would add a powder supplement to mashed potatoes or soups to increase calories. She tried liquid supplements. She wanted the liquid supplement to be administered when medications were administered. She tried different supplements if a resident only liked a specific flavor or if there was a supply issue. She added weekly weights as another intervention. She talked to speech therapy if the resident was on a pureed diet to see if the resident could move to a mechanical diet. She considered double portions for women if they had assistance at meals. She said double portions for elderly women was hard because the quantity was overwhelming. She considered changing from one supplement to another supplement if the resident had weekly weights and took 50% or less of the supplement. The RD said weekly weights were an intervention because it was an easy way to see an improvement or a decline. The first time a resident lost weight, she asked the staff to re-weigh in case the scale was not accurate. The nurse or nurse manager was responsible for notifying the family and the provider. If she was familiar with the family, she would notify them. She said the restorative program was responsible for weighing residents but in February 2024, the CNAs took over. She said CNAs did not do weekly weights. She would make requests but it did not happen. She sent lists to the DON. She said February 2024 was difficult because if she did not have the resident's weights, she was unable to do quarterly assessments or change in condition assessments. The RD said Resident #87 was always a good eater. She saw the resident's weight loss in February 2024. She was not notified in February 2024 that the resident was not eating well. She added weekly weights for the resident. She said the staff might not have weighed the resident because the scale the staff used regularly was in a different unit. The unit Resident #87 resided on was in an outbreak and staff might not have wanted to use the scale in the other unit. She was not sure why the resident was not eating in the past seven days. She said the resident was accepting the liquid supplements. She wanted the resident to gain one to two pounds a week. She was surprised the resident lost weight so she asked for a new weight. She said she would ask the kitchen to add more mashed potatoes to her meals. -However, mashed potatoes were not implemented based on the care plan and the RD's documentation (see above). The RD said Resident #92 required total assistance with her meals. She was not notified the abscess bothered the resident. If she was notified about the abscess she considered a downgrade in her diet so the food was easier for the resident to eat. The medical director (MD) was interviewed on 3/19/24 at 11:48 a.m. He said when a resident lost weight, he looked to see if the facility provided food that the resident liked, if food was given in a timely manner, where the resident ate and if the resident needed assistance. He looked at medical issues to see if there were medications that suppressed the resident's appetite. He checked labs to see if there was another cause of weight loss. He evaluated if the resident would tolerate a medication to stimulate the resident's appetite. He said weekly weights were an important intervention. He said he was unable to speak specifically about Resident #87 and Resident #92. -However many of the interventions the medical director suggested for weight loss were not implemented or tried to prevent the significant weight loss of Resident #87 and Resident #92.

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 standards of practice were followed for a respiratory syncytial virus (RSV) outbreak in the secured unit were followed; -Ensure Resident #17, #31, #7, #36 and #11 received the RSV vaccination upon consenting for it; and, -Ensure the facility had a water monitoring program to prevent the potential spread of Legionella and other waterborne pathogen infections. Findings include: I. RSV outbreak A. Professional reference The Centers for Disease and Prevention (CDC) Hand Hygiene in Healthcare Settings, last reviewed 1/30/2020, retrieved on 4/2/24 from https://www.cdc.gov/handhygiene/providers/guideline.html included the following recommendations, in pertinent part for hand hygiene, Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. B. Facility policy and procedure The Standard Precautions policy, dated September 2022, was provided by the nursing home administrator (NHA) on 31/8/24 at approximately 11:00 a.m. It read in pertinent part, Standard precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Personnel are trained in various aspects of standard precautions to ensure appropriate decision-making in various clinical situations. After gloves are removed, hands are washed immediately to avoid transfer of microorganisms to residents or environments. The Isolation - Categories of Transmission-Based Precautions policy, dated September 2022, was provided by the NHA on 3/18/24 at approximately 11:00 a.m. It read in pertinent part, Transmission-based precautions are initiated when ar resident develops signs and symptoms of a transmissible infections; arrives for admission with symptoms of an infection; ar has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet and airborne. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. The signage informs the staff of the type of CDC (centers for disease control) precaution(s), instructions for use of PPE (personal protective equipment), and/or instructions to see a nurse before entering the room. Signs and notifications comply with the resident's right to confidentiality or privacy. Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Staff and visitors wear gloves (clean, non-sterile) when entering the room. While caring for a resident, staff will change gloves after having contact with infective material. Gloves are removed and hand hygiene performed before leaving the room. Staff avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. Droplet precautions are implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large particle droplets that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning). Masks are worn when entering the room. Gloves, gown and goggles are worn if there is risk of spraying respiratory secretions. C. Observations On 3/13/24 at 12:43 p.m. an unidentified staff member went into an isolation room for Resident #17. The staff member did not change the mask before she went into the isolation room. At 12:46 p.m., the same staff member left the isolation room. She did not change masks. There was a sign that indicated the resident was on droplet and contact precautions. The sign documented to remove the face mask prior to exiting the room. During a continuous observation on 3/19/24 beginning at 7:41 a.m. and ending at 9:02 a.m. the following was observed: At 7:42 a.m. licensed practical nurse (LPN) #5 pulled down her mask within six feet of a resident and blew her nose. At 7:43 a.m. certified nurse aide (CNA) #9 exited a resident's room who was positive for RSV with a surgical mask below her nose. CNA #9 did not change her mask upon exiting the room. At 7:48 a.m. CNA #9 began putting on a gown. CNA #9 then reached into her pockets and got a pair of gloves. CNA #9 did not put perform hand hygiene prior to putting on gloves and entered a resident room on isolation for RSV positive. At 7:57 a.m. CNA #9 left the RSV positive room. She removed all personal protective equipment (PPE) in the room except for the surgical mask. CNA #9 did not change her mask upon exiting the room.CNA #9 applied hand sanitizer for six seconds. -However, hand hygiene needs to be completed for at least 15-20 seconds. CNA #9 asked CNA #10 for assistance in the RSV positive room. CNA #9 began putting on a gown and got gloves out of her pocket and put them on. CNA #9 did not perform hand hygiene prior to putting gloves on. CNA #10 put a pair of gloves on and then put a mask on. The room CNA #9 and CNA #10 entered, had a sign on the door that indicated they needed to wear an N95 mask. Neither CNA put on a N95 mask. At 8:03 a.m. LPN #5 pulled her mask down and blew her nose within six feet of residents. LPN #5 applied sanitizer and rubbed her hands together for eight seconds. She then shook her hands in the air to dry them. Her hands were still visibly wet when she began touching the mouse to the medication cart computer. At 8:06 a.m. without performing additional hand hygiene LPN #5 administered a resident his medications. At 8:08 a.m. CNA #9 exited the RSV positive room wearing the same surgical mask. CNA #9 did not change the surgical mask upon exiting the room. At 8:14 a.m. LPN #5 took Resident #17's blood pressure in the dining room. Resident #17 was RSV positive. The licensed nurse did not encourage the resident to go to his room since he was RSV positive. LPN #5 returned the blood pressure cuff to the medication cart without sanitizing the cuff. LPN #5 did not perform hand hygiene. LPN #5 then touched her mask. At 8:15 a.m. Resident #17 entered his room. LPN #5 entered Resident #17's room without PPE and took the resident's pulse. At 8:20 a.m. CNA #9 and CNA #10 began passing out beverages to the residents who were in the dining room. Resident #17 was not encouraged to go to his room to consume his drinks and food. Resident #17 took his mask down near other residents in the dining room and began drinking his coffee. At 8:34 a.m. LPN #5 entered an unidentified resident to administer medications. LPN #5 exited the resident's room and did not perform hand hygiene. LPN #5 touched the mouse to the computer and opened up the medication cart to retrieve medications. At 8:47 a.m. CNA #9 put a gown on and then put a pair of gloves on without performing hand hygiene and entered an RSV positive room. At 8:57 a.m. LPN #5 put a gown on and then gloves. LPN #5 did not perform hand hygiene prior to putting on gloves. CNA #10 put on a pair of gloves without performing hand hygiene and then put a gown on. LPN #5 and CNA #10 entered an RSV positive room. At 8:59 a.m. CNA #10 exited the room. CNA #10 applied hand sanitizer and rubbed her hands together for nine seconds. At 9:00 a.m. LPN #5 exited the room. LPN #5 did not change her mask upon exiting the room. LPN #5 left the door open and said Resident #72 was going to come out to the dining room for breakfast. Resident #72 was RSV positive. At 9:01 a.m. the staff assisted Resident #72 to the dining room. D. Staff interviews The infection preventionist (IP) was interviewed on 3/19/24 at 10:27 a.m. The IP said the first resident tested positive for RSV on 3/8/24. The IP said nine residents on the secured unit have tested positive for RSV. The IP said the staff were encouraging residents to stay in their room who were RSV positive or under monitoring for RSV symptoms. The IP said the staff had a difficult time encouraging the residents to stay in their rooms since they had dementia. The IP said LPN #5 and CNA #10 should have not brought Resident #72 to the dining room for breakfast. The IP said the staff knew who was positive for RSV through the report and the end of the shift. The IP said she needed to implement a plan to ensure agency staff were educated on which residents had RSV or were under isolation for RSV symptoms. The IP said she had spoken with the health department and the staff needed to wear a surgical mask, gown and gloves into the RSV positive rooms. The IP said the staff needed to put on the gown then the gloves. The IP said hand hygiene needed to be performed before and after gloves usage. The IP said N95 masks and eye protection did not need to be worn in the RSV positive rooms. She said she needed to review the isolation posting signs in the secured unit to ensure they were all up to date. The IP said the surgical mask that was worn into an RSV room needed to be removed and a new one needed to be worn after exiting an RSV positive room. The IP said hand hygiene needed to be completed after exiting an RSV positive room. The IP said hand sanitizer could be used for hand hygiene. The IP said the staff needed to apply hand sanitizer and rub their hands together until they were completely dry. The IP said it was not appropriate for the staff to shake their hands through the air to dry them. The IP said it was important to ensure their hands were completely dry prior to touching items. The IP said she had attempted to educate all of the staff prior to the start of their shirts on proper PPE usage and hand hygiene. The IP said LPN #5 was an agency staff member and she had not provided education to her yet. The IP said she called the health department today (3/19/24) to determine the length of isolation needed for RSV. The IP said LPN #5 needed to be away from residents when she removed her mask to blow her nose. The IP said LPN #5 needed to complete thorough hand hygiene after blowing her nose. The IP said the residents who were positive for RSV were on droplet and contact precautions. The medical director was interviewed on 3/19/24 at 11:35 a.m. The medical director said the most important step to reducing the spread of infection was proper hand hygiene. The medical director said the facility needed to notify and educate the staff on which residents were RSV positive. III. RSV immunizations A. Facility policy and procedure The Vaccination Policy-Residents, undated, was provided by the NHA on 4/19/24 at approximately 10:30 a.m. It read in pertinent part, All residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated. B. Resident #17 1. Resident status Resident #17, over the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included dementia, heart failure and chronic kidney disease. 2. Record review -A review of the resident's electronic medical record (EMR) on 3/18/24 revealed the resident had not received the RSV vaccination after the resident's representative consented for the resident to receive the vaccination on 10/18/23. C. Resident #31 1. Resident status Resident #31, age 66, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included fracture of left tibia (leg) and respiratory failure. 2. Record review -A review of the resident's EMR on 3/18/24 revealed the resident had not received the RSV vaccination after she consented to receive the pneumococcal vaccination on 10/24/23. D. Resident #7 1. Resident status Resident #7, over the age of 65, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included anxiety and dementia. 2. Record review -A review of the resident's EMR on 3/18/24 revealed the resident had not received the RSV vaccination after she consented to receive the vacation on 10/24/23. E. Resident #36 1. Resident status Resident #36, age 81, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), heart failure, chronic kidney disease, type two diabetes mellitus and gastro-esophageal reflux disease (GERD). 2. Record review -A review of the resident's EMR on 3/18/24 revealed the resident had not received the RSV vaccination after she consented to receive the vacation on 10/24/23. F. Resident #11 1. Resident status Resident #11, over the age of 65, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included Alzheimer's disease, morbid obesity and gastro-esophageal reflux disease (GERD). 2. Record review -A review of the resident's EMR on 3/18/24 revealed the resident had not received the RSV after the resident's representative consented for the resident to receive the vaccination on 10/12/23. G. Staff interviews The infection preventionist (IP) was interviewed on 3/19/24 at 10:27 a.m. The IP said she recently started working at the facility. The IP said when residents admitted to the facility their immunization history needed to be researched and documented in the medical record. The IP said the residents needed to be offered the immunizations they needed. The IP said Resident #17, #31, #7, #36 and #11 were offered the RSV vaccination in October 2023 and had not received the vaccination yet. The IP said she was unsure why the residents had not received the vaccination yet. IV. Water management program A. Professional reference According to Center for Disease Control (CDC), Legionella (Legionnaires Disease and Pontiac fever), last reviewed 3/25/21, retrieved from on 4/1/24: https://www.cdc.gov/legionella/wmp/toolkit/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Flegionella%2Fmaintenance%2Fwmp-toolkit.html and https://www.cdc.gov/legionella/wmp/overview.html. It read in pertinent part, Many buildings need a water management program to reduce the risk for Legionella growing and spreading within their water system and devices. Legionella bacteria are typically found naturally in [NAME] environments, but can become a health concern when they grow and spread in human-made water systems. Legionella can cause a serious type of pneumonia (lung infection) known as Legionnaires disease. Some water systems in buildings have a higher risk for Legionella growth and spread than others. Legionella water management programs are now an industry standard for many buildings in the United States. Legionella bacteria can cause a serious type of pneumonia (lung infection) called Legionnaires disease. Legionella bacteria can also cause a less serious illness called Pontiac fever. The key to preventing Legionnaires disease is to reduce the risk of Legionella growth and spread. Building owners and managers can do this by maintaining building water systems and implementing controls for Legionella. Water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. Seven key elements of a Legionella water management program are to: -Establish a water management program team -Describe the building water systems using text and flow diagrams -Identify areas where Legionella could grow and spread -Decide where control measures should be applied and how to monitor them -Establish ways to intervene when control limits are not met -Make sure the program is running as designed (verification) and is effective (validation) -Document and communicate all the activities. Principles: In general, the principles of effective water management include: -Maintaining water temperatures outside the ideal range for Legionella growth - Preventing water stagnation -Ensuring adequate disinfection -Maintaining devices to prevent sediment, scale, corrosion, and biofilm, all of which provide a habitat and nutrients for Legionella. Once established, water management programs require regular monitoring of key areas for potentially hazardous conditions and the use of predetermined responses to respond when control measures are not met. A consultant with Legionella-specific environmental expertise may sometimes be helpful in implementing and operating water management programs. According to Center for Disease Control (CDC), Controlling Legionella in Potable Water Systems, reviewed 2/3/21, retrieved from on 4/1/24: Store hot water at temperatures above 140? and ensure hot water in circulation does not fall below 120?. Recirculate hot water continuously, if possible. Store and circulate cold water at temperatures below the favorable range for Legionella (77-113?); Legionella may grow at temperatures as low at 68?. B. Facility policy and procedure The Legionella Water Management Program policy, revised September 2022, was provided by the NHA on 3/18/24 at approximately 10:00 a.m. It read in pertinent part, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. The water management program is reviewed at least once a year, or sooner if any of the following occur: the control limits are consistently not met; there is a major maintenance or water service change; there are any disease cases associate with the water system; or there are changes in laws, regulations, standards or guidelines. C. Record review The NHA provided the Legionella water management plan on 3/18/24. -The water management plan was undated. The water management plan did not include how the facility was monitoring for Legionella. The water management plan had worksheets for the facility to utilize to help develop the water management plan. -The templates were not filled out to include specifics of the facility. The NHA provided temperature logs the maintenance department utilized to track the water temperature throughout the building. The water logs specified the water needed to be below 120?. A review of the temperature logs revealed the following temperatures that did not meet the standards of practice for water temperatures for Legionella management: -On 2/2/24 the water temperature in the special care unit kitchen was 86?, 110? in the therapy room, 118? in the east common area sink and 118? in the west common area sink. -On 2/9/24 the water in the special care unit kitchen was 89?, 112? in the therapy room, 118? in the east common area sink and the west common area sink. -On 2/16/24 the water temperature in the special care unit kitchen was 95?, 110? in the therapy room and 120? in the east common area sink and the west common area sink. -On 2/23/24 the water in the special care unit was 100?, 110? in the therapy room, 120? in the east common area sink and 119? in the west common area sink. -On 3/1/24 the water in the special care unit kitchen was 118?, 119? in the therapy room, 115? in the east common area sink and 117? in the west common area sink. -On 3/8/24 the water in the special care unit kitchen was 116?, 120? in the therapy room, 115? in the east common area sink and 118? in the west common area sink. -On 3/15/24 the water in the special care unit kitchen was 114?, 120? in the therapy room, 117? in the east common area sink and 119? in the west common area sink. -The temperature logs did not include resident rooms, boilers, water holding tanks or eye washing stations. D. Staff interviews The maintenance director (MTD) and the NHA were interviewed on 3/19/24 at 12:43 p.m. The MTD said they did not have a system in place to monitor how long resident rooms were empty and if the water needed to be flushed. The MTD said the facility did not test the water temperature at the boilers and the water holding tanks. The MTD said the staff member who documented on the temperature logs was new and needed to be educated on how to take temperatures of the water. The MTD and the NHA said they were unsure the correct temperature the water needed to be when monitoring for Legionella. The NHA said he was unsure the last time the water management plan was reviewed. He said the staff that were listed on the last revision had not been at the facility for a while. The NHA said they would review and update the water management plan to make it more thorough and ensure it met the regulations.

Based on record review and interviews, the facility failed to establish an infection control program for antibiotic stewardship to include an antibiotic stewardship program. Specifically, the facility failed to have a process in place to track antibiotic usage in the facility. Findings include: I. Professional reference The Centers for Disease Control and Prevention (CDC), antibiotic prescribing and usage in hospitals and long-term care, dated 2019, retrieved from https://www.cdc.gov/antibiotic-use/core-elements/hospital.html on 4/1/24, included the following recommendations: Implement policies that apply in all situations to support antibiotic prescribing to include specifying the dose, duration and indication for all courses of antibiotics so that they are readily identifiable. Implement facility specific treatment recommendations, based upon the national guidelines and local susceptibilities and formulary options that optimizes antibiotic selections, duration, and common indications for the usage of community acquired pneumonia, urinary tract infections, skin and soft tissue infections. II. Facility policy and procedure The Antibiotic Stewardship policy, revised December 2016, was provided by the nursing home administrator (NHA) on 3/18/24 at approximately 10:30 a.m. It read in pertinent part, Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes policy, dated December 2016, was provided by the NHA on 3/18/24 at approximately 10:30 a.m. It read in pertinent part, Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection preventionist, or designess. The IP (infection preventionist), or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. III. Antibiotic tracking system and staff interviews The IP was interviewed on 3/19/24 at 10:27 a.m. The IP said she was new to her position and recently began working at the facility. The IP said corporate nurse consultant (CNC) #1 and/or CNC #2 would be at the facility until she finished her training. The IP said she was unsure which criteria the facility used for antibiotic stewardship. CNC #2 joined the interview at 11:15 a.m. CNC #2 said the facility used McGreer's criteria for antibiotic use. CNC #2 said the facility used a program embedded into the electronic medical records to track antibiotics. CNC #2 and the IP said they were unsure of which residents were on antibiotics in the facility and if they met McGreer's criteria. CNC #2 said Resident #63 frequently called her physician outside the facility and asked for antibiotics. CNC #2 said the physician could order whatever medications they wanted. The IP said she was unsure how to use the antibiotic tracking system embedded into the electronic medical record. The IP said she found a map used to track infections for February 2024 that CNC #1 had made prior to leaving on vacation. The IP said she would create maps to track infections for January 2024 and March 2024. The medical director was interviewed on 3/19/24 at 11:35 a.m. He said he was not aware that Resident #63 had called her physician outside the facility to request antibiotics. He said he would review the resident's chart and provide education if a physician was providing antibiotics regularly that did not meet criteria.

Based on record review and interview, the facility failed to ensure all grievances were followed up on and resolved timely and appropriately. Specifically, the facility failed to make prompt efforts to resolve resident and resident representative grievances about a variety or concerns including: -Provision of timely care; -Responding to resident call lights; -Ensuring competent staff; -Ensuring agency staff performed care services as assigned; -Ensure a resolution to the resident's complaint about poor care and services; and, -Maintain evidence of the result of all grievances. Findings include: I. Facility policy and procedures The Grievances/Complaints, Filing Policy, revised April 2017, was provided by the nursing home administrator on 3/20/24 at 11:41 a.m. It read in pertinent part: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response. Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint. The grievance officer, administrator and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated. The administrator will review the findings with the grievance officer to determine what corrective actions, if any, need to be taken. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems. a. The administrator, or his or her designee, will make such reports orally within ___ (this line was left blank/ the number of days was not documented in the facility policy) working days of the filing of the grievance or complaint with the facility. b. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office. II. Resident group interview Four alert and oriented residents (#63, #88, #33 and #4) who usually attended the resident council and were interviewed on 3/18/24 at 1:00 p.m. The residents all discussed how unhappy they were with the agency staff the facility had contracted to provide resident care. The group said the agency certified nurse aides (CNAs) were not oriented or trained on the expectations to provide resident care. Agency staff did not know how to operate the facility's call light system and they did not respond positively or timely to requests from residents for care assistance. The group said each time they got an agency staff responding to provide their care they had to train the staff themselves on how to perform their care and meet routine care requests in line with the established care plans because agency staff appeared to be unaware of their individualized care need. The group members said they often went without proper care due to the agency staff's lack of knowledge or unwillingness to perform their jobs appropriately. III. Resident interviews Resident #63 was interviewed on 3/19/24 at 9:21 a.m. She said the call lights did not work properly and/or they were not answered in a timely manner. She said she pushed her call light on 3/18/24 at 7:20 p.m. and staff did not answer her call until 8:30 p.m. She said sometimes her wait was longer. Resident #63 said she believed that the majority of the problem was the amount of agency staff that the facility used. She said the majority of all shifts were staffed with agency staff and they were not invested in providing good care in a timely manner. Resident #63 said that when an agency staff responded to provide care, she had to train the staff on how to respond and inform them of her care needs because they did not seem to have been trained properly to be able to provide good care. The staff were not responsive and timely to requests for care assistance. Resident #63 said she had talked with another resident in the facility and they told her agency staff were not providing good care to them either. Resident #63 said she had filed numerous complaints about the quality of care from agency staff but does not believe that the facility is taking grievance complaints seriously and has done little to resolve the numerous complaints they have received about nursing care and agency staff. Resident #88 was interviewed on 3/19/24 at 10:47 a.m. Resident #88 said management should focus on call light response times as that was a big problem in addition to providing agency staff with better training because there should be a higher work ethic for all staff. Resident #88 said the quality of care received and how quickly a call light gets answered depended on what time of day he needed assistance. Most of the agency staff hired just do not care and if no one was watching them most agency staff do not make the effort; they provide bad care and we have to wait a long time to receive that bad care. Resident #88 would like facility management to pay closer attention to the call lights and staff response to the resident's requests for care assistance. Resident #88 would like to see management staff hold agency staff accountable for providing good care and not have the resident be subject to poor care and service before they do something about the problem. Resident #33 was interviewed on 3/19/24 at 11:00 a.m. Resident #33 said evening shift call lights were not answered timely the response time averaged 45 minutes. The evening shift was mostly staff with agency CNAs who did not know her care needs, preferred routines or methods of care. Resident #4 was interviewed on 3/19/24 at 11:24 a.m. Resident #4 said the agency staff worked mostly evenings and nights and they were not prompt about answering call lights. Resident #4 said a good response time was 10 minutes; however, when agency staff were working she had to wait approximately 30 to 40 minutes for them to answer her call light and there were times when she went without care assistance well into the night because he staff did not respond to her call light at all. Resident #4 said it took two CNAs to transfer her in and out of bed and she said she needed her legs propped on a pillow at bedtime. She said the agency staff did not know how to do those things for her and she was often uncomfortable due to the agency staff's lack of knowledge or training on her specific care needs. Resident #4 said the agency staff needed to be trained properly so the residents received appropriate care. Resident #4 said she wanted the facility to hire more permanent staff so the residents did not need to explain to every new CNA how they should be providing competent care. Resident #63 was interviewed on 3/20/24 at 4:05 p.m. Resident #63 said she had filed several grievance reports with the same concerns about poor nursing care and response on several occasions and the facility continued to fail to address the root cause of her and similar concerns of her peers also living in the facility. Resident #63 said the facility used way too many agency staff who were poorly trained, had a bad attitude and bedside manner and then failed to hold those staff accountable to provide quality care. The resident said she chose this facility for its past reputation but lately, there had been so much turnover in leadership that no one was taking responsibility for ensuring the residents of the facility were receiving competent and quality care. Resident #63 said she was second guessing her decision to move into the facility. IV. Record review A request was made for a resident grievance concerns regarding nursing care from December 2023 to March 2024, 50 grievances were provided. A sampling of the grievance reviewed documented the following resident concerns. A resident grievance, filed on 12/7/23, revealed that an agency CNA performing an improper mechanical list caused her pain and discomfort in her foot. Resident #4 said the agency CNA was argumentative and disrespectful when she asked the CNA to change her approach to assisting her in a transfer with a mechanical lift. Per the resident, when she asked the staff to change her approach the CNA argued with her and told the resident she was the one who needed to be more respectful and not talk to staff in that tone. The facility responded by placing the agency CNA on a do not return status. -There were no other actions taken. A resident grievance, filed on 12/13/23, revealed an agency nurse was rude to a resident while administering a bedtime medication. The complainant said the nurse was impatient and rushed the resident through the medication administration process. Then when asked to leave the door open the nurse closed the door in a harsh manner. The facility responded to place the agency nurse on a do not return status. -There were no other actions taken. A resident grievance, filed on 12/22/23, revealed the resident activated his call light for staff assistance to get changed but no one answered his call light. The resident had to go down the hall to the nurse's station where three CNAs and a nurse were having a conversation and ask directly for staff to assist him with his care. The facility educated the CNAs that they needed to answer resident call lights and informed the resident/complainant that it was hard to educate agency staff who were not there on a regular basis. -There were no other actions were taken. A resident grievance, filed on 12/22/23, revealed one of the two agency staff on duty did not have a good bedside manner and everyone was upset with the scheduling of so many agency staff. The facility talked to the resident/complainant and explained that it was difficult to educate agency staff who were not there on a regular basis. -There were no other actions taken. A resident grievance, filed on 12/25/23, revealed that an agency was rough and non-caring and the resident/complainant and another resident did not want that CNA in their room again. The facility responded by placing the agency CNA on a do not return status. -There were no other interventions. A resident grievance, filed on 12/27/23, revealed that when a resident requested an accommodation based on preferred medication administration times and was told by the unit manager that nursing staff could honor that request. After the arrangements were documented, the nurse on duty told the complainant that she did not need her medications at that time. The facility's response included documentation that the resident's schedule was already in place and that staff knew the resident's actual preferred times. -There were no actions taken. A resident grievance, filed on 12/28/23, revealed the resident activated her call light and waited for two hours, the CNA did not respond. When the nurse on duty arrived to give the resident their medication three hours late the resident confronted the nurse and the nurse responded by telling the resident she did not like how she (the nurse) was binge-treated by the resident. The facility educated the nursing staff to answer call lights and administer medication timely and be respectful to the residents. Six separate resident grievances, filed on 12/29/23, revealed two residents had requested CNA #8 not be assigned to their care due to the CNA not providing care when they asked for assistance and when the CNA provided services she was rough with care. The facility educated the CNA. -There were no other actions taken to ensure the CNA was acting appropriately towards residents. A resident grievance, filed on 1/5/24, revealed an agency CNA put the resident to bed earlier than desired and was rude throughout the care process. After being put to bed the CNA would not speak to the resident. The resident feared retaliation for filing the grievance. The facility held an additional resident council meeting to discuss nursing concerns (see below). A resident grievance, filed on 1/9/24, revealed the resident asked for staff assistance to get dressed for bed and put on his pajama pants. The CNA threw the pajamas at the resident and told the resident to do it himself. When the grievance coordinator investigated the resident then responded to questioning that it only happened once and he was thankful for the other CNAs helping him. -The facility took no actions to address the resident initial grievance /complaint. A resident grievance, filed on 1/9/24, revealed a resident complaint about CNA turnover. The resident said facility staff were familiar with her routine and meeting her care needs. -The grievance form did not document if there were any actions taken to address the resident's grievance concerns. A resident grievance, filed on 1/10/24, revealed a resident complaint her medications were administered two and a half hours late because the agency nurse did not have access to the computerized medication administration record (MAR). -The grievance form did not document if there were any actions taken to address the resident's grievance concerns. The 1/31/24 resident council minutes revealed old business discussions included: poor call light responses. The previous director of nursing (DON) said agency staff were provided written instructions on how to use the call light system. Resident were encouraged to continue to use their call lights to request assistance. The DON said she would continue to educate staff and requested the resident to report concerns. Call light concerns were unresolved. New Business: The NHA started doing spot checks of the call lights systems and addressing staff directly. The NHA reported that the facility was making progress but the concerns were still a work in progress. Residents asked what was the reasonable timeline. The State would like the response to be 15 minutes at most; the NHA would like to get it a lot less. A resident grievance, filed on 1/22/24, revealed a resident activated his call light to request staff assistance to use the bathroom. A CNA responded and rudely told the resident I do what I want to do and slammed the resident door shut without helping the resident use the bathroom. The resident waited an hour and a half for staff to come and provide care and ended up urinating in his brief. The resident said this was not the first time he had problems with this CNA. The facility's response to the grievance was to interview the resident and when the resident said I think the staff are trying. -There was no further action taken. A resident grievance, filed on 2/1/24, revealed a resident complained that she pressed her call light for staff assistance to get ready for and to go to bed. After waiting an hour and a half no staff responded to her call light so she started yelling for help, eventually, staff went to assist the resident with care and assist her to bed. The facility updated the resident care plan. -No further action was taken. A resident grievance, filed on 2/25/24, revealed a resident had to refile grievance concerns about long call light wait times, poor nursing care and poor medication time management because the resident's concerns were not addressed the first time she filed the grievance/complaints. The facility told the resident concerns were unresolved due to leadership turnover and said they would continue to follow up and communicate with her until her concerns were resolved. A resident grievance, filed on 3/5/24, revealed when the resident complained of being uncomfortable during the showing process and the CNA laughed and said you just lie to complain. The resident asked that the named CNA not be assigned to assist him with care in the future. The facility changed the CNA's assignment and the DON was to meet with the CNA prior to the CNA's return to work. -There was no documentation if the DON ever met with the CNA or what was discussed with the CNA. V. Staff interviews The staff development coordinator (SDC) was interviewed on 3/19/24 at 10:45 a.m. The SDC said the facility was actively recruiting nursing staff but relied heavily on agency CNAs and licensed nurses to meet the needs of residents in the facility. Each agency staff were to read the contents of the binder before starting work and sign an acknowledgment of understanding the contents of the binder. The binder contained information on the mission and vision of the facility, confidentiality, communication, directions for logging into and documenting resident care in the resident electronic medical record and operating and responding to resident call lights. The SDC said the CNA leaving shift would give report to the CNA common on shift. While the CNAs did their best to provide a thorough report the CNAs leaving shift may forget to pass some information along. The SDC said all agency staff had access to the resident's medical records so they could check car plan information if needed. The DON was interviewed on 3/19/24 at 4:00 p.m. The DON said the goal was to hire staff and reduce the use of agency staffing so that the facility could fully train their own staff and hold them accountable for providing quality care to the residents. The DON said the facility had a problem with staff answering call lights timely and consistently because the call lights did not always work properly. Staff had a hard time turning off the call lights once activated, due to a functional issue. When a call light was alarming the staff had a habit of thinking that it was already answered and they did not go back to check on the residents. The DON said the CNA should return to the resident's room to check on the resident and not leave the room until they successfully deactivated the call light. The DON said she was not sure what training agency staff received prior to starting their shift but knew they were supposed to get a status report on each resident on the reassignment before starting work from staff leaving shift. The DON said if agency staff were not providing appropriate care or not performing to the facility's standards the agency staff was placed on a do not return list. 42193

Based on staff interviews and record review, the facility failed to ensure licensed nurses and certified nurse aides (CNA) were evaluated for competency and skill sets necessary to care for residents' needs as identified through residents' assessments and care plans. Specifically, the facility failed to have completed competency and skill sets training with licensed practical nurse (LPN) #3 and CNA#4, #5, #6, #7 and #8. Cross-reference to: -F585 failure to resolve resident grievance about agency nursing staff's competency while providing care assistance; -F692 failure to ensure residents received care and services to meet their nutritional needs; -F700 failure to assess and monitor the use of bed rails; and, -F880 failure to implement and practice proper infection control practices during a respiratory syncytial virus (RSV) outbreak. Findings include: I. Facility Policy -A request was made for the facility's policy on assessing nursing staff's competencies, however, the policy was not provided. The In-Service Training, All Staff policy, revised August 2022, was provided by the nursing home administrator (NHA) on 3/20/24 at 11:41 a.m. It revealed in pertinent part: The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training. II. Record review On 3/19/24 at 10:32 a.m., a request was made for the staff competencies assessments for five CNAs (#4, #5, #6, #7 and #8) and LPN #3 who were selected at random from all facility hired nursing staff. -The facility was unable to provide proof that any of the selected staff members had been assessed for competency in providing resident care and services. III. Staff interviews The staff development coordinator (SDC) was interviewed on 3/19/24 at 10:45 a.m. The SDC said she was new to the position and was not sure when nursing staff were assessed for competencies. The director of nursing (DON) was interviewed on 3/19/24 at 4:00 p.m. The DON said she was new to her position and had been in the facility for only a couple of days. The DON was unsure of the status of competency assessments for the facility's nursing staff. The NHA was interviewed on 3/20/24 at 1:34 p.m. The NHA said he was not sure when the facility last assessed the competency of nursing staff. The NHA said they had no documentation to show proof that nursing staff, including CNAs and/or licensed nurses, were assessed for competencies in the last 12 months.

Based on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for five (#17, #31, #7, #36 and #11) of seven residents reviewed for immunizations out of 34 sample residents. Specifically, the facility failed to: -Administer the pneumococcal vaccination after consent was provided for Resident #17, #31, #7 and #11; and, -Document risk versus benefit education for the pneumococcal vaccination for Resident #36. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged [AGE] years or Older, United States, 2022, retrieved on 4/1/24, from: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, in pertinent part, Routine vaccination-pneumococcal-For those ages 19 to 64 with an additional risk factor or another indication was: One (1) dose PCV15 (pneumococcal 15-valent conjugate vaccine PCV15 Vaxneuvance) followed by PPSV23 (pneumococcal 23-valent polysaccharide vaccine PPSV23 Pneumovax 23)or one (1) dose PCV20 (pneumococcal 20-valent conjugate vaccine PCV20 Prevnar 20). For those over the age of 65 who meet age requirements and lack documentation of vaccination, or lack evidence of past infection was: One (1) dose PCV15 followed by PPSV23 or one (1) dose PCV20. Special situations: Age 19-[AGE] years with certain underlying medical conditions or other risk factors who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown: One (1) dose PCV15 or one (1) dose PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose. A minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak to minimize the risk of invasive pneumococcal disease caused by serotypes unique to PPSV23 in these vulnerable groups. Note: Immunocompromising conditions include chronic renal failure, nephrotic syndrome, immunodeficiency, iatrogenic immunosuppression, generalized malignancy, human immunodeficiency virus (HIV), Hodgkin disease, leukemia, lymphoma, multiple myeloma, solid organ transplants, congenital or acquired asplenia, sickle cell disease, or other hemoglobinopathies. Note: Underlying medical conditions or other risk factors include alcoholism, chronic heart/liver/lung disease, chronic renal failure, cigarette smoking, cochlear implant, congenital or acquired asplenia, CSF (cerebral spinal fluid) leak, diabetes mellitus, generalized malignancy, HIV, Hodgkin disease, immunodeficiency, iatrogenic immunosuppression, leukemia, lymphoma, multiple myeloma, nephrotic syndrome, solid organ transplants, or sickle cell disease or other hemoglobinopathies. II. Facility policy and procedure The Vaccination Policy-Residents, undated, was provided by the nursing home administrator (NHA) on 4/19/24 at approximately 10:30 a.m. It read in pertinent part, All residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated. Prior to receiving vaccinations, the resident or legal representative will be provided with information and education regarding the benefits and potential side effects of the vaccinations. Provision of such education shall be documented in the resident's medical record. All new residents shall be assessed for current vaccination status upon admission. The resident or the resident's legal representative may refuse vaccines for any reasons. If vaccines are refused, the refusal shall be documented in the resident's medical record. III. Resident #17 A. Resident status Resident #17, over the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included dementia, heart failure and chronic kidney disease. The 1/2/24 minimum data set (MDS) assessment indicated the resident was not up to date on his pneumococcal vaccination but did not specify a reason. B. Record review -A review of the resident's electronic medical record (EMR) on 3/18/24 revealed the resident had not received the pneumococcal vaccination after the resident's representative consented for the resident to receive the vaccination on 10/24/23. IV. Resident #31 A. Resident status Resident #31, age 66, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included fracture of left tibia (leg) and respiratory failure. The 3/11/24 MDS assessment indicated the resident was up to date on her pneumococcal vaccination. B. Record review -A review of the resident's EMR on 3/18/24 revealed the resident had not received the pneumococcal vaccination after she consented to receive the pneumococcal vaccination on 10/24/23. V. Resident #7 A. Resident status Resident #7, over the age of 65, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included anxiety and dementia. The 12/15/24 MDS assessment indicated the resident was not up to date on her pneumococcal vaccination but did not specify a reason. B. Record review -A review of the resident's EMR on 3/18/24 revealed the resident had not received the pneumococcal vaccination after she consented to receive the vacation on 10/24/23. VI. Resident #36 A. Resident status Resident #36, age 81, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), heart failure, chronic kidney disease, type two diabetes mellitus and gastro-esophageal reflux disease (GERD). The 2/22/24 MDS assessment indicated the resident was up to date on her pneumococcal vaccination. B. Record review A review of Resident #36's EMR revealed the resident refused the pneumococcal vaccination on 10/24/23. The 10/24/23 communication with resident progress note documented in pertinent part, the resident was offered the pneumococcal vaccination and the resident stated she had already had them and been tested for pneumonia. The resident declined the vaccination. -However, there was no documentation educating the resident on receiving an updated pneumococcal vaccination. VII. Resident #11 A. Resident status Resident #11, over the age of 65, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included Alzheimer's disease, morbid obesity and gastro-esophageal reflux disease (GERD). The 1/10/24 MDS assessment indicated the resident was not up to date on her pneumococcal vaccination but did not specify a reason. B. Record review -A review of the resident's EMR on 3/18/24 revealed the resident had not received the pneumococcal vaccination after the resident's representative consented for the resident to receive the vaccination on 10/12/23. VIII. Staff interviews The infection preventionist (IP) was interviewed on 3/19/24 at 10:27 a.m. The IP said she recently started working at the facility. The IP said when residents admitted to the facility their immunization history needed to be researched and documented in the medical record. The IP said the residents needed to be offered the immunizations they needed. The IP said Resident #17, #31, #7 and #11 were offered the pneumococcal vaccination in October 2023 and had not received the vaccination yet. The IP said she was unsure why the residents had not received the vaccination yet. The IP said Resident #36 refused the pneumococcal vaccination because she had already received it. The IP said if the resident was up to date on the pneumococcal vaccination the facility should have not offered the vaccination to the resident. The IP said if the resident was due for an updated pneumococcal vaccination the facility should have provided education to the resident on the importance of the updated vaccination. The IP said she needed to review the CDC guidance on offering pneumococcal vaccinations.

Based on observations, record review and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (#1) of three residents out of three sample residents reviewed for accident hazards. The facility failed to ensure measures were in place to prevent Resident #1's fall with injuries. Resident #1 was identified as a high fall risk on her 8/6/23 Fall Risk Assessment and the 8/9/23 minimum data set (MDS) assessment documented Resident #1 required extensive assistance of two persons for bed mobility, transfers, toileting and bathing. Resident #1's care plan prior to her fall did not have interventions that included assistance from two people for bed mobility, transfer, toileting and bathing. She sustained a fall out of bed on 10/2/23 while receiving incontinence care followed by a bed bath from certified nurse aide (CNA) #1. Resident #1's injuries included a two and a half centimeter left forehead laceration, skin tears on both elbows, bruising and swelling to both cheeks, bruising to the nose and across her upper chest and on her left forearm. She was transported to the hospital where she received sutures to her forehead laceration and returned to the facility on [DATE]. Resident #1's care plan was updated to include providing care with two staff for Resident #1 after the fall. Documentation of completed tasks in the electronic medical record from 10/3/23 to 10/31/23 revealed staff continued to provided Resident #1 care from one staff member instead of two for toileting and bathing. Findings include: I. Facility policy and procedure The Safe Patient Handling policy and procedure, dated October 2022, was provided by the nursing home administrator (NHA) on 11/1/23 at 4:04 p.m. It revealed in pertinent part, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual resident's needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include the following: resident preferences for assistance; resident mobility and degree of dependency; resident size, weight-bearing ability, cognitive status; and whether the resident is usually cooperative with staff. Safe lifting and movement of residents is part of an overall facility employee health and safety program. II. Resident status Resident #1, age 88, was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO), the diagnoses included respiratory failure, chronic bronchitis, type two diabetes mellitus, chronic obstructive pulmonary disease (COPD), obesity, dementia and congestive heart failure. The 8/9/23 MDS assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. She required extensive physical assistance of two people with bed mobility, transfers, toileting and bathing. She needed supervision and set up help only with eating, and extensive physical assistance of one person for personal hygiene. She needed substantial to maximum assistance to roll left or right in bed, to move from sitting to lying on the bed and from lying to sitting on the bed, and for toileting hygiene and showering and bathing. III. Resident observation and representative interview Resident #1's representative was interviewed on 11/1/23 at 12:35 p.m. The representative said Resident #1 had only one staff member providing care when Resident #1 fell and the representative thought Resident #1 should have had two people providing care at the time. The representative said she thought if the facility had two staff members attending to Resident #1 then maybe Resident #1 would not have fallen. Resident #1 was observed on 11/1/23 at 2:28 p.m. Resident #1 had light red bruising and swelling on both cheeks right below the eye and on the bridge of her nose. The left cheek had yellow bruising. Resident #1 still had a bandaid above her left eyebrow that covered a scab. She had visible yellow and purple bruises across her chest above the breast area. IV. Record review A. Care plan and assessments Resident #1's fall care plan focus initiated 5/17/23 documented she was a high risk for falls due to confusion, deconditioning, gait and balance problems, incontinence and psychoactive drug use, with an intervention to have activities that minimized the potential for falls while providing diversion and distraction. Resident #1's activities of daily living (ADL) focus documented she had a self care performance deficit due to fatigue and impaired balance, with a goal to maintain her current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene. Pertinent interventions included bathing and total dependance on staff to provide a bath twice weekly as necessary; bed mobility and maximum assistance on staff for repositioning and turning in bed, all initiated on 5/17/23. Resident #1's mobility care plan focus documented Resident #1 needed maximum assistance with a full body lift with ambulation and transfers. Pertinent interventions included to provide assistance with bed mobility as necessary and staff assistance of two people to assist the resident in transferring with a full body lift, all initiated on 8/14/23. -Resident #1's care plan interventions did not include staff assistance of two people with bed mobility, transfers, toileting and bathing. Resident #1's quarterly Fall Risk Assessment completed 8/6/23 documented she was a high fall risk. She had intermittent confusion, was non ambulatory and needed assistance with elimination. Gait balance was not assessed as the resident was unable to complete the assessment. The 8/9/23 restorative screening progress note written at 5:36 p.m. documented Resident #1 was dependent on care staff in the following areas: self-care, and shower/bathe self, meaning the care staff did all of the effort or the assistance of two or more helpers were required for the resident to complete the activity. B. Fall 10/2/23 The 10/2/23 progress note written at 1:50 p.m. documented Resident #1 suffered a fall from her bed at approximately 1:00 p.m. while she was being changed by CNA #1. CNA #1 reported while she was changing Resident #1 and turned Resident #1 on her side, Resident #1 rolled out of bed without CNA #1 having time to catch Resident #1 before the resident fell . Resident #1 had a laceration on her forehead that was bleeding, skin tears to both elbows, along with several bruises on the left forearm. Resident #1 complained of pain and she was given tylenol and sent to the hospital for further evaluation and treatment. The 10/2/23 progress note written at 3:30 p.m. revealed verbal training was provided to CNA #1 regarding the rolling technique to clean Resident #1. -There was no documentation of additional staff training aside from CNA #1. A review of hospital records revealed Resident #1 was admitted to the hospital on 10/2/23 with head, face and neck trauma with pain. Resident #1 had significant left frontal forehead swelling, bleeding and facial tenderness, a two and a half centimeter laceration to the left side of her forehead and was bleeding significantly upon arrival. She had left cheek and periorbital (around the eye) soft tissue swelling. Resident #1 was provided with wound compression to control bleeding and then sutures. She was discharged the same day on 10/2/23 with follow up orders for wound monitoring and suture removal. C. Facility fall investigation and follow up The 10/5/23 physician progress note 10/5/23 written at 9:54 a.m. documented Resident #1 was seen at the facility for post hospital follow up. Resident #1 stated that her face no longer hurt. Resident #1 reported no pain in her upper extremities, check or neck area. The facility staff reported the incident occurred when CNA #1 tried to change Resident #1 and the bed was elevated. When CNA #1 rolled Resident #1 to the side to change her Resident #1 continued to roll and fell off the other side of the bed between the wall and the bed. EMS (emergency medical services) was notified and Resident #1 was subsequently taken to the emergency department for further evaluation. Resident #1's post fall facility investigation notes were provided by the NHA on 11/1/23 at 9:45 a.m. The investigation was documented as completed by the social services director (SSD). The summary of the interview with CNA #1 revealed CNA #1 reported Resident #1 had an episode of severe diarrhea. CNA #1 placed Resident #1 in bed to perform a bed bath. Resident #1 was in bed and CNA #1 rolled Resident #1 toward the wall while Resident #1 was lying on her side. When CNA #1 turned to grab more care supplies, Resident #1 rolled towards the wall and the resident fell to the floor between the wall and the bed. CNA #1 proceeded to notify a nurse and a nurse came into the room to assess the resident. CNA #1 denied unlocking the wheels on the bed prior to performing care. CNA #1 stated Resident #1's bed was flush against the wall. The facility investigation conclusion revealed Resident #1 would benefit from two person cares. Resident #1's bed was repositioned so that staff could get to both sides of the bed. Fall mats were placed on either side of the bed for the resident's safety. The facility investigation follow-up documented the following updates: Update Resident #1's care plan to reflect two person cares; update the kardex (task list) to reflect two person cares; pull resident's bed out from wall, keeping the bed in lowest position when resident was in bed and staff was not present; fall mats on both sides of Resident #1's bed to prevent injury. The late entry 10/20/23 progress note written on 10/23/23 at 3:33 p.m. documented two person cares were initiated for Resident #1's overall safety by request of the family. Resident #1's bed was to be moved from the wall for care to allow staff members access to the other side of the bed and help with changing the resident. The 10/24/23 progress note written at 9:26 p.m. documented CNAs were educated to provide Resident #1 cares in pairs for resident safety. D. Post fall care plan and task updates Resident #1's fall care plan plan focus documented updated interventions post fall that included two person assistance for changing briefs (no date was included for the added intervention); educate the resident, family, and caregivers about safety reminders and what to do if a fall occurred, revised 10/25/23; anticipate and meet the resident's needs initiated 10/25/23. Resident #1's updated ADL care plan focus documented updated interventions post fall that included two person assistance with checks and changes for peri care (no date was included for the added intervention); Resident #1 needed maximum assistance from staff for repositioning and turning in bed for bed mobility and ensure two person assistance, revised 10/20/23. Resident #1's mobility care plan focus documented updated interventions post fall that included to assist Resident #1 with bed mobility with two person assistance (no date was included for the added intervention); provide assistance with bed mobility as necessary, revised on 10/20/23. The task list in Resident #1's electronic medical record for ADL bed mobility documented Resident #1 required assistance from two people. Bed mobility included how the resident moved to and from lying position, turned side to side and positioned their body while in bed or sleeping. The ADL task completions were reviewed for 29 days from 10/3/23 to 10/31/23 for bed mobility. Staff documented they performed one person assistance instead of two person assistance for Resident #1's ADLs on 26 out of 29 days. The task list in Resident #1's electronic medical record for ADL toilet use documented Resident #1 required assistance from two people. Toilet use included how a resident used the commode, bed pan, or urinal, cleansed self after elimination and changed pad. The ADL task completions for toileting were reviewed for 29 days from 10/3/23 to 10/31/23. Staff documented they performed one person assistance instead of two person assistance for Resident #1's ADLs on 18 out of 29 days. V. Staff interviews CNA #1 was interviewed on 11/1/23 at 12:45 p.m. CNA #1 said she was working with Resident #1 the day she fell because Resident #1 had an incontinence episode. CNA#1 said she and another staff member transferred Resident #1 into bed with a hoyer (mechanical) lift. CNA #1 said she changed the resident, cleaned her and gave her a bed bath without an additional staff member. CNA #1 said Resident #1 just rolled off the opposite side of the bed from where CNA #1 stood. CNA #1 said she was right next to Resident #1 and she was washing off Resident #1's backside. CNA #1 said Resident #1 was lying on her side one second and then Resident #1 started to roll and fell down between her bed and the wall. CNA #1 said she had one hand on the resident and did not have time to grab Resident #1 and Resident #1 landed face down on the floor. CNA #1 said she had to push the bed out further to get to Resident #1 who had fallen all the way to the floor. CNA #1 said she ran out of the room and called for the nurse right away. CNA #1 said she was unsure if Resident #1 needed assistance from two people for bed mobility and bathing. She said the staff used handheld computer tablets to see residents' tasks for care. CNA #1 said Resident #1's fall was very unexpected. Licensed practical nurse (LPN) #1 and CNA #2 were interviewed on 11/1/23 at 1:00 p.m. LPN #1 and CNA #2 said they used the handheld tablets to look at resident tasks and see how many people were needed for resident assistance. CNA #2 said Resident #1 could assist with showers so CNA #2 was able to provide assistance from one person for Resident #1 instead of two people. LPN #1 said he followed up with other care staff as needed to let the staff know if a resident's abilities or status changed. The MDS coordinator (MDSC) was interviewed on 11/1/23 at 1:30 p.m. He said he provided verbal education to CNA #1 after Resident #1's fall. He said typically Resident #1 required one person assistance with a roll in bed and when CNA #1 turned to grab a care item when Resident #1 fell . He said CNA #1 was alone with Resident #1 when Resident #1 fell . He said the staff typically used the task list for resident cares located on their handheld tablets. He said there probably should have been two people in the room when Resident #1 was changed. He said the follow up training was provided to CNA #1 initially but not all staff. He said he updated on the task list for Resident #1 that she needed two person assistance and could provide education to additional staff members that afternoon. The SSD was interviewed on 11/1/23 at 2:09 p.m. She said there was no further education provided to staff other than CNA #1 after Resident #1's fall. The SSD interviewed the resident by herself and the resident could not remember the incident which was baseline for the resident. The SSD said CNA #1 gave Resident #1 a bath and cleaned her up after her incontinence episode. The SSD said CNA #1 turned to grab more supplies when Resident #1 fell . CNA #1 did not indicate to the SSD how far away the supplies were or if she was still touching the resident when she turned to grab more supplies. The SSD said CNA #1 was the only staff member assisting the resident. The SSD said she was not aware if there was not a process to ensure completed resident care plans matched the MDS assessment. LPN #2 and CNA #3 were interviewed on 11/1/23 at 3:00 p.m. LPN #2 and CNA #3 said the facility recently provided gait belt training. LPN #2 said a restorative staff member did the training for gait belts and transfers and she signed a document that she attended. CNA #3 said the training also covered hoyer transfers were always a two person lift. CNA #3 said if the task documented a resident required assistance from two staff members, the staff always completed the task with two staff members. LPN #2 said staff always ensured a second staff member was present if a resident required assistance transferring from two people. LPN #2 said to never have only staff member present if two staff members were required. The director of nursing (DON) and NHA were interviewed on 11/1/23 at 3:30 p.m. The DON said the facility did not provide all staff training after Resident #1's fall since she did not feel there was a lack of training issue. The DON said CNA #1 did not do anything wrong while providing care to Resident #1 and she was using the correct procedure. The DON said the facility updated Resident #1's care plan to reflect mats were on Resident #1's floor at bedside, the bed was pulled out from the wall and she was a wheelchair to bed transfer. The DON said Resident #1 should have care in pairs meaning two staff members provided care at all times and that included bathing. The DON said she had not yet audited the tasks completed in the electronic medical record to see staff recorded they provided Resident #1 with two person assistance. The DON said she put care in pairs in the special instructions so the nurses saw care in pairs when they opened Resident #1's electronic medical record and nurses assisted floor staff to ensure they were compliant with care requirements. The NHA said the last training for transfers and resident assistance was April and May 2023. She said on 11/1/23 and 11/2/23 the facility provided additional resident transfer training. The NHA said the facility provided a body mechanics training on 5/24/23 which included resident transfers and assistance. The NHA said a quarterly care conference was the time to review resident status changes. The NHA said a unit nurse would communicate resident status to the DON or another nursing supervisor. Two nurses were on the unit and were responsible for medications, treatment and directing care of the CNAs. V. Facility follow up Facility NHA and DON said they were in process of providing additional staff training resident transfers and assistance on 11/1/23.

Based on interviews and record review, the facility failed to ensure residents on two out of three units had the right to a dignified existence. Specifically, the facility failed to ensure residents experienced a dignified living experience by answering the call lights timely to include Residents #6, Resident #10, Resident #5 and Resident #15 who required extensive assistance or total assistance with toileting. From the untimely response to the call light, Resident #6 expressed feelings of dehumanization. Resident #6 said she felt very embarrassed and humiliated when she had an accident waiting for her call light to be answered. Resident #10 said she felt very upset/angry because she would have to go to the nurse's station or in the hallway to find help for herself or for her roommate (Resident #15). She said often this resulted in her soiling herself, which made her feel very upset. A frequent visitor said when she visited she observed and overheard Resident #5 calling out for help this was concerning as this resident was dependent upon staff for help and the facility had ongoing issues with staff resetting their web based call light system to ensure call lights were answered in a timely manner. Findings include: I. Facility policy and procedure The Call Light policy and procedure, revised 12/15/21 was provided by the nursing home administrator (NHA) on 3/23/22 at 11:20 a.m. It read, in pertinent part, When the call light is activated, a page goes to the C.N.A (certified nurse aide) pagers/devices and also to the broadcast communication panel. If the call is not answered within five minutes, another page will be sent to the C.N.A. If the call light is unanswered after ten minutes, a page then goes to the unit nurse to alert them. If the call light is still not answered after fifteen minutes, a page goes to the clinical manager. If the call light is still not answered after twenty minutes, an email goes to the DON (director of nursing) and/or designee. Education is provided to every new employee during general orientation and also as needed. Reports on all call activations and response times are recorded and reviewed as needed. If a particular resident is making frequent calls, it may indicate the need for nursing and physician assessment and intervention. The system allows administration to quickly identify situations where response time was inadequate and address those concerns in a timely manner. This is helpful when reassuring residents/family members that call lights are answered timely. II. Resident interviews A. Resident #6 Resident #6, with a brief interview for mental status (BIMS) score of 15 out of 15 indicating cognitively intact, was interviewed on 3/21/22 at 2:05 p.m. She said she was admitted to the facility for rehabilitation for a fracture to right lower extremity. She said she felt she needed to voice her concern because it had not been fixed. She said just two days ago it took staff over an hour to come help her to the bathroom and to go to bed. She said she called for help and it took a long time for them to come and when they did she said they finally took her to the bathroom, then put her in front of her sink. She said she told staff she wanted to lie down after she went to bathroom but she had to wait another hour to get to bed, by then it was over two hours from when she first called. She said multiple times this had happened to her. She said a previous time she asked the nurse to take her to the bathroom and the nurse told her to push her call light and she would get the CNA, she waited for over an hour. She said it was worse in the evening when she was ready to go to bed and it happened on a weekend as well. She said when that happened she called her daughter and she reported it to the staff. She said one of the staff was helpful with giving her a hand held call bell which helped, but it happened again just two days ago. She said she felt terrible and it made her very embarrassed and humiliated. B. Resident #10 Resident #10, with a BIMS score of 15/15 and who participated in a resident council meeting, was interviewed on 3/22/22 at 9:30 a.m. She said when she initiated her call light for assistance, it often took staff one to two hours to answer. She said sometimes staff never came when she pressed her call light for assistance. She said this often resulted in her soiling herself, which she said made her feel very upset. She said she had learned to stop a staff member that she trusts in the hallway to assist her to the bathroom when she had initiated her call light and had waited for an extended period of time. She said as the resident council president, seeing other residents who are unable to advocate for themselves when needing assistance makes her upset. III. Frequent visitor interview A frequent visitor, with knowledge of the residents and facility, was interviewed 3/22/22 at 11:10 a.m. She said she reported concerns of effectiveness of call light system, and its intermittent internet problems to the facility. She said she was told if staff did not reset the call light it would not work properly. She said when she visited she observed Resident #5 calling out for help and CNAs were not carrying the iPads on their person which made her concerned because this resident required extensive help. She said she was made aware their call light recently being down for about a week, and they had to round on residents frequently and gave the resident hand held call bells to use until the system was back online. IV. Record review A. Call light log The facility used a silent call light web based system. Staff utilized iPads in which they were to keep on their person unless on a break or charging. The staff would receive a call on the device, when answered (the staff member claimed the call light), when finished with a task the call light was shut off (the staff member cleared the light) (see interviews below). Call light logs were requested and provided by the NHA on 3/22/22 at 11:50 a.m. The report provided only indicated Date Clear Response Time (meaning the call light was activated the whole time) the report did not include the claim time (this report was requested, but not provided see, interviews below). The 3/8/22 to 3/22/22 call light logs showed the following call light response times. The Resident #6, called thirty nine times from 3/8/22 to 3/22/22, most lights were answered and cleared within minutes to second; however on several occasions the resident experienced a lengthy wait time which was documented as follows: -On 3/10/22, the resident called for assistance three times. The report indicated Date Clear Response Time one call for assistance was cleared in 28 minutes and six seconds, the second call for assistance was cleared in two hours, 22 minutes and 42 seconds and the third call for assistance was cleared 16 minutes and 37 seconds. -On 3/13/22, the report indicated Date Clear Response Time one call for assistance was cleared in two hours 47 minutes and 14 seconds. -On 3/14/22, the report indicated Date Clear Response Time one call for assistance was cleared in one hour and two seconds. -On 3/16/22, the report indicated Date Clear Response Time one call for assistance was cleared in one hour 21 minutes and 37 seconds. -On 3/19/22, the report indicated Date Clear Response Time one call for assistance was cleared in one hour six minutes and three seconds. The Resident #5, called forty two times from 3/8/22 to 3/22/22, most lights were answered and cleared within minutes to second; however on several occasions the resident experienced a lengthy wait time which was documented as follows: -On 3/8/22 the report indicated Date Clear Response Time one call for assistance was cleared in one hour 56 minutes and 30 seconds. -On 3/14/22 the report indicated Date Clear Response Time one call for assistance was cleared in three hours 28 minutes and 48 seconds. -On 3/15/22 the report indicated Date Clear Response Time one call for assistance was cleared in one hour three minutes and 10 seconds. -On 3/19/22 the report indicated Date Clear Response Time one call for assistance was cleared in two hours 30 minutes and seven seconds. -On 3/20/22 the report indicated Date Clear Response Time one call for assistance was cleared in one hour 42 minutes and 34 seconds. The Resident #15, in bed-1, called six times from 3/8/22 to 3/22/22, two lights were answered and cleared within minutes to second; however four out of the six times the resident called for assistance she experienced a lengthy wait time which was documented as follows: -On 3/13/22 the report indicated Date Clear Response Time one call for assistance was cleared in two hours 47 minutes and 50 seconds and a second call for assistance was cleared in one hour 47 minutes and 49 seconds. -On 3/19/22 the report indicated Date Clear Response Time one call for assistance was cleared in one hour 27 minutes and seven seconds. -On 3/20/22 the report indicated Date Clear Response Time one call for assistance was cleared in one hour 13 minutes and 15 seconds. The Resident #10 in bed-2, called eleven times from 3/8/22 to 3/22/22, most lights were answered and cleared within minutes to second; however the resident experienced a lengthy wait time which was documented as follows: -On 3/9/22 the report indicated Date Clear Response Time one call for assistance was cleared in two hours 37 minutes and 23 seconds. -On 3/10/22 the report indicated Date Clear Response Time one call for assistance was cleared in 26 minutes. -On 3/11/22 the report indicated Date Clear Response Time one call for assistance was cleared in two hours three minutes and 47 seconds. -On 3/14/22 the report indicated Date Clear Response Time one call for assistance was cleared in 40 minutes. -On 3/18/22 the report indicated Date Clear Response Time one call for assistance was cleared in 42 minutes. -On 3/18/22 the report indicated Date Clear Response Time one call for assistance was cleared in one hour 47 minutes and 28 seconds. B. Resident council minutes Review of the resident council minutes revealed the facility was aware of call light concerns during December 2021, January 2022 and February 2022. The December 2021 resident council minutes revealed the NHA reported to the residents the facility was putting a plan into place for call light monitoring. The January 2022 resident council minutes revealed the facility had a call light action plan in place and staff were monitoring the call light reports. The February 2022 resident council minutes revealed a question was raised by a resident(s) regarding a call lights in the event of a web outage; there was no response documented in the minutes; however it was documented residents were encouraged to wait for assistance and the facility was addressing the call light response. V. Facility action plan, education and staff interview The action plan was provided by the director of nursing (DON) and assistant director of nursing (ADON) on 3/22/22 at 3:18 p.m. The DON said she had just started working at the facility in the past three to four weeks. The ADON said she had been working at the facility for 18 months. The ADON said the silent call light web based system had been utilized by the facility for about three years. She said she first noticed they had call light problems, with remodel and moving offices in January 2022 (she did not remember the exact date) and then the facility was informed it was a system-wide catastrophic event which happened; the company contacted them immediately when the facility's call light system was offline. The facility had IT (information technology) come out to inspect their computer systems. At that time, they instituted 15 minute checks and those residents who were able to use a hand held call light were given them to use. She said the system was down for about one week. In addition, managers were completing rounds. She said in January 2022 they started an action plan regarding their call light system in January 2022 which included conducting an inventory of supplies and education provided to staff. She said the staff took an inventory and found there were many iPods that were unaccounted for. The equipment was on backorder, but they placed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . They said currently they had zero iPods on the units. There was five iPads on the west, five on the east, three in memory care, and three assigned to the rehabilitation. They said each time a staff member logged onto the system they were able choose the correct area they were assigned to. When a call light was activated, a staff member claimed (went into the resident's room to assist them) the light and it was acknowledged in the system. After they were finished with their task they would clear the call light. The ADON said there was a glitch in the system at times and staff were to notify management if there were any issues. She said they had an agency orientation packet with training/education on how to use the system; however five new employee education was requested for one nurse and four CNAs (LPN #1 and CNAs #3, #4, #5 and #6) and it was not provided. 1. Action plan Review of the facility's action plan revealed the following: The Call Light Action Plan dated 1/29/22 read Objective, action, goal date, person responsible and results. Staff will be provided education regarding equipment, signing the equipment in and out, the DON or designee would be responsible for training. A call light audit would be conducted twice a week, the DON or designee would be responsible for completing. Complete in-service regarding reset of call light when needs are met DON or designee would be responsible for completing. The plan was all ongoing with the exception of the education and audit. 2. Staff education Review of staff education (call light in-service) revealed the following: -All nursing staff needed to carry and iPod/iPad, remain logged into (web based name) for call bells. If you do not have a login, see ADON immediately. Staff need to use the CNA (certified nurse aide) assignment sheet to sign in and out equipment every shift. -Reset the call lights when you are providing cares, when leaving for break, inform your nurse and other CNAs so that they can cover your call lights. Nurses can answer and reset call bells too. Nurses have (web based name) open on their laptops to monitor call bell responses, If you are unable to reset a call bell please report it immediately. On 1/19/22, 12 staff signed acknowledgement. On 1/21/22, 21 staff signed acknowledgement. On 1/24/22, 10 staff signed acknowledgement. 3. Audits and interviews The Audits were reviewed from 1/24/22 to 3/21/22. There were several audits which indicated there was an increase in wait times on evening and night shift; however there was no further follow-up other than staff reminded/trained to clear the call light (the audit did not include who the training was provided to). The Audit had an average call light response time for the entire building and was not specific to a specific room. There was no follow-up with the resident who had a long wait time other than when a resident's call bracelet was changed 2/7/22 and grievance follow-up on 3/21/22, nor was there training with a specific staff member working during the time of long call light documented. Additionally, the audit did not document when the call alert was sent to managers after 15 minutes and 20 minutes of extended time with follow-up as per the facility policy (see above). The ADON said when they received a grievances they would check to see if it was regarding a specific staff member, happened on specific shift, or during a specific time frame. They said when they received the grievance for Resident #6 they gave her hand held call bell to alert staff and found out her major call light concerns were mainly at bedtime, so adjusted her bedtime schedule to ensure staff went in to assist her with transfers. She said the social services director (SSD) spoke with Resident #6 yesterday (3/21/22) and the resident said she did have an improvement with the call light being answered. She has not had problems with the way she transferred, we offered to post signage in her room to alert staff on preferences with care. The DON and ADON said they were not aware of any additional grievances that needed to follow-up related to long call light wait times. They said the SSD managed grievances would ensure the appropriate department received them to follow-up. The ADON said Resident #5 was an exception when it came to using her call light. She said Resident #5 would call the nurses station or call her family, stating she activated the call light; however it would not be activated. They said staff had a generic login-and any of the nurses are able to login-in to the call system from their lap-top to ensure call lights were answered timely. The ADON said when she discovered long call light wait times she interviewed the resident to see if they could give us any information and would check to see who was assigned to hall to see if we needed to provide more education; however this was not documented in the audits performed (the ADON said she provided training verbally). The ADON said when she completed the audits it was of the entire call system for the entire facility and she did not document long call wait times of a specific resident room and/or follow-up with those specific residents to ensure the resident had their call light answered timely. She said they were notified of concerns through resident grievances and would follow-up appropriately. They acknowledged the facility had ongoing call light concerns. The DON said she was new to the facility but planned to work on ongoing issues/concerns. VI. Additional staff interviews CNA #7 was interviewed on 3/22/22 at 12:57 p.m. She said she was an agency CNA and worked day shift at the facility for the past two weeks. She was sitting at the nursing desk with her iPad that was charging. She said when started a CNA showed her how to use the iPad and was told how to sign in and sign out the iPad. She said when a call light comes on the iPad you claim to accept the call light and then go into the resident's room and clear the call light after your finished providing care. She said there was usually four iPads on the unit. Registered nurse (RN) #1 was interviewed on 3/22/22 at 1:07 p.m. He said he worked full time day shift for the past eight months. He said the facility had a main message board on the west unit, but he was not sure how to access the alerts as it only showed where the resident was in the facility. He said he had tried to teach himself the system on the message board, but had not learned how to clear call light. He said just today administrative staff gave him a user name and password to access the call system on his laptop. RN #2 and licensed practical nurse (LPN) #2 were interviewed on 3/22/22 at 1:26 p.m. One iPad was observed charging. They said they had four iPads on the unit. They said they used to have small iPod (phone size) on the units, but a lot went missing. They said they had been lost for about three to four months. LPN #2 said today was the first day she was given a login for their laptops to check for call light alerts, before they would just rely on the CNAs and trust they would answer the call lights timely. They said constantly they would have to leave the iPad on the charger, but it would not charge fully, they said the particular iPad that was charging was only at 16%, and it had been on the charger for a while (they did not give a specific time). They said if call lights were constantly going off it would drain the battery. The NHA, DON and ADON were interviewed on 3/22/22 at 4:30 p.m. The NHA said back in January 2022 she made sure corporate was aware of the facility's action plan. She said on Tuesday 2/1/22 she was given information from (name of web based company) about their non-functioning global system and they implemented interventions. She said her IT (information technology) director sent her an email stating they will have the new devices (iPods) by the end of this week. She said the staff had been working hard on trying to fix the call light issues. The NHA said call lights had been an ongoing issue in which they have completed multiple action plans which started in September 2021. She said the charge on iPads should last at least for one shift if they are charging all night. They might need to be recharged after two hours if in use. She said all staff had been given a login for their laptop prior to today and had been trained on when a call light was activated and how to clear a call light. She said the login they received today (on their lap tops) was for the facility's mapped system so they would be able to see and hear when a call light was initiated. She said the call light system was ongoing and the facility continued to manage, missing cords, equipment, resetting the system and provided education again on the sign in, sign out process. She acknowledged the action plan did not specifically address any particular resident or unit during the audits and was only a randomized audit of the actual system for the entire building and did address if the residents needs were being met. VII. Facility follow-up No additional information or documentation was provided by exit of the survey on 3/23/22 or after the survey.

Based on record review and interviews, the facility failed to investigate allegations of abuse and neglect for one (#4) out of five sample residents. Specifically, the facility failed to investigate allegations and reports of possible sexual abuse and misconduct of Resident #5 against Resident #4. Review of progress notes for Resident #4 and Resident #5 revealed staff documented multiple incidents in the month of (MONTH) 2019 where Resident #5 sexually touched or could have touched Resident #4 while she was sleeping, therefore without her consent, as well as constant documentation of Resident #5 pursuing Resident #4 where staff intervened. The facility failed to investigate any of the documented incidents and failed to assess Resident #4 for her ability to give consent for sexual contact, which resulted in Resident #4 being victimized continuously over the month of (MONTH) 2019. Furthermore, the continued failure to investigate reports of possible sexual abuse of misconduct of Resident #5 against Resident #4 resulted in the facility's inability to identify sexual abuse and protect Resident #4. Findings include: Cross reference F609 Failure to report allegations of abuse, F835 Administration, and F867 Quality Assurance and Performance Improvement. I. Facility policy The Abuse Prohibition Policy and Investigation Protocols, undated, was provided by the nursing home administrator (NHA) on 9/23/19 at 4:30 p.m., it read, in pertinent part: The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, and misappropriation of property. Sexual Abuse is defined as, but not limited to, sexual harassment, coercion, or assault. Any allegations of abuse, regardless or type, will be thoroughly investigated. -The reporter shall report to the state agency and one or more law enforcement entities for the political subdivision in which this facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from this facility. -The reporter shall report immediately, but no later than two hours after forming the suspicion, if the events that cause suspicion result in serious bodily injury, or not later than 24 hours if the events that cause suspicion do not result in bodily injury. All staff are to report any complaints or concerns of alleged abuse as soon as they are aware, be it by observation, report from a resident, visitor or other party, or based on resident assessment, the report should be made to the immediate supervisor, or nurse in charge of that residents care at the time. Initial action is to protect the resident, treat the resident if needed, and begin the investigation of the event. Protection: Separate the resident from the alleged perpetrator. This may require removing residents from a certain area to avoid contact with each other. Treatment: 1. Treatment is rendered upon physical exam . 2. Notify the family member or Power of Attorney (POA) 3. Document. Complete the Allegations of Abuse form 4. Continue monitoring the resident every shift and document for 72 hours then as needed. Investigation: Complete the Allegations of Abuse form. Completion of this form requires interviewing the victim, the alleged perpetrator, and any witnesses. Document each person's recollection of the the event, while details are fresh in everyone's mind. An interview of other residents and staff who may have experienced similar events involving the alleged perpetrator will be conducted as well. This is to be done by the administrator or designee. Once the investigation is completed, the administrator will review the facts and statements and determine if the allegations of abuse are substantiated, and make necessary notifications, take disciplinary action etc based on that determination. Notification: Notify the administrator, DON, or designee at the time of the occurrence. II. Resident #4 Resident status Resident #4, age 90, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 8/16/19 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status score of three out of 15. She exhibited inattention and disorganized thinking. She required minimal assistance or supervision with her activities of daily living (ADLs) and mobility. III. Record review [NAME] Incapacitation statement A Physician Incapacity Statement was signed by Resident #4's physician on 4/15/19. B. Progress notes Review of Resident #4's progress notes revealed: On 8/11/19 a progress note read that the resident was seen kissing Resident #5 near the nurses desk. The residents proceeded to hold hands for several minutes. On 8/17/19 a social services note read Resident #4 understood but was not able to process and understand complicated information so staff anticipated her needs. The note also indicated staff informed the resident's daughter of an affectionate and consensual relationship formed with Resident #5, which the resident's daughter had no concerns about. On 8/22/19 a health status note written by the resident's physician read the resident's daughter believed that a male resident had been attentive to the resident and coming into her room at night and doing inappropriate things and the resident's daughter thought it was the source of the resident's [MEDICAL CONDITION] and daytime agitation, the staff had spoke to the male resident that was inappropriate and had warned him to stay away from the resident. On 8/30/19 a behavior note read the resident was on 15 minute checks to watch for the male resident who wanted to enter her room. On 9/5/19 a social services note read that on 8/28/19 a staff member reported Resident #5 had uncovered Resident #4 while she was sleeping and put his hands between her legs. Both Resident's families were informed of the incident and a meeting was held with the facility social worker, NHA, director of nursing (DON), unit manager (UM) where the relationship between the residents was discussed. On 9/4/19 the social worker followed up with the resident's daughter who expressed concerns regarding resident #4's safety regarding Resident #5. On 9/5/19 Resident #4's daughter informed the social worker the family had contacted a lawyer regarding their intent to file a restraining order against Resident #5 for Resident #4's safety. The DON advised the social worker to call the police and the ombudsman. C. 15 minute checks Documentation of the 15 minute checks for Resident #4 were reviewed and revealed documentation began on 9/6/19 and ended on 9/10/19 though an order for [REDACTED]. IV. Resident status Resident #5 Resident #5, age 82, was admitted on [DATE] and discharged on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 9/10/19 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of three out of 15. He exhibited fluctuating inattention and disorganized thinking as well as physical behaviors and wandering. He required minimal assistance or supervision with his ADLs and mobility. V. Record review [NAME] Progress notes On 7/31/19 a behavior note read the resident kept going into Resident 4's room to wake her and she did not want him in her room. Resident #5 began swearing at the nurse when she removed him. He continued to go into the room where Resident #4 was sleeping. On 8/1/19 a behavior note read the resident continued to try to get into Resident #4's room to get her up and redirection was provided by staff. On 8/5/19 a behavior note read Resident #5 was observed in Resident #4's room, the resident was trying to open windows and uncover Resident #4 to wake her up. Staff intervened and tried to redirect Resident #5 and explain he can not touch Resident #4 without her consent and can not be on Resident #4 when she was in bed. Resident #5 started yelling and screaming and refused to leave the room. On 8/5/19 a behavior note read the resident seemed very happy and was touching the neck of Resident #4 who told him not to do it. On 8/6/19 a behavior note read Resident #5 was trying to enter Resident #4's room and was redirected by staff. On 8/6/19 a behavior note read the nurse entered Resident #5's room, the door was closed and the curtain was closed. The nurse found Resident #5 with his pants down and Resident #4 had her hand between his legs. When Resident #5 saw the nurse he started pulling up his pants and told the nurse he did not know what the nurse was talking about. The note read the nurse informed the unit manager (UM) who spoke to Resident #4 and took her out of the room. Resident #5 was started on 15 minute checks for sexual behaviors. On 8/6/19 a behavior note read Resident #5 continued to attempt to enter Resident #4's room. On 8/7/19 a behavior note read staff spoke to Resident #5's family regarding Resident's sexually inappropriate behaviors toward Resident #4. On 8/8/19 a behavior note read Resident #5 took Resident #4 into his room and had her in his recliner. Resident #4 was redirected to her room. On 8/11/19 a behavior note read Resident #5 and Resident #4 were seen kissing and holding hands. Resident #5 told the nurse he did not know what she was talking about and Resident #4 was redirected to her room. On 8/12/19 a behavior note read Resident #5 was attempting to enter Resident #4's room to wake her up multiple times. When staff attempted to stop him he became agitated and cursed at staff. On 8/13/19 a behavior note read Resident #5 entering Resident #4's room and attempting to wake her up multiple times. On 8/13/19 a health status note read the unit manager called Resident #5's physician regarding the resident's aggressive and sexual behaviors. On 8/14/19 a physician note read the resident had a history of [REDACTED]. He was started on an antidepressant. On 8/15/19 a behavior note read Resident #5 refused a shower, was yelling and pushing people out of the way because he wanted to sit where they were sitting. On 8/17/19 a behavior note read Resident #5 was continuously trying to enter Resident #4's room. The nurse turned out the light in Resident #4's room so she could sleep. At 3:20 a.m. the nurse noticed the light was turned on in Resident #4's room and Resident #5 was sitting close to Resident #4's head and Resident #5 had turned off the air conditioning to try to wake her up. On 8/17/19 a behavior note read Resident #5 would not leave Resident #4 alone, holding her hands and not giving her space to eat. Resident was trying to push other residents away from her. An activity staff member saw him with his hand down Resident #4's pants. He has not left her alone all shift. On 8/17/19 a behavior note read the nurse returned from a break and noticed Resident #5 coming out of Resident #4's room. The nurse told the resident he was not allowed to go into Resident #4's room. The resident told the nurse to go to hell and he was with his lady. The nurse told other staff on the unit Resident #5 was not to go into Resident #4's room and if he attempted to enter the room, remove him due to Resident #4's safety and Resident #5 had been having sexual behaviors. On 8/18/19 a behavior note read Resident #5 attempted to get into Resident #4's room most of the day. When Resident #4 was unavailable, Resident #5 attempted to speak to and touch other female residents. On 8/19/19 a behavior note read the resident was exhibiting aggressive and sexual behaviors. He was attempting to get into Resident #4's room all day and would not leave her alone. The nurse called the resident's physician, the spiritual care director and the social services director (SSD) for assistance with Resident #5's behavior. On 8/19/19 a behavior note read Resident #5 spent the day trying to get into Resident #4's room, he was observed trying to coax Resident #4 into his room after breakfast. He sat and watched her room from breakfast through lunch. On 8/19/19 a behavior note read the unit manager spoke to the physician assistant for orders to control the resident's sexual and aggressive behaviors. The resident's anti-psychotic medication was increased and an anti-anxiety medication was ordered. Notes written from 8/19/19 - 8/27/19 read the resident was stalking Resident #4, would not leave her alone, had to be stopped when attempting to enter her and other female resident rooms and would become aggressive with staff who tried to stop him. On 8/28/19 a behavior note read Resident #5 was attempting to go into Resident #4's room and would cuss at staff who tried to stop him, he sat next to the resident all day and would not stop touching her or give her personal space. The nurse wrote she put a sweater on Resident #4 and covered her with a blanket so Resident #5 could not touch her skin. The note continued, Resident #4 was sleeping in the common area and Resident #5 removed the blanket and put his hand between her legs while she was sleeping. Later Resident #4's family came in to visit and Resident #5 kept his distance. On 8/28/19 a behavior note read Resident #5 needed to be separated from Resident #4 several times, he put his hand on her shoulder when family was visiting and Resident #4's family separated them. Notified oncoming nurse to keep the two residents separated per Resident #4's family wishes for Resident safety. Notes written from 8/30/19 - 9/4/19 continued to reveal Resident #5's pursuit and insistence on being close to and entering Resident #4's room. On 9/4/19 a trial was attempted to remove Resident #5 from the secure unit, though notes revealed Resident #5 continually made his way back to the secure unit, entered the secure unit and sought out resident #4. On 9/4/19 a health status note read Resident #5 would return to the secure unit and 15 minute checks would resume. Staff were educated regarding resident relationships. Notes written from 9/5/19 - 9/11/19 read the resident continued to seek out, follow and attempt to enter Resident #4's room and a 1:1 caregiver was required to keep Resident #4 safe. Resident #5 discharged on [DATE] to an all male secure unit at a different facility. B. 15 minute checks Documentation of the 15 minute checks completed for Resident #5 revealed the checks were first started on 8/6/19 due to observations of sexual behaviors and these checks ended on 8/10/19. Review of the 15 minute checks documentation showed many missing checks and long periods of time crossed off the sheets. Behaviors documented on the 15 minute check sheets did not reflect the behaviors documented in the above behavior notes, the behaviors primarily consisted of in bed, in dining room, at nurses station, or activities. A second round of 15 minute checks for Resident #5 were started on 8/29/19 and continued 8/31/19, the documentation sheets again revealed large holes in documentation and behaviors consisted of in bed, in room, in dining room, or activities, which did not reflect the behavior notes above. A third round of 15 minute checks for Resident #5 were started on 9/6/19 and continued through his discharge on 9/11/19. At the time these 15 minute checks were completed the resident had a 1:1 caregiver 24 hours a day. The behaviors documented included in room, in bed, in dining room, and sleeping and did not reflect the behaviors in the notes above. VI. Family interview Resident #4's daughter was interviewed on 9/20/19 at 12:00 p.m. and stated the facility informed her and her family regarding the relationship between her mother and Resident #5 in mid-August. She stated shortly after the family was informed of the relationship, family started to notice Resident #5 stalking and targeting their mother when they would visit. She continued, that she spoke to the staff on the unit and the resident's physician regarding concerns the family had about the relationship. She said she did not feel Resident #4 was consenting to Resident #5's behaviors. She stated she would feel it necessary to take Resident #4 off the unit when visiting to get her away from Resident #5. She continued, when she was informed by the staff of Resident #5 going into her mother's room and touching her when she was sleeping, she felt this was assault and contacted a lawyer when the facility did nothing to stop the behavior. VII. Third party interview A regular visitor was interviewed on 9/20/19 at 12:30 p.m. and stated the facility should have done more, sooner in regards to Resident #5's behaviors and apparent obsession with Resident #4. She stated a full investigation should have been done and analysis of the relationship should have been completed by staff. VIII. Staff interviews The UM was interviewed on 9/20/19 at 3:00 p.m. and stated Resident #5 had behaviors of aggression and sexual aggression during his time at the facility. She stated the relationship between residents #4 and #5 was consensual with talking, hand holding and kissing at first, the family members of both residents were informed and had no concerns. She stated the relationship between the two residents was known to all staff members and was reviewed by administrative staff and determined to be consensual. She stated they tried to keep him away from her with 15 minute checks and monitoring. She stated she felt the 15 minute checks were effective. The social services director (SSD) was interviewed on 9/23/19 at 12:21 p.m. and stated she was aware the two residents were fond of each other and had the understanding the relationship was consensual. She stated she did not find out until much later Resident #5 was wanting to be around Resident #4 all the time and was acting out to try to get to her. Once the family of resident #4 became upset by the relationship, the police were called to conduct their own investigation. She stated the facility staff interdisciplinary team (IDT) did not feel any abuse had occurred. The social service assistant (SSA) was interviewed by phone on 9/23/19 at 2:06 p.m. and stated the relationship between the two residents was determined to be consensual and the staff and families were aware of the relationship. She stated on 8/28/19, when the nurse reported Resident #5 had touched Resident #4 while she was sleeping was the turning point where Resident #4's family started to question the resident's safety and when the facility administrative staff started Resident #5 on 15 minute checks and to trial Resident #5 off of the secured unit the next week. She stated she was not aware of previous 15 minute checks earlier in August, or that the staff on the unit had been trying to keep Resident #5 away from Resident #4 for weeks prior to the incident. A licensed practical nurse (LPN #1) was interviewed on 9/23/19 at 2:38 p.m. and stated the staff on the unit had to continually monitor Resident #5 and constantly remove or redirect him away from resident #4. He was very focused on her and very compulsive. He stated the staff had Resident #5 on 15 minute checks, which helped but were not 100% effective. He stated Resident #5 would try to sneak into Resident #4's room. He stated the administrative staff including the UM and DON were made aware of Resident #5's behaviors, and they handled it from there. The DON was interviewed on 9/23/19 at 3:00 p.m. and stated the resident's had a consensual relationship and staff monitored them continuously to ensure consent. She was unable to show documentation or explain how consent was ensured. She continued once Resident #4's family reported Resident #5's behaviors, the staff did their best to keep them separated per the family's wishes with 15 minute checks and eventually 1:1 care and monitoring due to Resident #5's persistence. She stated the facility IDT team did not feel Resident #4 had been sexually abused. She did not comment on whether or not the resident could give consent while she was sleeping. She stated the police were called to do their own investigation and told the facility no crime had been committed. She stated the ombudsman also came in and provided education to the IDT team regarding resident relationships. The NHA was interviewed on 9/23/19 at 5:00 p.m. and stated the IDT team had reviewed the relationship between the two residents and determined it to be consensual. She stated the IDT team reviewed the situation and called the police once Resident #4's family informed the facility staff they had contacted a lawyer. She stated the IDT team did not feel the situation was abuse but tried to keep the residents separated per Resident #4's family wishes. She stated no investigation was completed and the incidents were not reported to the state agency as the team did not feel abuse had occurred and the police reported no there was no crime committed. She could not explain how the team determined Resident #4 was consenting, and she could not comment whether the resident could give consent if she was sleeping. She stated she was out of town during the time of the 8/28/19 incident and the meetings with the resident's family and did not return until after Resident #5 was discharged to another facility. She stated it was reported to her by the IDT team that no abuse was alleged or had occurred. She stated she had not reviewed all of the documentation related to Resident #5's behavior or the incidents and was not aware of all of the details.

Based on observations, record review, and interviews; the facility failed to maintain acceptable parameters of nutritional status for two (#14 and #29) of four residents reviewed for nutrition out of 48 sample residents. Specifically, the facility failed to: -Adequately assess, monitor, and address the nutritional needs for Residents #14 and #29; -Identify and assess a weight loss of 5.45 percent (%) over an eight-week period for Resident #14; -Demonstrate continuity of communication, documentation, and all possible interventions were implemented to prevent weight loss for Resident #29, and he experienced a significant weight loss, and -Consistently implement interventions to prevent further weight loss for Residents #14 and #29. Findings include: I. Facility policy and procedures The Interventions for Unintended Weight Loss policy, dated (YEAR), was provided by the registered dietician (RD) on 7/11/19 at 5:42 p.m. It included individuals with unintended weight loss or insidious weight loss be identified and monitored so that appropriate interventions could be implemented. The Potential Interventions for Unintended Weight Loss policy, dated (YEAR), was provided by the RD on 7/11/19 at 5:42 p.m. It documented research suggested that an individualized nutrition approach could enhance the quality of life and nutritional status of older adults in healthcare communities. It was often beneficial to minimize restrictions (liberalize the diet), consistent with an individual's condition, prognosis, and choices, and assure food and beverage preferences were met before using oral nutritional supplements. Food fortification and supplementation examples to improve nutrient intake included: adding protein, fat, and/or carbohydrates to foods such as hot cereal, mashed potatoes, casseroles, and desserts, offering smaller, more frequent meals, providing between-meal snacks or nourishment, increasing the portion size of favorite foods and meals, and providing oral nutritional supplements. The Nutrition at Risk Committee (NAR) policy, dated (YEAR), provided by the RD on 7/11/19 at 5:42 p.m. It included the interdisciplinary team in the nutrition at risk (or weight/wound intervention and nutritional support-WINS committee) meeting would discuss individuals assessed to be at nutritional risk. The following procedures were outlined: 1) The nutrition at risk committee might consist of the following interdisciplinary team (IDT) members: director of food and nutrition services, nutrition and dietetic technician registered (NDTR), registered dietitian nutritionist, director of nurses (DON), charge nurses, and/or restorative nursing or other direct care staff as appropriate for the facility. 2) The committee would meet weekly or as needed to address the needs of high-risk residents/patients. 3) The RD or designee would provide the list of individuals to be discussed at the meeting to the appropriate committee members (new admission residents, individuals with new tube feeding, those with less than 50% food intake for three days, or nine consecutive meals, until intake was stable, those identified as being at risk or having malnutrition or undernutrition, significant unintended weight changes, or insidious weight loss, until stable, pressure injuries, fluid imbalance, those receiving thickened liquids or fluid restrictions). 4) Each committee member would review the resident's medical record and complete a reassessment as appropriate. Each member would go to the meeting prepared with information to share with the IDT. The individual's medical record would be brought to the meeting and/or electronic record would be accessed. 5) Clinical documentation in the medical record would be completed according to the results of the IDT's decisions. II. Resident #14s' status Resident #14, age 65, was admitted on [DATE] and readmitted [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 4/9/19 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. He had no [MEDICAL CONDITIONS], or rejection of care, and was independent with eating. He had no signs or symptoms of a swallowing disorder and did not have a poor appetite. His height was 73 inches and his weight was 165 pounds (#). It was somewhat important to him to have snacks available in between meals and he had no or unknown weight loss of five percent or more in the last month or loss of 10 percent in the last six months. He did not have a therapeutic or mechanically altered diet. A. Observations and resident interviews On 7/9/19 at 10:04 a.m., Resident #14 was lying in bed and his blanket was pulled up to his shoulders. His breakfast of toast and two fried eggs were uncovered on the plate on his bedside table, untouched. At 3:30 p.m., Resident #14 was in his wheelchair being pushed by a therapy staff member back to his room. He was wearing an orange shirt and he was very thin in appearance with visible collarbones and sunken cheeks. At 4:25 p.m., Resident #14 was sitting in his recliner in his room with his headphones on and he was watching TV. His lunch tray was still sitting on his bedside table, untouched, and half of an eight-ounce glass of juice had been consumed. He said the food was good but said his appetite was not very good, but did not know why. He asked if it was okay if he stayed up late at night, and explained he liked to stay up and watch TV until 11:00 p.m. on most nights. On 7/10/19 at 12:35 p.m., Resident #14 was sitting in his recliner with his headphones on and he was watching TV. His breakfast tray of eggs and bacon were uncovered and sitting on his bedside table. He had eaten approximately 50% of it and he said he did not know if that was his breakfast or lunch meal, and said it tasted okay. At 6:00 p.m., Resident #14 was sitting at a table in the main dining room with two other men eating his dinner meal. He ate 75% of his meal, but did not eat the French fries, and was scraping the bottom of a container of ice cream. He was not offered any additional food and left the table at 6:12 p.m. On 7/11/19 at 9:03 a.m., Resident #14 was lying in bed in his room on his left side, and had not yet gotten up for the day. His breakfast tray was on his bedside table and none of it had been eaten. B. Record review The care plan, initiated 4/8/19 and revised 7/9/19 (during survey), identified he had nutrition risks related to a history of [MEDICAL CONDITION] (cardiovascular accidents), depression, dementia, and GERD. The goal was he would have no significant weight loss of greater than 5% for 30 days or greater than 10% for 180 days, and his body mass index (BMI) would remain greater than 18.5. The approaches included to encourage food and fluid at and between meals, honor food preferences (liked all meats, potatoes, corn, all fruits, coffee, and Coke, and did not like most vegetables except those mentioned above), monitor labs, weights, oral intake, fluid volume status and skin integrity, and serve a regular diet with a regular consistency. An intervention added to the care plan on 7/9/19 included chocolate Ensure [MEDICATION NAME] (nutrition shake) was increased from daily (4/8/19) to QID (four times a day) due to undesirable weight loss. The CPO for (MONTH) 2019 included the following orders: -Regular diet, regular texture, thin consistency, started 4/2/19 -Ensure [MEDICATION NAME] four times a day for weight loss (chocolate), started 7/9/19 The initial nutritional assessment, dated 4/8/19, documented the resident's admission weight was 165#. His ideal body weight was 184# and his usual body weight was 162-169#. His appearance was documented as normal and was not on a physician-prescribed weight-loss regimen. The comments included his oral intake was good and he was meeting greater than 75% of his estimated nutritional needs. His BMI was within normal limits and he liked chocolate Ensure [MEDICATION NAME] so it was recommended for twice a day between meals. He was able to feed himself, denied chewing or swallowing issues, and said his dentures were a little loose, but he was still able to wear them. The weight history documented the following: -4/2/19 165# (admission) -4/9/19 164# -5/2/19 161# -6/2/19 156# -7/1/19 151# In summary, Resident #14 lost 5.45% in eight weeks, and -8.48% overall since his admission to the facility. The quarterly nutritional assessment, dated 7/1/19, documented the resident's current weight was 151# and he had an undesirable weight loss over the last quarter with a significant weight loss over 90 days. He received Ensure [MEDICATION NAME] daily and an evening snack. Oral intake seems to have declined over the last quarter, especially at his breakfast meals. He often will not get up to breakfast because he sleeps through it and is too tired to get up. Talked to him regarding his weight loss and he agrees to add another Ensure [MEDICATION NAME] mid-morning. The summary documented the resident used to go to the dining room for all of his meals, but he tended to sleep through the breakfast meal now, and since that was the case, they would send his breakfast meal to his room. There were no additional interventions or approaches implemented other than the nutritional shake throughout his stay at the facility. The Medication Administration Record [REDACTED]. The MAR for (MONTH) 2019 was reviewed and documented the Ensure [MEDICATION NAME] was started on the afternoon of 7/1/19 and administered to the resident each morning and evening. Resident #14 consumed 120 to 237 milliliter (ml) each time. The food preferences for Resident #14 were listed on his tray ticket. He liked apple slices, bananas, beef, canned fruit, eggs, peaches, pork, potatoes, toast and cauliflower. He did not like asparagus, broccoli, or cauliflower. (Cauliflower was listed in both the likes and dislikes columns). The meal intake records were reviewed from 4/3/19 through 7/10/19, and the following was documented: -In April, ate 0-50% a total of 14 out of 84 meals and refused x8 -In May, ate 0-50% a total of 27 out of 93 meals and refused x1 -In June, ate 0-50% a total of 22 out of 90 meals and refused x2 -In (MONTH) 1-10, ate 0-50% a total of 11 out of 30 meals and refused x2 -There were a total of 22 meals void of documentation. In summary, the meal intakes reveal a significant change in his breakfast intake between (MONTH) and (MONTH) 2019. In May, he consumed 0 to 25% of his breakfast meal 24 out of 31 times, compared to (MONTH) when he ate greater than 51% the majority of his breakfasts. C. Staff interviews Certified nurse aide (CNA) #9 was interviewed on 7/11/19 at 2:33 p.m., and she confirmed she routinely worked with Resident #14. She said he was not independent with his ADL care and some days he was able to do more for himself, and some days he did less. She said he liked to sleep in late and skip breakfast a few times a week. She did not know why, or if he stayed up late at night. She said he ate most of his meals in the main dining room and liked to eat toast, bacon and eggs for breakfast. She said she had no concerns about his eating habits. She explained there was a refrigerator in his neighborhood that he had access to that had snacks like string cheese, cookies, applesauce, and gelatin. She said the residents were offered snacks between breakfast and lunch. She said the CNAs were responsible for documenting meal intakes on the tray tickets from the kitchen. She said there was a folder where the tray tickets were placed in the dining room and the CNAs were supposed to get the tickets and enter the information into the electronic medical record for each meal. Registered nurse (RN) #8 was interviewed on 7/11/19 at 4:50 p.m. She said she routinely worked with Resident #14. She said he received nutritional supplements When he wants them, and explained he did not always accept them. She said during the evenings they offered snacks to the residents, and he occasionally accepted them. She confirmed he had lost weight and said, Minus 7.5% weight loss since he was admitted She said she had not been aware of his weight loss prior to that. She explained the restorative nursing staff obtained resident weights and those were reported to the RD. Dietary supervisor (DS) #2 was interviewed on 7/11/19 at 4:15 p.m. She said she had worked at the facility for [AGE] years. She was asked how the facility fortified foods for certain residents, and she said they had not provided fortified foods for years, and there was not currently any residents who was on a fortified diet. The RD was interviewed on 7/11/19 at 3:38 p.m. She said she had been at the facility for about two years, and worked full time with the residents. An additional RD worked in the building Mondays, Wednesdays, and Thursdays. She said the routine process for obtaining residents' weights was to check them on a monthly basis after they had been in the facility for one month. She said they monitor the weights monthly in a quality assurance and performance improvement (QAPI) meeting to see who had lost weight. She would provide a list of residents who needed to have their weights checked to the restorative aides who would obtain them preferably on the weekends. She said the restorative aide would let her know verbally if there was a big discrepancy in a resident's weight, and she would have them re-weigh the resident. She stated, Sometimes it's accurate, and sometimes it's not. She said there was a dashboard system in their electronic medical record that would alert her if a resident had a significant weight loss. The RD said the facility's process for documenting meal intakes had changed recently. She said in the recent past they identified residents in the building were having weight losses, but the documentation for meal intakes was not accurate. They changed their process and now the dietary staff working in the dining room document the residents' meal intakes on tray tickets and then place them in a folder for each meal. Then the CNAs come after the meals and enter the meal intakes into the electronic medical record. She said there was still a problem with the meal intake documentation and explained sometimes there would be duplicate entries for the same meal. She said she had noticed blank spaces on the meal intake records as well. The RD said Resident #14 was doing really well in the beginning of his stay, eating and going out to the dining room for meals. She said, He seemed a lot more lively when he first got here, and she confirmed he had a significant weight loss. She thought he might be a little bit depressed and that he had agreed to take a little more chocolate nutritional supplement. She stated, I don't want that to be all he is living off of. She did not know why he was not eating very well. She did not know if he stayed up late at night in his room and said he did like to watch TV. She was not aware that the meal time could be altered to accommodate the resident's sleeping preferences. The RD said she had noticed his significant weight loss that day, and said she increased his chocolate Ensure to be given four times each day. She said no additional approaches or interventions had been put in place to address his weight loss. She said she was not aware of what fortified foods were available, and she did not know if the facility had recipes to follow to provide residents with fortified foods. The director of nursing (DON) was interviewed on 7/11/19 at 6:50 p.m. She said the facility's process for managing residents' weights was to follow the physicians' orders. She said the restorative nursing staff obtained the weights, and the list of those residents was provided to them by the RD. She said if there was a discrepancy of five pounds or more, the resident was re-weighed. She said the facility had interventions to prevent weight loss including doing nutritional assessments, nurses were watching the weights, the RD was watching the weights, meal percentages were documented, and they had a variety of house supplements they could provide. She said she was made aware of residents' weight loss by either the RD or a discussion with staff regarding a significant change MDS that was done, and all information was emailed to the appropriate staff members in order for the staff members to address issues/concerns. She said the accuracy of the meal intake records was ensured by the RD who reviewed them, and a night nurse did a nightly audit to check them and ensure they were entered correctly. She said she was not aware of Resident #14's significant weight loss. III. Resident #29's status Resident #29, age 91, admitted on [DATE]. According to the (MONTH) 2019 CPO [DIAGNOSES REDACTED]. The 4/18/19 minimum data set (MDS) assessment documented the resident with both short and long-term memory loss with modified decision-making with activities of daily living. She required set up for meals with supervision, oversight, encouragement and cueing. She was coded with no or unknown weight loss of five percent in one month or ten percent in the last six months although within the prior quarter, the resident had a weight loss of nineteen pounds. A.Resident observation and interview The resident was interviewed on 7/9/19 at 11:15 a.m. She was observed in bed awake and watching television. She gestured that she was hard of hearing as she pointed to her ears. She gestured to use the white erase board setting on her recliner to communicate with her. The resident was edentulous and she appeared to be of normal build. She was pale in color. She was asked how the food was and she said not good, and pointed to a container of Ensure [MEDICATION NAME] and a small can of soda on her over bed table. She became impatient with answering questions and the interview was ended. The resident was interviewed on 7/10/19 at 4:09 p.m. She was awake and lying in bed. The over bed table was next to the bed on her right side. There was a bottle of Ensure [MEDICATION NAME] (a supplement drink) and a small can of soda on the table. The resident said she was worried that she had lost weight and thought she had lost a little weight. She said no one had told her how much she had lost in the last six months. She said her appetite had not been good and that the staff brought her food she did not like. She said no one had talked to her about what kind of foods she preferred. She said they just came in and brought her food without asking what she might have wanted. She said she would eat better if they brought her food she liked. She said she had trouble swallowing and chewing at times because she did not have any teeth. She said she was not on a special textured diet. She said she would like to gain some of her weight back. At 12:30 p.m., the residents lunch tray was delivered to her by CNA #8. CNA #8 placed the tray on the over bed table and walked out. At 12:45 p.m., the resident was observed in her room, in bed with her eyes closed. Her lunch tray was observed on the over bed table in the same position and untouched. The table was positioned to the right side of the bed and not within her reach. She had a sandwich and a small bowl covered with a lid and a glass of orange beverage. There were two containers of Ensure [MEDICATION NAME] supplement setting on her table. At 12:48 p.m., certified nurse aide (CNA) #8 entered the resident's room and called her name to waken her and eat her lunch. CNA #8 placed the table and tray closer to the resident's reach and removed the plastic lid from the bowl. The resident asked what the meal was. The CNA told her it was a grilled sandwich and soup. The CNA asked the resident if she wanted her food reheated and the resident said no. The CNA then handed the spoon to the resident, told her to enjoy her food and walked out of the room. The resident nodded her head and began to eat the soup. B. Record review The (MONTH) (YEAR) CPO documented in part the resident was on a regular diet, regular texture with thin liquids. Ensure [MEDICATION NAME] (dietary supplement) twice a day for poor intake (start date 1/21/19). A nutrition quarterly assessment dated [DATE] documented in part the resident refused an (MONTH) weight. She had a significant weight loss of five percent or more in the last month or loss of ten percent or more in the last six months and not on a prescribed weight-loss regimen. Will honor residents request not to be weighed. She had been drinking one to two Ensure [MEDICATION NAME] daily and she enjoyed them and enjoyed drinking cola. She was not meeting her nutritional needs and weight loss was expected. She was no longer going to the dining room for meals and was now eating in her room. There was no additional interventions recommended to include reviewing specific food preferences or staying with the resident to offer companionship during eating. A comprehensive nutritional assessment, dated 1/21/19, documented in part the resident was admitted to hospice on 1/9/19 related to heart failure. Her weight thirty days prior to the assessment was 176 pounds. She refused four meals in the prior thirty days. Her food preferences listed included pancakes, cream of wheat, grilled cheese, banana bread, crackers and cheese, potatoes, scrambled eggs, peanut butter and jelly sandwiches, broccoli, cauliflower, carrots, desserts. Her fluid preferences included water, soda pop and black tea. She was on a regular diet but chose soft foods due to not having dentures or many teeth. She did not want her food mechanically altered. She was eating in the main dining room but was not eating her meals in her room. The nutritional goal was food and fluids as desired for comfort times 90 days. The nutritional care plan initiated 7/27/12 and revised on 1/21/19 identified the resident at nutritional risk with limited food acceptance related to food preferences, irritable bowel syndrome (IBS), dementia, dysphagia and obesity. The goal was food and fluid as desired for comfort for ninety days. Interventions included honor food/meal preferences (food preferences from 1/21/19 above added here), monitor intake, weight, labs, chewing/swallowing and self-feeding ability, offer alternatives for refused foods, serve regular diet, serve room trays as (resident) prefers to stay in her room. The care plan did not include the dietary supplement mentioned in the physician's orders [REDACTED]. Nutrition progress notes from 1/1/19 to 7/9/19 were requested from the director of nursing (DON) on 7/11/19 at 5:30 p.m. There were no nutrition progress notes found for this time period. 1.Meal intakes records from 1/1/19 to 7/10/19 revealed the following: January-32 entries with no documented intake. Fourteen refusals. February-22 entries with no documented intake. Five refusals. March-25 entries with no documented intake. Eleven refusals. April-one entry with no documented intake. Ten refusals. May-two entries with no documented intake. Twenty-six refusals. June-one entry with no documented intake. Twenty-six refusals. July-one entry with no documented intake. Six refusals. 2.Weights over the last six months -1/8/19, 175.6 -3/19/19, 156 -4/19; no weight -5/2/19; 151 -6/2/19; 152 -7/7/19; 145.2 There was no documentation found that the resident, with known and documented weight loss, was reassessed for food preferences since 1/19. There was no documentation found that staff reapproached resident to offer an alternate food item on the days she refused. There was no documentation found staff re-approached her in (MONTH) 2019 to attempt to obtain her weight after she refused. The 7/19 Medication Administration Record [REDACTED]. C. Staff interviews The RD was interviewed on 7/10/19 at 2:20 p.m. She said when evaluating a resident's nutritional status, quarterly, she reviewed the meal intake documentation. She also talked with the nurses and CNAs for any additional concerns. She said she expected them to communicate any concerns to her right away including weight loss. She said she would also talk to the residents about their eating patterns. She said residents were usually weighed monthly unless they were losing weight. She said if a resident was experiencing weight loss she would intervene right away. She said the IDT discussed residents with concerns during the daily morning meeting. She said they did not have a nutrition-at-risk committee. She said that she would also complete a monthly quality assurance performance improvement (QAPI) report for any nutritional issues. She said Resident #29 has had a nutritional decline and was currently on Hospice. She said the resident ate all of her meals in her room and staff tried to encourage her to come out to the dining room but she refused. She said the resident did not have a swallowing problem, however; she did have a chewing issue because of her dentition. She said the resident had a significant weight loss of about ten percent over the last quarter. She said the resident was a picky eater and refused many meals. She said the resident refused obtaining her weight in (MONTH) when she did her quarterly assessment. She said staff did not communicate to her if they had tried to reapproach her for another weight. She said she should have written an order for [REDACTED]. She said she saw the resident's recent weight on 7/7/19 and it was 145 pounds since it was a seven pound loss from previous month. She said she would have expected staff to communicate that to her right away because she would have asked for a reweigh. She acknowledged she could have implemented more and different interventions over the past month or so to help maintain Resident #29's weight. She said she expected the nursing staff to notify her of any significant weight changes. She said staff mostly communicate changes to her verbally. She said the communication and documentation could have been better from nursing. She said she had spoken to the resident several times regarding her diet and preferences but her documentation did not reflect that. Licensed practical nurse (LPN) #2 was interviewed on 7/10/19 at 3:18 p.m. She said any time a resident refused their meal or if they refused to be weighed the CNAs should communicate this to her immediately. She said she would communicate any concerns regarding poor meal intake to the RD. She said she was responsible for reviewing the CNAs documentation regarding resident meal intakes. She said that the restorative aides (RAs) were responsible for obtaining resident weights. She said that Resident #29 lost quite a bit of weight and used to be much heavier. She said she believed some of the resident's medications might have contributed to her weight loss. She said the resident was currently on hospice. She said she believed the resident's weight loss could be due to boredom and depression. She said the resident used to go to the dining room for meals, however; now she ate all meals in her room. She said the RD was aware of the resident's condition. She said she asked the RD how much Ensure she should give the resident and the RD told her to give her whatever made her happy. She said staff provided verbal encouragement for the resident to eat her meals, because she would not allow anyone to assist her to eat. RA #1 was interviewed on 7/11/19 at 2:37 p.m. She said the restorative department was responsible for obtaining the monthly and weekly weights throughout the building. She said the weights were done on Sundays. She said they had the ability to print out a list of residents who needed weights. She said on the list they are able to see the residents' previous weight so they could see if there had been any changes from the previous weight. She said if they saw a difference, they would report it to the nurse and the nurse would report it to the RD. She said they would automatically re-weigh a resident if there were a difference of five pounds either lost or gained. She said for residents who showed a weight loss of three pounds in one week; they would reweigh the resident and report to the nurse. She said if a resident refused a weight they would go back and attempt to re-weigh. Sometimes having a different person attempt the re-weigh would work. She said they would document the refusal and could write a note if they had reattempted. At 2:40 p.m. RA #2 was interviewed. She said that she weighed Resident #29 on 7/7/19 and noticed that there was a significant difference in her weight; almost ten pounds. She said the RAs always used the mechanical lift that had a scale on it for bedridden residents. She said she let the nurse know right away about the resident's weight. She said as soon as the weights were completed, the RAs would put the information into the resident's electronic records. She said if a resident refused to be weighed, they would document the refusal and had the ability to document on a restorative progress note. Both RA #1 and RA #2 said they could tell the resident was losing weight based on how she looked. They were aware the resident had not been eating well. CNA #3 was interviewed on 7/11/19 at 11:00 a.m. She said that Resident #29 had not been eating good and refused her meals. She said the resident only liked to drink Ensure. She said before each meal, they would let the resident know what was on the menu and give her what she ordered. She said the resident only wanted Ensure and soda. She said the resident did like soft foods like cream of wheat, soups and grilled cheese. She said if a resident refused their meals, they would offer something different and then let the nurse know right away. She said the resident required set-up assist only and did not like to be assisted to eat. The RD was interviewed a second time on 7/11/19 at 3:18 p.m. She said she reviewed the resident's preferences during the last quarterly review in (MONTH) 2019 and then yesterday. She said she did not ask the resident specifically what type of foods she would like to eat or liked to eat in the past. She said the resident pointed to the Ensure and the soda on her table. The RD said she had not attempted introducing fortified foods to the resident because she did not know what fortified foods meant. She said she felt like she had tried all interventions with this resident. IV. Facility follow up On 7/10/19 at 6:18 p.m., after the concern was brought to the facility's attention, the RD provided follow up regarding Resident #29. She said she talked to the resident and offered to trial a different consistency of food. Specifically, pureed which the resident did not like, see resident interview above. She said she also increased the resident's Ensure [MEDICATION NAME] (nutritional supplement) to four times a day from twice a day and added protein vanilla pudding four times a day. The care plan was updated to reflect these changes.

Based on observation, interview, and record review, the facility failed to ensure two (#141 and #115) of six residents out of 37 sample residents were as free from accident hazards as possible, through the proper use of equipment for Resident #141 and timely development and implementation of fall prevention interventions for Resident #115. Resident #141 used a Broda chair for fall prevention. Staff failed to recline the Broda chair after transferring the resident into it. The resident fell from the chair and fractured both of her knees. Findings include: A. Failure in accident prevention Resident #141 - failure to properly place resident in Broda chair 1. Resident #141, age 90, was admitted to the facility on [DATE]. According to the computerized physician orders [REDACTED]. According to the minimum data set (MDS) assessment dated [DATE], the resident required extensive assistance from two or more staff for bed mobility and transfers. She used a wheelchair for mobility. The resident was severely cognitively impaired. 2. Resident status A review of the resident's medical record revealed [REDACTED]. According to the care plan dated 6/30/11, the resident was at high risk for falls related to weakness, impaired balance and coordination, hypertension, and a history of falls. The goal was for the resident to have a reduced number of falls and a decrease in risk of injuries from falling. Interventions included physical and occupational therapy (PT/OT) evaluations and treatment and an assessment of the root cause of previous falls to guide interventions. An OT assessment dated [DATE] revealed OT #1 had seen the resident for fall prevention. The intake note revealed the nursing staff had reported the resident slid forward in her current wheelchair (which was a reclining chair), and the goal of the therapy interventions was to increase comfort and safety and reduce the risk of falls. -The OT assessed the resident had poor static and dynamic balance sitting in her wheelchair and the current equipment was not effective in assisting the resident to maintain alignment. -The OT obtained and assessed the resident in a Broda chair and noted the resident was able to maintain safe positioning in the Broda chair. -The OT noted she provided education to the resident's primary certified nurse aide (CNA) #9 about the use of the chair, including reclining the Broda slightly for transfers to ensure the resident was in a safe position. Attempts to interview OT #1 about the resident, her use of the Broda chair and staff education on 4/17/18 and 4/24/18, were unsuccessful. 3. Fall 1/17/18 with injury A post fall assessment dated [DATE] read the resident at fallen from her Broda chair in the shower room at 5:00 p.m She had finished receiving her shower and had been assisted to transfer from her shower chair to the Broda chair. The CNA (CNA #8) reported he had turned around to grab clothes and turned back to see the resident sliding from her Broda chair. The resident hit both knees on the ground. She received pain medication and ice for pain relief. A review of the facility's investigation of the fall revealed the following in pertinent part: - Both CNA #8 and Registered nurse (RN) #6, who had completed the transfer of the resident to Broda chair, stated they used a gait belt to transfer the resident from the shower chair into her Broda chair. - The Broda chair was not reclined either prior to the transfer or after the resident was seated in the Broda chair in order to maintain her static positioning. - RN #6 left the room following the transfer. CNA #8 turned his back to collect clothing for the resident. He turned around to see the resident sliding from the upright Broda chair. The resident fell , striking both knees on the ground. The post fall assessment indicated the resident's right knee appeared slightly twisted after the fall. Fifteen minutes after the fall, the knee was swollen and warm to the touch. The resident verbalized she hurt. Due to the resident's cognitive status, a Face, Legs, Activity, Cry, Consolability (FLACC) pain scale was conducted with a score of 6 of 10. Orders were obtained from the physician for an x-ray of both knees and her hip. X-rays obtained on 1/17/18 revealed two fractures in the resident's right knee; a [MEDICATION NAME] fracture (a fracture across the bone) to her tibial neck (the upper part of the shin-bone) and an oblique (diagonal) [MEDICAL CONDITION] (the other major bone in the lower leg.) The x-rays also revealed a distal femoral shaft fracture (break to the lower part of the thigh-bone) to the resident's left leg. A written note on the x-ray revealed the resident was sent to the emergency department. 4. Staff interviews CNA #10 was interviewed on 4/10/18 at 3:11 p.m. She said residents that used a Broda chair were supposed to have two staff plus a Hoyer lift for transfers. She said the staff were supposed to make sure the Broda chair was slightly reclined during the transfer and after the transfer for fall prevention. RN #5 was interviewed on 4/10/18 at 3:21 p.m He said any resident who required a Broda chair was to be transferred using a Hoyer lift for fall prevention. He said when a Broda chair was ordered for positioning, the therapy department would educated the CNAs on its use and then the staff would update the Kardex (written communication tool for CNAs). The NHA was interviewed on 4/10/18 at 11:47 a.m She said the facility had conducted an investigation into the resident's fall on 1/29/18 and had identified two areas for improvement: the method of the transfer, and the positioning of the resident in the Broda chair. -The NHA said that to transfer the resident safely into her Broda chair, staff were to use a Hoyer lift. She said the transfer conducted by CNA #8 and RN #6 using a gait belt was inconsistent with the resident's needs. She said this was not determined to be the root cause of the fall, but said the different texture of the wheelchair seat versus. the Hoyer sling may have been a contributing factor. -The NHA said the root cause of the fall had been the incorrect use of the Broda chair. She said the resident had received orders for the Broda chair after being evaluated by OT #1 for fall prevention after a previous fall. She said the OT had determined the resident slid out of the upright wheelchair due to her poor trunk strength She said the Broda chair was supposed to be reclined to provide support for the resident's body to stay in the chair. -The NHA said while the CNA and RN had positioned the resident correctly in the chair, they had failed to recline the chair and as a result, the resident slid out, causing the fall. 5. Actions taken following Resident #141's fall The facility initiated a performance improvement plan that included: - Education and corrective action for the CNA and RN involved in the transfer. - An audit of all residents using Broda chairs and other specialized wheelchairs. New OT assessments were completed to ensure correct fit of the chairs. - Facility-wide education for all nursing staff by the therapy department about appropriate Broda chair positioning and transfers. - Random monitoring checks of all residents in specialized chairs for correct positioning. B. Continuing failure in accident prevention Resident #115 - failure to timely develop interventions to prevent accidents and failure to ensure implementation of interventions once developed. 1. Resident status Resident #115, age 75, was admitted on [DATE]. According to the (MONTH) (YEAR) CPO, [DIAGNOSES REDACTED]. According to 3/19/18 MDS assessment, the resident had a severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. She required extensive assistance for transfer and limited assistance for bed mobility and toilet use. She was occasionally incontinent of bladder and continent of the bowel. She had no fall history on admission. She received a diuretic for six days. 2. Failure to timely develop safety interventions to minimize Resident #115's fall risk after admission. Record review revealed the resident was known to be at risk for falls; however, no interventions were developed to minimize her risk until after the resident was found on the floor in the bathroom on 3/27/18. a. Review of the resident's 3/13/18 fall risk data revealed the resident had a history of [REDACTED]. Other data included that the resident was receiving diuretics (per the (MONTH) CPO, [MEDICATION NAME] ([MEDICATION NAME]) (Diuretic) 20 mg (milligram) tablet by mouth daily) and antihypertensive medications. Her vision was adequate and she was able to ambulate with a walker. b. Resident #115's family member was interviewed on 4/16/18 at 2:45 p.m. She said the facility was aware that the resident was a fall risk. c. Review of fall incident reports revealed the resident fell on [DATE]. The fall incident report read the resident was found on the floor in the bathroom. The incident report read, Resident was found to be sitting on floor hanging on to the bathroom grab bar with her knees bent, she was not wearing shoes or socks, the floor was dry, no apparent injuries. Fall occurred during a fire drill, it is likely that resident was startled. The contributing factors were the resident ambulates independently in room, no shoes/socks, decreased cognition, does not use call light and fire drill. Prior to the fall, the resident was seen sleeping in bed during the last rounds of the night certified nurse aide (CNA). The family and physician notified. Interventions included apply non-skid socks and call light in place. c. Although a care plan, identifying the resident with a fall history, impaired balance, poor coordination, and unsteady gait and with safety interventions (assist for all ambulation, proper and non-slip footwear, the bed in lowest position assistance in the bathroom), was initiated 3/27/18 after the resident's fall, record review revealed no safety interventions on the 3/13/18 baseline care plan, in effect from 3/13/18 to 3/27/18, even though the baseline care plan identified the resident as a fall risk and her fall risk data (see above) identified her history of falls in the last six months. 3. Failure to implement care planned interventions after 3/27/18 a. Failure to ensure the resident received ambulatory assistance as care planned. Review of (MONTH) (YEAR) physician orders [REDACTED]. Review of 4/12/18 PT progress note revealed the resident continued to have functional deficits including transfers and gait. She was at risks of falls and nonverbal. The goal was resident would safely ambulate over changes in surface, around obstacles, and in and out of elevators with contact guard assist (CGA) and the handheld physical assist. (1) Notwithstanding her known functional deficits with transfers and gait (see care plan and PT progress notes above), the resident fell when she attempted to ambulate to the dining room without staff assistance. Specifically: Review of a fall incident report dated 4/13/18 read the NHA found Resident #115 kneeling on the floor with blood on her head. No alarm in place. It was a repeat fall. The resident was nonverbal, confused and does not request for help. She was attempting self-ambulation to dine without assistance. The fall was unwitnessed. (2) Observations revealed the resident ambulating without assistance. Specifically: -On 4/7/18 at 8:45 a.m., the resident was observed walking in the hallway with a walker. She was wearing red slippers (unisex Christmas slippers with a smooth, non-grip and worn sole). No staff was standing by or assisting the resident during ambulation. Her gait was observed to be unsteady. -On 4/19/18, from 8 35 a.m. to 8:55 a.m., the resident was observed in the dining room, again wearing the red slippers. The resident observed to walk by herself from the dining room back to her room with a walker. -On 4/19/18 at 12:26 p.m., the resident was observed going into the dining room wearing the red slippers and walking with a walker. No staff was assisting the resident to walk to the dining room. b. Failure to ensure bed in low position as care planned. Observations revealed the resident's bed was not in a low position as care planned and at times, she was positioned in bed in a manner that increased her risk to fall. Specifically: -On 4/16/18 at 2:46 p.m., the resident was observed sitting up in bed. The bed was not in a low position. -On 4/17/18 at 10:06 a.m., the resident was observed in bed sleeping. The bed was in high position. -On 4/18/18 at 2:15 p.m., the resident was observed in bed sleeping. Both legs were observed dangling off the bed and the bed was in high position. -On 4/18/18 at 6: 15 p.m., the resident was observed in bed watching television. She was wearing her red slippers on both feet. The bed was in high position and call light was not in resident's reach. 4. Staff Interviews The clinical care manager (CCM) #4 was interviewed on 4/18/18 at 2:57 p.m. She confirmed the resident was at risk to fall. She said the resident had interventions such as the need for one-person assistance with ambulation and transfer, non-slip footwear and supervision walking in the hallway. She said the resident had never fallen out of bed and that was the reason there was no intervention regarding the bed positioning. She said she was not aware the resident fell a second time on 4/13/18. She said there was no interdisciplinary team (IDT) review for the last fall and the resident's care plan was not updated. The NHA was interviewed on 4/19/18 at 9:31 a.m. She said she found Resident #115 on 4/13/18 on the floor on her knees with a drop of blood on her head and on the floor. She said the resident was observed holding onto her walker and was attempting to get up for breakfast. She said she alerted the nurse in charge of the resident to assess her. She said the resident scraped her head on something. The Director of Nursing (DON) was interviewed on 4/19/18 at 11:32 a.m. She said the nurse who assessed Resident #115 should have come up with an intervention immediately to prevent further falls. She said the CCM in charge should have reviewed the resident's care plan interventions to see if they were appropriate or needed to be revised, and then make changes immediately to prevent more falls. She said Resident #115 should have had in place, low bed, a padded call light and non-skid socks immediately after the fall.

Based on record review, observation and staff interviews, the facility failed to implement appropriate and timely interventions to ensure one (#1) of six sample residents received the necessary care and treatment to prevent the development of new pressure ulcers. The resident was admitted to the facility without pressure ulcers, and a history of pressure ulcers. The facility failed to ensure that interventions, including those to promote pressure relief, were timely implemented in order to maintain skin integrity, promote healing, and prevent further skin breakdown. Specifically, the facility failed to place proper pressure relief devices to the resident's bed and chair. These failures contributed to the development of an unstageable pressure ulcer. The findings included: A. Expectations 1. Professional References a. According to the Agency for Healthcare Research and Quality, Pressure Ulcer Prevention and Treatment Protocol, 2012, http://www.guideline.gov/content.aspx?id= &search=cleaning+wound#Section420 <http://www.guideline.gov/content.aspx?id= &search=cleaning+wound>, (March 2016), immobility is the most significant risk factor for pressure ulcer development. Patients have greater intensity of pressure over the bony prominences when sitting in a chair, because there is less distribution of weight. Along with increased weight over the bony prominences, there is a tendency for the body to slide in a downward motion, causing shearing and destruction of the soft tissue over the bony prominences. A sitting position includes sitting in bed with head elevation greater than 30 degrees, a cardiac chair, recliner or wheelchair. When in this position, it is important for the patient to shift weight every 15 minutes if he/she is able to do so independently. This includes small shifts of weight such as pushing up on their arms, raising or lowering their head slightly to redistribute the weight, or lifting from side to side. If the patient is unable to shift weight independently, his/her position should be changed by care providers on an hourly basis. b. According to the National Pressure Ulcer Advisory Panel, NPUAP Pressure Ulcer Stages/Categories 2014, http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stages-categories (March 2016): International NPUAP-EPUAP Pressure Ulcer Definition -A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear . Pressure Ulcer Stages/Categories: Category/Stage II: Partial thickness 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 or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation. *Bruising indicates deep tissue injury . Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured 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 are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] 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. 2. Facility Policies and Procedures The Pressure Ulcer Prevention Interventions per Braden Scale policy was provided by nursing home administrator/ registered nurse (NHA) on 3/7/16 at 10:00 a.m. The risk category, total score and interventions were listed in pertinent part as follows: For all patients -- daily head-to-toe skin check, keep positioned off bony prominences, use [MEDICATION NAME] and nutrashield as needed, encourage eating and drinking, turn regularly as indicated. Additional interventions were listed for residents at risk, moderate risk, high risk and very high risk. There was addendum: if patient has other major risk factors, such as advanced age . upgrade patient to a higher risk category . Pay extra attention, looking for subtle signs of pressure damage, as the patient is not able to report pain . A low-air-loss surface mattress may be beneficial. B. Resident #1 Resident #1, age 99, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 12/9/15 annual minimum data set (MDS) assessment, the resident's cognition was severely impaired. No mood or behavior symptoms were noted. The resident required extensive to total assistance of one to two staff members for all activities of daily living (ADL) including transfer, bathing and eating. She was incontinent of bowel and bladder. Her weight was 103 pounds and she was 60 inches tall. No pressure sores were noted. 1. Record Review The resident's Braden scale, dated 12/1/15, identified a score of 14 which indicated moderate risk for developing pressure sores. The physician telephone orders (TO) dated 1/7/16 read: Pressure ulcer right buttock resolved on 1/4/16. Continue [MEDICATION NAME] ointment and change [DIAGNOSES REDACTED]. The Braden scale dated 2/10/16 noted a score of 13, which indicated moderate risk for pressure sore development. The facility failed to upgrade the resident's risk level to high or very high due to advanced age (99), poor nutritional intake and inadequate hydration (identified in the nutritional assessment/care plan with a revision date of 2/16/16). The weekly skin assessment, dated 2/9/16, noted an open area 1cm x1cm on the right inner gluteus with 0.1 mm depth. The wound was cleaned with normal saline (N/S), hydrogel was applied to the wound bed and covered with foam dressing. There was no other skin issue noted. Nutrition progress notes dated 2/10/16 read the resident has new stage II to right gluteus, currently getting milkshakes twice daily with med pass 120 ml three times a day, which is sufficient to meet estimated needs for wound healing. The weekly wound documentation, dated 2/15/16, read in permanent part, unstageable pressure wound in-house acquired on 2/9/16 to right gluteus with 1.5 cm length x1.5 cm width x 0.1 cm depth; 95% slough, serosanguineous with moderate amount of drainage without odor. Wound edges were intact with [DIAGNOSES REDACTED]. There was no pain associated with the wound, progress was declining. -Interventions were: weekly skin assessment, reposition every two hours and PRN (as needed), perineal care after each incontinent episode, elbow protectors, air overlay and bunny boots to bilateral extremities. The previous order was discontinued and the new order was to clean the wound with normal saline, santyl to wound bed, cover with allevyn dressing changed daily and PRN. The next wound documentation, dated 2/22/16, noted an unstageable wound measuring 1.7 x1.8 x 0.1cm; 95% slough, serous with moderate amount of drainage without odor. Wound edges were intact and macerated, no pain noted. The same treatment was recommended and no changes in interventions. Follow up wound documentation, dated 2/29/16, described the wound as above with no changes in size or description. The same treatment was recommended and no changes in interventions. The weekly pressure ulcer report, dated 3/7/16, noted clarification of the area (sacrum not right buttocks), measuring 1.4 x1.3 x <0.1cm with 100% slough, peri-wound pink and intact with moderate amount of serosanguineous drainage without odor. That day, a Roho cushion was added to the interventions. Treatment remained the same and physician was called for recommendations. 2. Observations and Staff Interviews The resident was observed on 3/4/16 from 8:10 a.m. to 10:00 a.m. The resident was in bed slightly turned to the right side. The resident was observed on 3/4/16 from 11:35 a.m. to 12:30 p.m., in the dining room sitting in a wheelchair. On 3/4/16 at 2:30 p.m., the dressing change was observed while the resident was in bed. During the observation, the nursing home administrator/registered nurse (NHA/RN) was present and the dressing change was conducted by licensed practical nurse (LPN) #2. -The wound was located on the resident's sacrum. The wound bed was mostly slough, the surrounding skin was pink. There was no odor. Some serosanguineous drainage was noted on the old dressing. The LPN said the dressing was changed daily and PRN. The wound team (unit managers and director of nursing) assessed and measured wounds on a weekly basis. The resident's overlay mattress was observed having a minimal amount of air and the wheelchair cushion was very fluffy. -The NHA/RN said the wound was unstageable. She said the overlay mattress was flat and a foam cushion was on the wheelchair; both were inappropriate for a resident with an unstageable wound on the sacrum. The NHA added that she ordered a Roho cushion for the resident. The resident's provider and therapist would be contacted for recommendations. On 3/7/16 at 8:10 a.m., the resident was observed in bed in her room. She was turned to the right side and supported with a pillow. The mattress had a new air overlay and the wheelchair had a Roho cushion. The occupational therapist (OT) was interviewed on 3/7/16 at 8:30a.m. She said any resident with a history of pressure ulcers and a new open area on their bottom should have proper protective equipment to protect and promote healing of the wound. She added that the therapy department did not get involved with wound rounds. If the resident was not on their case load, they did not look at every patient in the facility. The OT said this particular overlay didn't have an adjustable pressure pump, so the mattress couldn't be adjusted for patient weight, like the low-air-loss mattress which would be beneficial for a small resident with an unstageable pressure ulcer. The NHA was interviewed on 3/7/16 at 11:00 a.m. She had ordered a low-air-loss mattress to be rented for the resident. The mattress was observed on the resident's bed prior to exit. The facility failed to ensure resident #1 was provided the care and services necessary to prevent and promote healing of pressure ulcers.

Based on observations, interviews, and record review, the facility failed to provide supervision and monitoring to prevent accidents for residents, and to provide an environment free from accident hazards. Specifically: 1. The facility failed to assess, care plan, and implement interventions for fall prevention for one resident (#35) out of four sample residents out of 33 sample residents. The resident subsequently fell and sustained a hip fracture. 2. The facility failed to ensure that oxygen was kept a safe distance from electrical equipment in the beauty parlor. 3. The facility failed to have a system in place to ensure that beverages were served at a safe temperature. The findings include: 1. Fall Prevention a. Facility Policy The facility's fall risk assessment policy, as provided on 10/20/15, indicated the following: -- An interim care plan should be in place to address falls for new admissions. -- A comprehensive care plan, guided by the falls assessment, should be developed for residents at risk for falls. -- Interventions should be developed, implemented and monitored for appropriateness. The facility's accident/incident occurrence policy for fall response, as provided on 10/20/15, indicated the following: -- All falls should be investigated to identify possible or likely causes of the incident. -- Location of the fall, current interventions, status of the resident, fall history and immediate interventions should be put in place to prevent future falls. -- The fall assessment should be reviewed or a new assessment completed for a more in-depth review of fall risk areas. -- The results of the assessment and investigation should be forwarded, along with any orders and recommendations to the interdisciplinary team to develop a fall prevention intervention plan within 1-7 days after the fall. -- Modifications to the resident's care plan should be made for any new interventions. b. Resident Status and Observations Resident #35, age 94, was admitted to the facility on [DATE]. The resident's face sheet, as provided on 10/20/15, indicated admitting [DIAGNOSES REDACTED]. The resident's most recent minimum data set (MDS) assessment, dated 9/23/15, indicated that the resident required the physical assistance of one person for transferring and ambulation, and that he experienced mild balance deficits. The MDS indicated that the resident had vision impairment and was not necessarily able to identify objects. The MDS indicated that the resident's brief interview for mental status (BIMS) score was five out of 15, indicating severe cognitive impairment. On 10/14/15, resident screening was conducted. During the interview, the resident was noted to have deficits in short term memory. Specifically: -- The resident was wearing skin protectors on his arms, but was not aware of what they were, and did not remember when they had been put on. -- When cued to press his call light, the resident expressed confusion about what his call light was and what it was for. On 10/16/15 at approximately 2:30 p.m., the resident was observed in his room attempting to get up out of his bed. The resident's nasal cannula was in place and was attached to his oxygen concentrator, which was limiting his movement. The resident had not triggered his call light. Facility staff was immediately notified by the observers that the resident needed some assistance getting out of bed. c. Admission MDS and Fall Risk The resident's admission MDS, dated [DATE], indicated the following: -- The resident had falls within the month prior to admission. -- The resident was assessed to be highly impaired in regards to vision. -- The resident's brief interview for mental status (BIMS) was a three of 15, indicating severe cognitive impairment. -- The resident required a one person physical assist for ambulation and transferring. -- The resident required the extensive assistance of two or more persons for toileting. -- The resident's balance when moving from seated to standing, walking, turning around, moving on and off the toilet, and transferring between the bed and chair demonstrated unsteadiness. The care area assessment (CAA) section of the MDS indicated that the resident was assessed to be at risk for falls, and that this risk would be addressed in the resident's care plan. A fall assessment, conducted on 9/9/15, indicated that the resident was at moderate risk for falls due to the following factors: -- Use of hypoglycemic agents -- Memory and cognition -- History of falls -- Recent admission to the facility -- Severe vision impairment -- Gait and balance concerns, including the inability to independently come to a standing position, need for hands on assistance to move from place to place, and use of an assistive device. A review of the resident's care plan, conducted on 10/19/15 at approximately 1:30 p.m., demonstrated that no care plan had been created to address the resident's fall risk. d. Falls in Facility Fall #1 -- A nurse's note, dated 9/26/15, indicated that the resident had informed the nursing staff that he had fallen in his room and hit his left elbow. The note indicated that the resident sustained [REDACTED]. -- The incident report for the fall, dated 9/26/15, indicated that the resident reported that he had fallen in his room while trying to turn off his oxygen concentrator. -- No current interventions were indicated in the incident report. -- There were no witness statements to determine resident status, or timeframe of the fall. -- There was no documentation of fall history. -- There were no immediate interventions put in place to prevent another fall. -- There was no documentation of a review of the resident's current fall assessment and no new fall assessment was completed. -- There were no orders or recommendations forwarded and no fall prevention intervention plan was created. -- No care plan was created for falls, and there were no modifications to the resident's current care plan. Fall #2 -- A nurse's note, dated 10/17/15, indicated that the resident was found on the floor in front of his sink. His left leg appeared shorter than the right and was rotated outward. The left hip was bulging and the resident complained of pain at a 10/10 upon slight movement of the limb. The note indicated that the room was uncluttered and the resident stated he tripped on something and fell . The resident was sent to the hospital. -- The incident report for the fall, dated 10/17/15, did not include any witness statements from staff to determine a timeline for the fall. A note in the assessment indicated that the resident was blind and had hearing loss, and that he tended to ambulate around his room without notifying facility staff. -- The incident report for the fall, dated 9/26/15, indicated that the resident reported that he had fallen in his room while trying to turn off his oxygen concentrator. -- No current interventions were indicated in the incident report. -- There were no witness statements to determine resident status, or timeframe of the fall. -- There was no documentation of a fall history. -- There were no immediate interventions put in place to create another fall. -- There was no documentation of a review of the resident's current fall assessment and no new fall assessment was completed. -- There were no orders or recommendations forwarded and no fall prevention intervention plan was created. -- A care plan was generated on 10/19/15. e. Staff Interviews Interviews with the nursing staff on the resident's unit demonstrated that the resident's history of falls in the facility had not been communicated when the resident moved from the rehabilitation section, and there were no interventions formally in place to prevent the resident from falling. -- On 10/14/15, licensed practical nurse (LPN) #1, who was the nurse for the resident's wing, was interviewed. The LPN stated that the resident had not fallen in the last thirty days. -- On 10/20/15, registered nurse (RN) #2 was interviewed. The RN stated that the resident had fallen over the weekend (10/17/15), had sustained a hip fracture, and was currently in the hospital. The RN described the resident as being very confused and stated that he was oriented x1. The RN stated that the resident was physically strong enough to get up and walk with his assistive devices, but that he was legally blind, and that as a result, he required a one person assist to transfer and walk. The RN stated that the resident was compliant with cares, but that his memory was poor. The nurse stated that the resident usually remembered to use his walker, but that he frequently did not remember to use his call light and that he did not understand that he needed staff with him. The RN stated that the resident had transitioned to the long term care unit within the last few weeks, and the RN was not aware that the resident had fallen in the facility prior to the fall on 10/17/15, and the RN was not aware of any formal fall prevention interventions. The RN stated staff were cuing the resident to use his call light; however, this was not necessarily effective because the resident did not remember to do so. -- On 10/20/15 at 12:44 p.m., the social service assistant (SS #2) and the clinical care manager (CCM #6) for the rehabilitation unit were interviewed. SS#2 described the resident as pleasant, cooperative, and able to communicate his basic needs, but stated that he had difficulty with his memory and did not remember to call for assistance. The SSA stated that as a result, the staff on the rehab unit had been instructed to anticipate his needs. CCM #6 stated that the resident was admitted to the rehab unit for falls, and that he came to the unit for skilled physical therapy and occupational therapy. The CCM stated that the resident was at risk for further falls due to his history of previous falls, as well as general weakness and vision impairment. -- On 10/20/15 at 12:44 p.m., physical therapist (PT), occupational therapist (OTR), and the director of therapy (SLP) were interviewed. The PT and OTR stated that the resident required stand-by assistance for safety due to visual deficits, and that he needed hands on contact for transfers and locomotion. The OTR stated that the resident had also been assessed as having difficulty with problem solving and memory. -- On 10/20/15 at 2:10 p.m., the director of nursing (DON), CCM #4 (who managed the resident's current unit) and CCM #6 (who managed the rehabilitation unit) were interviewed. The DON stated that when residents moved units, the staff from the initial unit were supposed to give report about the resident's status to the new staff and help orient the resident. She stated the fact that the new staff were unaware of the resident's previous fall indicated that there had been some holes in that communication. The DON confirmed that there had not been a care plan in place for falls, and stated that there should have been one in the resident's initial care plan based on the resident triggering the care area in his MDS, a facility assessed fall risk, and he came into the facility following a fall. The DON confirmed that a comprehensive care plan for falls was generated on 10/19/15, but agreed that this was not timely. The DON also confirmed that although the resident was acknowledged to be at risk for falls on the certified nurse aide (CNA) care tracking, there were no action items in place to address this. The DON stated that she would look to see if any further documentation was available to staff that would provide guidance about fall prevention. The DON stated that following a fall, the facility used a fall incident report to assess the resident's condition and environment to determine what may have led to the fall. The DON stated that a full investigation of the incident would be required to assess whether the current interventions were still appropriate. On 10/20/15 the DON stated that she had not found any documentation of any interventions in place for falls, and stated that any potential interventions could not have been communicated to the staff on the resident's current unit. The DON confirmed that there were no interventions in the physician orders, medication administration records, treatment notes, or therapy notes to provide guidance to the nursing staff about how to prevent the resident from falling. On 10/20/15, the DON stated that after reviewing the documentation available from both incident reports, there were no interviews conducted, and while some data was available about the resident's status and the environment, there was not sufficient data to make a determination about what led to the fall and to assess the appropriateness of current interventions. f. Change in resident status: Pre fall: -- The resident's most recent minimum data set (MDS) assessment, dated 9/23/15, indicated that the resident required a one person physical assist for supervision for bed mobility (moving around in his bed), transferring (moving between surfaces) and walking in his room. The MDS indicated that the resident required limited hands on assistance of one person to walk outside of his room and dress. The MDS indicated the use of either a walker or a wheelchair for mobility. -- The pain assessments for October 2015 indicated that the resident had no reports of pain from 10/1/15 to 10/17/15, and no as needed pain medications were administered. A nurse's note dated 9/29/15 indicated that the resident was moved from the rehab unit to the long term care unit on that date. Post fall: -- The resident returned from the hospital on [DATE] at approximately 12:30 p.m. The resident's hospital record, obtained on 10/20/15, indicated that the resident was admitted to the hospital on [DATE] following a closed displaced subtrochanteric fracture of the left femur (a hip fracture in which the bones were no longer in place). The resident had surgery to repair the hip fracture on 10/18/15. -- A new admission assessment, dated 10/20/15, indicated that the resident required extensive hands on assistance for bed mobility, dressing, and transferring. The assessment also indicated that the resident would require a wheelchair for mobility. The admission assessment also indicated that at the time of assessment, the resident was experiencing moderate pain (five of 10) in his left hip. The assessment indicated that the pain was aggravated by movement. 2. Oxygen use a. Professional Reference: Professional Reference: The National Home Oxygen Patient's Association's Understanding Oxygen Therapy guide for the use of oxygen stated, in pertinent part, that: -- Oxygen is not flammable, but is an accelerant. -- Oxygen should not be worn while using electrical equipment such as razors or hair dryers due to the potential for sparks. The National Home Oxygen Patient's Association, Understanding Oxygen Therapy: A Patient Guide to Long-Term Supplemental Oxygen, 2013, http://www.homeoxygen.org/assets/docs/UnderstandingOxygenTherapy2013.pdf (Web access on 10/28/2015). b. Policy Review The facility's policy titled Oxygen Administration last revised/updated 10/15/15 provided by the facility director of nursing (DON) on 10/15/15 at 2:50 p. m., revealed in pertinent part: Remove all potential flammable items (lotions, oils, alcohol, smoking articles, etc.) from the immediate area, defined as 5 (five) feet per the compressed gas association, where oxygen is to be administered. Unplug and /or relocate all electrical devices (e.g. , radios, televisions, electric shavers, etc,) in the immediate area, defined as 5 feet per the compressed gas association, where oxygen is to be administered. Use of appliances such as electric shavers, blow dryers, etc.must not be allowed by those wearing oxygen. c. Facility failure Observation: On 10/15/15, between 9: 05 a. m. and 9:10 a. m., four residents were observed in the beauty salon. One of these residents was observed to be sitting under the working hair dryer in her wheelchair with an oxygen nasal canula in their nostrils, the portable oxygen tank observed hanging behind the resident wheelchair under the working hair dryer. Staff Interviews On 10/15/15 at 9:15 a. m., the beautician (BT) was interviewed. The BT said normally she would leave the working oxygen with the nasal canula on the resident's nostrils whenever they came to the beauty salon to get their hair done and she never removed the oxygen or the nasal canula from the resident's nostrils when the resident needed to go under the hair dryer. On 10/15/5 at 9:20 a. m., the DON was interviewed. The DON said the facility did not have a policy and procedure in place regarding the use of oxygen in the beauty salon, but the DON said she would have to put a policy and procedure in place soon and then in-service the beautician. 3. Hot beverages potential hazard A. References According to the Consumer Product Safety Commission (CPSC) Safety Alert: Avoiding Tap Water Scalds, Publication 5098, 03/2012, Web, accessed 10/26/2015, http://www.cpsc.gov/pagefiles/ 2/5098.pdf: The majority of injuries and deaths involving tap water scalds are to the elderly and children under the age of five . Most adults will suffer third-degree burns if exposed to 150 degrees Fahrenheit (ºF) water for two seconds. Burns will also occur with a six-second exposure to 140ºF water or with a thirty second exposure to 130ºF water. According to the Burn Foundation Safety Facts on Scald Burns. www.BurnFoundation.org http://www.BurnFoundation.org, Web, accessed 10/26/2015, http://www.burnfoundation.org/programs/resource.cfm?c=1&a=3 : Hot liquids burn like fire. Over 500,000 scald burns occur annually in the United States.The two highest risk populations are children under the age of 5 and adults over 65 .Coffee, tea, soup and hot tap water can be hot enough to cause serious burn injury .Most scald injuries can be prevented. Hot water causes third degree burns:- in 1 second at 156ºF- in 2 seconds at 149ºF- in 5 seconds at 140ºF- in 15 seconds at 133ºF. According to Brown and Diller, The Journal of the International Society for Burn Injuries, Calculating the Optimum Temperature for Serving Hot Beverages, Volume 34, Issue 5, (2008), page 648-54, Web, accessed 10/26/2015 http://www.ncbi.nlm.nih.gov/pubmed/ 454 : Hot beverages such as tea, hot chocolate, and coffee are frequently served at temperatures between 160 ºF and 185ºF . Brief exposures to liquids in this temperature range can cause significant scald burns . The preferred drinking temperature of coffee is specified in the literature as 140+/-15ºF .The analysis points to a reduction in the presently recommended serving temperature of coffee to achieve the combined result of reducing the scald burn hazard and improving customer satisfaction. (see complete text of study at http://www.bme.utexas.edu/attachments/article/80/Burns.2008.optimum%20hot%20bevrg%20temp.pdf) B. Observations On 10/20/15 at 11:35 a.m., dietary aide (DA) #1 and DA #2 were observed preparing beverages for lunch service. DA #1 was observed to be making coffee in a large coffee brewer, dispensing the brewed coffee into a plastic pitcher and immediately pouring the brewed coffee into a smaller insulated carafe. DA #1 was not observed to check the temperature of the brewed coffee before or after filling the insulated carafes. There were no temperature logs observed on or near the large coffee brewer or hot beverage machines. When DA #1 was requested to check the temperature of the hot coffee ready for service, the temperature was 177ºF. On 10/20/15 at 11:45 a.m., the assistant food service director (AFSD) was observed to inform DA #1 of temperature issues and assist with adding ice to the brewed coffee to reduce the temperature to 155ºF. On 10/20/15 at 12:35 p.m., the temperature of the coffee in the insulated carafe in the main dining room was 150ºF. C. Interviews On 10/20/15 at 11:40 a.m., DA #1 and DA #2 stated that they were not trained on any procedures to check the temperature of the hot coffee prior to service. They were not aware that hot coffee was a potential hazard, and they did not know the proper temperature to serve the hot coffee. On 10/20/15 at 11:45 a.m., the AFSD stated that the staff were not checking the temperature of the hot coffee prior to service. The coffee brewer heated water to approximately 185ºF to brew the coffee. She was aware of the potential burn hazard and stated she would have the staff cool the hot beverages to 155ºF or below before the lunch service that day. On 10/20/15 at 12:55 p.m., the food service director (FSD) and registered dietitian (RD) stated that they did not have a procedure to ensure that hot beverage temperatures when served to residents was appropriate for resident safety. They stated that there were current residents who would not be able to safely handle hot beverages. The FSD stated that the dietary staff was not checking the temperature of hot beverages prior to service to residents, but she would begin training the staff immediately. She confirmed that the coffee brewer heated water to approximately 185ºF to brew the coffee. She was aware of the potential burn hazard and stated she would have the staff cool the hot beverages to 155ºF or below prior to service. On 10/20/15 at 2:45 p.m., the nursing home administrator (NHA) stated that she would expect a procedure to be in place that would prevent hot beverages from being served above 155ºF to prevent accidental burns.

Based on observations, record review and staff interviews, the facility failed to ensure that one of 42 sample residents (#168) and two supplemental sample residents (B and C) received the care and services necessary to attain or maintain their highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically: -The facility failed to transcribe orders for blood sugar monitoring for resident #168 at the time of her admission, and failed to consistently monitor the resident's blood sugars after admission. The resident's blood sugar level was not checked on 2/16/12 until the family requested that it be checked. Her blood sugar level was between 27 - 33. - The facility failed to clarify physician orders [REDACTED]. -The facility failed to have appropriate interventions to address [DIAGNOSES REDACTED] stored in a readily accessible area, and consistently on each of the three nurses' stations. The findings include: A concern was filed with the health department related to blood sugar management at the facility. An onsite visit occurred at the facility in conjunction with the recertification survey. I. Professional Standard: According to the National Diabetes Association, at <http://www.diabetes.org/>, last updated 2011, it is important to maintain blood sugar within tight parameters. When blood sugar gets too low (below 70 mg/dL), a condition known as [DIAGNOSES REDACTED], it can be caused by several factors such as too much insulin, not enough sugar from carbohydrates, exercise, or even alcohol consumption. Symptoms of [DIAGNOSES REDACTED] include the following: shakiness, dizziness, sweating, headache, [MEDICAL CONDITION], clumsy or jerky movements, confusion, [MEDICAL CONDITION], or death. . . It is extremely important that an individual with insulin dependent diabetes have their blood sugar checked regularly and to avoid episodes of [DIAGNOSES REDACTED] and [MEDICAL CONDITION], as either condition can lead to death. II. Resident #168 Resident #168, age 84, was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident was admitted to hospice on 3/4/12, and passed away that same day. a. Record Review The resident's discharge instructions from the hospital (dated 2/14/12), included the instructions "Check your blood sugar before meals and at bedtime. Repeat chemistry panel on 2/15/12 to follow sodium and potassium." The medications ordered included "[MEDICATION NAME] 10 mg orally daily" and "[MEDICATION NAME] 13 units subcutaneously at bedtime." b. Hypoglycemic Episode 2/16/12 Review of nurses' notes and an investigation report revealed that the resident had poor intake after admission and on 2/16/12, and that her blood sugar dropped well below 70. (1) Nurses' Notes read: On 2/14/12 at 8:00 p.m., the evening nurse wrote in pertinent part " . . .Resident on mechanical soft/thin liquid diet. Likes coffee. Likes milk. Resident's [MEDICATION NAME] held. BS (blood sugars) - 69 noted. Milk with sugar and fruits given. . ." On 2/15/12 at 2200 (10:00 p.m.), the evening nurse charted " . . .Appetite very low - bites only. Anxiety in evening;- worse when family was present. Pain medication given with good results." On 2/15/12 at 1430 (2:30 p.m.) the day nurse noted " . .. Food intake - breakfast 25%, lunch 50%. Fluids 500 plus cc. Patient in recliner at this time. . . ." On 2/16/12 at 1:00 p.m., the day nurse wrote in pertinent part ". . .Res(ident) ate breakfast and lunch though poorly, and attended therapy sessions. Will continue to monitor." On 2/16/12 at 2230 (10:30 p.m.) the evening nurse charted "Resident in room alert, responsive and sleeping until 1500 (3:00 p.m.) Neb(ulizer) inhaler given at 1630 (3:30 p.m.) during dinner time. Resident continues being sleepy. No sweating (not diaphoretic). Blood sugar checked, and was between 27 - 33. Accepted two [MEDICATION NAME] of glucose gel with 60 cc orange juice. BS went up to 57. Physician called. Order received to start D 5 NS 70 cc/hr X (times) 1 bag. Resident at 7:00 p.m. became more awake and sleepy at this time. Blood sugar was 60. (Name of ambulance company) called and IV started at 2000 (8:00 p.m.). At this time blood sugar went up to 119. IV continues running at the rate of 70 cc/hr. Resident became more alert. Requested to have glass of milk and applesauce. Accepted full glass and one cup of applesauce. At 2200 (10:00 p.m.), blood sugar went to 157. IV (unknown word) on L(eft) arm patent, no infiltration. Hoyer transfer. No pain. . . .At this time 750 cc IV fluid left in the bag. . ." On 2/17/12 at 2:20 p.m. the day nurse wrote " . . .Res on monitor for low blood sugar. BS @ 311 by 1:45 p.m. Res continues on IV D5 NS infusion. IV patent and flowing. Res up for both meals, but in bed after lunch. Res has c/o (complaints of) pain or discomfort." On 2/17/12 at 2200, the evening nurse wrote ". . . Recognizes family. Answers questions appropriately. IV D/C"d (discontinued) @ 1930 (7:30 p.m.). IV site clean with no s/s (signs/symptoms) inflammation. See MAR (medication administration record) for blood sugars. Res ate 25-30% of eve(ning) meal. Fluid intake fair.. . . ." (2) Change of Condition forms On 2/16/12 at 1900 (7:00 p.m.), the nurse documented "Resident alert and being sleepy. Blood sugar checked 27 - 33. Resident able to accept [MEDICATION NAME] of glucose orally. Physician called and order received to start D5 NS at 70 cc/hr, and hold [MEDICATION NAME] (insulin) tonight. Reduce HS [MEDICATION NAME] to 8 units. BMP (lab panel) tomorrow a.m." On 2/17/12 at 1530 (3:30 pm.), the nurse documented "Unstable blood sugars @ present with episode of low blood sugar last eve. Order to check BS QID (four times/day), ac (before meals) and HS (at bedtime)." (3) 24 Hour Report -The 24 Hour Report for 2/16/12 contained no entries regarding resident #168. -The 24 Hour Report, dated 2/17/12, documented the following information for the West Station "(Name of resident) IV L(eft) AC 70 cc/hr. Started on 2/16/12 at 0815 p.m. (Should read 2015). D5 1/2 NS." At 0800 p.m.: D/C IV for (Name of resident). Med A." (4) Physician Note The "Assessment" section of a Physician Note dated 2/17/12, read in pertinent part as follows: ". . ..2.) DM II (diabetes mellitus type 2) - H/O (history of) labile BG (blood glucose) - BS (blood sugar) low last eve(ning) 20 -30. Given juice and D 5 1/2 NS IVF ([MEDICATION NAME] and normal saline intravenously) started with improvement. [MEDICATION NAME] dose decreased - Monitor BS closely . . ." c. Facility Failures (1) Failure to transcribe orders for blood sugar monitoring Review of the printed Computerized Physician order [REDACTED]. q HS (bedtime) and "[MEDICATION NAME] 5 units q AM dx: diabetes." Further review of the CPO revealed Treatment Procedure orders for [MEDICATION NAME] testing, wound care, oxygen, air boots, and safety devices, but no orders for blood sugar monitoring. The Ancillary Orders included an order for [REDACTED]." The orders for the blood sugar monitoring as documented in the discharge instructions from the hospital were not transcribed to the CPO or Medication Administration Record (MAR) until 2/17/12. Review of the resident's 2/12 (MAR) and Nurses' Notes (see above) revealed inconsistent blood sugar monitoring after admission, and no monitoring on 2/16/12, until after the resident's hypoglycemic episode. Specifically: -Review of the MAR revealed [MEDICATION NAME] (13 units) at HS was held on the evening of 2/14/12. (See above; Nurses' Notes documented a blood sugar 69). -Review of the MAR revealed the resident received [MEDICATION NAME] (5 unit) the morning of 2/15/12 and [MEDICATION NAME] (13 units) at HS. No blood sugar was documented in the Nurses' Notes or on the MAR. -Review of the MAR revealed [MEDICATION NAME] (5 units) was administered in the morning dose on 2/16/12. No blood sugar was documented on the MAR or in the Nurses' Notes, although the notes documented the resident ate poorly at breakfast (see above). On the evening of 2/16/12, [MEDICATION NAME] (13 units) was held with documentation in the Nurses' Notes (see above). A blood sugar of 157 (after treatment for [REDACTED]. Further review of the MAR dated 2/1 - 2/29/12, indicated that it was printed on 2/17/12 or later. The Treatment/Procedure of "Check blood sugar four (times) a day, before meals and at bedtime. Notify MD if less than 70 or greater than 400" was noted as being ordered on [DATE]. (2) Failure to develop a plan of care for diabetic management Record review revealed no care plan for the resident addressing the resident's diabetic management until 2/16/12. Record review revealed the facility used a carbonless form with three sections on the same page. The first section was labeled "Care Plan Update." The second section was labeled "Change of Condition" and the third was "Telephone Orders." Two Care Plan Updates forms, dated 2/16/12 and 2/17/12, with the notation "Acute Care Plans" written across the top, were found in the resident's closed medical record. -The first one identified the problem as "Low blood sugar. DM (diabetes mellitus)". The Approach included "Reduce [MEDICATION NAME] to 8 units at HS as long as blood sugar is above 100. Keep 5 units [MEDICATION NAME] at am. D5 N/S 70 cc/hr X's 1 bag. BMP at a.m. tomorrow (2/17/12). Hold [MEDICATION NAME] tonight. Dx: DM. Crush med to be given per family request." -The second one was identified as "Unstable blood sugars" with the approach of "Check blood sugar via glucometer ac & HS (4x's/day)." The above concerns were not transferred to either the resident's Interim Plan of Care (2/21/12), or the Comprehensive Plan of Care. -Review of the comprehensive Plan of Care dated 2/27/12, identified adjustment to long-term care, deficits in cognition and communication, mood issues, activities and interests, and nutritional risk as being areas for care planning. The Nutritional Care Plan identified the resident as being at high nutritional risk related to her underweight status (107 lbs), poor appetite, dementia, swallowing difficulty, and impaired nutrient utilization due to her diabetes mellitus. The Interventions included a restricted carbohydrate pureed diet with nectar thick liquids, Sugar Free House (nutritional) Supplement, Pro-Stat, and supervision/assistance at meals. -There was no specific care plan for diabetic management even though the physician documented on 2/17/12 "H/O (history of) labile BG (blood glucose). . ." d. Staff Interviews On 4/11/12 at about 3:30 p.m., the Licensed Practical Nurse (LPN) who had taken care of the resident during the evening of her hypoglycemic event was interviewed by phone. -He stated that the resident had been admitted to the East Station only a couple of days before the hypoglycemic episode, and that the staff did not know her very well, but he had heard in report that she had been sleepy that day..The LPN also said that the resident did not have orders for blood sugar monitoring in the computer. -He said that around 5:30 or 5:45 p.m., the resident's family came to the Nurses' Station and asked him to check her blood sugar. The LPN stated that he checked the resident's blood sugar, and it was between 27 - 33. He said that another nurse, the Evening Supervisor was helping him at this point, and she went to get the glucose gel from the Med Room and juice for the resident. -The LPN stated that the resident did seem kind of sleepy, but when they talked to her, she became alert enough to swallow the glucose gel and drink the juice. He said that he called the doctor and left a message. -The LPN said when he re-checked the resident's blood sugar after she had swallowed the glucose gel, it was between 57 and 62. It had been 30 minutes since he had called the doctor and he had not heard back, so he called the emergency phone number. He said that if the doctor ordered a [MEDICATION NAME] injection, the Evening Supervisor would have to get it from the West Med Room because she had the keys. -The LPN said that they had gotten the resident sitting up in bed, and she was drinking the juice. The doctor called back and said to hold her [MEDICATION NAME] that evening, and to start a D5 IV (5% [MEDICATION NAME] intravenously). -The LPN said the RN Evening Supervisor was unable to start the IV because the resident had not been eating or drinking well. The LPN called the paramedics, and they arrived very quickly and were able to start the IV without problems. He thought that they got to the facility about 6:50 p.m. After the IV ran for a few minutes, he said he checked the resident's blood sugar again, and this time it was 119. -The LPN said that he had attended the recent inservice on [DIAGNOSES REDACTED] (see below), and that the [MEDICATION NAME] kit was kept in the Med Room on the West Station. On 4/11/12 at 6:15 p.m., a Registered Nurse (RN) who had worked on the East Station on 2/16/12, evening was interviewed. She stated that she was working on another one of the three halls, but that she had been aware that there was a problem going on with a resident's blood sugar. The RN said "I don't think that she had orders," referring to orders for blood sugar monitoring. On 4/10/12 at 3:10 p.m., the Director of Nursing (DON) provided the facility's "Protocols for [DIAGNOSES REDACTED]" handout as requested. -The DON stated that the facility did not have a protocol or policy for glucose monitoring as the nurses were expected to follow each resident's physician orders [REDACTED]. -The DON said that a reference manual - the Med Pass Nursing Services Policy and Procedure Manual for Long-Term Care - was available and kept in the Conference Room. The DON provided a copy of the policy "Obtaining A Fingerstick Glucose Level" from the manual's section on Diabetes Care. On 4/12/12 at 10:00 a.m., the DON was interviewed again regarding management of low blood sugars. She stated that the staff had been inserviced recently. -When informed of the inconsistent findings from interviews with staff at the three Nursing Stations (see interviews below) on whether they had glucose gel available and where it was kept, she said that when a nurse used the glucose gel on their unit, he or she would be responsible to notify Central Supply so that more could be ordered. -The DON stated the previous Central Supply person used to check with the nurses as to whether they needed any supplies. She stated that the facility was working with a new supply company, and that the new Central Supply person would be trained to monitor and order the glucose gel as needed. -She said that the three Nurses' Stations should be consistent with where they store the glucose gel, but if it was needed, the House Supervisor (Charge Nurse) had keys to the supply room. On 4/12/12 at about 11:00 a.m., the DON provided an email confirming the facility's registration for participation in a webinar/teleconference on diabetes management for residents in long term care. The presentation was scheduled for 4/24/12, and its target audience was to be nurses and nursing home administrators. On 4/12/12 at 1:15 p.m., the Staff Development Coordinator (SDC) was interviewed regarding the inservices she had given on diabetes management and/or [DIAGNOSES REDACTED]. The SDC stated that she had recently given two inservices on the symptoms and treatment of [REDACTED]. She provided the outline and the sign in sheets for the two inservices. The first one was done on 12/5/11, and the second one on 2/22/12 after the resident experienced [DIAGNOSES REDACTED] on 2/16/12. III. Additional Diabetic Management Issues A. On 2/22/12 the facility re-educated nursing staff with the hypoglycemic protocols. When reviewing the protocol for [DIAGNOSES REDACTED], the following information was reviewed in pertinent part: "This policy is to assure any resident with symptoms of [DIAGNOSES REDACTED] receives rapid effective treatment of [REDACTED]. Also to assure residents using sliding scale insulin receive routine monitoring of the glucose levels to avoid instances of [DIAGNOSES REDACTED]. Blood glucose levels will be monitored per physician order, which will dictate frequency of monitoring and parameters for response to abnormal levels. This should include a prn (as needed) order for signs of [DIAGNOSES REDACTED]...Residents found to have any of these symptoms of [DIAGNOSES REDACTED] will have glucose level checked by fingerstick. For glucose less than 60 - immediate treatment will be as follows: A. Determine if the resident is able to swallow, if so give an 8 oz. glass of juice or soda, 3-4 sugar cubes, hard candy or other fast acting carbohydrate or B. Use the instant glucose and give the entire 31 gram tube (this is available in the med room), C. Also give a protein food (such as cheese and crackers), D. In the event the resident cannot take anything orally, access the E-kit and give IM [MEDICATION NAME] or give [MEDICATION NAME] 50% IV (if they have an IV line in place).." B. Failures Following 2/22/12 In-service Although staff was re-educated on blood sugar protocols on 2/22/12, staff did not ensure glucose gel was available on one cart or physician orders [REDACTED]. 1. Resident B, [AGE] years old, was admitted to the facility on [DATE]. According to the admission sheet, the medical [DIAGNOSES REDACTED]. Review of the resident's 9/14/07 diabetic care plan identified a problem with unstable blood sugars (not all inclusive). Staff was directed to monitor for signs and symptoms of [MEDICAL CONDITION] (high blood sugar) and [DIAGNOSES REDACTED] (low blood sugars). Another intervention was to administer hypoglycemics per physician orders. Review of the physician orders, care plan and treatment/medication records revealed the resident received two types of insulin. [MEDICATION NAME] was administered three times a day. [MEDICATION NAME] was administered twice a day. Staff was checking the resident's blood sugar levels twice a day. The physician had notification parameters in place to call if the blood sugar was below 60 or above 500. Insulin coverage was adjusted based on the blood sugar readings. Even with the medical history of [REDACTED]. 2. Resident C, [AGE] years old, was admitted to the facility on [DATE]. According to the admission sheet, the resident's medical [DIAGNOSES REDACTED]. Review of the 8/30/10 diabetic care plan revealed the resident was at risk for altered health. One intervention prompted nursing to call the physician or nurse practitioner of signs/symptoms of [DIAGNOSES REDACTED] for further orders/evaluation immediately. Staff monitored blood sugars twice a day and was directed to call the physician if less than 60 or greater than 400. The resident received insulin once a day at midnight. The insulin dose was adjusted by the physician based on the blood sugar readings. Review of the physician's orders [REDACTED]. 3. Through interviews with nursing staff and observations on 4/10/12 (around 2:30 p.m.) they revealed: -Around 2:30 p.m. - only one nursing unit - 100 hall, had an Emergency kit with the IM - [MEDICATION NAME] syringe and the [MEDICATION NAME] IV solution. There were three nursing units in the building. The 200 hall was approximately 130 feet away from the E-Kit. The secured unit nursing unit was approximately 170 feet away from the E-kit. The staff on the 100 hall and the house supervisor had access to the medication room. The other nurses would have to get the supervisor or a nurse from the 100 hall to access the medication room for a [MEDICATION NAME] injection and return to their individual unit. -Between 2:00 p.m. and 3:05 p.m., five facility nurses were interviewed regarding the location of the glucose gel and [MEDICATION NAME] injections for the intervention of [DIAGNOSES REDACTED]. East Hall: At 2:05 p.m., a nurse on the East Hall (200 Hall) stated that glucose gel was usually kept in the Medication Room at each Nurses' Station, and that the [MEDICATION NAME] injections were kept in the E(mergency) Kit at the West (100) Hall's Medication Room. She unlocked the East Hall's Medication Room, and an unopened 3-pack of Insta-Glucose (glucose gel) was observed. West Hall: At 2:20 p.m., the Clinical Care Coordinator Nurse (CCC) on the West Hall stated that she thought that each of the Medication Nurses kept glucose gel on their individual medication carts. --The first Medication Nurse checked her cart for the glucose gel. There was not any. She said that she could get more from the Medication Room, but that the nurse on the Medicare Hall had the keys. --The Medicare Nurse was in a resident's room giving discharge instructions, and was unavailable for interview. --A second Medication Nurse was able to get the keys to the Medication Room from the Medicare Nurse. She unlocked the Medication Room, and showed the surveyor the two Emergency Kits. One was locked, and contained the narcotics. The second one was unlocked, and contained the sealed [MEDICATION NAME] injection kit. The second Medication Nurse stated that she would observe diabetic residents to see if they were sweaty, clammy or non-responsive as signs that they were experiencing [DIAGNOSES REDACTED]. Secured Unit: At 3:05 p.m., an Evening Shift nurse on the Secured Unit was interviewed. She stated that she would expect a resident experiencing [DIAGNOSES REDACTED] to be diaphorectic, clammy and confused. The Evening Nurse unlocked her medication cart, and there were two tubes of glucose gel in the top drawer. 4. Additional Staff Interviews On 4/11/12 at 1:15 p.m., the Director of Nursing (DON) stated there were diabetic protocols in place but no standing orders. The DON continued that if the resident could not swallow the [MEDICATION NAME] gel (in the case of [DIAGNOSES REDACTED]), the resident could choke. With reference to the location of the [MEDICATION NAME] IM, the DON stated that by the time the nurse obtained the [MEDICATION NAME] shot, a resident's blood sugar could have dropped some more and the resident would require hospitalization . On 4/12/12 at 10:03 a.m., the DON acknowledged the orders for residents B and C only directed staff to notify the physician about the blood sugar readings; there was no direction with the management of low blood sugar readings. -The DON further stated nursing staff should be knowledgeable about standard nursing protocols regarding hypoglycemic events and treatment needs. The DON stated glucose gel should be available at all nurses' stations. The DON was informed of the finding above that glucose gel was not available on the 100 hall on 4/10/12. The DON stated there has only been one [MEDICATION NAME] shot in-house for awhile and that seemed to work for the building. -The DON did not know how many diabetics were residing in the facility; she said she could check. The DON stated the protocols were reviewed at orientation and there were no standing orders for residents B and C to direct nursing staff in following the hypoglycemic protocol (see above) if blood sugars dropped below 60.

Based on record review and staff interviews, the facility failed to ensure that ten of 42 sample residents and sixteen supplemental sample residents (#88, #89, #C, #L, #H, #I, #P, #J, #M and #O) received the care and services necessary to attain or maintain their highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically: The facility failed to appropriately monitor blood sugars, and failed to report blood sugars to the physician as ordered when outside of parameters. The findings include: I. Professional Standard: According to the National Diabetes Association, at <http://www.diabetes.org/>, last updated 2011, it is important to maintain blood sugar within tight parameters. When blood sugar gets too low (below 70 mg/dL), a condition known as [DIAGNOSES REDACTED], it can be caused by several factors such as too much insulin, not enough sugar from carbohydrates, exercise, or even alcohol consumption. Symptoms of [DIAGNOSES REDACTED] include the following: shakiness, dizziness, sweating, headache, [MEDICAL CONDITION], clumsy or jerky movements, confusion, [MEDICAL CONDITION], or death. . . It is extremely important that an individual with insulin dependent diabetes have their blood sugar checked regularly and to avoid episodes of [DIAGNOSES REDACTED] and [MEDICAL CONDITION], as either condition can lead to death. Resident failures: 1. Resident #88 Resident #88 was a [AGE] year old female admitted to the facility on [DATE], and according to her face sheet her [DIAGNOSES REDACTED]. Record review revealed that she had an order for [REDACTED].[REDACTED]. Interview with director of nursing (DON) on 6/21/12 at 3:21 p.m., revealed that they did not have a reason why the blood sugar was not taken on June 17th and 18th for resident #88. She stated that the resident did sign out for the day, but was back by 4:00 p.m. so she would expect them to have a blood sugar taken. 2. Resident #89 Resident #89 was an [AGE] year old female admitted to the facility on [DATE], and according to her face sheet her [DIAGNOSES REDACTED]. Record review revealed that the resident was ordered to have her blood sugar checked every Monday twice daily and to call the doctor if below 60 or above 400. There was no evidence of monitoring on the morning of 6/18/12, and no note available explaining the lack of monitoring. Interview with the DON on 6/21/12 at 3:57 p.m., revealed that she could not find any indication why the blood sugar was not taken as ordered. 3. Resident #C Resident #C was a [AGE] year old male admitted to the facility on [DATE], and according to his face sheet his [DIAGNOSES REDACTED]. Record review revealed that the resident was ordered by the physician to have his blood sugar monitored twice daily and to report to the doctor if less than 60 or greater than 400. Review of the MAR indicated [REDACTED]. A nurses' note provided by the facility, dated 6/9/12 at 5:30 p.m., documented that the resident refused his evening blood sugar monitoring. An interview with the DON on 6/21/12 at 3:57 p.m., revealed that she would expect a note for each occasion of a missed or refused blood sugar, but she could only find evidence of documentation for one out of three instances where the resident refused or missed his blood sugar monitoring in June. 4. Resident #L Resident #L was an [AGE] year old female admitted to the facility on [DATE], and according to her face sheet her [DIAGNOSES REDACTED]. Record review revealed that the resident was ordered to have her blood sugar tested twice daily and notify the doctor if below 90 and above 250. In May there were eleven instances of the resident's blood sugar being above 250 ranging up to 368. There were no documented interventions on the MAR. Interview with the DON on 6/21/12 at 3:57 p.m., she stated that they did not have any documentation for out of range blood sugar for resident #L. 5. Resident #H Resident #H was an [AGE] year old male admitted to the facility on [DATE], and according to his face sheet his [DIAGNOSES REDACTED]. Record review revealed that from his date of admission he had a physicians order to monitor his blood sugar three times a day for seven days then call the doctor with the results. The MAR indicated [REDACTED]. Interview with the DON on 6/21/12 at 3:57 p.m., revealed that there was no note as to why the resident did not receive monitoring as ordered three times a day for the full seven days. 6. Resident #I Resident #I was an [AGE] year old female admitted to the facility on [DATE], and according to her face sheet her [DIAGNOSES REDACTED]. Record review revealed that she had a physician's orders [REDACTED]. She also had an order initiated on 6/9/12, that stated to inject 5 units of [MEDICATION NAME] sub-q before every meal. An additional order written on 6/14/12, stated for blood sugar greater than 250 give an additional two units of [MEDICATION NAME] with the usual 5 units. Review of the MAR indicated [REDACTED]. Interview with the DON on 6/21/12 at 4:45 p.m., revealed she/he did not have any documentation as to why the resident would be receiving the two additional units if her blood sugar was below 250, and she saw no documentation regarding the resident having additional orders for two additional units for the instances where it was administered and her blood sugar was below 250. 7. Resident #P Resident #P was an [AGE] year old female admitted to the facility on [DATE], and according to her face sheet her [DIAGNOSES REDACTED]. Review of the resident MAR indicated [REDACTED]. On 6/6/12, she had a blood sugar of 48, on 6/13/12 she had a blood sugar of 59 at noon and 41 in the evening. On 6/21/12 an interview with the DON at 3:58 p.m., revealed that there were no notes or interventions documenting the low blood sugars of resident #P, nor any indication that the physician had been notified as ordered. 8-10. Residents #J, #M and #O Residents #J, #M and #O, all had orders in their records that indicated that they were to have blood sugar monitoring. Review of the individual MARs revealed the following: -Resident #J- June 16, and 17, 2012, no documentation when order read to monitor blood every evening. -Resident #M- no documentation of blood sugar on June 18, 2012, when ordered every Monday, Wednesday and Friday. -Resident #O- No documentation of blood sugar which was ordered to be taken four times daily, on June 3, 5, 7 (twice), 8, 9, 11, 12, 14, 15, 16 (twice), 17, 18 and 19. Interview with the DON on 6/21/12 at 4:58 p.m., revealed that she could not find any documentation or explanation as to why the residents listed above did not have their blood sugar monitored as ordered.

Based on record review and staff interviews, the facility failed to ensure the resident environment, including the environment of eight of 24 sample residents (#2, #8, #12, #13, #16, #17, #18 and #21) and 23 supplemental sample residents (#27, #29, #30, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, and #54), remained as free of accident hazards as possible. Specifically: -The facility failed to ensure interventions were developed and in place to prevent injuries from self-transfer. Resident #12 sustained two hip fractures. -The facility failed to ensure residents in the secured unit were free from resident-to-resident abuse. The facility did not provide adequate interventions to protect the residents on the secure unit from further abuse. -The facility failed to assess the safety of rails and mattress gap. Findings include: I. Inadequate supervision and/or assistive devices to prevent falls 1. Resident #12, age 67, was re-admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set (MDS), a significant change dated 10/3/10, the resident's cognition was assessed as being moderately impaired. She was totally dependent on staff for ambulation and bathing, and required extensive assistance with transfer and dressing. The resident needed limited assistance with hygiene, and supervision with eating. The resident's current medications included Celexa, Protonix, Vitamin D, Zofran, Fentanyl, Coumadin, and Vicodin. 2. Resident interview and Physician Notes On 11/9/10 at 10:25 a.m., the resident was interviewed in her room. She stated that she was very happy because she had been able to walk unassisted for a short distance during that morning's physical therapy session. The resident said that she had been walking with her walker with supervision for the past couple of weeks. She stated she had problems with her balance, and had fallen twice at the facility, breaking a hip each time. Review of the Physician's Notes documented a Progress Note dated 10/28/10, revealed under History of Present Illness was the entry "This [AGE] year old female was admitted to (Name of facility) on 6/22/10 from (Name of hospital) after repair of a perforated diverticulum, intra-abdominal abscess and colostomy placement. While in rehab the resident underwent [REDACTED]. Hospital course complicated by[DIAGNOSES REDACTED] and esoph(ageal) stricture requiring dilatation..." 3. Identified fall risks Review of the resident's Care Plan indicated that on 7/13/10, the focus area of falls was identified for the resident, and read as follows: "risk for falls due to multiple risk factors related to: impaired balance, unstable health condition, unsteady gait. Actual fall 8/25/10 (should read 8/12/10) resulting in right hip fx (fracture)." The Goals and Interventions were developed on 9/7/10, prior to the second fall on 9/18/10. The Goals as listed were: "No injury from falls and decreasing number of falls." The Interventions included: "-- Analyze previous resident falls to determine whether pattern/trend can be addressed. --Assist of one for all ambulations --Call light within reach when in room --Do not leave unattended on toilet or commode --Encourage resident to use handrails or assistive devices properly --Ensure environment is free of clutter and well lit --Evaluate effectiveness and side effects of psychotropic drugs with physician for possible decrease in dosage/elimination of medication --OT/PT (occupational and physical therapies) eval/TX PRN (evaluate/treat as needed) --Reinforce need to call for assistance" 4. Falls 8/12/10 and 9/18/10 During the End of the Day Meeting on 11/10/10 at 3:30 p.m., the Director of Nursing (DON) was asked to provide investigations of the resident's two falls (8/12/10 and 9/18/10). On 11/11/10 the DON provided an Event Summary for each fall along with the Change of Condition documentation. -The Event Summary for 8/12/10 documented the fall as occurring at 1730 (5:30 p.m.), being unwitnessed, and reported by a Certified Nurse Aide (CNA). Under the section describing the event was the following narrative "Resident stated she was attempting to self transfer from w/c (wheelchair) to bed. She was unable to stand alone and when she attempted to sit back down, her w/c moved because the brakes were not locked and she fell to the floor. CNA was walking back from lunch and noticed resident on the floor and immediately called for the nurse." The immediate interventions taken were "Neuros with vitals started STAT. X-ray call in by RN (registered nurse) house supervisor after assessment of resident. R(ight) elbow cleaned with normal saline, TAO and band-aid. 3 person assist into bed." Review of the accompanying Change of Condition Form dated 8/12/10 at 1730 (5:30 p.m.), revealed the following entry: "Fall from w/c (wheelchair) to right side. Resident states 'I was trying to get into bed.' RN assessed R(ight) hip/pelvic pain. R(ight) elbow ST (skin tear) and excoriation... Monitor with neuros (neurological checks), VS (vital signs) next 72 hours for latent injury. STAT (immediate) x-ray to R(ight) hip, R(ight) pelvis. Cleanse R(ight) elbow NS (normal saline), TAO (triple anti-biotic ointment), and Band-aid. Monitor every day until resolved then D/C (discontinue)" A second Change of Condition Form for 8/12/10 was filled out at 2100 (9:00 p.m.) and read "X-ray results to R(ight) hip show stress fracture of subcapital femoral neck . . . Daughter states to sent to (Name) Medical Center for evaluation. Wants her to go to the closer hospital." -The Event Summary for 9/18/10, documented the fall as occurring at 1400 (2:00 p.m.), being witnessed, and reported by a Licensed Practical Nurse (LPN). The narrative section read as follows: "(Name) LPN looked up and saw elder falling to floor. Had risen from couch. Appeared legs did not hold elder up. fell to L(eft) side hitting body first, then head.". The immediate intervention taken was documented as "Res(ident) assessed for injury. C/O (complains of ) pain to L(eft) hip." Review of the accompanying Change of Condition form dated 9/18/10 at 1400 (2:00 p.m.) showed the following entry under Status Change "... Res(ident) failed self transfer from couch to wheelchair. Resident hit her head. C/O (complains of ) pain to L(eft) hip. STAT x-ray of hip called in." A second Change of Condition form was filled out on 9/18/10 at 2330 (11:30 p.m.), and read "X-ray of L(eft) hip confirmed L(eft) femoral neck fracture. T.O. (telephone order) per (Dr's Name) to send resident to (Name) E. R. (emergency room ). Tylenol 650 mg provided for increase in temperature since her fall today. No effect. Temperature continued to increase, as well as her pain. Two EMT's (Emergency Medical Technicians) from (Name of Ambulance Company) escorted resident to (name of Medical Center) via gurney bed at 1830. Daughter, (Name), notified and went to hospital." 5. Failures in Facility's Response after Fall on 8/12/10 Review of the care plan revealed there was no documentation that after the resident's first fall 8/12/10, that individualized interventions - that took into account the resident's cognitive impairment and tendency to self-transfer - were developed. There were no directives to staff to ensure adequate supervision and no measures to alert staff of self-transfers; self-transfers by the resident were not specifically identified as a concern on the care plan. On 11/11/10 at 4:20 p.m., the Clinical Manager was interviewed regarding resident #12's falls. She stated that new falls were discussed every Friday in the Clinical Review Meeting. The Clinical Manager said resident #12 had been admitted with several complex medical issues. She said that after the second fall, the resident started to feel better, and interventions to help prevent further falls included stopping her Marinol, and decreasing the strength of her Duragesic patch. II. Resident-to-Resident Abuse A. Residents 1. Resident #16, an [AGE] year old female, was admitted to the facility on [DATE]. She had diagnoses, according to her face sheet that included dementia, hypertension, osteoarthrosis, osteoporosis and major depression. The resident resided on the secure unit. According to her most recent Minimum Data Set (MDS), an annual completed on 9/15/10, the resident had moderate cognitive impairment; exhibited sad moods and pained expressions; she was independent in transfers and ambulation; required the assistance of one staff member for dressing, hygiene and bathing and supervision with eating. 2. Residents #17, #18, #29 and #30 were all residents that resided on the secured units (two units that intermingle) with resident #16. All had some level of cognitive impairment due to dementia. B. Record Review - Documented incidents of Resident-to-Resident Abuse - Facility response Review on 11/10/10 of facility incident reports revealed four documented episodes of resident to resident abuse that involved resident #16 since 4/10. There was also evidence of another episode of abuse by resident #16 against an unidentified resident. 1. 4/4/10 - Resident #16 was rubbing the face of resident #29 with a cleaning cloth in an aggressive manner.2. 6/18/10 - Resident #16 struck resident #17 in the hand with a knife/fork. 3. 9/9/10 - Resident #30 stated she was slapped by resident #16.4. 10/3/10 - Resident #16 scratched resident #18 on the face with a fork.5. 11/1/10 - Resident #16 was observed to hold another resident's shoulder and noted to be angry and attempted to fight with the other resident. The incident was documented in resident #16's chart but the victim was not identified. (The victim was identified subsequently as being resident #18 when the Registered Nurse and Certified Nursing Assistant were interviewed by phone on 11/11/10.) C. Record review revealed the following interventions were to be put in place after each of the four documented episodes: 1. 4/4/10 - Resident #16 was rubbing the face of resident #29 with a cleaning cloth in an aggressive manner. Intervention: "Monitor X 72 hours for further episodes".2. 6/18/10 - Resident #16 struck resident #17 in the hand with a knife/fork. Intervention: "Monitor X 72 hours for further episodes". 3. 9/9/10 - Resident #30 stated she was slapped by resident #16. Intervention: "Monitor the resident for any increase in aggressive or territorial behaviors", no time frame noted.4. 10/3/10 - Resident #16 scratched resident #18 on the face with a fork. Intervention: Continue to monitor resident for aggressive/territorial behavior-started 9/9/10"5. 11/1/10 - Resident #16 was observed to hold another resident's shoulder and noted to be angry and attempted to fight with that other resident. Residents #17, #18, #29 and #30, per facility incident reports, were unable to provide details of the above incidents or able to recall them later. Resident #30 self-reported that she had been slapped by resident #16, but it was unwitnessed and she was unable to recall the incident the following day. D. Facility failure to adequately intervene to protect residents from further abuse. 1. Care plan Review of resident #16's care plan revealed the only behavioral problem the resident was care planned for was wandering. A hand-written additional intervention was noted on 10/4/10, that read, "Have resident sit at table where Certified Nursing Assistant is helping other residents to observe for and help prevent altercations with other residents." The care plan did not identify the resident's aggressive behaviors which the facility began to monitor in 9/10, or triggers that had been identified by staff in behavior monitoring reports and staff interview. Specifically: On 11/11/10 at approximately 11:30 a.m. the Unit Manager/RN (Registered Nurse), the Charge Nurse/LPN (Licensed Practical Nurse) and the SW (Social Worker) for the Secure Units (SCU) were interviewed together. They said they were all very familiar with resident #16. They all maintained that resident #16 did not randomly initiate altercations with other residents. They all agreed her episodes of resident-to-resident abuse were as a result of her reacting to other residents, most often because the residents were "chatting incessantly," which would set her off. 2. Behavior monitoring Review of the resident #16's behavior monitoring records (1/10 to 11/10/10) revealed staff was not monitoring the resident's aggressive behaviors until 9/10, and monthly behavior documentation and staff interventions did not correlate. Specifically, review of the records revealed that from January 2010 through 11/10/10, resident #16 had only six behaviors documented on their behavior tracking forms. However, the facility nursing staff documented that they put interventions in place on 73 different occasions. Cross-reference F250 for further details on behavior monitoring. E. Failure to thoroughly investigate and report incidents of resident-to-resident abuse. Cross-reference F225; investigation of violations involving abuse, mistreatment, and injuries of unknown origin. The facility Abuse Prohibition and Investigative Protocols dated 8/24/07, read, in pertinent part: "...All staff are to report any complaints or concerns of alleged abuse as soon as they are aware, be it by observation, report from a resident, visitor or other party, or based on resident assessment. The report should be made to the immediate supervisor or nurse in charge of that resident's care at the time..." See above; on 11/1/10, resident #16 was observed to hold another resident's shoulder and noted to be angry and attempted to fight with that other resident. At the time of the incident report review (11/11/10), management staff was unaware of this incident; there was no planned intervention. Specifically: On 11/11/10 at approximately 11:30 a.m. the Unit Manager/RN (Registered Nurse), the Charge Nurse/LPN (Licensed Practical Nurse) and the SW (Social Worker) for the Secure Units (SCU) were interviewed together. -When asked about the incident on 11/1/10 (noted in #16's chart) the three SCU staff all stated they were unaware of the incident. The UM called the Registered Nurse and Certified Nursing Assistant on duty at that time. They both identified the victim as resident #18. The RN stated she had not documented it on the 24 hour Report nor had she followed facility protocol and reported it. III. Environmental Hazards A. Side rails and mattress safety 1. Resident #27 Resident #27 was most recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. Resident Status The resident's most recent Minimum Data Set, dated dated [DATE], documented the resident had short-term and long-term memory impairments, and was severely impaired for daily decision-making. The resident did not display any behaviors. The resident required extensive assistance with bed mobility, transfers, and eating and was totally dependent on staff for dressing and toilet use. The resident had not had any recent falls. b. Observations During initial tour on 11/9/10 at 9:45 a.m., resident #27's bed was observed. The resident was not present in the room. The bed was a high-low bed with a quarter side rail placed on the left side. There was a 4 inch gap between the side rail and the mattress, and the mattress moved when pressure was applied. The bed and side rail were observed throughout the survey, until the morning of 11/11/10, when the side rail was removed from the bed. c. Record Review The resident's clinical care plan, last updated 8/13/10, documented the problem of "self care deficit r/t (related to) limited mobility, weakness, decline in executive functioning." The approaches included, in pertinent part, "...Transfers: Provide extensive assist with transfer for safety ..." Another problem documented, "Risk for falls characterized by history of falls/injury, multiple risk factors related to limited mobility, dementia, limited ROM (Range of Motion) weakness." Approaches included, "Hi/Lo bed for safety, leave bed in low position while resident is in bed. Blue Floor mat next to bed (lipped mattress)." The resident's clinical care plans did not include a care plan for the use of the side rail. The resident's clinical record did not contain an order for [REDACTED]. There was no safety assessment for use of the side rail. d. Interviews The Director of Nursing (DON) was interviewed on 11/10/10 at 3:45 p.m. The DON stated that a consent, pre-restraint evaluation, and possible physical therapy evaluation were needed before side rails were placed on the bed for resident use. The DON also stated that maintenance placed the side rails on the beds; however, the side rails were not checked for gaps or safety "often enough." The Licensed Practical Nurse (LPN) was interviewed on 11/11/10 at 8:15 a.m. The LPN stated resident #27 was a one person assist with a gait belt for transfers, and was able to bear some weight. The LPN stated she had not observed the resident use the side rail for transfers. The DON was interviewed again, on 11/11/10 at 8:40 a.m. The DON stated the side rail had been taken off of resident #27's bed the day before after brought to the facility's attention by the survey team. The DON stated the new Minimum Data Set coded the side rails differently than the last version, and now the facility was looking at all side rails as a restraint instead of assistive device, and was in the process of assessing all side rails. The Certified Nurse Aide (CNA) was interviewed on 11/11/10 at 10:25 a.m. The CNA stated the resident was able to sit up and bear slight weight; however, the resident did not use the side rail to assist with transfers. The CNA stated the resident used a walker placed in front of her, a gait belt, and one person assist to complete transfers. The CNA stated the resident did not use the side rail to transfer. 2. Bed canes a. Observations and Facility Record Review During initial tour on 11/9/10 at 9:45 a.m., the facility was observed to have multiple beds on the East, West, and special care units with "bed canes" attached to them. The "bed cane" was a single, wide white rail, with a large 15.5 inch gap in the center. The bed canes remained on the beds throughout the facility through the survey (11/9 - 11/11/10). -On 11/11/10 at approximately 9:45 a.m., the facility provided a list of residents that used the bed canes; fifty-seven residents had a bed cane on their bed. -On 11/10/10, the manufacturer's recommendations for safe use of the bed cane were requested on 11/10/10. The facility was unable to provide any manufacturer recommendations. -Facility documentation (therapy screens, side rail assessments) revealed that 25 of the 57 residents (#2, #8, #13, #21, #27, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, and #54) as having a bed cane on their bed did not have any type of therapy screen or assessment for safe use. b. Interview The Director of Nursing (DON) was interviewed on 11/10/10 at 3:45 p.m. The DON stated that a consent, pre-restraint evaluation, and possible physical therapy evaluation were needed before side rails were placed on the bed for resident use. The DON also stated that maintenance placed the side rails on the beds, however the side rails were not checked for gaps or safety "often enough." The DON stated the facility was in the process of ordering new bed canes that did not have such a big gap in the center, however, they had not yet changed any of the bed canes. In a follow up interview on 11/11/10 at 8:45 a.m., the DON stated the new Minimum Data Set coded the side rails differently than the last version, and now the facility was looking at all side rails as a restraint instead of assistive device, and they were in the process of assessing all side rails for safe use. An occupational therapist (OT) was interviewed on 11/11/10 at 1:30 p.m. The OT stated the therapy department was trying to complete quarterly screens for all residents with assistive devices. The quarterly screen was a "hands off," observation only screen which could indicate further evaluation was necessary. The therapist spoke to the staff to ensure the resident was still able to utilize the assistive device properly. A Unit Manager (UM) was interviewed on 11/11/10 at 1:45 p.m. The UM stated a physician's orders [REDACTED]. The UM stated that previously, there had not been a formal assessment prior to placing the side rail; however, the resident was informally assessed for upper extremity range of motion, diagnoses, and cognitive level for appropriate use. The UM stated no one "formally" went back to observe the resident for appropriate use or appropriate placement once maintenance placed the side rail. On 11/11/10 at 2:58 p.m., the DON stated that clinical care managers recently completed audits to track which residents used side rails, and the audit should have been updated weekly. The DON stated again that the facility was in the process of changing the type of side rail used in the facility. B. Unlocked Medication Cart 1. Professional standard According to "Clinical Nursing Skills & Techniques," by Perry & Potter, 5th Edition, (2004), pages 457 & 459: "Medications are safeguarded when locked in cabinet or cart. Do not leave drugs unattended. Nurse is responsible for safekeeping of drugs." 2. Observation On 11/11/10 at 4:00 p.m., a medication cart, identified as cart number one, on the east station was observed unlocked and unattended by both the surveyor and the evening RN (registered nurse) supervisor. The RN immediately walked over to the cart and pushed the lock into the locked position. At the time of the observation above, the RN was asked if the medication cart should be locked while unattended. The RN shook her head in disbelief and acknowledged the cart should be locked when unattended. At 4:30 p.m. after the above observation was made the director of nursing (DON) was notified. The DON acknowledged medication carts are to be locked when unattended.